Van Der Hart Disociac

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Structural Dissociation of theStructural Dissociation of thePersonality: The Key to UnderstandingPersonality: The Key to Understanding

Chronic Traumatization and ItsChronic Traumatization and ItsTreatmentTreatment

Onno van der Hart, PhDOnno van der Hart, PhD

Utrecht UniversityUtrecht University

Plenary Presentation at thePlenary Presentation at theESTDESTDFirst BiFirst Bi--Annual Conference,Annual Conference,

Amsterdam, April 19, 2008Amsterdam, April 19, 2008


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Pierre JanetPierre Janet18591859 -- 19471947


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Pierre Janet on HysteriaPierre Janet on Hysteria

[read: Dissociative Disorders][read: Dissociative Disorders] HysteriaHysteria is a malady of theis a malady of thepersonal synthesispersonal synthesis..

Hysteria isHysteria is

[1] a form of mental depression [[1] a form of mental depression [i.e., reduction ofi.e., reduction of

integrative capacityintegrative capacity] characterized by] characterized by [2] the retraction of the field of personal[2] the retraction of the field of personal

consciousness andconsciousness and

[3] a tendency to the dissociation and emancipation[3] a tendency to the dissociation and emancipation

of the systems of ideas and functions that constituteof the systems of ideas and functions that constitute

personality.personality.Pierre Janet (1907, p. 332)Pierre Janet (1907, p. 332)


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Integrative Capacity and ItsIntegrative Capacity and Its

LimitationsLimitations

Our personality is a constructionOur personality is a construction

We must integrate highly aversive experiences into ourWe must integrate highly aversive experiences into ourpersonalitypersonality

This requires high integrative capacityThis requires high integrative capacity

When our integrative capacity is too low, we may notWhen our integrative capacity is too low, we may notbe able to integrate such experiencesbe able to integrate such experiences

This inability generates mental injury, i.e., traumaThis inability generates mental injury, i.e., trauma

It involves a lack of integration, a dissociation of theIt involves a lack of integration, a dissociation of thepersonalitypersonality


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IntegrationIntegration Integration entails two major componentsIntegration entails two major components

SynthesisSynthesis in a constructed moment, our experienced presentin a constructed moment, our experienced present

across constructed timeacross constructed time

RealizationRealization personificationpersonification

presentificationpresentification

TraumaTrauma--related disorders are disorders ofrelated disorders are disorders ofsynthesis and realizationsynthesis and realization

Janet described these disorders as disordersJanet described these disorders as disorders

of nonrealizationof nonrealization


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William McDougall onWilliam McDougall on

DissociationDissociation

Normal personality, as we know it inNormal personality, as we know it inourselves and in our neighbours, is theourselves and in our neighbours, is the

product of an integrative process ... and isproduct of an integrative process ... and is

susceptible tosusceptible to disintegrationdisintegrationthat results in thethat results in the

manifestation of two or more personalitiesmanifestation of two or more personalities

[i.e.,[i.e.,parts of theparts of thepersonality] in and throughpersonality] in and throughthe one bodily organism.the one bodily organism.

William McDougall (1926, p. 545)William McDougall (1926, p. 545)


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A Definition of PersonalityA Definition of Personality

PersonalityPersonalityisis

the dynamic organizationthe dynamic organization

within the individualwithin the individual of those biopsychosocial systemsof those biopsychosocial systems

that determine his or her characteristic actionsthat determine his or her characteristic actions Inspired by Allport (1981) and Janet (1907)Inspired by Allport (1981) and Janet (1907)


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In the Context of Traumatization,In the Context of Traumatization,

Dissociation is a Dissociation of theDissociation is a Dissociation of thePersonalityPersonality A dissociation among biopsychosocial systems

described as: (Alter) personalities

Identities

Discrete behavioral states

Ego-states

Dissociative/dissociated self-states

Modes

Dissociative parts


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Structural Dissociation of theStructural Dissociation of the

Personality and the DissociativePersonality and the DissociativeDisorders FieldDisorders Field

Regardless of terminology used, all cliniciansRegardless of terminology used, all cliniciansworking with dissociative parts to fosterworking with dissociative parts to fosterintegration of the personality base theirintegration of the personality base theirapproach on a theory of (structural) dissociationapproach on a theory of (structural) dissociation

of the personalityof the personality

The integrative theory of structural dissociation ofThe integrative theory of structural dissociation of

the personality can be seen as an elaboration andthe personality can be seen as an elaboration andprecision of existing theoriesprecision of existing theories


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The Theory of Structuraltructural

Dissociation of the PersonalityDissociation of the Personality

TheThe theorytheoryof structural dissociation of theof structural dissociation of thepersonality has been shaped by notions frompersonality has been shaped by notions fromJanetJanets action psychology, and learning,s action psychology, and learning,

systems, cognitive, affective, attachment,systems, cognitive, affective, attachment,psychodynamic and object relations theory, aspsychodynamic and object relations theory, aswell as evolutionary psychology,well as evolutionary psychology,

psychobiology, especially affectivepsychobiology, especially affectiveneuroscience and polyvagal theoryneuroscience and polyvagal theory

It is meant to be a metaIt is meant to be a meta--theorytheory


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WhyWhy StructuralStructural inin StructuralStructural

Dissociation of the PersonalityDissociation of the Personality? (1)? (1)

Out of necessity, given the confusion aboutOut of necessity, given the confusion aboutthe concept of dissociationthe concept of dissociation

Dissociation of the personality does notDissociation of the personality does not

take place at random, but likely occurstake place at random, but likely occursalong existingalong existingfault linesfault lines

Hence, there is a (dynamic) organizationalHence, there is a (dynamic) organizational

structure among dissociative parts of thestructure among dissociative parts of thepersonalitypersonality


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WhyWhy StructuralStructural inin StructuralStructural

Dissociation of the PersonalityDissociation of the Personality? (2)? (2)

The termThe term structuralstructural refers to therefers to thedynamic organization of dissociativedynamic organization of dissociative

parts within a single personalityparts within a single personality

We do not imply that dissociative partsWe do not imply that dissociative partsare completely separate, static structuresare completely separate, static structures


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Personality (1)Personality (1)

The existence of two or more insufficientlyThe existence of two or more insufficiently

integrated subsystems within the wholeintegrated subsystems within the wholebiopsychosocial system that constitutes thebiopsychosocial system that constitutes theindividualindividuals personalitys personality

Each of these subsystems encompassesEach of these subsystems encompassesconsciousness and selfconsciousness and self--consciousnessconsciousness

They include their ownThey include their own

idea of self,idea of self, idea of the world, andidea of the world, and

idea of selfidea of self--inin--thethe--worldworld

Van der Hart & Nijenhuis (2008)Van der Hart & Nijenhuis (2008)


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Personality (2)Personality (2)

Phenomenologically, this lack of integration ofPhenomenologically, this lack of integration of

the personality manifests in dissociativethe personality manifests in dissociativesymptomssymptoms

NegativeNegative: functional losses such as amnesia and: functional losses such as amnesia andparalysisparalysis

PositivePositive: intrusions such as flashbacks and voices: intrusions such as flashbacks and voices

PsychoformPsychoform: e.g., amnesia, hearing voices: e.g., amnesia, hearing voices

SomatoformSomatoform: e.g., anesthesia, tics: e.g., anesthesia, tics

Van der Hart & Nijenhuis (2008)Van der Hart & Nijenhuis (2008)


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Dissociative Symptoms:Dissociative Symptoms:

Traditional ViewsTraditional ViewsPsychoform Somatoform

dissocation dissociation

Negative Amnesia Sensory and motor

symptoms Out-of-body losses, e.g.,experience out-of-body

Positive Re-experiencing Re-experiencingsymptoms trauma trauma, e.g.,Dissociative hyper-esthesia

psychosis Dissociative movements


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Dissociative Points of ViewDissociative Points of View Dissociative parts have different points ofDissociative parts have different points of

view involving different ideas of self,view involving different ideas of self,world and selfworld and self--inin--thethe--world. Ellertworld. EllertNijenhuis (2008)Nijenhuis (2008)

These ideas encompass differentThese ideas encompass differentperceptions and related action tendenciesperceptions and related action tendencies

These various points of view are oftenThese various points of view are oftenhighly conflictualhighly conflictual


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Points of ViewPoints of View Points of view are determined by our needs andPoints of view are determined by our needs and

perception of salient stimuli (i.e., interoceptive andperception of salient stimuli (i.e., interoceptive andexteroceptive stimuli), including those ofexteroceptive stimuli), including those ofsignificantsignificantothersothers..

In any given situation, various points of view areIn any given situation, various points of view are

possible and the challenge to make the decision forpossible and the challenge to make the decision forthe most adaptive one and related actionsthe most adaptive one and related actions

In structural dissociation, this adaptive decisionIn structural dissociation, this adaptive decision--

making is hampered because of the rigidity of partsmaking is hampered because of the rigidity of partsand the extreme difficulty to resolve these innerand the extreme difficulty to resolve these innerconflictsconflicts


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The Basic Action Systems Involved in OurThe Basic Action Systems Involved in Our

Decision Making and Subsequent ActionsDecision Making and Subsequent Actionsin Daily Life and under Threat (1)in Daily Life and under Threat (1)

Evolution has createdEvolution has created emotional operatingemotional operatingsystemssystems (Panksepp, 1998):(Panksepp, 1998): psychobiologicalpsychobiologicalsystemssystems involving limited response flexibilityinvolving limited response flexibility

Functioning in daily lifeFunctioning in daily life: social engagement;: social engagement;attachment; energy regulation; exploration;attachment; energy regulation; exploration;

sexuality/reproduction; playsexuality/reproduction; play Functioning under threatFunctioning under threat: defense (Fanselow: defense (Fanselow

& Lester, 1988)& Lester, 1988)


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The Basic Action Systems in OurThe Basic Action Systems in Our

Decision Making and SubsequentDecision Making and Subsequent

Actions in Daily Life and under ThreatActions in Daily Life and under Threat

The essence of these systems is performingThe essence of these systems is performing

adaptiveadaptive behavioral and mental actionsbehavioral and mental actionsinin

the worldthe world Therefore, they areTherefore, they are action systemsaction systems

Are different dissociative parts mediatedAre different dissociative parts mediated

by different action systems?by different action systems?


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Personality and Action SystemsPersonality and Action Systems

Hypothesis: TraumaHypothesis: Trauma--related dissociationrelated dissociation

involvesinvolves

a structural dividedness of the organizationa structural dividedness of the organizationof the personalityof the personality

into two or more partsinto two or more parts

that are essentially mediated bythat are essentially mediated by different action systemsdifferent action systems

or constellations of action systemsor constellations of action systems


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Daily Life Action Systems:

Survival of the Species Social Engagement

Attachment Sociability

Care-giving

Exploration

Play

Energy regulation (rest, eating, etc.)

Sexuality / Reproduction Dominance of higher order action tendencies of

daily life

Predominantly mediated by the ventral vagal system(a branch of the parasympathetic nervous system)


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Defense Action System::

Mobilizing ActionsAttachment cry

Hypervigilance Flight

Fight Mediated by the sympathetic nervous

system

Immobilizing

Freezing (rigid muscle tone) and

analgesia


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Defense Action System:

Immobilizing Actions Collapse

Submission with anesthesia Death feigning as a defense against

predators Catalepsy Lack of awareness Unresponsiveness

Predominantly mediated by dorsal vagalsystem (a branch of the parasympatheticnervous system)


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The Metaphor of Safety (Porges):

A Basic Principle of Our Nervous System

Environment

outside the bodyinside the body

Nervous System

Safety Danger

Neuroception

Spontaneously engages otherseye contact, facial expression, prosodysupports visceral homeostasis

Defensive strategiesfight/flight behaviors (mobilization)

Life threat

Defensive strategiesdeath feigning/shutdown (immobilization)

Where is freeze?


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ShockShock(Photo: Eli Somer, August 10, 2006)(Photo: Eli Somer, August 10, 2006)


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Prototypes of Structural Dissociation

The entire individual, i.e., the

personality, is traumatized

Various dissociative parts cope withbeing traumatized in different ways


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Prototypes of Structural DissociationPrototypes of Structural DissociationAlternations betweenAlternations betweenandand

coco--existence ofexistence of

TraumaTrauma--fixated part(s) that experiencefixated part(s) that experience tootoomuchmuchreliving of trauma;reliving of trauma; mediated mainly bymediated mainly bydefense action systemdefense action system

TraumaTrauma--avoidant part(s) that experienceavoidant part(s) that experiencetoo littletoo little -- numbing, detachment, amnesia,numbing, detachment, amnesia,conscious and unconscious avoidanceconscious and unconscious avoidancestrategies;strategies; mediated mainly by daily life actionmediated mainly by daily life action

systemssystems


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Charles S. MyersCharles S. Myers


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Charles Myers (1940)Charles Myers (1940)

APPARENTLYAPPARENTLY

NORMAL PART OFNORMAL PART OF

THE PERSONALITYTHE PERSONALITY apparent normality, butapparent normality, but

has:has:

emotional and bodilyemotional and bodily

anesthesiaanesthesia partial to completepartial to complete

amnesiaamnesia

intrusionsintrusions

avoidance of traumaticavoidance of traumaticmemoriesmemories

traumatic memories lefttraumatic memories left

unintegratedunintegrated

EMOTIONAL PARTEMOTIONAL PARTOF THEOF THE

PERSONALITYPERSONALITY ReRe--enacts the traumaenacts the trauma

in emotional andin emotional andsensorimotor wayssensorimotor ways

disoriented in time,disoriented in time,situation, and identitysituation, and identity

May intrude in ANPMay intrude in ANPssawareness andawareness and

interfere with ANPinterfere with ANPssfunctioningfunctioning

W ld W I S ldi in F nWorld War I Soldier in France:


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World War I Soldier in France:World War I Soldier in France:

Emotional Part of theEmotional Part of thePersonality (EP)Personality (EP)


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Attachment to TraumaAttachment to Trauma

[Traumatized] patients [i.e., their EP[Traumatized] patients [i.e., their EPs]...s]...are continuing the action, or rather theare continuing the action, or rather the

attempt at action, which began when theattempt at action, which began when thething happened, and they exhaustthing happened, and they exhaust

themselves in these everlastingthemselves in these everlasting

recommencements.recommencements.

Pierre Janet, (1919/25, p. 663)Pierre Janet, (1919/25, p. 663)


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The ApparentlyThe ApparentlyNormalNormal

Part of thePart of thePersonalityPersonality

Described byDescribed by

Charles MyersCharles Myers

(1940)(1940)

ErnestErnest

HemmingwayHemmingway

World War IWorld War I


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Development and Action Systems Under good enough developmental conditions,

action systems become increasingly integrated andsophisticated, so the child is able to adapt to changingcircumstances

Under chronically traumatizing conditions, actionsystems: May fail to mature

May fail to integrate

May not become rigidly activated in inappropriatecircumstances, e.g. defense instead of social engagement inrelationship

Normal Integrative Development involving ActionNormal Integrative Development involving Action


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Normal Integrative Development involving ActionNormal Integrative Development involving Action

SystemsSystems

Attachment

Seeking

Flight

Freeze

Submission

Attachment

Attachment

Seeking

Flight

Freeze

Submission

D

e

v

e

lo

p

m

e

nt

Survival of the Species/Normal F. Survival of the Individual

Play

Play


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Trauma Interfering with Integrative Developmental ProcessTrauma Interfering with Integrative Developmental Process

Attachment FlightFreeze

Submission

Attachment to

perpetrator

Attachment to

caretaker

Seeking

Flight Freeze

Submission

D

e

v

e

lo

p

m

e

nt

ANP EP

Seeking

Play

Play

Fight

Fight:

against the self


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Dissociative Parts: DynamicDissociative Parts: Dynamic

Subsystems Involving OrganizedSubsystems Involving OrganizedSets of ActionsSets of Actions

ANP EPShared

Actions


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Dissociative Parts are LessDissociative Parts are Less

Separate than is CommonlySeparate than is Commonly

AssumedAssumed

Dissociative parts of the personality may appearDissociative parts of the personality may appear

separate and even display no awareness of oneseparate and even display no awareness of one

another. But together theseanother. But together these divideddividedoror doubleddoubledparts of the personality make up the individualparts of the personality make up the individualss

complete psychological experience, and they maycomplete psychological experience, and they may

influence each other more than commonly isinfluence each other more than commonly is

assumed.assumed.

Van der Hart & Dorahy (in press)Van der Hart & Dorahy (in press)


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Explicit Memory (Knowing that)Explicit Memory (Knowing that)

Using neutral stimuli, DID patients were notUsing neutral stimuli, DID patients were not

found to be characterized by an actual memoryfound to be characterized by an actual memoryretrieval inability, in contrast to their subjectiveretrieval inability, in contrast to their subjectivereportsreports

Using an eUsing an evaluative conditioning procedure,valuative conditioning procedure,results indicated transfer of neutral andresults indicated transfer of neutral andemotional material between dissociative partsemotional material between dissociative parts

Huntjens et al. (2006, 2007)Huntjens et al. (2006, 2007)

Primary Structural Dissociation:Primary Structural Dissociation:


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Primary Structural Dissociation:Primary Structural Dissociation:

One Apparently Normal Part of the Personality (One Apparently Normal Part of the Personality (ANPANP) &) &

One Emotional Part of the Personality (One Emotional Part of the Personality (EPEP))

ANP: action systems forfunctioning in daily life and

survival of the species

EP: action systems for defense

from major threat:

survival of the individualOverlap indicates

shared access to

implicit and explicit

memory Nijenhuis, Van der Hart, & Steele, 2001

EP


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SimpleSimpleCase ofCase of

StructuralStructuralDissociationDissociation


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Miss America by DayMiss America by Day

Without realizing it, I fought to keep my twoWithout realizing it, I fought to keep my two

worlds separated. Without ever knowing why, Iworlds separated. Without ever knowing why, Imade sure, whenever possible, that nothingmade sure, whenever possible, that nothing

passed between the compartmentalization I hadpassed between the compartmentalization I hadcreated between the day child and the nightcreated between the day child and the night

child.child.

Marilyn Van Derbur (2003, p. 26)Marilyn Van Derbur (2003, p. 26)

Maintenance of Structural Dissociation:Maintenance of Structural Dissociation:


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Maintenance of Structural Dissociation:Maintenance of Structural Dissociation:

Phobia of Traumatic Memory and RelatedPhobia of Traumatic Memory and RelatedInnerInner--Directed PhobiasDirected Phobias

ItIts too dangerous for me to put these thingss too dangerous for me to put these things[combat trauma] into words. I am afraid they[combat trauma] into words. I am afraid theymight become gigantic and I be no longermight become gigantic and I be no longer

able to master them.able to master them. E.M. Remarque (1929/82, p.E.M. Remarque (1929/82, p.

165)165)

The moment any [Holocaust] memory orThe moment any [Holocaust] memory or

shred of a memory was about to floatshred of a memory was about to floatupwards, we would fight against it as thoughupwards, we would fight against it as thoughagainst evil spirits.against evil spirits. A. Appelfeld (1993, 1994, p. 18)A. Appelfeld (1993, 1994, p. 18)

Sh d S l Di i iSh d S l Di i i


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Shame and Structural DissociationShame and Structural Dissociation

(1)(1) Shame is highly involved in maintaining phobiasShame is highly involved in maintaining phobias

of inner experiences, of attachment, and ofof inner experiences, of attachment, and ofchangechange

Shame is maintained or heightened by schemasShame is maintained or heightened by schemasor scripts, i.e., rigidor scripts, i.e., rigid points of viewspoints of views of variousof variousdissociative partsdissociative parts

Various schemas support particular defensesVarious schemas support particular defenses

against shameagainst shame


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Shame and Structural Dissociation (2) Shame involves defensive strategies that can beShame involves defensive strategies that can be

correlated with mammalian defenses against threat: theycorrelated with mammalian defenses against threat: they

have similar physiological organizations and similarhave similar physiological organizations and similargoals: fight, flight, freeze, collapsegoals: fight, flight, freeze, collapse

Nathanson (1992; cf., Kluft, 2006) has describe theNathanson (1992; cf., Kluft, 2006) has describe theCompass of Shame:Compass of Shame:

Attack others (fight)Attack others (fight)

Attack self (one part attacking another internally:Attack self (one part attacking another internally:fight)fight)

Withdrawal (collapse, freeze, behavioral flight)Withdrawal (collapse, freeze, behavioral flight)

Avoidance (mental flight)Avoidance (mental flight)

Pierre Janet on VehementPierre Janet on Vehement


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Pierre Janet on VehementPierre Janet on Vehement

EmotionsEmotions Traumas produce their disintegrating effects

in proportion to their intensity, duration andrepetition. P. Janet (1909, p. 1558)

Modern research adds that traumatization at

an early age is a major factor correlated withdissociation

More severe, chronic trauma leads to morecomplex structural dissociation of thepersonality, i.e., more EPs, and eventually,

more ANPs


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S ndor Ferenczi (1932) onSandor Ferenczi (1932) on


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Sandor Ferenczi (1932) onSandor Ferenczi (1932) on


If traumatic events accumulate duringIf traumatic events accumulate duringthe life of the growing person, thethe life of the growing person, thenumber and variety of personality splitsnumber and variety of personality splits

increase, and soon it will be ratherincrease, and soon it will be ratherdifficult to maintain contact withoutdifficult to maintain contact withoutconfusion with all the fragments, whichconfusion with all the fragments, which

all act as separate personalities but mostlyall act as separate personalities but mostlydo not know each otherdo not know each other..

S d St t l Di i ti


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Secondary Structural Dissociation:

Complex Trauma, BPD, DESNOS, DDNOS

ANP: Actions SystemsOf Daily Life

EP: Defense

Freeze

EP: DefenseFight; Attack

EP: DefenseSubmit

Nijenhuis, Van der Hart, & Steele ( 2001)

PERSONALITY


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Patientenbild 1

Disorganized/Disoriented Attachment


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Disorganized/Disoriented Attachment

DD attachment and Dissociationattachment and Dissociation


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DD--attachment and Dissociationattachment and Dissociation

DD--attachment has been described as a predictor ofattachment has been described as a predictor of

[psychoform] dissociation (e.g., Ogawa et al., 1997;[psychoform] dissociation (e.g., Ogawa et al., 1997;

LyonsLyons--Ruth et al., 2006)Ruth et al., 2006)

We propose it is not a predictor, but rather is aWe propose it is not a predictor, but rather is a

manifestationmanifestationof (structural) dissociationof (structural) dissociation

Indicates alternation between approach and avoidanceIndicates alternation between approach and avoidanceactions that are simultaneous and contradictoryactions that are simultaneous and contradictory

These contradictory actions are likely directed by innateThese contradictory actions are likely directed by innate

psychobiological systems of daily lifepsychobiological systems of daily life(approach/attachment) and of defense (avoidance/(approach/attachment) and of defense (avoidance/

fight/ flight/freeze/submission)fight/ flight/freeze/submission)

DD--attachment in the Motherattachment in the Mother--InfantInfant


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DialogueDialogue (1)(1)

Infant DInfant D--attachment behavior seems to be a response toattachment behavior seems to be a response to

high levels of disrupted [maternal] affectivehigh levels of disrupted [maternal] affectivecommunication (e.g., Ogawa et al., 1997; Lyonscommunication (e.g., Ogawa et al., 1997; Lyons--Ruth etRuth et

al., 2006), i.e., the [motheral., 2006), i.e., the [mothers] inability to be a reliables] inability to be a reliable

source of comfort for fearful arousal from any sourcesource of comfort for fearful arousal from any source(Lyons(Lyons--Ruth et al., 1999)Ruth et al., 1999)

In this disrupted maternal communication, withdrawal orIn this disrupted maternal communication, withdrawal or

psychological unavailabilitypsychological unavailability has a major impact in thehas a major impact in theinfantinfants Ds D--attachment behaviorattachment behavior

DD--attachment in the Motherattachment in the Mother--InfantInfant


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DialogueDialogue (2)(2)

[Maternal] withdrawal is the strongest predictor of[Maternal] withdrawal is the strongest predictor of

(psychoform) dissociation at adolescent age (Lyons(psychoform) dissociation at adolescent age (Lyons--RuthRuthet al., 2006)et al., 2006)

This withdrawal has been calledThis withdrawal has been called hidden traumahidden trauma

(Lyons(Lyons--Ruth et al., 2006)Ruth et al., 2006) We hypothesize that suchWe hypothesize that such hidden traumahidden trauma is a majoris a major

form of chronic childhood traumatizationform of chronic childhood traumatization

Hence, high levels of [maternal] withdrawal should causeHence, high levels of [maternal] withdrawal should cause

high levels of structural dissociationhigh levels of structural dissociation

Treatment Implications of


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Treatment Implications of

D-attachment and Dissociation Various parts have different attachment styles

The alternation and competition among thesepatterns results in the D style of attachment

Therapist must understand the pattern of eachdissociative part, as well as related conflictingneeds and affects

Therapist must respond with even-handednessto the relational needs and defenses of each part

DD tt hm nt Di i ti n ndattachment Dissociation and


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DD--attachment, Dissociation, andattachment, Dissociation, and

Object RelationsObject Relations Internal representations of self and other are multiple,Internal representations of self and other are multiple,

contradictory, and reciprocally dissociatedcontradictory, and reciprocally dissociated Representations gradually become the basis forRepresentations gradually become the basis for

development of more autonomous and complexdevelopment of more autonomous and complex

dissociated mental structures [dissociative parts of thedissociated mental structures [dissociative parts of thepersonality] and object relationspersonality] and object relations

Some representations may be defense based, some areSome representations may be defense based, some are

attachment based, i.e., the are mediated by action systemsattachment based, i.e., the are mediated by action systemsof daily life or defenseof daily life or defense

----Inspired by G. Liotti, 1999Inspired by G. Liotti, 1999

Tertiary Structural Dissociation:


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Tertiary Structural Dissociation:

Dissociative Identity Disorder (DID)

ANP

EPFight

EP: Submit

Nijenhuis, Van der Hart, & Steele ( 2001)

PERSONALITY

ANP

ANPEP

Freeze

EP

EP

EP

Levels of StructuralLevels of Structural


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Levels of StructuralLevels of Structural

Dissociation of the PersonalityDissociation of the Personality PRIMARYPRIMARY

Simple PTSDSimple PTSDSimple Dissociative DisordersSimple Dissociative Disorders (DSM(DSM--IV, ICDIV, ICD--

10)10)

SECONDARYSECONDARY

Chronic, complex PTSD/DESNOSChronic, complex PTSD/DESNOS

BPD, DDNOSBPD, DDNOS

TERTIARYTERTIARY

DIDDID Van der Hart, Nijenhuis & Steele, 2000

Reactivation of TraumaticReactivation of Traumatic


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Memories: Extreme Forms ofMemories: Extreme Forms ofDysregulationDysregulation

Usually involvesUsually involves hyperactivationhyperactivation, mediated by, mediated bysympathetic nervous system, and low mentalsympathetic nervous system, and low mental

efficiencyefficiency

However, may also involveHowever, may also involve hypoactivationhypoactivation,,

mediated by dorsal vagal system (a branch of themediated by dorsal vagal system (a branch of the

parasympathetic nervous system)parasympathetic nervous system)

Hyperarousal & Hypoarousal:Hyperarousal & Hypoarousal:


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Hyperarousal & Hypoarousal:Hyperarousal & Hypoarousal:

Biphasic Trauma ResponseBiphasic Trauma Response

Window of ToleranceOptimal Arousal Zone

HyperarousalHyperarousal

HypoarousalHypoarousal

Ogden and Minton (2000)

Wh t H pp n Wh n th Int r tiWhat Happens When the Integrative


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What Happens When the IntegrativeWhat Happens When the Integrative

Level is Insufficient?Level is Insufficient?

Symptoms can be understood as substituteSymptoms can be understood as substituteactionsactions

Substitutes for adaptive or integrative actionSubstitutes for adaptive or integrative action

include intense agitation, selfinclude intense agitation, self--mutilation,mutilation,substance abuse, maladaptive lowering ofsubstance abuse, maladaptive lowering of

consciousness, social isolation, attachment toconsciousness, social isolation, attachment to

perpetrators,perpetrators, traumatrauma--related phobiasrelated phobias, avoidance, avoidance

of intimacyof intimacy

S b tit t A ti n


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Substitute ActionsSubstitute Actions

These are maladaptive lower level action thatThese are maladaptive lower level action thatreplace adaptive higher level action tendenciesreplace adaptive higher level action tendencies(e.g., impulsive actions where reflective actions(e.g., impulsive actions where reflective actions

are more adaptive)are more adaptive)andand

maladaptive higher level action tendencies thatmaladaptive higher level action tendencies that

replace adaptive lower level action tendenciesreplace adaptive lower level action tendencies(e.g., maladaptive reflection where immediate(e.g., maladaptive reflection where immediateaction is needed)action is needed)

andand One type of higher level action tendencyOne type of higher level action tendency

substitutes for another higher level actionsubstitutes for another higher level action

(workaholism vs. inner awareness and reflection)(workaholism vs. inner awareness and reflection)

Treatment involves:Treatment involves:


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Gradually raising the integrative capacity necessary forGradually raising the integrative capacity necessary foradaptive and integrative actionsadaptive and integrative actions

Completing unfinished actions, including conflictsCompleting unfinished actions, including conflictsamong parts, and engaging in more adaptive actionamong parts, and engaging in more adaptive action

tendenciestendencies IncludingIncludingresolving conflictsresolving conflictsamong dissociative parts andamong dissociative parts and

fostering mutual understanding and cooperationfostering mutual understanding and cooperation

The integration of traumatic memories (majorThe integration of traumatic memories (majorunfinished actions) are among the most demandingunfinished actions) are among the most demandingintegrative actionsintegrative actions

Raising the integrative level is facilitated by the patientRaising the integrative level is facilitated by the patientss

relationship with therapist (involving the socialrelationship with therapist (involving the socialengagement and the attachment system to mitigateengagement and the attachment system to mitigatedefensive strategies)defensive strategies)

Raising Integrative Capacity


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Raising Integrative CapacityRaising Integrative Capacity

THE WELL INITIATED, EXECUTED,THE WELL INITIATED, EXECUTED,

AND COMPLETED MENTAL ANDAND COMPLETED MENTAL ANDBEHAVIORAL ACTION RAISESBEHAVIORAL ACTION RAISES

MENTAL EFFICIENCYMENTAL EFFICIENCY

Pierre JanetPierre Janet

Treatment of Primary StructuralTreatment of Primary Structural


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y


Involves overcoming ANPInvolves overcoming ANPs phobia of traumatics phobia of traumaticmemories and overcoming ANPmemories and overcoming ANPs phobia of EPs phobia of EP

Whether or not the dissociative nature of PTSDWhether or not the dissociative nature of PTSDis recognized as such by patient and/or therapistis recognized as such by patient and/or therapist

Recommended Treatment of PrimaryRecommended Treatment of Primary


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Recommended Treatment of PrimaryRecommended Treatment of Primary

Structural DissociationStructural Dissociation

Basic applications of EMDR, CBT orBasic applications of EMDR, CBT or

Sensorimotor Psychotherapy usuallySensorimotor Psychotherapy usually

appropriateappropriate

Treatment of Secondary and TertiaryTreatment of Secondary and Tertiary


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Treatment of Secondary and TertiaryTreatment of Secondary and Tertiary


There is no short cut to reparation andThere is no short cut to reparation and

attempts to find one may merely lead toattempts to find one may merely lead to

further denial and disillusionment.further denial and disillusionment.Jeremy Holmes (1991, p. 104)Jeremy Holmes (1991, p. 104)

The Standard of Care:The Standard of Care:


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Phase-Oriented Treatment of ComplexTrauma Disorders

(secondary and tertiary dissociation) PHASE 1PHASE 1:: Symptom reduction,Symptom reduction,

stabilization, and skills buildingstabilization, and skills building

PHASE 2PHASE 2:: Treatment ofTreatment oftraumatic memorytraumatic memory

PHASE 3PHASE 3:: PersonalityPersonality(re)integration and(re)integration and

(re)habiliation(re)habiliationJanet (1898); cf., Brown et al. (1998); Kluft (1993); VanJanet (1898); cf., Brown et al. (1998); Kluft (1993); Van

der Hart et al. (1989, 2006)der Hart et al. (1989, 2006)

Treatment Approaches


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Treatment Approaches

Simulatneous approaches:

Attention to therapeutic relationship;countertransference and transference

work with dissociative parts and their conflictsdirectly and indirectly

Attention to daily life functioning stabilization andimprovement

Problem solving

Psychoeducation

Systems perspective

PhasePhase--Oriented Treatment ofOriented Treatment of


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Complex Trauma DisordersComplex Trauma Disorders

PhasePhase--oriented treatment involves a sequence oforiented treatment involves a sequence of

interventions which systematically address innerinterventions which systematically address inner--

and outerand outer--directeddirectedphobiasphobias(the phobia of traumatic(the phobia of traumatic

memories being the most basic one)memories being the most basic one) These phobias can be categorized as: (1) phobia ofThese phobias can be categorized as: (1) phobia of

traumatic memory, (2) phobia of attachment, (3)traumatic memory, (2) phobia of attachment, (3)

phobia of traumaphobia of trauma--related mental actions, (4) phobiarelated mental actions, (4) phobia

of dissociative parts of the personalityof dissociative parts of the personality

Van der Hart, Nijenhuis, & Steele (2006)Van der Hart, Nijenhuis, & Steele (2006)

PhasePhase--Oriented Treatment ofOriented Treatment of


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Complex Trauma DisordersComplex Trauma Disorders

Overcoming these phobias involves completingOvercoming these phobias involves completing

previously incomplete and unachieved actions andpreviously incomplete and unachieved actions and

thus increasing integrative capacitythus increasing integrative capacity(Van der Hart, Nijenhuis,(Van der Hart, Nijenhuis,& Steele, 2006)& Steele, 2006)

Skills training (e.g., interpersonal skills, regulatoryskills) may an essential part of increasing integrative

capacity

Phobias in PhasePhobias in Phase--Oriented TreatmentOriented Treatment


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Phobias in Phaseob as ase Oriented TreatmentO e ted eat e t

Phase OnePhase One:: Symptom Reduction and StabilizationSymptom Reduction and Stabilization

Overcoming the phobia of attachment (loss) in ANP(s) to the therOvercoming the phobia of attachment (loss) in ANP(s) to the therapistapist

Overcoming the phobia of traumaOvercoming the phobia of trauma--related mental actionsrelated mental actions

Overcoming the phobia of dissociative parts (ANPs, EPs)Overcoming the phobia of dissociative parts (ANPs, EPs)

Phase TwoPhase Two::Treatment of Traumatic MemoriesTreatment of Traumatic Memories

Overcoming the phobia of unresolved attachment to the perpetratoOvercoming the phobia of unresolved attachment to the perpetratorr

Overcoming the phobia of attachment of EPs to the therapistOvercoming the phobia of attachment of EPs to the therapistOvercoming the phobia of traumatic memoriesOvercoming the phobia of traumatic memories

Phase ThreePhase Three:: Integration and RehabilitationIntegration and Rehabilitation

Overcoming the phobia of normal lifeOvercoming the phobia of normal life

Overcoming the phobia of healthy riskOvercoming the phobia of healthy risk--taking and changetaking and change

Overcoming the phobia of intimacyOvercoming the phobia of intimacy

VVan der Hart, Nijenhuis, & Steele (2006)an der Hart, Nijenhuis, & Steele (2006)

PHASE 1PHASE 1


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Symptom Reduction andSymptom Reduction andStabilizationStabilization

Overcoming the phobia ofOvercoming the phobia ofattachment andattachment anddetachmentdetachment: Approach and avoidance of contact: Approach and avoidance of contact

with the therapistwith the therapist

Overcoming the phobia ofOvercoming the phobia ofmental actions andmental actions andrelated contentsrelated contents (thoughts, feelings, needs, wishes,(thoughts, feelings, needs, wishes,

fantasies)fantasies)

Overcoming the phobia ofOvercoming the phobia ofdissociative parts ofdissociative parts of

the personalitythe personality

Phase 2: Treatment ofPhase 2: Treatment of


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Traumatic MemoryTraumatic Memory Overcoming the phobia ofOvercoming the phobia ofattachmentattachment::

Therapeutic attachment with EPsTherapeutic attachment with EPsandand

Disengagement fromDisengagement from insecure attachmentinsecure attachmentto perpetratorsto perpetrators

Overcoming the phobia ofOvercoming the phobia oftraumatictraumaticmemoriesmemories

Van der Hart, Nijenhuis & Steele, 2000


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Phase 3: Personality (Re)integrationPhase 3: Personality (Re)integrationand (Re)habilitationand (Re)habilitation

Overcoming the phobia ofOvercoming the phobia ofattachment:attachment:intimacyintimacy

Overcoming the phobia ofOvercoming the phobia ofnormal life and changenormal life and change

Overcoming the phobia ofOvercoming the phobia ofhealthy riskhealthy risk--takingtaking

Van der Hart, Nijenhuis & Steele, 2000

Treatment Conclusions (1)


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Treatment involves working directly andTreatment involves working directly and

indirectly with ANP(s) and EP(s) within theirindirectly with ANP(s) and EP(s) within their

window of tolerancewindow of tolerance Treatment involves engaging in integrativeTreatment involves engaging in integrative

(mental and behavioral) actions, including(mental and behavioral) actions, including

reflective functioning; including realization ofreflective functioning; including realization oftraumatic experiences and their consequencestraumatic experiences and their consequences

Treatment Conclusions (2)


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Realization, involving personification andRealization, involving personification and

presentification, presupposes joint activation ofpresentification, presupposes joint activation of

ANP and EP, and eventually requires the highestANP and EP, and eventually requires the highestlevels of integrative capacitylevels of integrative capacity


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Van Der Hart Disociac

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