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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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Structural Dissociation of theStructural Dissociation of the
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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Structural Dissociation of theStructural Dissociation of the
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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Structural Dissociation of theStructural Dissociation of the
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
DissociationDissociation
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
DissociationDissociation
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
DissociationDissociation
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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