Elizabeth F. Howell - Understanding and Treating

Understanding and Treating
Dissociative
Identity Disorder
Relational PeRsPectives Book seRies

Volume 49
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Understanding and Treating Dissociative The Analyst in the Inner City, Second
Identity Disorder: Edition:
A Relational Approach Race, Class, and Culture Through a
Elizabeth Howell Psychoanalytic Lens
Neil Altman
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Relational Psychoanalysis and the Christian Dare to be Human:
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Rita Wiley McCleary
Understanding and Treating
Dissociative
Identity Disorder
A Relational Approach
Elizabeth F. Howell
New York London

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Library of Congress Cataloging‑in‑Publication Data
Howell, Elizabeth F., 1946-

Understanding and treating dissociative identity disorder : a relational
approach / Elizabeth Howell.
p. cm. -- (Relational perspectives ; 49)
ISBN 978-0-415-99496-5 (hardcover : alk. paper) -- ISBN 978-0-415-99497-2
(pbk. : alk. paper) -- ISBN 978-0-203-88826-1 (e-book)
1. Dissociative disorders--Diagnosis. 2. Dissociative disorders--Treatment. 3.
Dissociation (Psychology) I. Title.
RC553.D5H693 2011
616.85’23--dc22 2010041387
Visit the Taylor & Francis Web site at

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and the Routledge Web site at
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ISBN 0-203-88826-X Master e-book ISBN

With gratitude to my patients for their generous
permission to share about their lives and treatment
and for what they have taught me.
Contents
A Personal Note xiii

Preface xv
Acknowledgments xxi
Introduction 1
Part 1
Understanding Dissociative Identity Disorder 13
1 The Lives and Psychotherapy of Three People With DID 15
2 The Dynamic Unconscious and the Dissociative Structure

of the Mind 27
3 “The We of Me”: Personality Organization in DID 55
4 DID Is a Trauma Disorder 73
5 Dissociated Self-States, Trauma, and Disorganized

Attachment 85
6 Some Neurobiological Correlates of the Structure and

Psychodynamics of Dissociated Self-States 109
7 Dissociated Self-States: Creation and Contextualization 133
xi
xiiâ•… Contents
Part 2
Treating Dissociative Identity Disorder 145
8 Assessment and Diagnosis of DID 147
9 Phase-Oriented Treatment 167
10 Facilitating Coconsciousness and Coparticipation in the

Treatment 187
11 Working With Persecutory Alters and Identification

WithÂ€the Aggressor 211
12 The Therapeutic Relationship: Multiple Dimensions

ofÂ€Coconstruction 225
13 Dreams in DID 239
14 Suicidality in DID 249
15 Comorbidity and Seeming Comorbidity: Problematic

Outcomes of Severe and Rigid Dissociative Structuring
ofÂ€the Mind 263
References 275
Index 301
A Personal Note
If this book were a piece of music, the hauntingly beautiful, melancholy,

and soul-searing thematic melody to Tchaikovsky’s 1876 ballet, Swan Lake,
might be its preface. When I recently watched a performance of this ballet,
it suddenly dawned on me that the premise of the folk myth the ballet dra-
matizes is child sexual abuse: An evil predator has captured young maidens
and turned them into swans. The melody evokes the isolation from human-
ity and the longing for human form and human interaction as well as the
horror of being trapped in one’s deprivation and pain. This is what child
abuse does: It deprives people of their human birthright to exist comfort-
ably in their bodies, in their minds, and in interaction with other humans.
It is not possible to help people with dissociative identity disorder (DID)
to improve their lives significantly without acknowledging in the deepest
way the horrors of child abuse. The majority of persons suffering from the
extremes of bouncing from one reality to another, often without control
and often without knowing it, come by this affliction as a result of early,
prolonged, and repeated child sexual abuse, usually at the hands of some-
one who is supposed to love them and has the role of a protector. And,
many who have severe posttraumatic stress disorder (PTSD) and dissocia-
tive problems that do not rise to the level of DID have suffered this same
kind of abuse that betrays their trust and fractures their ability to orient in
the world.
This topic is especially meaningful to me since I have a brother and a
sister whose early deaths were indirect results of child sexual abuse. My
brother, Kit, who died of lung cancer at age 43, was an endearingly pretty
boy who was abused by a school teacher, a man much admired on the fac-
ulty. My sister, Gwynneth, died at age 57 from an autoimmune disorder
and other complications. She was abused throughout her adolescence by
our father. I was lucky enough to have certain family dynamics in my favor
that protected me from overt sexual abuse. But, I had to watch it happening
to my sister and could do nothing about it.
xiii
Preface
One of my patients told me that for as long as she could remember, she had
always used “the ‘we’ of me” when referring to herself in her own mind.
She never really thought much about what this meant; it was just one of
those things. As far as she remembers, she did not hear voices as a child
or overtly switch identity states (to her knowledge or to the observation of
others). Even though she did derive substantial benefit from several decades
of psychotherapy, she still did not know that she had dissociated identi-
ties. All she knew was that she had struggled for many years to overcome
an extraordinarily difficult childhood. When her dissociated identities
began to emerge in psychotherapy with me, her conscious life transformed.
Although in many ways profoundly more painful, her world was now much
richer, even if more complicated, with so many “people” in it who had
much to say to her, to each other, and to me. The phrase she had always
used to describe herself—“the ‘we’ of me”—now made sense.
This is the case with many who are dealing with dissociative identity dis-
order (DID). They have lived confusing, often crisis-ridden, terrifying, and
quite routinely painful—even if sometimes outwardly successful—lives.
Frequently, they had no idea of what was really the matter with them until
some revelatory crisis took place. Some, for example, have broken down
when their own child or a young relative reached the age at which they
had been abused. This triggering event caused them to be flooded with
unbearable memories that had been previously dissociated. One such per-
son, before her breakdown, would openly speak without affect of how her
brother-in-law had continuously raped her as a child. She proudly thought
she was strong to have withstood such duress. It is true that she, or at least
her defenses, were strong up to a point—the point at which her biologi-
cal child became the age at which her own brutal childhood abuse began.
For other people, the trigger for breakdown is different. Those who have
used addictions to quell and mask unbearable feelings of horror and pain,
terrifying memories, and internal voices may find that achieving sobriety
unleashes the voices, the nightmares, and the undeniable presence of the
dissociated parts of themselves. If they are lucky enough to be in therapy
xv
xviâ•… Preface
with someone who can recognize these shifts, the dissociated parts can be
welcomed into the treatment.
One highly dissociative patient of mine vigorously debunked the idea of
DID and spent a good deal of time talking around his pain until a crisis
plunged him into such despair that when he called me, it was undeniable
for both of us that a dissociated part of him I had never met before was
present. At that point, I was able to address that dissociated part of him,
and from then on, we could talk much more openly. It was a “terrible”
relief for him: His biggest fear had come true, but at least he no longer had
to fear it. Now, the others who had been there all along had a chance to
become known.
In my experience as a DID therapist and a frequent consultant to thera-
pists with dissociative patients, it makes all the difference in the life of a
person with DID to have a therapist who can recognize their dissociated
parts and work with them. Unfortunately, there are many patients with
DID who have sought therapy and, although somewhat improved, were
nonetheless left feeling hollow in comparison to what could have been or
what did occur later when they were able to get the proper treatment.
What, then, are the obstacles to being understood that face people who
have severe dissociative disorders who are receiving help from the mental
health profession? One of the obstacles is the paucity of accurate profes-
sional, as well as public, knowledge about DID. Ironically, the personal-
ity organization of highly dissociative individuals mirrors the dissociative
organization of our culture.
Our culture has dissociated dissociativity. Profound aggressor/victim
themes and psychodynamics, along with narcissistic, sadistic, or psycho-
pathic coloring, run deep in our culture while simultaneously being denied.
Victims are often blamed and shamed. One of the most shaming aspects of
DID may be that this extremely painful and disorganizing problem of living
is so often viewed as not existing. Until recently, abnormal psychology and
psychiatric textbooks routinely informed their readers that multiple person-
ality disorder (MPD), now termed DID, is an extremely rare presentation,
if it exists at all. The existence of dissociative parts is often disbelieved, and
therapists who listen to these aspects of their clients are often accused of
reifying (i.e., making real something that is not) a delusional multiplicity.
The pervasiveness of professional resistance to the acknowledgment of
DID is sometimes remarkable. To illustrate, I was recently told by two
different colleagues of two almost identical series of events having to do
with the hospitalization in two different hospitals of two different patients
with DID: Both patients were hospitalized for suicidal behavior, and both
had told the hospital staff that they had DID. In both cases, the hospital
staff immediately contradicted the patients, telling them that they did not
have DID because it does not exist. In one case, the therapist was point-
edly informed by the attending doctor that DID does not exist because he
Prefaceâ•… xvii
had never seen it. Then, something changed: In both cases, the patients
began to floridly switch, demonstrably proving the existence of DID to
the staffs and supporting proper diagnosis of the patients. In one case, the
patient (who was educated about her condition) was able to instruct some
of the staff about DID and its symptomatology. As a result, staff members
were able to recognize and understand her switches when they occurred.
However, the continued similarity in the trajectory of events for the two
patients was rather chilling. Having finally understood that DID exists
and that its symptoms can be witnessed, the administration and staff next
requested of these vulnerable, suicidal patients that they consent to being
filmed. Fortunately, both patients refused.
Despite the frequent denial of the existence of DID, current epidemio-
logical research sets the prevalence of DID at 1.1% to 3% of the general
population (International Society for the Study of Trauma and Dissociation
[ISST-D], in press). This puts the prevalence of DID as at least equal to
or higher than schizophrenia, which is at about 0.5% to 1.5% (American
Psychiatric Association, 2000, p. 308). According to Foote and Park (2008),
“A fair amount of data suggests that DID is encountered worldwide and
may not be rarer than schizophrenia” (p. 221). A recent large scale study of
a representative sample of 628 women in Turkey by Sar, Akyuz, and Dogan
(2006) found that 18.3 had a lifetime diagnosis of a dissociative disorder.
Of these, 8.3% had DDNOS and 1.1 had DID.
Prevalence among patient populations is even higher. Foote, Smolin,
Kaplan, Legatt, and Lipschitz (2006) found that 29% of an outpatient
group had a dissociative disorder. Of these 10% had dissociative amnesia,
9% had Dissociative Disorder Not Otherwise Specified (DDNOS), 6% had
Dissociative Identity Disorder (DID), and 5% had depersonalization disor-
der. Interestingly, only 5% of this group of 82 patients had a dissociative
diagnosis recorded in their charts. Brand, Classen, Lanius, Loewenstein,
McNary, Pain, and Putnam (2009), collapsing the results of many stud-
ies, report prevalence rates of dissociative disorders among outpatients that
range from 12 to 38%. Sar, Koyuncu, Ozturk, Yargic, Kundakci, Yazici, et
al. (2007) found that 37.9% of patients presenting to the psychiatric emer-
gency room had a dissociative disorder.
DID is usually the outcome of chronic and severe childhood trauma,
which can include physical and sexual abuse, extreme and recurrent terror,
repeated medical trauma, and extreme neglect. Pathological dissociation
generally results from being psychically overwhelmed by trauma. In a recent
study, Brand, Classen, Lanius et al. (2009) found that 86% of their sample
of patients with dissociative disorders reported having suffered childhood
sexual abuse and 79% reported physical abuse. However, the traumatic
experiences that may result in dissociative disorders do not always stem
from sexual, physical, or emotional abuse. Disorganized attachment which
often underlies the dissociative structure of dissociative disorders (discussed
xviiiâ•… Preface
more fully in Chapter 5) may result from overwhelming experiences in the

infant’s interpersonal environment that are not caused by parental mal-
treatment. Parental illness, depression, or problematic attachment styles
may be psychically overwhelming and lead to disorganized attachment.
In addition, medical trauma may be dissociogenic. For example, some dis-
sociative patients have reported histories of chronic medical problems and
hospitalizations that involved severe pain and unavoidable separations from
well-meaning parents. Medical trauma may involve both the chronic and
severe pain of certain diseases and conditions as well as painful procedures
intended to remediate these medical conditions. Some dissociative adult
patients have reported the trauma of being left alone to suffer their pain as
children in the hospital. Such children may be additionally confused by the
fact that their parents are either hurting them, as part of necessary medical
interventions or allowing others to hurt them (Na’ama Yehuda, personal
communication, 2010).
Despite the fact that child abuse is frighteningly common and that sto-
ries about the abduction and sadistic sexual torture of little children are
often in the news, the denial of child abuse remains rampant in our soci-
ety. Estimates of prevalence of contact (i.e., physical rather than verbal)
sexual abuse of girls below the age of 18 average at about 25%. One study
(Amodeo, Griffin, Fassler, Clay, & Ellis, 2006) placed the prevalence rate
of child sexual abuse at 27.9%. A Canadian study (Hébert, Tourigny, Cyr,
McDuff, & Joly, 2009) revealed a prevalence rate of 22.1% for women and
9.7% for men. Another large study, encompassing over 15,000 interviews
with young adults (Hussey, Chang, & Kotch, 2006), found that 28.4% of
the respondents reported experiencing physical assault from a parent or
adult caregiver, and 4.5% reported contact sexual abuse perpetrated by
a parent or adult caregiver before the beginning of the sixth grade. These
numbers are consistent with those of earlier reports on abuse prevalence.
A study of 900 women (Russell, 1986) found a rate of 38%, and Gartner
(1999) estimated a sexual abuse rate of approximately 17% for boys.
Attitudes about dissociative disorders seem to be highly connected to both
knowing and not knowing about child sexual abuse. Of course, perpetra-
tors want to remain hidden. And understandably, most of us would rather
avoid identifying with either the perpetrator or the victim. To acknowledge
that this kind of trauma could happen to us or to those we love can be
utterly terrifying. For many, denying the existence of such abuse reduces
the anxiety of dealing with the reality that it does exist.
DID is a prototype for the dissociative structure of the mind. I am in agree-
ment with Bromberg (1998, 2006) that this mental structure characterizes
us all. Taking into account the inevitability of trauma, especially relational
trauma, and the fact that dissociation is a common aspect of trauma, how
could it be otherwise? Many of today’s clinicians are increasingly apprecia-
tive of a multiple-self view of the personality and the dissociative structure
Prefaceâ•… xix
of the human mind. From this perspective, none of us is a singular unit,

but rather a highly organized aggregation of self-states that are internally
dissociated to varying degrees and in varying ways. In this way, work with
people with DID (“multiples”) may serve to inform us of new approaches
for providing “good psychotherapy” for people who are not multiples.
Acknowledgments
I am immensely grateful for the help and contributions to this book of

generous friends and colleagues. First of all, thanks to Cheryl Seaman, an
artist as well as specialist in DID, for her evocative and on-target book
cover illustration. Special thanks to Marg Hainer and Na’ama Yehuda,
who independently spent hours on hours reading over and making sug-
gestions for many of the chapters, including different versions of the same
chapters. I am grateful to Rich Chefetz and the Shielagh Shusta-Hochberg
for their generosity in carefully reading and fully and helpfully comment-
ing on several major chapters. Many thanks to Giovanni Liotti, who care-
fully read and commented on Chapter 5. Deep appreciation is given to John
O’Neil for his reading of Chapter 2 and his many astute observations and
to Kelly Forrest for her reading of and comments on the attachment chapter
and for her sharing with me access to her own work. I wish to give special
thanks to my daughter Alicia Murray, a psychiatrist, for her extremely
helpful—and last minute—reading of an earlier version of the chapter on
neuroscience. My gratitude is extended to Bethany Brand for her reading
and comments on the chapter on diagnostic assessment and access to her
work, to Karen Hopenwasser for her helpful reading and comments on the
section on dissociative attunements, to Sheldon Itzkowitz for his reading
of and suggestions about Chapter 10, and to Cleonie White for her help-
ful comments on the neuroscience chapter. (Of course, any mistakes are
mine.) Very importantly, I want to thank Philip Bromberg for the theoreti-
cal inspiration that he has continuously given. I also want to express my
appreciation to Richard Kluft for the pioneering work he has done in the
field of dissociative disorders giving to the mental health world conceptual
and technical tools for understanding and treating dissociative disorders.
I cannot say enough to thank my editor, Lewis Aron, for his astute read-
ing and suggestions for the book and his encouragement. He has a wonder-
ful eye for spotting what needs to be clarified, what is missing, and what
kinds of reorganizations might be helpful. I also want to express my appre-
ciation to Kristopher Spring, editor, and Marsha Hecht, project editor, for
their capable help and support.
xxi
xxiiâ•… Acknowledgments
Finally, I want to thank my fiancé, Patrick Flanagan, for the many, many
tireless, but really, tiring hours he spent copyediting and for helpful com-
ments about organization and style. I also thank him for making room in
his life in the last year for this book, along with me.
The generosity of all of these people is a wonderful gift.
Introduction
Despite the significant prevalence of dissociative disorders—rates rang-

ing from 12–38% for dissociative disorders in outpatients (Brand, Classen,
Lanius, et al., 2009), as high as 18% for dissociative disorders in the general
population (Sar, et al., 2006), and a prevalence rate of 1.1—3% for DID in
the general population (ISST-D Guidelines, in press), professional education
has not usually included training in the treatment of dissociative disorders.
Because of this paucity of training, clinicians are often at a loss regarding
how to recognize, diagnose, and work with their highly dissociative patients.
All too frequently, when clinicians do recognize that a patient has a serious
dissociative disorder, they fear that they will be unable to acquire the skills
necessary to treat dissociation and that they must refer their patient else-
where. A therapeutic relationship may thus be unnecessarily broken.
Working with highly dissociative patients, however, is not necessarily as
daunting as it might first seem. Although the conceptual language about the
organization of dissociated self-states and knowledge about working with
these dissociated self-states need to be learned, it is not difficult to do so.
This knowledge transcends theoretical orientation, adding to the clinician’s
understanding of the human mind. Once therapists have worked with their
first correctly diagnosed DID patient, the picture can become much clearer.
Prior to having the nature of their problems understood, highly dissociative
patients may simply seem to be extremely “difficult” patients, persons who
are full of contradictions, unexplainable extremes of emotions, and inclina-
tions to self-destruction. Yet, when it becomes apparent that the contradic-
tory statements, extreme emotional states, and self-destructive behaviors
are coming from different dissociated parts of the person, the overall pre-
sentation becomes less confusing and the prognosis far more hopeful.
A recent naturalistic study of the reports of 280 patients with dissocia-
tive disorders and their therapists indicates that the prognosis for people
with dissociative disorders—when treated by a clinician who is knowledge-
able about such treatment—is good. Patients in the later stages of treat-
ment engage in less self-injury and have fewer hospitalizations; they report
less distress and lower posttraumatic and dissociative symptoms; and their
1
2â•… Introduction
functioning is more adaptive overall than in those patients who are in initial
stages of treatment (Brand et al., 2009). Although clearly it is challenging,
work with highly dissociative patients is also some of the most reward-
ing psychotherapeutic work that one can do. Although treating DID does
require specialized knowledge, this knowledge becomes general knowledge
useful in understanding almost every patient a clinician sees—“the disso-
ciative mind” is increasingly understood to characterize us all.
DID Is Frequently Misdiagnosed

as Something Else
Because DID has erroneously been thought to be rare (because highly dis-
sociative people tend to present polysymptomatically and because the dis-
order is so often hidden), assessing and treating clinicians have often missed
the diagnosis. As a result, patients have often been given other diagnoses
that remain in their charts while the underlying highly dissociative struc-
ture of their personality continues to be missed. Research has showed that
people with DID spend from 5 to nearly 12 years in the mental health
system before receiving a correct diagnosis (as cited in ISST-D, in press).
People with DID have often been previously misdiagnosed as schizophrenic,
schizoaffective, bipolar, or borderline. Many never recover from the effects
of these misdiagnoses. What is worse, their real issue—DID—is less likely
to be addressed, with the result that they may never receive the treatment
they need. Instead, patients often have received inappropriate medications,
and they may have received unnecessary electroconvulsive shock therapy.
DID Is Often Hidden
Although it is not rare, DID is often hidden. In contrast to the flamboyant

and dramatic switches portrayed by Sally Field in the movie Sybil (Petrie,
1976), switches of identity states can often be subtle or even invisible to
an observer. Kluft (2009) observed that only about 6% of those with DID
exhibit obvious switching in an ongoing way. Another reason for DID to
have been thought to be rare is that, to the extent that they are aware of
their extreme dissociativity, many highly dissociative people work to hide
it. Often, they are afraid that they will be considered crazy and will be put
away if they are found out. Simply put, it is not socially adaptive to show
one’s fragmented personality. In addition, many with DID are not aware
of this fragmentation. All they know is that their lives are chaotic and hard
to manage: They may often be overwhelmed by intense affects like terror,
black despair, or fury that seem to come out of nowhere; they may lose
huge chunks of time and not know what they did or thought; they may be
Introductionâ•… 3
unaware of their behavior and therefore be unable to explain it to others;

they may find themselves in strange places with no explanation of how they
got there. Although as adults they look like grown-ups, when switched into
a child identity they often feel like and can appear like helpless children
(e.g., speaking in a childlike voice) and may be unable to negotiate impor-
tant interpersonal matters with others. Their fragmentation may not be
recognized until attentive emotional intimacy with another human being,
often a therapist, allows it to be known.
What Is DID?
The person with DID essentially lives with various simultaneously active
and subjectively autonomous strands of experience that are rigidly and pro-
foundly separated from each other in important ways, such as in mem-
ory, characteristic affects, behavior, self-image, body image, and thinking
styles. These different segments of experiencing have their own sense of
separate identity—their own sense of an “I”—including a sense of personal
autobiographical memory; they may have different names. Putnam (1989)
described these different identities as “highly discrete states of conscious-
ness organized around a prevailing affect, sense of self (including body
image), with a limited repertoire of behaviors and a set of state dependent
memories” (p. 103). This division of the self into different dissociated sub-
jectivities puts people with DID at a loss regarding how to understand or
explain their experience, and it often makes their lives difficult to manage.
The term dissociative identity disorder, currently used in the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American
Psychiatric Association [APA], 1994) and its text revision (DSM-IV-TR; APA,
2000), is an improvement over the previous term multiple personality disor-
der (MPD), which was used in the third edition (DSM-III; APA, 1980). MPD
was, as a term, misleading in its suggestion that there were literally separate
personalities, rather than interrelated though differentially dissociated parts
with separate subjectivities that are all facets of one person. The dissociative
parts are not separate persons—they are part of one person. Even though
individuals with DID may experience their dissociated identities as different
persons, even as having separate bodies, it is important that clinicians (while
understanding and empathizing with their patients’ subjective reality) not
reify a delusional sense of separateness but help the patient understand that
dissociated identities are all part of who they are.
The extent to which these separate strands of experience (involving a sense
of self-in-relationship, certain dominant affects, a sense of history, subjectiv-
ity, and relative sovereignty) are linked with or dissociated from other aspects
of mental life varies among patients. Different dissociative parts may or may
not have knowledge of the affects, behaviors, histories, motives, and thoughts
of other parts. How coconscious patients are also varies—that is, the extent
to which they have knowledge of and are privy to the thoughts, history, and
affairs of the other parts varies. Often, the part of the self that is in executive
control is unaware of the thoughts and activities of other parts (often called
one-way amnesia). However, this is a tricky topic to try to make clear. For
example, coconsciousness may be minimal before beginning psychotherapy
for DID but tends to increase considerably in the course of appropriate psy-
chotherapeutic work. Although parts other than the part who is most often
in executive control (often called the “host”) are more likely to know of each
other and of the host, this is not always the case and is not always the same
for different parts of the same patient. Some parts may be unknown by many
of the others. The dissociative structure of each patient is different.
Switching
The phenomenon generally considered most characteristic of DID is switch-

ing: Different internal identities can be prone to suddenly taking executive
charge, in effect pushing the identity that had previously been in charge, out
of charge. This generally results in amnesia on the part of the identity that
had been pushed aside for the events that occurred while the other identity
was in control. Switching is also known as full dissociation (Dell, 2009c).
Clearly, switching is a problem when people do not remember portions of
their activities and thoughts. To compensate for this lack of memory, peo-
ple with DID will often try to fill in the blanks with something they think
makes sense given the context, especially in social situations. However,
because their compensatory version of events may not match what did
happen, and because their behavior may have been different in different
identity states, persons with DID may be accused of lying and may indeed
come to feel that they are liars. Amnesia can be even worse when people do
not know they have amnesia—or that they have dissociated identities—for
them, life is and feels even more chaotic.
The current diagnosis in DSM-IV-TR (APA, 2000) places the primary
emphasis on the phenomenon of switching and provides the following diag-
nostic criteria for dissociative identity disorder (300.14):
A. The presence of two or more distinct identities or personality
states (each with its own relatively enduring pattern of perceiv-
ing, relating to, and thinking about the environment and self).
B. At least two of these identities or personality states recurrently
take control of the person’s behavior.
C. Inability to recall important personal information that is too
extensive to be explained by ordinary forgetfulness.
D. The disturbance is not due to the direct physiological effects of

a substance (e.g., blackouts or chaotic behavior during Alcohol
Intoxication) or a general medical condition (e.g., complex partial
seizures). Note: In children, the symptoms are not attributable to
imaginary playmates or other fantasy play. (p. 529)1
There Is Not Only Full Dissociation

but Also Partial Dissociation
Full dissociation (i.e., switching) is not the only problem in DID. Switching,
when an identity state has disappeared from consciousness and another
has taken its place, can indeed be quite a problem. However, there is a
larger set of problems that has to do with the influence of dissociative parts
who are “beneath the surface” on the part that is in executive control at a
given time. Such partial dissociation (Dell, 2006b, 2009a, 2009c, 2009d)
includes the following phenomena: intrusive visual images; auditory experi-
ences (including hearing voices in the head); olfactory experiences; somatic
experiences; unbidden, unsettling, and unexplainable thoughts and emo-
tions; experiences of “made” volitional acts, impulses, and thoughts; and
the withdrawal of perceptions, thoughts, and emotions.
In cases of made volitional acts, parts of the body—a hand, an arm, or
a leg—may not be in the person’s control and can seem to have a life of its
own. For example, a person may feel that her hand, not herself, performed
a certain motion. In addition to experiences being intruded into conscious-
ness, aspects of experiences may also be withdrawn: Vision, hearing, bodily
sensations, emotions, and thoughts may be “taken away” either in part or
in whole from the person’s experience (or from the experience of the iden-
tity that is in executive control). Withdrawn experiences may include “hys-
terical” symptoms such as functional blindness or can manifest as partial
blindness for certain things, as in negative hallucinations (something or
someone who is there is not perceived). For example, one of my patients
reports that when she goes into the grocery store, she does not see any other
people. (Seeing the other people would make her overwhelmingly anxious.)
Such intrusions and withdrawals, especially when constant, can have the
potential to make a person’s life chaotic indeed. There are occasions when
intrusions or withdrawals may be visible or known to others—as in the
case of a paralysis or a reported hallucination—but for the most part these
experiences remain unknown and contribute to private turmoil or agony
(Dell & O’Neil, 2009).
This last aspect of DID—partial dissociation—has often been misunder-
stood as schizophrenia. Dell (2001, 2002, 2006b), Kluft (1987a), Putnam
(1997), and Ross (1989) have outlined the ways in which dissociative dis-
turbances have often been misunderstood as indications of psychosis or
schizophrenia. Kluft reported that patients with DID endorse 8 of the 11

first-rank Schneiderian symptoms (Schneider, 1959, as cited in Kluft, 1987a)
that are considered pathognomonic of schizophrenia. These symptoms are
voices arguing, voices commenting on one’s action, influences playing on
the body, thought withdrawal, thought insertion, made impulses, made
feelings, and made volitional acts. In DID, rather than as indications of
schizophrenia, the hallucinated voices and the made actions are under-
stood as due to the activities of a dissociative identity. The psychotic person
is more likely to attach a delusional explanation, such as “The CIA has
implanted a chip in my brain.” In contrast, the person with DID, although
probably unaware of the source, often knows that these experiences are
not normal and does not seek to explain them in a delusional way (Dell,
2009c). In addition, the person with DID—as opposed to someone who is
psychotic—often has the ability to be in two states of mind at once: While
the person experiences the self as having the “crazy” thought, the person
is able to hold the tension and know that it is just that, a crazy thought.
Of course, this knowledge that one is having thoughts that others would
consider crazy only tends to contribute to the highly dissociative person’s
fear or belief that he or she is crazy!
DID Is Confusing to Everyone
The phenomena of full and partial dissociation are highly confusing to the
person with DID as well as to those who notice them. Unlike someone who
suffers primarily from depression or anxiety and who can label the problem,
the person with DID generally suffers from amnesia about the very symp-
toms experienced and often cannot specifically identify the problem. For
the person with DID, the sense of self, of continuity of being, of identity, is
highly discontinuous. As noted in DSM-IV-TR (APA, 2000), “the essential
feature of the Dissociative Disorders is a disruption in the usually integrated
functions of consciousness, memory, identity, or perception” (p. 519).
This emphasis on disturbance in identity is an important one. Because
there is more than one identity, our linguistic descriptions often imply,
but do not state, differences in the perspectives of the different identities.
Understanding DID can be complicated, and it is hard to escape the con-
siderable awkwardness that ensues when we try to speak and write of such
things as consciousness, disruptions of consciousness, intrusions into con-
sciousness, even amnesia. Especially as when we speak this way, we are
often speaking from the perspective with which we, as “singletons,” think.
For instance, consider the amnesia requirement of Criterion C: “Inability to
recall important personal information that is too extensive to be explained
by ordinary forgetfulness” (APA, 2000, p. 529). One might ask, “Who
(which part) fails to recall?” “Whose consciousness?” or “Whose thinking
has been disrupted?” These questions are especially relevant when the host,
the part of the self that usually presents to the world, is a collection of sev-
eral parts who pinch hit for each other or when the host is primarily a shell
who faces the world while other parts “fill in” as needed. From the perspec-
tive of dissociative parts who want to be in executive control but who are
not currently “out,” their bids for time to be in control of the body or for
attention are not intrusions. However, the part that is in executive control
most of the time may experience these bids as intrusions and disruptions,
and an observer may classify them as such. The perspective one takes—
part or whole, looking out or looking in—makes all the difference.
Multiple Self-States and

Dissociated Identity States
When we speak of partial dissociation as an important aspect of DID, it

is important to note that partial dissociation is not specific to DID or even
to dissociative disorders. It also characterizes posttraumatic stress disor-
der (PTSD): The flashbacks and intrusions so characteristic of PTSD are
examples of partial dissociation. In addition, partial dissociation can be an
aspect of everyday life for most people. The self of all of us is not a unity
but consists of multiple self-states that emerge and alternate in accordance
with which self-state is in the forefront of consciousness at a given time.
Current research in neurobiology, cognitive psychology, and developmental
psychology indicates that the brain, the mind, and the self are normally
multiple (Dennett, 1991; Erdelyi, 1994; Gazzaniga, 1985; Kirmayer, 1994;
Siegel, 1999). Neurobiologists increasingly understand the brain as orga-
nized into neural systems that to some degree function independently of
one another (LeDoux, 2002). Such parallel and multitrack processing help
to explain dissociative phenomena on a neurological level. Furthermore, as
Siegel (1999) maintained, “the idea of a unitary, continuous ‘self’ is actu-
ally an illusion our minds attempt to create.â•ƒ.â•ƒ.â•ƒ.â•ƒWe have multiple and varied
‘selves,’ which are needed to carry out the many and diverse activities of
our lives” (p. 231).
Yes, we all have multiple self-states. For all of us, our mental life is char-
acterized by constant changes in self-state to match the current context.
Much of the time, most of us are aware (although less often than we think)
of the matches of self-state to context, and we remember both (or we think
we do). For example, we may wear a “therapist hat” while in the office, have
a caregiving orientation when in contact with our children, and respond in
a different way, involving early attachment system internal working mod-
els, when speaking to our parents. What is important for psychological
health is the degree of dissociation between self-states or, to put it more
positively, the degree to which we experience our multiple self-states as
contextually interrelated and part of what comprises the sum of who we

are. Or, as Philip Bromberg (1998) has put it, health is the ability to “stand
in the spaces between realities without losing any of them” (p. 186).
Contextualization
As humans, we adapt to the varying contexts of our lives. However, we

may not always be aware of the extent to which our lives are bound by con-
text. For example, when I go to my gym, I have to recite a certain eight-digit
number to get in. When I stand in front of the admission desk, I remember
this number, but only then. If someone were to ask me my number anywhere
else in the building or outside of it, I would not be able to recite it. This is a
mild version of what DID is like. My point is not that I have a “gym self,”
but that my memory for how to get in to the gym has to be triggered. Away
from the front desk, I have no conscious memory of that number. Although
this may mean that my gym self is in great need of support and integration
with the rest of me, the point here is that there is a piece of memory that has
to do with my internal world that is not usually available to me. To access
it, I have to deliberately and physically trigger it.
Although this is not representative of a dissociative disorder (a dissocia-
tive experience alone does not constitute a dissociative disorder), I am called
to access a memory that is related to only a specific context. A person with
DID has more and larger modules of self-contained experiences that are
not easily accessible to consciousness, but the basic organization of context
dependency is the same. In infancy, behavior is organized as a set of discrete
behavioral states, such as states of sleep and waking, eating, elimination,
and so on. These behavioral states become linked over time and grouped
together in sequences (Putnam, 1997). Psychological trauma impedes this
linkage; as a result, individuals who have been severely neglected or highly
traumatized in childhood have not had the interpersonal attention, sup-
port, and encouragement necessary to interconnect their self-states and the
varying contexts of their lives.
Therapist Training for DID
Therapists who work with dissociative patients should have solid skills
and knowledge in general psychotherapy, such as in assessment, bound-
ary management, ethics, transference and countertransference, general
therapeutic skill, as well as concern and empathy. Although working with
highly dissociative people does require solid therapeutic skills, a specialized
understanding of the highly dissociative mind is also necessary. Specific
theoretical and technical approaches may vary, but those that result in
facilitating psychic health derive from an understanding of the psychic

structure underlying DID.
The first step needs to be arriving at a correct diagnosis. It is impor-
tant to remember that DID is a problem of hiddenness. Therapists treating
patients with DID should be aware of the signs of switching from one iden-
tity state to another as well as the signs of intrusions or partial dissocia-
tion. Untrained clinicians may be unaware of the switching in the session
and assume that they are meeting with only one identity state throughout.
This deprives them of important information. For instance, if the patient
cannot remember or make sense of what was said in the session, this may
well not be due to resistance or anxiety as we might normally understand
them but could be due to dissociation. When it is understood that different
dissociative identities not privy to the experience of other identities may
have been present, the behavior of the patient makes more sense. As clini-
cians, we strive to be alert to when the patient’s experience has radically
changed either through a switch or through partial dissociation. Working
with highly dissociative people requires familiarity with trauma treatment
as well as the ability to deal with traumatic transferences and to tolerate
strong emotional pressures in the consulting room.
The ISST-D has a training program for clinicians for work with dissocia-
tive disorders. Training information may be found at http://www.isst-d.org
under Training and Conferences.
Organization of This Book
In the chapters that follow, I explain the nature of dissociation and dis-
sociative disorders and how I work psychotherapeutically with people who
are highly dissociative. I use examples from my practice liberally to illus-
trate various principles.
Chapter 1 introduces three of my patients who have generously given
me permission to use descriptions of their lives and their psychotherapy in
an ongoing way in this book. Their stories serve as anchoring points for
understanding what the experience of having DID is like and for under-
standing ways to work with DID psychotherapeutically.
Chapter 2 explores the topic of the dynamic unconscious and the disso-
ciative structure of mind. The interrelationships of dissociation, relational-
ity, and multiplicity are examined, and finally the historical context of the
waxing and waning of recognition of dissociative processes and dissocia-
tive problems is explicated.
Chapter 3 examines the organization of the personality system in DID,
the “We of Me.” This includes the most commonly active dissociative identi-
ties and how they are organized in relationship to each other, trance logic,
the closed system, and the third reality as described by Kluft (2000). It also
explains different conceptual schemes for understanding the organization of

dissociated parts of the self.
Chapter 4 describes how DID is a trauma disorder. It also explains why
trauma is best defined as “that which causes dissociation.” It explains the
meaning of complex trauma, relational trauma, and the proposed working
diagnosis, disorders of extreme stress not otherwise specified (DESNOS).
Chapter 5 covers the development of DID as understood both through
the trauma model and in terms of disorganized attachment. The self does
not begin as a unity. Consequently, the dissociative fragmented self is not
so much a “shattered self” as one in which early attachment dilemmas dic-
tated disorganized attachment while the early interpersonal environment
did not facilitate integration.
Chapter 6 covers some neurobiological correlates of the structure and
psychodynamics of dissociated self-states.
Chapter 7 addresses understanding the organization of dissociated self-
states under the rubric of the Karpman triangle of victim, persecutor, and
rescuer. It also covers the creativity of creating self-states and the impor-
tance of contextualization within the self in healing.
Chapter 8 covers assessment and diagnosis. It addresses the importance
of assessing both switching and intrusions in DID. Face-to-face interviews
as well as screening and assessment instruments are discussed.
Chapter 9 deals with a frequently covered topic in trauma treatment:
phase-oriented treatment. Important topics are avoiding retraumatiztion,
stabilization, grounding, and so on, as part of Phase 1. It also covers what
I call “the central conflict,” which concerns the tendencies of some dissoci-
ated parts to want to tell about the traumas while other parts do not want
to be bothered with their feelings and are afraid of being destabilized. This
chapter also covers the topic of abreaction, which is viewed as an interper-
sonal and integrative activity.
Chapter 10 covers facilitating coconsciousness and coparticipation in the
treatment. Many different kinds of problems and solutions, with illustra-
tions from my practice, are presented.
Chapter 11 deals with working with persecutory alters and understand-
ing how they have come into being. This chapter includes an extensive
case vignette.
Chapter 12 includes multiple dimensions of coconstruction in the therapeu-
tic relationship, including multiple transferences and countertransferences,
traumatic and erotic transferences, and issues of boundary management that
stem from disorganized attachment. It also includes the topics of projective
identification and dissociative attunements.
Chapter 13 covers dreams in DID and in trauma, including how they
are both very different from and also similar to more ordinary dreams.
Some of the important differences are spelled out, including how the same
dream may be dreamt from different perspectives by different dissociative
identities. It includes two vignettes about the use of dreams in therapy with
DID patients.
Chapter 14 discusses the topic of suicidality, which is a significant risk
for those with DID. The complicated meaning of suicidality is covered,
including the many ways that what looks suicidal from the outside may be
construed by parts of the system. For example, some parts may be homi-
cidal toward other parts, engaging in activity that from the outside looks
suicidal. Although this is delusional because the physical death of the body
includes all parts and the behavior is not intended to be suicidal to the part
that is out, the danger of lethality is just as high.
Chapter 15 covers the dissociative structure of the mind across diagno-
ses, including the topic of comorbidity. I examine a case of “psychosis” that
was in fact about somatoform and dissociatively held memories. The psy-
chosis was resolved when the dissociated material was pulled together in
a story. I also examine the particular way in which I think that borderline
personality disorder is dissociation based. Finally, I suggest that the univer-
sality of some archaic superego problems stems from dissociation and cuts
across diagnostic levels.
In this book there are many excerpts from sessions that are intended to
illustrate various principles. Obviously, I have my own particular style in
the way I work and interact, just as everyone has their own style; so these
excerpts are not meant to be prescriptive. Everyone working with DID will
develop their own style.
Secondly, for the reader unfamiliar with DID, the switching, the various
cast of characters who come forth in one body, and the trance logic may
seem strange, perhaps even too strange to initially take in. Trance logic
could be described as a waking dream logic, in which the ordinary rules
of logic do not apply. To some degree, we all operate with trance logic—
and to say so is not pejorative. We accept and value trance logic in art and
some religious ceremonies. Or, for example, a person in mourning may
expect the dead person to enter the room. In the personifications of the
inner world of DID, thinking is more concrete, contributing to the trance
logic. Instead of “I feel so sad I can hardly stand it,” The Sad One appears,
newly in central command of the body.
Despite this patina of strangeness, when you think about the psychic
system and its psychodynamics, this basic structure of multiple self-states is
universal, although its elaboration varies with the person. Perhaps it is like
talking about quarks when the prevailing theory is atoms: The intricacy
of the structure that characterizes us all is simply more manifest in DID.
Once you accept this proposition—not so difficult when it is before you, the
experience is comprehensible and compelling.
Note
1. The proposed fifth edition of the DSM (DSM5), slated for publication in 2013,
modifies these criteria for DID.
Part 1
Understanding Dissociative
Identity Disorder
Chapter 1
The Lives and Psychotherapy

of Three People With DID
Introduction
I have enormous respect and admiration for the courage, endurance, and
capacity to love that these individuals with dissociative identity disorder
(DID) have, and I am grateful to them for their consent for me to use inci-
dents from their lives as they reported them to me and from their treatment
to illustrate what it is like for a person to have DID and what it is like for a
therapist to work with a person who has DID. Although identifying infor-
mation has been changed, these are not composites. Before I begin to tell
of their stories, I want to remind the reader that life can be stranger than
fiction. These are horrifying stories. I refer to work with three patients
(Janice, Dennis, and Margaret) at various points throughout this book.
The work with them is not the only discussion of case examples, but these
individuals offer anchoring cases.
Janice
Janice is a 43-year-old woman, recently remarried, who has two teenage

daughters. Although an accomplished painter, she is just beginning to show
her work. An extremely caring person who is kind and sensitive to the feel-
ings of others, she generally presents as upbeat, cheerful, optimistic, and
highly energetic. Yet, there have been many times when she has privately
experienced overwhelming depression and suicidality. Especially as a child,
Janice got through life by pleasing others. She developed a pleasing face
and a funny face, among others—faces that hid her immense grief. Luckily,
she is extremely intelligent, and this helped her to figure out and adaptively
adjust to many unbearably difficult situations as she was growing up.
Janice came into treatment with me almost 4 years ago to work on her
newly discovered DID. She has been in therapy with a number of different
therapists for most of her adult life, but her DID was never diagnosed until
a recent 2-month hospitalization in a trauma program. During this time,
15
16â•… Understanding and Treating Dissociative Identity Disorderï»¿
she did much work on herself. She did time lines of her history, drawings,
and some of her alters were identified. In our early work, her awareness
that she has DID emerged gradually, like an increasingly flickering light-
bulb that finally comes on. This began with an examination of her need to
rescue stray, needy, damaged people, people who could in fact sometimes
be dangerous. When the rescuer part was contacted, a very sad child of
about 6 emerged who described the most recent rescue operation in detail,
as well as others. She finally admitted with great sadness and pain that she
rescued others because she could not rescue Janice. The enormous sad-
ness of this part was partially communicated to Janice. She was amazed
to know about this part of herself and to know the sadness of this part.
Following this session, other parts emerged, each time with Janice experi-
encing some of their sadness, an experience often upsetting and sometimes
overwhelming to her. As a result, this initial work with parts was care-
fully titrated. She recently reported that she realized that she had always
thought of herself as The “We” of Me, but that she had never before now
put together its meaning.
All Janice remembers about the development of her multiplicity is that by
the time she was in middle childhood, she would privately refer to herself as
The We of Me. Janice’s “we” is a polyfragmented multiple. She has at least
a hundred parts, many of them for particular purposes or roles, existing in
many clusters and layers, parts behind other parts. Most of the parts do not
have names, although I recognize many of them by their behavior. There is
a little 4-year-old who speaks with a lisp and with a 4-year-old’s language
structure. There are many young children who go by “Janey,” some adoles-
cent ones, and several adult ones. Of those who have specific names, there
is Tomboy, who is a cheerful, enthusiastic, happy tomboy companion to
her father. There is The Little Girl in the Torn Dirty Slip, who was sexually
abused and has always felt tortured and ashamed. There is The Mother,
who takes care of her children when Janice, as the host, is too exhausted.
There is The Driver, who takes care of safe driving when other parts have
become too upset. There is The One Who Knows How to Get Things Done.
There is The Sexy One. Then, there are many prison guards and gatekeepers
who have functioned to keep parts with overwhelmingly scary, shameful,
angry, and painful memories and feelings locked up, and there is a hierarchy
among these guards and gatekeepers. There is the seemingly suicidal, but
actually internally homicidal, Ereshkigal, who wants to kill the host, Janice.
Then, there are The Suicides, who become activated when things begin to
feel hopeless. They have provided hope to the system with their prospective
solution of ending pain by ending life. However, in our work together, they
have continued to expand the realm of their subjectivity to include connec-
tions with other parts. They have also gained awareness that as an adult
Janice has much more power than she did as a child, that in current reality,
pain is not forever, and that if she did murder herself, her children would
The Lives and Psychotherapy of Three People With DIDâ•… 17
suffer immeasurably. (See Chapter 14 for more discussion of suicidality.)

Then, there are many other parts who come and go. In response to my ask-
ing their identity, they often say, “Oh, I’m just one of them.”
Janice is a middle child in a family of four, with two older brothers and
a younger sister. She grew up as a kind of real-life Cinderella, but without
the unqualified happy ending. From her infancy until she was about 5, she
was sickly: As a baby and young child, she could not hold food down and
frequently had a fever, facts of life that made her mother angry. If Janice
had a temperature in the morning before kindergarten and first grade, the
school would not take her. Janice described how this infuriated her mother
because it interfered with her daily bridge game. When it was finally discov-
ered that she was allergic to milk, Janice began to thrive physically.
Janice remembers that she was frequently punished, but she rarely under-
stood the reasons for her punishments. Her mother often spanked her with
a hairbrush on many parts of her body, including her chest and back, arms,
and hands as well as her butt. When Janice tried to defend herself by put-
ting her hands in front of her chest or behind her back, her mother would
strike her hands with the brush.
Janice’s mother did not intervene when her father heaped strange and
sometimes violent punishments on her. Although he also spanked her with
a belt, his most notable punishment was his placing her in a certain chair,
where she would have to sit and listen to him excoriate her verbally for what
he saw as her misdeeds and inadequacies. There were many times when she
was forced to sit in this chair for hours while he stood over her telling her
what a terrible person she was. In particular, he would demand that she
repeat after him that she was “a liar, a thief, and a cheater.” Janice knows
the phrase by heart by virtue of being forced to repeat it so many times.
Despite this maltreatment, Janice also found ways to please her father. This
included singing songs to him while still a child, such as “I’m a little teapot,
short and stout; sock to me baby, let it all hang out.” She recalled that her
father and his friends thought it was hilarious.
Janice soon learned to keep her mouth shut and put on a happy face. She
developed the art of servicing the different members of her family in dif-
ferent ways. For her father, she was hostess and maid for his many cocktail
parties. She also developed an alter, Tomboy, who was her father’s sidekick
in his hunting expeditions with his cronies. Tomboy knew just when to
get down when the rifles would go off. Unlike other children and her sib-
lings, Janice had to be home from school by 4 p.m. to attend to household
chores. Janice brought tea to her mother on a tray every day when she came
home from school. She also massaged her mother’s back often because her
mother was frequently bedridden with what she described as back pain.
By the time she was a young adolescent, Janice cooked many family meals.
She poignantly remembers baking her father’s birthday cake when she was
about 10 years old—only to have him become furious with her because the
candles on the cake had melted by the time she was able to carry the cake
to him. She made a birthday party for her sister, also only to be rebuffed.
On her mother’s instruction, she sewed her sister’s wedding dress and two
bridesmaid’s gowns. In contrast to the way she treated Janice’s siblings,
whom she showered with expensive clothing, Janice’s mother refused to
buy all but the bare necessities for Janice. (It should be borne in mind that
Janice’s desperate need to please—as well as her ability to do so—might
have contributed to the way that her family came to rely on her.)
Considering that Janice’s parents seem to have had a great need to control
her and to keep her at home, it seems strange that she seemed as a young
child to be wandering around a great deal on her own, with no one notic-
ing. When Janice was about 5, some friends of one of her brothers enticed
her into the basement of an abandoned house. This was her “torture room.”
They would force her to lie down. Then, they would fill her vagina with
muddy sand. Next, they would place a board on her and walk on her pelvis.
They told her that they would kill her if she told, and she never did. Her
mother never seemed to be curious about her frequent urinary tract infec-
tions. Even today, since she has remembered these times, she has tortured
herself with wondering why she went back, and the complete answer to this
is still not clear. Most likely, she was terrified to refuse, and possibly, even
though it was bad attention, it was some attention. In addition, her body
was aroused—just as are the bodies of children who voluntarily engage in
sex play. Because of the terror and shame, these awful experiences were dis-
sociated as The Little Girl in the Torn Dirty Slip until recently. There was
so much shame about these instances that The Little Girl in the Torn Dirty
Slip was isolated, “locked up,” by other parts, who believed that she was
dirty and bad and should not be allowed to come out. Gradually, in therapy
this part found the courage (and was allowed out by the rest of the system)
to come out and to talk about these harrowing times, including the physical
pain, terror, and shame. It is because she came out to talk to me that this
paragraph could be written in a coherent narrative sequence. Before that, it
was a bad feeling that would come over her, but it was also what she called
a “butterfly” memory. She would at times have a fleeting memory of this
or other harrowing times, but then it would disappear, and all she would
remember is the image of a butterfly.
As a child, she would often wander into the woods for long periods of
time, often taking off her clothes, and dancing around, pretending that she
was a fairy. On one occasion, two wild boars came by. She quickly climbed
a tree and was completely still and quiet in utter terror for a long time. As
soon as they left, she ran home. She told no one because she did not want
anyone to know that she had been out, and she did not want the privilege
taken away from her. In her later, early adult years, she often traveled in
third-world countries, alone, in third-class transport and not wearing a
bra. Now, in the present, she remembers the driver looking at her breasts
and realizes that she could have been raped, killed, and disappeared. She
has had many close calls in her life and has, indeed, cheated death many
times. For example, she was attacked by a widely feared and dangerous
rapist and was raped and nearly murdered in her apartment.
Janice’s parents did not want to be disturbed after Janice’s bedtime.
Because she was so terrified of her parents and of disturbing them, and
because she symbolized them as monsters at the doorway of her bedroom
who would kill her if she exited, she was afraid to get up from bed and go
to the bathroom at night. As a result, she often wet the bed. This contin-
ued until she was 8 years old. Her mother’s solution to this was to refuse
to wash the sheets, to make Janice sleep in them, and when she did have
them washed, to hang them out in the yard for everyone to see and to
know that Janice had again wet the bed. Furthering this humiliation, her
brothers would then ride their bikes through the neighborhood, informing
the neighbors that Janice had wet the bed. Needless to say, Janice’s sister
followed suit and treated her in the same humiliating manner as did her
parents.
Despite continuous, flagrant, serious maltreatment, Janice focused her
life on pleasing her mother, and this most likely did establish the kind of
inverted caretaking bond that her mother apparently needed as well as pal-
liate her mother’s ire at her. She became a little soldier (or many such)
with respect to herself, containing her pain, fury, terror, and longings. Not
surprisingly, Janice attempted to hang herself with her mother’s stockings
when she was 8 years old.
Odd attitudes about sexuality were enacted by both of her parents and
an uncle and aunt toward the child, Janice. When she was 12, Janice had
sewed her own Easter dress, but before she could wear it to church, she
remembers that her mother suddenly flew into a rage and ripped out the
hem, insisting that Janice had made it an inch shorter than what she thought
she had marked. Her father often told her, but not her sister, that girls and
women could only be wives, secretaries, or prostitutes. However, neither
she nor any of her parts have reported physical incest with her father.
By the time Janice was a preadolescent and an adolescent, she began to
spend summer months and many weekends with some friends of her parents,
whom she addressed as uncle and aunt. The “uncle” was, in fact, her father’s
boss. Until she was in the postpartum period of the birth of her first child,
she had always remembered these times as idyllic. These people were kind to
her, did things with her, and showered positive attention on her. In contrast
to how she was treated at home, they thought well of her and praised her.
They did not demand that she perform such chores as cooking and sewing.
She idealized them and thought of them as her saviors.
While she was recuperating from the birth of her first child, she was
plunged into severe depression by the onset of a different sort of memo-
ries of the time she spent with the uncle and aunt. She became largely
unable to function or to paint for about 13 years. She remembered that the
uncle would come into her room at night and fondle her. In addition, to
“Uncle’s” nightly fondlings, she remembered sudden gushings of vaginal
blood that alarmed no one. Both the uncle and his wife stated to Janice
that she should support herself through college by prostitution, with no
embarrassment or reflection on what they were saying. The uncle planned
to continue his sexual exploitation of her beyond her childhood by sug-
gesting to her that she should support herself through college by going to
the environs of the Alaska pipeline and setting up shop as a prostitute. He
told her that he would help her get set up in this work, and that he would
visit her. At the time, it did not occur to her that this might be objection-
able. It was not until her mid-20s that Janice began to feel weird about
having sex with him and stopped it. She did not formulate the experience:
She did not think about or remember any precursors to this behavior. It
was just something she did.
In the home of her nuclear family, there also were strange issues with sex-
uality and control in which it seemed that Janice was the recipient of much
projection about sexuality. She was also frequently “locked up,” confined
to her room for long periods of time or to the home for months at a time in
the summer, as if she were promiscuous, which she was not.
About a year ago, Janice received some elucidating information: The situ-
ation of her birth was highly unusual. Janice’s mother was having an affair
about 9 to 12 months before her birth and mistakenly believed that Janice
was the biological offspring of the man with whom she had been consort-
ing. When Janice was a baby, her mother told her father of the affair. It is
only recently that Janice recovered this memory from her mother, on a spe-
cial trip that she had arranged both to comfort and to become closer to her
mother. This information was the explanatory key that had been missing
from so much of her story of brutal sadistic abuse and extreme exploitation
on the part of her parents and her “uncle.” Since her sister and brothers had
not been treated as she was, it was always curious to her (and to me) why
she had been singled out for such treatment. The pattern of triangulation
(in Murray Bowen’s terms; both parents made her a scapegoat to protect
the harmony of their own relationship) had always been apparent, but there
had been no obvious explanation regarding why. For instance, while her
siblings were sent to college by her parents, Janice put herself through col-
lege. The implication that she was a “whore” that was attributed to her in
late childhood and adolescence becomes her parents’ projection regarding
her mother’s extra-marital affair. Following her mother’s revelation, Janice
requested genetic testing. This testing revealed that her father was indeed
her biological father.
Dennis
Dennis, who has DID, is a personable, extremely intelligent, 32-year-old

man. He works in finance and owns a motorcycle repair shop on the side.
Clearly, he is a man of many talents. Yet, he suffers an inner chaos and
immense psychic pain. He finds some surcease from his suffering in focused
work and in the joy of being in the presence of true friends. He came into
treatment with me after finding my earlier publications on the Internet. At
that time, he stated that he was aware that he had some dissociative prob-
lems and was interested in dissociation but did not “believe in” DID. We
have been working together for about 3 years, but not continuously, as he
has had to take some breaks for financial reasons. Much of this work has
been painful for him as some horrifying memories have come back to him
in the process.
Dennis endures painful conflicts around his right and ability to make a
living, his right to have enough food to eat, and life versus death. He has
experienced a horrifying history. Over the time of our work together, a
number of his parts have shared their thoughts and feelings and let me into
their worlds. Since then, he has regained some important memories, and his
parts have become more collaborative with each other; as a result, his life
has made more sense to him and is somewhat less difficult.
Dennis is the only child of two artists, a father who was chronically and
dangerously drug addicted, often on crack and speed, and a mother des-
perately trying to cope with the situation as well as with personal troubles
and extremely physically debilitating rheumatoid arthritis. Unfortunately,
there was no one available in an extended family willing and able to help.
Dennis reports that when he was a baby his mother often had to leave the
apartment and spend nights walking around to escape his father’s violence
(and he does have an iconic memory of being in a carriage outside in the
snow, looking up at his mother). When he was 3, he was placed in day care
in someone’s home so that his mother could work. Unfortunately, the sons
of the woman who ran the day care center forced him and some of the other
children to perform fellatio on them in the bathroom. He was unable to tell
his mother because even at 3 years of age, he felt too alone and afraid of
upsetting her fragile equilibrium.
When he was young, Dennis began to see images of a beautiful young
girl with long dark hair, an alter named Sophia. He felt that she was nur-
turing to him, and he took great comfort in her presence. At first, he experi-
enced her as literally outside himself. Somewhat later, he interpreted her as
a poltergeist. Then, she became an imaginary companion. Later, she went
back inside (in his subjective experience), where she grew up alongside him.
When he was young, she was almost always a source of solace. When he
became an adult, some competition for ownership and control of the body
began to emerge.
As the abuse, violence, and terror in his household continued, his mother
was eventually able to escape with her son to another state, where she
thought her dangerous husband would be unable to find them. They lived
in relative peace for a few years until the father did find them, when Dennis
was 7 years old. When Dennis’s mother discovered that his father knew their
whereabouts, she was certain that she and her son were in grave danger,
and that the father may be intending to kill her and perhaps both of them.
The father did appear and stated that he wished to take Dennis away with
him to California. Dennis’s mother knew not only that if she refused him
things could get dangerous but also that Dennis’s life would be in jeopardy
if he went with his father. Dennis, consciously knowing little of the father
whom he had not seen for so many years, on hearing that the father was
nearby, wished that he could go with his father. After the mother refused
his father’s request to take Dennis away with him, the father came by the
next day, “out of his mind” high on speed and with a gun. The mother, who
had prepared herself for this eventuality, had put Dennis to bed and told
him not to come out of his bedroom. A friend had given her a gun, and she
shot Dennis’s father on the stairs as he was coming to kill her. Despite hav-
ing been put to bed, Dennis did leave his room and witness the event. He
has only recently become aware that he saw the shooting, having previously
only remembered loud sounds from that night. Throughout his childhood
and adolescence he had frequent episodes of unexplained hysterical blind-
ness, probably related to his amnesia for witnessing this event.
Following the shooting, Dennis disappeared into the woods for 3 days,
hiding in trees, at times motionless. When he emerged, he was both more
divided and much more psychologically distressed as well as internally
oppressed. Dennis has never recovered from this tragedy. Even though he
was a child, this tragedy was an adult-onset trauma (in which the self col-
lapses as well as divides) for him. This adult onset-type trauma is partly
about the intimate knowledge of death (Boulanger, 2007). A common
problem of those who have confronted or barely escaped their own death
or have been suddenly confronted with horrors of the death or murder of
someone close to them is the belief that they are dead. This amounts to a
strong, dark shadow of death in life cast continuously over existence. It
creates a posttraumatic reduction of thinking to psychic equivalency (in
which one’s thoughts are the exact equivalents of external events) such that
the capacity to think about one’s feelings and thoughts is vastly diminished
or even wiped out. Since subjectivity has collapsed, so has intersubjectivity.
In this sense, the self actually has died for the symbolic universe on which
selfhood depends has been destroyed. Even today, Dennis frequently has
zombie dreams.
Thereafter, Dennis suffered from both adult-onset trauma and the child-
hood-onset trauma that result in the dissociative divisions of selfhood. As
a young child, he had extremely high blood pressure and was often ill. The
doctors could not figure out what was wrong with him.
Following her husband’s death, Dennis’s mother moved the two of them
to another state. As a single mother seriously physically disabled because of
rheumatoid arthritis, she was not always able to find work, and they were
extremely poor. She had raised him alone, emotionally and financially.
Neither her family nor her deceased husband’s family had been available to
help. When he was a child, his mother had been almost his only emotional
contact. She loved him, cared for him, and did the best she could in mother-
ing him, but she was limited psychologically as well as physically. Her own
work skills were limited by her physical disability, and there were many
times that the two of them were completely without food. At these times, it
would be up to Dennis to find ways to obtain food by raiding the homes of
people nearby who were away. He would also siphon the gas from others’
cars when they were away, even sometimes when they were not. He felt ter-
rible about doing these things, but they were simply necessary. To illustrate
the severity of the deprivation that he and his mother experienced, when
his mother was able to acquire and keep work and when the paychecks
came in, she would buy food, and they would gorge until they were sick.
Not surprisingly, Dennis currently becomes extremely anxious about hav-
ing enough money to eat.
In their new location, by the time Dennis was 8, a new trauma began.
His mother, trying to compensate for his lack of a father, located the Big
Brother charity. Unfortunately, the two men assigned to him were sadistic
pedophiles who took him into the woods, tied him up and raped him—
repeatedly—for about 2 years. He would often get a terrible stomachache
before it was time for him to go with them, but he was unable to tell his
mother of the abuse and terror that he was enduring alone. He was again
afraid of upsetting her. He was afraid that she would kill these men if she
knew, and that then his mother would be taken away from him.
Despite all the trauma that he endured, Dennis kept his mind. He was a
brilliant child who spent most of his time in the library. He was so intelli-
gent that on more than one occasion a teacher would accuse him of plagia-
rism on a paper that he had written because the teacher could not imagine
that someone his age would be capable of writing it.
He completed high school and managed to get through college despite
the fact that he was switching frequently, although in his “host” presenta-
tion he was unaware of this. As Sophia became more and more frequently
out, that part sought to take over Dennis’s body, and plans for a sex change
operation were begun with a psychologist and a physician who specialized
in this process. As Dennis consumed massive amounts of female hormones,
he became increasingly suicidal. He was hospitalized on multiple occasions
and eventually received shock treatments.
When he was released from the hospital, he began to try to recoup his
losses. Although he was not aware at the time that the sex change process
had been initiated because he had DID, he did realize that it would not work
for him to change his sex.
Soon after this event, he began psychotherapy with me.
Margaret
Margaret is a 35-year-old woman, married with two children, who is

employed as a university professor of literature. She is well groomed, attrac-
tive, and well put together. Margaret is a remarkable woman: loving and
well loved, highly intelligent, energetic, highly sensitive, psychologically
astute, multitalented with a strong work ethic. Mercilessly persecuted as a
child, she still, but increasingly less so, suffers conflicts about her right to
exist for herself and not solely as an object of use for others. Under stress,
she has had some periods of amnesia as well as minifugues, not remember-
ing how she got to a destination. In her childhood and adolescence, a great
portion of her life was about managing continued survival, a project that
often became exhausting and that led to profound states of depersonaliza-
tion and derealization. Since almost no one was interested in her feelings, it
is understandable that she has rageful and murderous self-states who give
her a lot of trouble, at times contributing to suicidality.
The oldest of three girls, she reports that she was torturously abused
throughout her childhood by her mother, her father, her stepfather, and
her stepfather’s son. On many occasions, she was raped, beaten almost to
a pulp, tied up, or left for dead. On two occasions, her father attempted to
murder her. Her mother was brutally cruel to her. As an adolescent, she
often was on her own, sleeping in alleys, sometimes wishing that her heart
would just stop and that death would wipe out her misery. She has also had
an adult near-death experience following childbirth.
There was one saving grace. She had a beloved grandfather, who loved
her and whom she adored. She spent some happy times in the summer with
him until he died when she was 11 years old, and her memories of those
times are positive and comforting.
Her mother would rarely feed her children, although she would leave
milk and cereal for them on the bottom shelf of the refrigerator so that they
could feed themselves when they were young. Margaret raised the young-
est child from babyhood until Margaret left home at 15. While Margaret’s
mother was frequently physically abusive to her, for instance, slamming
her against the wall if she thought Margaret was in her way, her constant
verbal humiliations were far worse: She would call Margaret a “fat cow”
and other similar derogatory appellations (Margaret was not overweight).
Margaret fared worse in her mother’s treatment than her younger sister
did because her mother identified with her sister, and rejected her, saying
that she looked like her father. Margaret remembers that on one occasion,
when she was a young adolescent, her mother sent her off overnight with
a strange man. She was lucky to have survived for the man took her to a
motel room where he and other men raped her. However, in other ways,
the mother’s household was an equal opportunity reign of terror: On one
occasion, her mother deliberately killed the children’s pet cats by running
over them with her automobile.
Probably the worst aspect of the way Margaret’s mother treated her was
that she was a blaming bystander for the physical and sexual abuse of her
children by her husbands. Since she was a little girl, Margaret’s father had
abused her sexually, sometimes in sadistic ways, such as tying her up and
leaving her alone, still tied up, for hours after he was done. Her father, a
tortured and torturing soul who was also an alcoholic, tried to murder her
on more than one occasion, once by drowning when she was a young child
and once by trying to shoot her with a gun. Fortunately, Margaret was able
to run away, and she was savvy enough to grab and run away with the bul-
lets so that he could not use the gun to kill her. Her father was also physi-
cally abusive and could fly into a rage on a dime, with little or no warning.
On one occasion, he knocked out Margaret’s front teeth as well as bruis-
ing and bloodying many parts of her body. Her mother’s response, rather
than anger at her husband or protectiveness toward Margaret, was anger at
Margaret that she would now have to get the blood out of the blouse. On
another occasion, her father threw her out of his moving car and then tried
to run over her.
Margaret’s mother left her father for her stepfather when Margaret was a
young adolescent. The stepfather’s rapes and sexual abuse were even more
sadistic than her father’s. One on occasion, he announced that he was going
to take her to get an abortion because he said he knew that she had been
sexually promiscuous with boys. He first took her to a hotel room, where he
raped her. Then, he took her to a seedy place, where a dilation and curettage
(D & C, often used for early-term abortions) was performed. Following this,
he delivered her to her place of work, instructing her to tell her employer
that she would need to sit, rather than stand, that afternoon. This situation
was odd since the stepfather had had a vasectomy, and he also knew that
Margaret was not having sex with boys. Margaret today surmises that his
purpose was blackmail—that if she were ever to complain about his rapes
of her, that he would be able to blame her for alleged “promiscuity” instead,
presenting himself as “the good guy” who took her to get an abortion.
When Margaret was 11, on the occasion of the funeral of her beloved
grandfather, she was brutally raped and severely beaten by the teenage son
of her stepfather. She had to find a way to bury her bloody clothes so that
her mother would not punish her further.
When Margaret was physically able at age 15 to leave home, she did. She
found a job at a department store, taking herself to school for classes, and
sleeping in the store after hours. When she was unable to sleep in the store,
she would sleep in alleyways. The temperature at night was often cold, and
she many times wished that she would just die in her sleep. Eventually, she
was able to buy herself a car. She would sleep in her car when the nights
were freezing. She remembers that her mother would send messages to her,
via her sister at school, to come home, and eventually she did go home—
where, of course, the rapes recommenced. Finally, Margaret told a school
counselor whom she felt she could trust about the rapes and about her
intention simply to leave town. Not anticipating the extent of Margaret’s
mother’s response, the counselor reported Margaret’s visit to Margaret’s
mother whose response was to have Margaret arrested in the process of her
attempted getaway and to have her hospitalized for 3 months on the basis
of her being supposedly mentally disturbed. (The purpose was to protect
the mother’s reputation; i.e., the mother was not negligent or abusive and
Margaret was crazy.)
Some of these events reported here Margaret has always known. But,
some of the events of her life, perhaps the worst ones, were deeply dissoci-
ated, and she has become conscious of them from piecemeal recollections
and through the communications of dissociated identities when they were
ready to do so. Through our work, as Margaret has pieced more and more
of the shards of her life together, she more and more feels that “she has a
story.” Her life makes more sense to her. The major task of Margaret’s early
life was survival. For her, unlike Janice, pleasing her parents was not an
option: They could not be pleased. Neither was it safe for her to express any
sort of angry feelings. Luckily, she was able to internalize the good experi-
ences she had with her grandfather. To her credit, she was able to establish
good relationships with some teachers, by whom she felt somewhat emo-
tionally supported. But on the whole, Margaret was starkly alone, her sur-
vival up to her alone, and the ambivalent conflicts regarding whether she
wanted to survive also hers alone. She has a tremendous capacity to con-
nect meaningfully with other people, which she has used as an adult, but
that capacity was seldom met with adequate environmental opportunity
when she was growing up.
While Margaret made two suicide attempts in her early adult life and has
been suicidal at some times in our work, there have been no actual attempts
during this time. While much healing has occurred, more remains to be
done. There is at least one murderous and furious, but extremely pained,
self-state who exists alone and needs more communication with me and with
Margaret. There are other raging self-states as well, who need more commu-
nication. On an interpersonal level, Margaret is improving in her ability to
support herself in the accurate acknowledgment of angry feelings. There is a
remarkable beauty to her courage and her ability to love.
Chapter 2
The Dynamic Unconscious

and the Dissociative
Structure of the Mind
The longer we have been occupied with these phenomena, the more we
have become convinced that the splitting of consciousness which is so
striking in the well-known classical cases under the form of “double
conscience” [the French term is “dual consciousness”] is present to a
rudimentary degree in every hysteria, and that a tendency to such a dis-
sociation, and with it the emergence of abnormal states of conscious-
ness (which we shall bring together under the term “hypnoid”) is the
basic phenomenon of this neurosis.
Freud (Breuer & Freud, 1893–1895a, p.â•¯12; italics in original)
Today, but only just recently in historical time, dissociation, relationality,

and multiplicity have become part of mainstream models of the psyche.
We are in a position now to revise and enrich the way we understand the
dynamic unconscious from the standpoint of knowledge of the dissocia-
tive structure of the mind. In this chapter, I examine the interrelationships
of multiplicity, relationality, trauma, dissociation, and repression and the
effect of all of these on the way we understand the dynamic unconscious.
Current understandings and meanings are well rooted in past ones. To
that end, in the second part of this chapter, I provide a somewhat brief his-
tory of the trajectory of how dissociation has been understood in the mental
health culture. Dissociation is like the Cheshire Cat in Lewis Carroll’s Alice
in Wonderland: Now you see it, now you don’t—it is irrepressible and keeps
popping up.â•¯Thus, I examine the social and historical context from which
our understanding of dissociative identity disorder (DID) has emerged.
Relationality, Multiplicity,
Trauma, and Dissociation
Many have said that with the advent of relational theory, psychoanalysis
has undergone a sea change. But, it is the amalgamation of this model with
other emergent viewpoints that makes for such a profound shift in the way
27
we understand the mind. Together with awareness of multiplicity, trauma,

and dissociation, this change is even more profound. Our concept of the
unconscious undergoes a radical revision to include a tightly woven system
of interrelated dissociated self-states; our concept of psychic structuring
emphasizes dissociation and the effects of trauma, as well as internaliza-
tions of relationships, well beyond the classical id/ego/superego structural
model; our understanding of therapeutic action shifts to include and perhaps
even to emphasize bearing witness, including affective responsiveness and
affective honesty, especially with trauma patients, but to others as well. The
relational unconscious, which involves communication between interacting
unconscious minds, takes on more texture and complexity when we consider
the various dissociated self-states that comprise the individual unconscious.
Relational Theory
Relational theory, which puts the emphasis on relationship, pulls together
the intellectual work of many clinicians and is influenced by different social
movements. As Bromberg (2009b) described it:
Relational psychoanalysis is now a central piece of the psychoanalytic

landscape, most notably in the United States and increasingly so inter-
nationally.â•ƒ.â•ƒ.â•ƒ.â•ƒThe school of Relational psychoanalysis was not born of
a single seminal theorist or homogeneous group of theorists from which
it then evolved, diverged, or remained loyal, and it is thereby not subject
to evaluation by its degree of deviation from orthodoxy. Freud, Klein,
Ferenczi, Fairbairn, Winnicott, Sullivan, and Kohut are all important
parental figures but none carries parental authority. The range of the-
ory, moreover, is extremely diverse because the value accorded a given
concept or system of concepts derived from any given figure is more
clinically than theoretically determined. The term “relational”â•ƒ.â•ƒ.â•ƒ.â•ƒwas
selectedâ•ƒ.â•ƒ.â•ƒ.â•ƒ[because] [i]t clearly and concisely represented the core view-
pointâ•ƒ.â•ƒ.â•ƒ.â•ƒthat the human mind, its normal development, its pathology,
and the process of its therapeutic growth are relationally configured
and it assured that the term be not so conceptually specific that it would
convey adherence to one given set of ideas. (pp.â•¯347–348)
The relational orientation thus bridges the intrapsychic and the inter-
personal, internal object relations with external interpersonal ones.
However, it not only bridges but also synthesizes these for the intrapsy-
chic and the interpersonal are closely interrelated, each influencing the
other (Aron, 1996). Increasingly, we understand problems in living as the
result of failed relationships, usually with attachment figures of early life.
Recognition of the importance of attachment comes with the relational
model. Human beings are innately wired for attachment and relationality
The Dynamic Unconscious and the Dissociative Structure of the Mindâ•… 29
(Bowlby, 1969/1982). But, along with attachment comes the capacity for
shame (Lewis, 1981). While shame has its prosocial purposes, too much of
it can be traumatic, bringing about dissociation (Bromberg, 1998). Thus a
key explanatory model for what causes these failed relationships to become
continuous problems in living is dissociation.
Relationality, multiplicity, and traumatic dissociation all come together
to frame a different way of understanding the human mind. We see the
impact of ways the person was traumatized, the shame the person felt about
that, and how the person has defensively responded to anxiety and shame.
While acknowledging the importance of conflict, relational theory in its
focus goes beyond drive and defense as well as beyond simply maladap-
tive behavior. It addresses the conflict between differing and opposing rela-
tional aspects and configurations of the self, for example, the shamed self
versus other parts of the self that may operate more adaptively and with
less conscious pain. Stephen Mitchell’s (1993) observation about the impor-
tance of being able to experience the conflict between multiple versions of
the self was prescient:
One of the great benefits of the analytic process is that the more the
analysand can tolerate experiencing multiple versions of himself, the
stronger, more resilient and durable he experiences himself to be.
Conversely, the more the analysand can find continuities across his
various experiences, the more he can tolerate the identity confusion
entailing by containing multiple versions of self. (p.â•¯116)
If Sigmund Freud would have been able to see and work with the idea
that dissociation could be used defensively (O’Neil, 2009), that is, that the
dissociative structure of the mind, as well as autohypnosis, are defensively
relied on, we might have a different psychodynamic grounding today. The
concept of conflict in the relational psychodynamics among dissociated
self-states—as was adumbrated in the work of Pierre Janet (1907, 1925) in
his descriptions of phobias of memories and parts of the self that hold trau-
matic memories—might have been passed on to us clearly. Dissociative dis-
orders might have been accepted all along, rather than seemingly banished
into the ether, only to return to people’s awareness more recently from the
same unconscious cultural place of banishment. And, if Freud (1896/1962)
had stayed with his first theory of hysteria, his so-called seduction theory,
in which he connected child sexual abuse to hysteria, our current psychol-
ogy might be different. But, the upshot is that both the dissociative struc-
ture of mind and the reality of child abuse had to be largely rediscovered.
The dissociative model of the mind was already in the zeitgeist when Freud
began to write. Multiple personality was well recognized, even a fascination,
among a sizable group of clinicians at that time. Theorists and clinicians
were writing about “double consciousness,” as was the early Freud. Freud
continued to write about how real relationships affect psychodynamics,

notably in Mourning and Melancholia (1917/1959a). His description of how
the shadow of the object falls on the ego in situations of psychic loss that are
infused with hate not only adumbrated his later descriptions of the superego
but also set the stage for later articulations of internalized object relations.
Yet, aside from his clinical cases, much of his later writing moved away
from explicitly interpersonal concerns—and away from direct attention to
dissociation. In the work that followed, Freud exposed “the belief inâ•ƒ.â•ƒ.â•ƒ.â•ƒcon-
scious thought as an ultimate datum of human experience” (Fromm, 1980,
p.â•¯134). His popularization and descriptions of the operations of the uncon-
scious gave us a way to understand interior life in a way that had not been pre-
viously possible. Freud’s emphasis on unconscious determinism, unconscious
defense, sexuality, aggression, fantasy, dreams, and our roles in the creations
of our problems, along with his provision of a psychoanalytic method for
relieving human suffering, as a partial list, provided a way of thinking about
the mind that resonated with people’s wish for self-understanding.
Many find certain aspects of Freud’s theories objectionable, for example,
his sexism, but he also gave us the tools to understand sexism. From Freud’s
work, we inherit, in the archeological idiom that he so loved, a multilay-
ered tradition of acceptance of trauma and denial of trauma, attention to
the child’s conflicts around sexuality and aggression in the theory of the
Oedipus complex, but in a theory that was itself embedded in the recogni-
tion of trauma.1
In accordance with Freud’s turning aside from exogamous trauma and dis-
sociation, explicit theories and approaches involving human interpersonal
relationships were developed separately by such people as Karen Horney,
Harry Stack Sullivan, Clara Thompson, Steven Mitchell, Judith Herman,
Philip Bromberg, Heinz Kohut, Jessica Benjamin, Lewis Aron, Donnel
Stern, Jody Davies, Mary-Gail Frawley-O’Dea, Robert Stolorow, Adrienne
Harris, and Jean Baker Miller and her cohorts at the Stone Center, among
others. Sullivan’s interpersonal theory of human development emphasized
each person’s history of interpersonal relationships with significant real
others, and he described the organization of self in terms of the internal-
izations of the interactive patterns of these relationships. Mitchell (1991,
1993, 2000) not only articulated the concept of the multiple self, emphasiz-
ing the embeddedness of humans in human relationships, but also noted
the dynamic struggle between needs for intimacy and closeness along with
corresponding needs for differentiation and separateness.
The women’s movement, which explicated relational trauma such as
rape as both personal and political, required a relational posture, one that
acknowledged trauma. Then, the end of the Vietnam War, with masses of
traumatized soldiers returning home, made the importance of trauma unmis-
takable. This created a space for some women’s problems such as rape, bat-
tering, and child sexual abuse to be recognized as traumatic. Trauma and
relationality, as joined ideas, became a natural outflow of the confluence of

these two movements in time. But, once these influences dialectically fed
each other, enabling a consolidation of the relational turn, trauma was rerec-
ognized as implicit, such that dissociation became implicit in relationality as
well. Judith Herman (1992) powerfully articulated a relational approach to
posttraumatic and dissociative problems in living. Davies and Frawley (1994)
incorporated trauma theory and dissociation into their relational psychoana-
lytic theory, with its emphasis on various transference-countertransference
positions. But, it is Bromberg who articulated in most depth and in most
specificity the effects of relational trauma on the human mind.
Relationality, Trauma, and Dissociation

Relationality puts the emphasis on relationships, including the intercon-
nectedness of selves to other selves as well as parts of the self to each other.
But, it also serves as an explanatory platform for understanding disconnec-
tion of selves and parts of selves. As Lewis Aron noted (1996), “Relational
theory isâ•ƒ.â•ƒ.â•ƒ.â•ƒanchored in the idea that it is relationships (internal and exter-
nal, real and imagined) that are central” (p.â•¯18). The idea that relationships
are central applies both to the genesis of problems and to the mode of treat-
ing them. It acknowledges that people are who they are largely because of
their relationships and how they have represented these intrapsychically,
and that in the therapeutic relationship, the therapist is part of the relation-
ship that is coconstructed rather than some objective outside party who
does not influence the interactions.
This shift from a one-person psychology to a two-person psychology
allows for the awareness that a substantial portion of psychological prob-
lems is likely to be exogenous (external) in origin rather than endogenous
(internal). As such, a two-person psychology allows for the rerecognition
of the reality of trauma. In a one-person model, the credo of unconscious
psychic determinism too often foreclosed awareness that there is a world
beyond our own unconscious intentions and orchestrations. In contrast, the
relational psychoanalytic approach allows for the recognition that trauma,
in and of itself, not just as a result of inner conflicts and instinctual pres-
sures, arouses overwhelming and intolerable affects—and thus the inevita-
bility of dissociation.
Although psychoanalysis traces its origins to the treatment of trauma and
dissociation (Breuer & Freud, 1893–1895a,b), until the last few decades the
trauma/dissociation field and that of psychoanalysis have existed by and
large separately from one another. This was in part because Freud’s views
on instinctual drives and infantile development for the most part left out
exogamous trauma and blamed the child as the guilty one for having inces-
tuous wishes (Betcher & Pollack, 1993; Devereux, 1953; Fromm, 1980;
Pines, 1989; Rachman, 1997; Ross, 1982; Stolorow & Atwood, 1979).
And, partly as a consequence of this omission, trauma theories have relied

on learning theory and cognitive psychology rather than psychoanalysis for
their theoretical foundations.
Multiplicity and Dissociative Multiplicity

Multiplicity is implicit in both a relational and a dissociative model of
mind. The capacity for multiplicity is involved in social interactions and
fostered the survival of human groups (Slavin & Kreigman, 1992). None
of us could enact different roles, such as mother, father, daughter, son, stu-
dent, teacher, victim, rescuer, persecutor, and so on without the capacity
for multiplicity. People’s minds are patterned into a multitude of organi-
zations in accordance with experiences, feelings, thoughts, and fantasies
about significant others. And, this patterning reflects different aspects of
many people in many relationships. Thus, psychic representations of these
relationships are multiple and various. As Mitchell (1991) noted, “because
we learn to become a person through interactions with different others and
through different interactions with the same other, our experience of self is
discontinuous, composed of different configurations, different selves with
different others” (p.â•¯128). Building on these concepts but adding the influ-
ence of dissociation, Bromberg (2009a) wrote:
Today, increased attention is being paid to the normal multiplicity of

states of consciousness. This is evoking a conceptual shift toward a
view of the mind as a configuration of discontinuous, shifting states of
consciousness. These states are understood to have varying degrees of
access to perception and cognition because many domains of dissoci-
ated self-experience have only weak or nonexistent links to the experi-
ence of “I” as a communicable entity. (p.â•¯638)
Thus, it is not only that we have multiple self-states, in accordance

with roles, context, evoked affect, and so on but also that, as a result of
experiences that were traumatic, many of these ways of being we have are
separated, dissociated from each other. The inevitability of trauma, espe-
cially some relational trauma, along with the psychic splits it occasions,
requires a construct of psychic structure that encompasses dissociation. A
construct of psychic structuring based on relationships, then, must include
dissociation. Trauma is ubiquitous and affects us all to varying degrees. In
Chapterâ•¯4, I show how the presence of trauma implies the presence of dis-
sociation. Especially as trauma becomes a more dominant discourse, more
and more practitioners in the field are aware of “the dissociative structure
of the mind” (Bromberg, 1998, p.â•¯8). From this perspective, none of us is a
unity but rather a highly organized aggregation of self-states that may be
barely, mildly, or highly dissociated.
Although the topics of multiplicity and dissociation come from differ-

ent sources, together they are aptly relevant to a discussion of dissociated
self-states and DID. In double-bind situations of contradictory attachment,
such as child abuse by a parent or caregiver or in traumatic bonding, dis-
sociative multiplicity allows the child’s attachment to and love of caretak-
ers, both vital to survival and psychological well-being, to endure relatively
undisturbed despite experiences such as abandonment or abuse that might
otherwise be psychologically ruinous. An implicit recognition of the impor-
tance of dissociative multiplicity and how too much problematic dissocia-
tion can interfere with personal cohesion is embedded in our language:
We regularly say things such as, “pull yourself together,” “he is coming
unglued,” “she was beside herself,” “don’t fall apart,” and so on.
In dissociative problems in living, the mutuality of relationships, between
people as well as within the organization of the self, has largely collapsed or
is missing. The person can only rely on the self and thus creates a relatively
closed system of the personality to compensate for the missing mutuality.
A closed system, dominated by defensive dissociation, precludes intersub-
jectivity—the mutual recognition of separate, self-reflective, and agentic
selves. The closed system also impedes intersubjectivity between self-states,
what I call interstate intersubjectivity. This is the awareness of the contex-
tual interdependence and interrelatedness of parts of the self that comprise
personal depth. The closed system is evidence of the lack of an adequate
internalization of an empathic other who could be influenced as well as be
influential. It is this route in from a standpoint outside the self that facili-
tates the linkage of parts of the self. To address the deficits of the closed sys-
tem, mutuality in the psychotherapeutic relationship is paramount. Aron’s
(1996) statement that “relational analysts share an emphasis on mutuality
and reciprocity in the psychoanalytic relationship” (p.â•¯123) is especially apt
for trauma and for dissociative patients.
When we begin to talk about the dissociative multiplicity that character-
izes those with DID, and to some extent all of us, we have an intricately
multilevel structure in which there are internal relationships (intrapersonal)
as well as external ones (interpersonal) that mirror and repeat in important
ways the problems in the early relationships. There is a correspondence
and reciprocal relationship between the intrapsychic and the interpersonal.
The psychodynamics among the parts replay the patterns and motivations
that existed between key figures in the early interpersonal environment and
the child. This means that we will likely find both intrapersonal and inter-
personal repetitions of dominant/submissive, annihilating/annihilated, and
sadistic/masochistic patterns that characterized interpersonal relationships
of the early environment, usually either the family or other kinds of total
environments such as day care or both. The dissociated parts of the person-
ality are in powerful and passionate dynamic interaction.
The Construct of the Unconscious
Probably the most fundamental concept to psychoanalysis and psycho-

dynamic psychotherapy, of whatever persuasion, is the unconscious. Freud’s
popularization of the construct of the unconscious made it possible for ordinary
people, not just philosophers, to think about and understand their actions,
thoughts, and motivations with much more complexity and expansiveness.
The repressed unconscious is considered a unity, the contents of which were
formed by the agency or will, albeit unconscious, of the person. There is a
feeling of power about the repressed unconscious. In contrast, the dissociated
unconscious consists of many autonomous subcenters of consciousness that
are not necessarily a product of a person’s agency. They are more likely the
result of a person’s having been psychologically overwhelmed.
As we consider dissociative multiplicity, our understanding of uncon-
scious life undergoes a radical revision to include a tightly woven system
of interrelated dissociated self-states. Dissociative multiplicity allows us to
ask whether the unconscious as a unitary construct that is solely repres-
sion based is the best explanatory model. It also allows us to question the
idea of conscious and unconscious as separate realms that at best interact
(Bromberg, 2006). Bromberg’s contrasting view of mental life is “as a non-
linear, self-organizing repatterning of self-state configurations that produce
shifting representations of ‘me’” (p.â•¯3). Bromberg (1993) articulated an
expansion of the construct of the unconscious:
What we call the unconscious might usefully include the suspension or

deterioration of linkages between self-states, preventing certain aspects
of self—along with their respective constellations of affects, memories,
values, and cognitive capacities—from achieving access to the person-
ality within the same state of consciousness. (p.â•¯182)
Indeed, we have in DID the most striking example of making the unconscious
conscious. This lies in the intercommunication of dissociated identity states
and the integration of their memories and affects, after which the person has
much more access to what had been part of the dissociated unconscious.
Repression
As we think about the unconscious, we usually invoke the concept of repres-
sion. The usefulness of also invoking dissociation has just been discussed.
How are repression and dissociation defined? The word repression refers
to a willful exclusion of information from consciousness; the “essence of
repression lies simply in turning something away, and keeping it at a dis-
tance, from the conscious” (Freud, 1915/1959b, p.â•¯147). It involves push-
ing out of consciousness both unpleasant and unwanted memories and any
wishes that conflict with internalized prohibitions. With respect to the lat-
ter, repression could be said to involve will acting on wishes.
One important issue is that repression is usually understood to be an
unconscious process, initially as well as throughout. There is a logical prob-
lem with the specification that repression is solely an unconscious process,
though, because this requires knowing and not knowing at the same time:
Repression can ultimately require an infinite series of inner homunculi to do
the repressing (Erdelyi, 1994; Kihlstrom, 1984; Stern, 1997). The repress-
ing part of the ego must repress that it is repressing and so on. Potential
solutions might allow that repression could initially be conscious (Erdelyi,
1994) as well as the invocation of dissociation as explanatory process. (For
further discussion of this matter, see Howell, 2005, pp.â•¯144–151.)
What Is Dissociation?
Because the word dissociation is used so variously, especially as it pertains
to different theoretical perspectives, people are often confused regarding
what it really means. In the most general sense, dissociation refers to the
separation of realms of experience that would normally be connected. As
Putnam (1989) says, views about dissociation “converge around the idea
that dissociation represents a failure of integration of ideas, information,
affects, and experience” (p.â•¯19). However, the word refers to many kinds of
phenomena, processes, and conditions:
• Dissociation refers to dissociative structure in which self-states are

kept rigidly segmented. A spatial metaphor for dissociative structure
is vertical splitting (Hilgard, 1977; Kohut, 1971), but it also refers to
processes, such as spacing out, psychic numbing, and even experienc-
ing oneself as floating above one’s body.
• Dissociation is both adaptive and maladaptive, both verb and noun,
both cause and effect (Spiegel, 1990b; Tarnopolsky, 2003).
• Dissociation is both a psychologically defensive response, protecting
against painful affects and memories, and an organismic and auto-
matic response to immediate danger (Van der Hart, Nijenhuis, &
Steele, 2006).
• Dissociation can be understood as taxonic, that is, as describing a cer-
tain type of individual or, alternatively, as existing on a continuum—
describing all of us, varying in degrees (Putnam, 1997).
• Dissociation is both occurrent (in evidence or in process) and disposi-
tional (a capability that can be tapped) (Braude, 1995, 2009).
Thus, there are multiple views of the etiology and nature of dissocia-
tion. Yet, when dissociation is so many things, there is the potential for
conceptual confusion—the word can be used so loosely that it begins to

lose its meaning.
To my way of thinking, the simplest organization of these multiple mean-
ings is in terms of, first, the dissociative structure of mind and, second, the
dissociative processes. Dissociative structure is exemplified in Fairbairn’s
endopsychic model as well as in Van der Hart, Nijenhuis, and Steele’s (2006)
theory of the structural dissociation of the personality, which expands on
Janet’s (1907, 1925) early thoughts. It also includes Sullivan’s (1933) “not
me” and Bromberg’s (1998, 2006) descriptions of dissociated self-states.
And, it includes Bucci’s (1997, 2002, 2003) cognitive-psychoanalytic model
of dissociation that involves the lack of sufficient referential process to link
symbolic and subsymbolic aspects of experience. In addition, dissociative
structure may include unformulated experience (Stern, 1997), especially
inasmuch as one dissociative part of the person is unformulated by another
(Howell, 2005). Finally, dissociative structure is manifested in identity con-
fusion, identity alterations, and both macro- and microamnesias.
Dissociative process refers to activity such as going into trance as well as
depersonalization and derealization. It also includes Sullivan’s selective inat-
tention: As a result of unbearable anxiety arising from interactions with care-
givers, certain kinds of experiences may become part of “not-me.” Dissociative
processes may contribute to the dissociative structure. Stern (1997) partially
relied on the concept of selective inattention to develop his model of unfor-
mulated experience. Here, keeping the experience unformulated into mean-
ingful constructs does not have to imply a dissociated self-state. However, the
existence of unformulated experience may lead to dissociative structure. For
example, Mary and Jane are separate dissociated identity states. As Mary
begins to learn about Jane’s experience through integrative processes, Jane’s
experience becomes more and more formulated to Mary.
John O’Neil (2009) uses the term “dissociative multiplicity” to make the
distinction between dissociation that does not imply multiplicity (such as
trance states, selective inattention, some forms of depersonalization) from
dissociation that does imply multiplicity (such as multiple dissociated self-
states). O’Neil’s distinction of dissociation of function versus multiplicity
largely parallels my distinction between dissociative process and structure.
Repression and Dissociation

Repression is only active and motivated. In contrast, dissociation is both
an automatic, psychologically passive, and an active motivated defense.
Repressed “materials are experienced as once familiar, rediscovered aspects
of mental lifeâ•ƒ.â•ƒ.â•ƒ.â•ƒ[which] have been previously experienced, psychologically
digested, encoded, and then forgotten” (Davies & Frawley, 1994, p.â•¯66).
In contrast, dissociation occurs when the person is unable to integrate or
synthesize experience, and dissociated material is generally organized in
such a way that one realm of experience requires the exclusion of another.
However, probably the most important difference is that dissociation is
occasioned by experience that is unassimilable, often unbearable, whereas
repression is a defense that deals with the unpleasant.
Bromberg (2006) describes how defensive dissociation involves unbear-
able conflict between different versions of “me”:
Repression defines a process that is designed to avoid disavowed mental

content that may lead to unpleasant intrapsychic conflict. Dissociation
shows its signature not by disavowing aspects of mental contents per se,
but through the patient’s alienation from aspects of self that are incon-
sistent with his experience of “me” at a given moment. It functions
because conflict is unbearable to the mind, not because it is unpleasant.
(p.â•¯7; emphasis in original)
Some differences between repression and dissociation are outlined:
• Repression is both motivated and defensive. In contrast, dissociation

often is, but does not have to be motivated or psychologically defen-
sive. For example, dissociation can arise automatically in the moment
of trauma or nondefensively in response to hypnosis.
• Repression refers to formulated experience, and dissociation as a pro-
cess often implies unformulated experience (Stern, 1997).
• Repression usually refers to a piece of information that was acces-
sible at one time but not at another, whereas dissociation refers to
states and systems of states that are often mutually exclusive (Spiegel,
1994). They exist side by side. For example, “My father is a wonder-
ful man” is fiercely believed by one self-state, while another suffers
from the memories of abuse. The metaphor for repression is horizon-
tal splitting, and that for dissociation is vertical splitting (Hilgard,
1977; Kohut, 1971).
• In contrast to repressed memories, which are assumed to have been
willfully (albeit, supposedly unconsciously) forgotten and are there-
fore at least somewhat independent of context, dissociated experience
is especially vulnerable to being elicited by context (adapted from
Howell, 2005, p.â•¯147).
Dissociation and Repression Interact

Does the unconscious then pertain to repressed or dissociated material? I
think that its contributors include both dissociation and repression, often
in interaction and put into effect one by the other. I think that the dis-
sociative model is the best place to start, but room should be allowed for
the operation of repression. For example, a model that includes different
interacting autonomous centers of unconscious activity, which themselves

have repressive capabilities and actions, might be more comprehensive than
either the strictly repression-based or dissociation-based model.
As O’Neil (2009) observes, dissociated identities (alters) in people with
DID have the capacity for repression: “In generalâ•ƒ.â•ƒ.â•ƒ.â•ƒa given alter has its
own Id, Ego, and Superego” (p.â•¯113). Repression and dissociation also
often potentiate each other (Dell, 2009b).
Psychoanalysis traces its origins to the study of dissociative unconscious
processes involving double consciousness and multiplicity. Double con-
sciousness implies dual centers of conscious. (Because the centers are dis-
sociated, their respective mental activity is unconscious, each to the other.)
However, Freud discontinued writing in this way, adopting instead his con-
struct of the (unitary) unconscious. In their observations of the double con-
sciousness of hysteria, Breuer and Freud (1893–1895a) stated, “The basis
and the sine qua non of hysteria is the existence of hypnoid states” (p.â•¯12).
In “The Preliminary Communication,” Freud both endorsed hypnoid hys-
teria (dissociation) and then later, in his own chapter on the psychother-
apy of hysteria, renounced it, advocating for the active defensive activity
of repression. He wrote: “I have never in my own experience met with
a genuine hypnoid hysteria. Any that I took in hand turned into defense
hysteria” (Breuer & Freud, 1893–1895, p. 286). As O’Neil (2009) noted,
Freud’s “inaugural category mistake” was “of assuming that the hypnoid
state could not be the result of active defense” (p.â•¯319).
But, here we are getting ahead of ourselves. We return to Freud shortly.
Now, the immediate question is, “What has happened with dissociation?”
DID as the Cheshire Cat: A Historical View
Trance, Hypnosis, Demons, and DID

Dissociative capacity is part of our human DNA, probably developed in the
service of survival (Dell, 2009b). This capacity has the potential for both
adaptive and maladaptive utilization. Throughout the world and long before
people thought in terms of categories of mental disorders (e.g., psychosis,
neurosis, schizophrenia, bipolar, depression, etc.), human cultures have
valued the human capacity to enter into dissociative trance. Positive mani-
festations of trance have been a part of the religious ceremonies of many
communities and have been exhibited in various rituals and healing cer-
emonies as well as in personal mystical and religious experiences of intense
absorption, ecstasy, and transformation (Cardeña, 2001; Ellenberger, 1970;
Hilgard, 1994; James, 1902/1958; Levine, 1997). Dissociative trance is also
essential for the work of shamans, healers across cultures and throughout
history, who have used it as a way to heal the afflictions of others and to
prepare the body to be entered by spirits (Randal, Geekie, Lambrecht, &

Taitima, 2008, p.â•¯340). Interestingly, the shaman is not so much possessed
by the spirits but rather summons and takes possession of them.
One particular kind of dissociative trance that has been documented
throughout history is possession trance. This includes both benign spirit
possession and demon possession (Cardeña, 2001; Hilgard, 1977; Levine,
1997). Currently, at least 50% of our 488 non-Western cultures “have a
structured belief in Spirit Possession as a valued and valid aspect of self”
(Hegeman, 2010, p.â•¯99). In many cultures, possession trance provides
socially accepted ways for the powerless to exert some power and influ-
ence. For example, Lewis-Fernandez (1994) described how possession by
the spirit of a deceased relative allowed a powerless new bride some respect
and control over her life. The spirit instructed the in-laws to provide the
daughter-in-law with better care. Because the in-laws respected and feared
the spirit, the possession syndrome also allowed the daughter-in-law greater
control over her life.
Spirit possession—especially demon possession—can tell a story sym-
bolically and express important conflicts. Somer (2004) documented the
occurrence of trance possession in 16th-century Near Eastern Judaism, in
which a dybbuk, the spirit of a deceased person, clung to the possessed per-
son. Interestingly, records of the exorcisms indicated that the spirits in these
cases were male, and they often entered the possessed person’s body through
the vagina and the rectum, suggestive of sexual intercourse. According to
Somer (2004), “by allowing individuals to communicate about their for-
bidden secrets and inner conflicts through a ‘non-me’ agent, the dybbuk
may have enabled ventilation and some processing of otherwise inexpress-
ible traumatic and/or guilt-promoting experiences” (pp.â•¯142–143).
Somer (2004) further noted that the phenomenology of these possession
experiences is similar to that of DID. Similarly, as Ellenberger (1970) spec-
ulated, “instances of multiple personality may have existed long ago, but
remained unnoticed” (p.â•¯127). And, Kluft (1994) maintained that “DID is
the contemporary and demystified form of an anthropological common-
place” (p.â•¯2). As in demon possession, people with DID often have parts
named Devil, Satan, or Lucifer. As in demon possession, demon parts in
DID refer to the host in the third person and often in contemptuous terms,
for example, calling the host a wimp, an idiot, and so on.
In Western culture, before the Enlightenment, the remedy or treatment
for demonic possession was exorcism by priests. (Of course, this practice
is still present, but much less so.) The process by which the dissociative
symptoms of demon possession came under the purview of science and
became understood as mental health problems first took a route through
the study of hypnosis (Dell, 2009b) and only secondarily through the route
of understanding the effects of trauma. Hypnosis offered the first approach
to understanding the division of the personality, and it was understood that

these parts of the person preexisted the application of the hypnosis.
The Study of Dissociative Trances

Began With Hypnosis
Anton Mesmer (after whom mesmerism took its name) offered the first
challenge to exorcism as a cure for demon possession in the late 1770s. His
magnetism, a secular form of hypnotism that he considered “scientific,”
began a process by which the treatment of emotional distress was liberated
from the domination of the church. Mesmer’s magnetic approach elicited
altered states of consciousness and evidence of dissociation; indeed, accord-
ing to a fascinating account by Middleton, Dorahy, and Moskowitz (2008),
“accounts of individuals switching between identity states and demonstrat-
ing amnesia between states or switching into fugue states, had always been
part of the literature associated with mesmerism” (p.â•¯10).
In Mesmer’s magnetic healing, practitioners called animal magnetists
would make magnetic passes with their hands, and the patient would go
into a sort of hysterical crisis, which would then result in relief or improve-
ment of the patient’s symptoms. Among his followers was the Marquis de
Puységur, who in the late 1700s discovered what he called artificial som-
nambulism. In one case, instead of developing a crisis, the patient appeared
to go into a deep sleep in which he spoke, but about which he had amnesia
on awakening. Because of the similarity to sleepwalking, about which peo-
ple have amnesia, or natural somnambulism, it was called artificial som-
nambulism (Dell, 2009d, p.â•¯714; Van der Hart & Dorahy, 2009).
Thus, while convulsive hysterical crises had been described by doctors
and philosophers of ancient Greece, as well as in the Middle Ages and
the Renaissance (Janet, 1907), these crises could now be linked to the
dual consciousness of somnambulism. Increasingly, the dissociative symp-
toms that had formerly been seen as signs of demonic possession were
understood as secular, personal problems. By the late 1700s, what we now
understand as DID was described as a particular disorder. In 1791, the
mesmerist Gmelin published an 87-page report on the dramatic switch-
ing of identity states of a young woman (cited in Middleton, Dorahy, &
Moskowitz, 2008). Following Gmelin’s report and others like it, many
cases of dual and multiple personalities were reported and published dur-
ing the 1800s in both Europe and the United States. The most influential
of these early cases was that of Mary Reynolds (1785–1854) in the United
States. At the age of 26, she suffered a series of fits, which left her deaf and
blind for several weeks. This was followed by the emergence of a young
child state and eventually a more energetic and cheerful new Mary, but the
switches went on for 18 years. Her changes in state were accompanied by
amnesia (Carlson, 1986).
Following the discovery of evidence of a double consciousness and multi-

ple personality, the topic was the subject of considerable study and thought.
Especially in France, there were notable contributions to the study of the
division of consciousness (dédoublement) in the early to late 1800s. In
1888, Jules Janet, an uncle to Pierre Janet, used the model of double con-
sciousness in a way that was a precursor to the idea of multiple personali-
ties (Van der Hart & Dorahy, 2009).
In addition to double personality, before and during the 19th century
there was considerable interest in the spontaneous occurrences of trances,
state-specific memory, and autohypnotic trance speaking in France as well
as England. Frederick Myers (1887) proposed the existence of a supralimi-
nal self and a subliminal self in psychic structure. In England, the Society
for Psychical Research was an important organization that studied such
events. In the late 1800s, this organization hailed members such as William
James and Pierre Janet—and even Sigmund Freud as a corresponding mem-
ber (Alvarado, 2002).
Hysteria and Double Consciousness

By the mid-1800s, clinicians were beginning to link the phenomenon of dou-
ble consciousness, or the splitting of consciousness, that occurred in hypnosis
with hysteria (Van der Hart & Dorahy, 2009). Generally, the central problem
for people with hysteria was dissociation. The people who studied dissociation
in the 19th century were a motley group, including magnetizers, philosophers,
and physicians, among others. The topics studied, although wide ranging,
cohered closely around hypnosis, autohypnosis, and double consciousness:
In addition to somnambulism, dissociative phenomena of interest

included possession phenomena, automatic writing, talking tables,
mediumship, and various manifestations of hysteria. Multiple person-
ality disorder, which was regarded as the most complex form of hyste-
ria, received special attention. (Van der Hart & Dorahy, 2009, p.â•¯9)
However, hysteria covered a range of problems in living (primarily in

women), including what we would now call dissociative disorders, somato-
form disorders, borderline personality disorder (BPD), posttraumatic stress
disorder (PTSD), and reactive psychosis. Hysteria was commonly used as a
diagnostic medical term from the 1700s until its elimination from the DSM
in the late 1900s.
Charcot Finds the Link

It was Jean Martin Charcot, a renowned neurologist based at the Salpêtrière
Clinic in France and teacher to Freud, and others who began to make the
link among dissociation, trauma, and hysteria. His understanding of neu-

rology and his dramatic demonstrations of the dissociative nature of hys-
teria “brought aboutâ•ƒ.â•ƒ.â•ƒ.â•ƒa synthesis between the traditions of hypnosis and
official psychiatry, at the same time elevating hypnosis to a level worthy
of scientific investigation” (Middleton et al., 2008, p.â•¯11). Charcot linked
hysterical symptoms with subconscious ideas that had been split off from
consciousness, but he believed that the basic cause of hysteria was consti-
tutional weakness (Dell, 2009b; Van der Hart & Dorahy, 2009). Freud
was greatly influenced by Charcot, whose work he translated, as a result
of which some of Charcot’s work appeared in German before it appeared
in French (Dell, 2009b). Freud even named his son, Martin, after Charcot.
Janet’s Giant Step

It was Charcot’s student at Salpêtrière, the eminent Pierre Janet, who explic-
itly linked hysteria to traumatic antecedents. His descriptions of that link-
age were astute, precise, and prolific. Despite his large body of published
work, it should be noted that Janet worked within the French tradition
of scientific investigation that advocated careful observation, not grand
theory building (Dell, 2009a, 2009d). Starting in his 1889 doctoral thesis,
Janet wrote of the influence of trauma on hysteria and was the first to use
the concepts of trauma and dissociation to explain the many symptoms of
hysteria (Nijenhuis & Van der Hart, 1999; Van der Kolk & Van der Hart,
1989). He observed that “vehement emotions” evoked by trauma can pre-
vent the integration of traumatic memories, to the extent that frightening
or novel experiences may not be integrated into the existing cognitive sche-
mata. As a result, aspects of these experiences became separated from ordi-
nary consciousness, operating subconsciously and autonomously (Janet,
1907, 1919, 1925). “Fixed ideas” (idées fixes), which are volatile thoughts
or images that have become subconscious, are formed around memories
of vehement affect organizing “cognitive, affective and visceral elements
of the trauma while simultaneously keeping them out of conscious aware-
ness” (Van der Kolk & Van der Hart, 1989, p.â•¯1532). Because these fixed
ideas become isolated from personal consciousness and one’s will, they
are vulnerable to being triggered by emotions and ideas (Van der Hart &
Friedman, 1989; Van der Kolk & Van der Hart, 1989). Consequently, they
powerfully organize symptoms, intruding into consciousness as behavior,
emotions, and thoughts. Janet’s word to describe this process, by which
aspects of experience were separated and stored subconsciously, was dés-
agrégation, which meant dissociation.
Importantly, the frightening or overwhelming event does not disap-
pear but remains active as a fixed idea that becomes a subconscious cen-
ter around which other aspects of psychological experience may cohere.
As Janet (1907) stated, “Things happen as if an idea, a partial system of
thoughts, emancipated itself, became independent and developed itself on

its own account” (p.â•¯42). Importantly, Janet emphasized that fixed ideas
belong to a mental system that is not subject to conscious will: “The power
of such ideas depends upon their isolation. They grow, they install them-
selves in the field of thought like a parasite, and the subject cannot check
their development by any effort on his partâ•ƒ.â•ƒ.â•ƒ.â•ƒbecause they exist by them-
selves in a second field of thought detached from the first” (1925, p.â•¯600).
Awareness of Dissociation Spreads to America:

William James and Morton Prince
Many of Janet’s concepts and ideas (e.g., his descriptions of what we now
call PTSD and more recently somatoform disorders) have had considerable
influence on and have been assimilated into the psychological and mental
health literature (Van der Hart et al., 2006). In particular, one of Janet’s
students was Jean Piaget, who relied heavily on Janet’s ideas about assimi-
lation and accommodation (Ellenberger, 1970).
Janet, an eminent scholar and sought-after clinician, was well known in
his time and had many followers in America as well as in Europe (Van der
Hart & Friedman, 1989; Van der Kolk & Van der Hart, 1989). In the early
1900s, William James and Morton Prince, among others, were fascinated by
Janet’s ideas and wrote prolifically about dissociation and multiple person-
ality disorder (MPD). James, who was also influenced by Frederick Myers’s
idea of the subliminal self, wrote of dissociation in Principles of Psychology
(1890/1950). Morton Prince (1906/1969) published the well-known multi-
ple personality case of Miss Beauchamp, as well as other works on dissocia-
tion and multiple personality. Boris Sidis published Multiple Personality:
An Experimental Investigation Into the Nature of Human Individuality
(1904), which he dedicated to James.
Dissociation in Europe: Jung and Bleuler

Janet’s ideas about dissociation directly influenced those of Carl Jung,
whose concept of “complex,” which he described in terms of dissocia-
tion, had a similar meaning to Janet’s concept of fixed ideas (Ellenberger,
1970; Moskowitz, Read, Farrelly, Rudegeair, & Williams, 2009). Similar
to Janet’s description of fixed ideas, Jung described complexes as “affec-
tively-charged clusters of ideas accompanied by somatic interventions”
(Moskowitz et al., 2009, p.â•¯522). Again similar to Janet, Jung (1907/1960)
emphasized the relative autonomy of complexes: “Today we can take it as
moderately certain that complexes are in fact ‘splinter psyches.’ The etiol-
ogy of their origin is frequently a so-called trauma, an emotional shock, or
some such thing, that splits off a bit of the psyche” (p.â•¯98).
Jung’s term complex was also adopted by Eugen Bleuler, his close asso-
ciate at the Burgholzi Hospital (Moskowitz et al., 2009). In his book
Dementia Praecox (1911/1950), in which he introduced the term schizo-
phrenia, Bleuler, like Jung, emphasized the importance of dissociation,
stating that “different psychic complexesâ•ƒ.â•ƒ.â•ƒ.â•ƒdominate the personality for a
time” (p.â•¯9) and observing that “the patient appears to be split into as many
different persons or personalities as they have complexes” (p.â•¯361).
Freud also incorporated Jung’s term complex into his own writing and
terminology, although he changed the meaning by draining it of assump-
tions of autonomy (Moskowitz, 2008). For instance, the term he coined,
Oedipus complex, describes a conflict of a unified person’s desires and
internalized prohibitions rather than a subconscious part of the self that
has its own autonomy.
Sigmund Freud
As we know, psychoanalysis began with the study of dissociation; of course,
it would have, given its historical context. Freud and his early colleague,
coauthor of Studies on Hysteria (1893–1895a,b) Josef Breuer, utilized con-
cepts of dissociation that were current, involving double consciousness, som-
nambulism, splitting of consciousness, and so on. According to Ellenberger
and Janet, Breuer and Freud adopted some of Janet’s ideas and terms. Janet
(as cited in Ellenberger, 1970) claimed priority for the discovery of fixed
ideas and cathartic therapy, and by 1914, Janet expressed the conviction
that Freud took many of his ideas, renamed them, and called them his own.
In Psychological Healing (1925), Janet stated that he introduced the term
subconscious, after which Freud wrote of the unconscious; he also claimed
that after he wrote of psychological analysis, Freud coined psychoanalysis.
Ellenberger (1970) also noted that Janet’s concept, the function of reality,
was renamed as the reality principle, and cited his agreement with Regis
and Hesnard’s statement that, “The methods and concepts of Freud were
modeled after those of Janet, of whom he seems to have inspired himself
constantly—until the paths of the two diverged” (pp.â•¯539–540).
The dissociative nature of hysteria is clearly described in Studies on
Hysteria (Breuer & Freud, 1893–1895a,b). Breuer’s patient, Anna O.
(Bertha Pappenheim), described therein with her switching of languages
and her amnesia for occurrences in other states, probably had DID—as did
some of Freud’s patients described in the same book (Ross, 1989).
In the “Preliminary Communication” to Studies on Hysteria (1893–1895a),
Breuer and Freud emphasized hypnoid states, a term that Breuer adopted
from Charcot (Breger, 2000), which in turn Charcot had adapted from the
French expression for somnambulistic states (Van der Hart & Dorahy, 2009).
Indeed, Breuer and Freud stated that the existence of hypnoid states was “the
basis and the sine qua non of hysteria” (1893–1895a, p.â•¯12; italics in original).
They went on to connect these hypnoid states with traumatic memories that
have not been associatively linked with other thoughts, and that are “found
to belong to the ideational content of hypnoid states of consciousness with
restricted association” (p.â•¯15). These ideas are associated among themselves
and form a “more or less highly organized rudiment of a second conscious-
ness, a condition seconde” (p.â•¯15; italics in original).
In the “Preliminary Communication” to Studies on Hysteria (1893–
1895a), Breuer and Freud explicitly linked hysteria with splitting of con-
sciousness, and dissociation:
The longer we have been occupied with these phenomena, the more we
have become convinced that the splitting of consciousness which is so
striking in the well-known classical cases under the form of “double
conscience” [footnote: the French term “dual consciousness”] is pres-
ent to a rudimentary degree in every hysteria, and that a tendency to
such a dissociation, and with it the emergence of abnormal states of
consciousness (which we shall bring together under the term “hyp-
noid”) is the basic phenomenon of this neurosis. In these views we
concur with Binet and the two Janets. (p.â•¯12; italics in original)
Despite these statements, Freud soon dismissed hypnoid hysteria, even in

Studies on Hysteria (1893–1895b), in favor of defense hysteria, saying that
every case of seeming hypnoid hysteria that he had seen had turned into
defense hysteria. Thus, while dissociation was the crucible for the birth of
psychoanalysis, this period in which it was explicitly studied came to be
called the prepsychoanalytic period by Freud and his followers.
O’Neil (2009) views this as unfortunate, noting that Breuer’s hypnoid
hysteria was the “first psychoanalytic example of a state of mind” (p.â•¯317),
and that Freud made a category mistake in dismissing it. O’Neil cogently
asks: “Why can the rationale for dissociation not be defense? The auto-
hypnotic nature of hypnoid states was clear from the beginning to all con-
cerned. Why was Freud unable to conceive of such an act of autohypnosis as
unconsciously motivated or intended?” (p.â•¯308). Following from an earlier
discussion, in which he contrasted Pythagorean splitting (which consists
of a number of polar opposites, such as “good/bad, light/dark” and so on)
and the orthogonal grid of Empedocles (which would enable one to think
of good and dark, for example), O’Neil says,
Freud was trapped in his own Pythagorean table of opposites. One

side of the table would be bad, Janet, Breuer, heredity, degeneracy,
trauma splitting of consciousness, hypnoid hysteria, dissociation. The
other side would be good, Freud, drive, defense, repression, conversion.
He was unable to advance an Empedoclean grid which would have
allowed for the defensive dissociative induction of hypnoid states, a
move which would have allowed him to distinguish dissociation from

repression, without dismissing it, and forego the subsequent general
psychoanalytic marginalization and abandonment of that significant
patient population represented by a number of cases in his own Studies
on Hysteria (Breuer & Freud, 1895). And so the latter is not only the
primal book of psychoanalysis, but also the primal book of the psycho-
analytic misinterpretation of major posttraumatic pathology. (p.â•¯308)
Another step that many have regarded as unfortunate was Freud’s aban-
donment of his so-called seduction theory, which was his first theory of the
etiology of hysteria. In 1896, Freud presented “The Aetiology of Hysteria”
(1896/1962), which described his theory of hysteria that linked the symp-
toms of hysteria with child sexual abuse. In this article, Freud stated that he
had discovered that in each of 18 cases of hysteria, 2 of them corroborated,
there were “one or more occurrences of premature sexual experience”
(p.â•¯203). In this work, he claimed that he had found the cause of hysteria,
of which he and Breuer had earlier only found the mechanisms. He likened
his discovery to finding the caput Nili—the source of the Nile—of neuro-
pathology (p.â•¯203). (The discovery of the source of the Nile River in Africa
was the most important discovery of the 19th century, according to Janet,
1925.)
Freud (1896/1962) clearly felt strongly about this issue of the sexual
abuse of children, arguing that:
The idea of these infantile sexual scenes is very repellent to the feelings
of a sexually normal individual; they include all the abuses known to
debauched and impotent persons, among whom the buccal cavity and
the rectum are misused for sexual purposesâ•ƒ.â•ƒ.â•ƒ.â•ƒon the one hand, the
adultâ•ƒ.â•ƒ.â•ƒ.â•ƒwho is armed with complete authority and the right to punish,
and can exchange one role for the other to the uninhibited satisfaction
of his moods, and on the other hand, the child, who in his helplessness
is at the mercy of this arbitrary will, who is prematurely aroused to
every kind of sensibility and exposed to every sort of disappointment,
and whose performance of the sexual activities assigned to him is often
interrupted by his imperfect control of his natural needs—all these gro-
tesque and yet tragic consequences reveal themselves as stamped upon
the later development of the individual and of his neurosis, in countless
permanent effects which deserve to be traced in the greatest detail.
(pp.â•¯214–225)
However, Freud did not think that his presentation was received well,
writing to Fliess soon afterward that Krafft-Ebing, who chaired the meet-
ing, had called it a “scientific fairy tale,” and that the “donkeys gave it an
icy reception” (p.â•¯189).
As we know, soon after, in 1897, Freud supplanted his seduction theory

with his theory of infantile sexuality and the Oedipus complex. Reversing
his former stance about the reality of child abuse that he felt had not been
accepted, he posited that most often patients’ memories of sexual abuse
were instead wishful manifestations of oedipal desire. It was these desires
rather than sexual traumas that were repressed. (Freud never denied that
child sexual abuse does occur and is pathogenic.)
Among Freud’s officially stated reasons for his change of mind was that
if all of these hysterics had histories of child sexual abuse, this would mean
that an unbelievable percentage of the adult population would be abusers.
This logic is fallacious for there is not a one-to-one correspondence between
number of child abusers and victims; most pedophiles and child abusers
have more than one victim. Indeed, some have thousands (Salter, 2003).
Freud also pointed to the fact that when he informed his patients of his
discovery that they had been abused, they fled treatment, which he took as
an indication that he had been wrong. He also noted the difficulty of deter-
mining the veracity of the unconscious. Whatever all the reasons may have
been, his view of the child’s dilemma soon changed significantly (Breger,
2000; Brothers, 1995; Davies & Frawley, 1994; Gay, 1988; Kupersmid,
1993; Masson, 1986; Matari, 1998; Tabin, 1993).
Breger (2000), Brothers (1995), Kupersmid (1993), and Masson (1984)
suggested that Freud’s internal conflicts, as opposed to the officially pre-
sented version of theoretical views, led to his abandonment of the seduc-
tion theory. In the year and a half between his presentation of “Aetiology
of Hysteria” (1896/1962) and his abandonment of the seduction theory,
Freud’s father died, and recognition of his father’s abuse of his siblings may
have influenced his retraction. In 1896 and 1897, he wrote letters to his
friend Robert Fleiss; he “baldly asserted that his father had sexually abused
several of his siblings and was responsible for their neuroses” (Masson,
1985, p.â•¯231, as quoted in Brothers, 1995, p.â•¯8). Regardless of the reasons,
the upshot was that Freud’s new theoretical focus deemphasized dissocia-
tion and the traumatic roots of hysteria in child sexual abuse.1
Despite the fact that his official dissociation period was short-lived, Freud’s
future work did describe dissociative phenomena without emphasis that
this was the case. In The Dissociative Mind (Howell, 2005), I outlined four
different models, or ways of thinking about dissociation (Dissociationisms
1, 2, 3, and 4), which Freud adopted in the course of his work:
• Dissociationism 1 was the splitting of consciousness that he and

Breuer espoused in the “Preliminary Communication” (1893–1895a).
This has to do with hypnoid states, in which the phenomenon is one of
doubling or multiplication, by which one becomes more than one. This
was similar to Janetian dissociation and was more of Breuer’s position
than Freud’s in the course of Studies on Hysteria (1893–1895a,b).

Here one becomes two.
• Dissociationism 2, also present in the “Preliminary Communication,”
was the beginning of Freud’s concept of repression. It was about how
“one makes two,” that is, how people can make some matters uncon-
scious, dividing the mind into conscious and unconscious parts. This
process has to do with things
all of a distressing nature, calculated to arouse the affects of
shame, of self-reproach, and of psychical pain, and the feeling of
being harmed; they were all of a kind that one would prefer not to
have experienced and would rather forget.â•ƒ.â•ƒ.â•ƒ.â•ƒ[ This incompatible
idea] provoked on the part of the ego a repelling force of which
the purpose was a defense against this incompatible idea [which
was]â•ƒ.â•ƒ.â•ƒ.â•ƒforced out of consciousness and out of memory. (Breuer
& Freud, 1893–1895b, p.â•¯269)
The person repressing memories or wishes acts as a unity, at least
with respect to the material being repressed, and a structural dis-
sociation is created. Part of experience, whether it is a memory or a
wish, is no longer accessible.
• Dissociationism 3 had to do with the split between the ego and the
superego, which was adumbrated in Mourning and Melancholia
(1917/1959a) and in Group Psychology and Analysis of the Ego
(1921/1955) and outlined in The Ego and the Id (1923/1961a): “This
modification of the ego retains its special position; it confronts the
other contents of the ego as an ego ideal or super-ego” (p.â•¯34).
• Dissociationism 4 concerns, “The Splitting of the Ego in the Process
of Defence” (Freud, 1938/1961b), in which he describes how two con-
tradictory views of reality can exist in the mind simultaneously with-
out an experience of conflict or resolution. He seemed to be addressing
the effects of trauma in this article, but he never finished it.
Back to Bleuler: Schizophrenia

Incorporates and Overshadows Hysteria
and Multiple Personality Disorder
Shortly after Freud abandoned his seduction theory, Bleuler changed the
term dementia praecox, which had been Kraepelin’s term, to schizophre-
nia, describing the new disorder, schizophrenia, as dissociation based, a
move that would ironically have the ultimate effect of overshadowing dis-
sociative processes in mental disorders. In Dementia Praecox or the Group
of Schizpophrenias, Bleuler (1911/1950) introduced schizophrenia, drawn
from the Greek, meaning “split mind.” He chose this term to replace the
earlier term, dementia praecox, which he considered less exact on the
basis that the disorder was not necessarily early (praecox) or dementia
(Moskowitz, 2008). What Bleuler wanted to emphasize about schizophre-
nia was that “the ‘splitting’ of the different psychic functions is one of its
most important characteristics” (p.â•¯8). Clearly, many of Bleuler’s patients
had what today we would describe as DID and dissociative disorder not
otherwise specified (DDNOS), Example 1, as described in DSM-IV-TR.
As previously noted, Bleuler and Jung were close collaborators, and
Bleuler adopted use of Jung’s term, complex, which was so similar to Janet’s
fixed ideas. Fixed ideas and dissociation were the hallmarks of hysteria,
and now we have dissociation also as the hallmark of schizophrenia. Thus,
as Moskowitz et al. (2009) observed, in the fruits of these collaborations
between Jung and Bleuler, we have the beginning of a nosological problem:
Dissociation was the hallmark now of both hysteria and schizophrenia.
Another confound is that hysteria and MPD were understood to be neuro-
ses with traumatic origins, while Bleuler believed that schizophrenia was
biologically based (Moskowitz et al., 2009).
With Bleuler’s (1911/1950) emphasis on the importance of dissocia-
tion in schizophrenia, dissociative disorders also came to be largely sub-
sumed under the category of schizophrenia. Writers such as Harold Searles
and R.Â€ D. Laing, who wrote on schizophrenia in the 1950s and 1960s,
described many cases of schizophrenia as involving overt switching of
identity states—clearly cases of DID. And even today, many people under-
stand schizophrenia as split mind and confuse it with DID, which in fact
it once included.
In the late 1800s and early 1900s, many clinicians, both in Europe and in
the United States, were interested in dissociation and dissociative disorders.
For the first decade or so of the 20th century, MPD, now termed DID, was
accepted and familiar. However, by the mid-1900s there was little explicit
interest in dissociation, and with a few exceptions, dissociation and MPD
became rarely discussed. After around the 1920s and until recently, disso-
ciation, along with the topic of child sexual abuse, had been largely disso-
ciated—if not banished—in psychoanalysis. Like dissociated content itself,
the topic of dissociation did not go away but kept popping up, sometimes
using different terms, but the clinical descriptions were similar. Jung wrote
of dissociative problems using his term complexes. Other theorists such as
Fairbairn and Ferenczi also wrote of dissociation, but most predominantly
used the word splitting rather than dissociation.
Much as he valued Freud’s work, Fairbairn (1944/1952a) felt that theory
needed to go back to hysteria for an adequate understanding of the mind.
Fairbairn’s thinking was also influenced by Janet’s view of the causal role of
dissociation in hysteria. Instead, however, of pursuing this line of thinking,
the theory Fairbairn developed emphasized the psychic structural conse-
quences of problematic attachments. Notably, Fairbairn believed that dis-
sociative and the schizoid personality organization was normative.
Fairbairn worked with sexually abused children and acknowledged the

importance of child abuse as a contribution to schizoid disorders. He wrote
of MPD (1931/1952b), although he did not emphasize it in the articulation
of his theory.
In his famous “Confusion of Tongues” paper, Ferenczi (1932/1949)
emphatically pointed to the problem of adults’ sexual exploitation of chil-
dren and its disastrous effects on their emotional lives. In this, as well as in
earlier papers and his Clinical Diary (Dupont, 1988), he clearly spelled out
dissociative responses to abuse and the clear structuring of the personality
into dissociated parts, stating, “There is neither shock nor fright without
some splitting of the personality” (1932/1949, p.â•¯229). He added that each
of the fragments behaves like “a separate personality yet does not know,
even of the existence of the others” (p.â•¯229). Like Fairbairn, Ferenczi also
viewed dissociation as normative, and according to Bromberg (2009):
Ferenczi pioneered the contemporary analytic view that regressive

reliving of early traumatic experiences in the analytic transference is
to some degree curative in itself because it encourages active mastery
of the traumatic “past” through use of the here-and-now analytic
relationship.â•¯(p.â•¯638)
Although the issue is complicated—Aron and Harris (1993) emphasized

that it was primarily Ferenczi’s unorthodox experiments with clinical tech-
nique rather than his views about the disastrous results of childhood sex-
ual trauma that disturbed Freud—Ferenczi was “diagnostically” slandered
(Breger, 2000) by Freud and Ernest Jones, who viewed him as demented,
a view contradicted by the reports of others that his mind was sound
(Rachman, 1997). However, the fact that everyone saw what happened to
him after expressing his views must have been important implicit profes-
sional instruction.
So, what happened to cause the sudden decrease in explicit attention
to dissociation in the early 20th century? One thing that happened was
that, from about 1910 to 1925, interest in dissociation was displaced by
psychoanalysis (Dell, 2009b). Concurrent with this was the encapsulation
of dissociation within the new diagnosis of schizophrenia. With respect to
social forces in the United States, Hilgard (1977) noted that three things
led to the decrease of the popularity of thinking about dissociation. First,
there was the rise of psychoanalysis with its focus on incestuous wishes;
next came the rise of behaviorism, which eschewed anything unconscious
or subconscious; finally, a third development had to do with academia,
where thinking about dissociation had also been current. Some academ-
ics, notably Clark Hull (Dell, 2009d), espoused the noninterference theory,
which held that there was no influence between dissociated parts of the
mind. Had these academics been clinicians, the incorrectness of this stance
probably would have been obvious. The position was correctly attacked
by other scientists, but the unfortunate result was that the theory of non-
interference then became a refutation of dissociation theory itself, and as
a result, “dissociation theory went out of favor without effective criticism”
(Hilgard, 1977, p.â•¯12).
However, dissociative symptoms did not just go away, but reemerged
under different names.
Back to Hysteria: Shell Shock

The symptoms of hysteria, the woman’s disease, returned in grand force in
soldiers during World War I, but it was called shell shock. Again, after the
Vietnam War, with so many psychologically damaged veterans returning
home, it became impossible to ignore the effect of trauma and traumatic
dissociation. PTSD became an official psychiatric diagnosis, replacing ear-
lier terms such as shell shock and battle fatigue. Soon, with the advent of
the women’s movement, it was noticed that not only soldiers were trauma-
tized but also women and girls by rape and child sexual abuse, with severe
dissociative consequences. Furthermore, these occurrences were not “out
of the ordinary” (Brown, 1991). Soon, child sexual abuse, along with its
dissociative consequences, became more thinkable almost a century after
Freud’s abandonment of the seduction theory.
Dissociation Today
Today, there is a resurgence of interest in the dissociative mind and how it
operates. Although relational psychoanalysts are in the forefront, the idea of
dissociation and multiple self-states currently influences much of the field of
psychotherapy. The current explosion in relational psychoanalysis concern-
ing dissociative processes has included writers such as Bromberg, Chefetz,
Davies, Frawley-O’Dea, Frankel, Grand, Harris, Hegeman, Howell,
Itzkowitz, Mitchell, Pizer, Reis, Schwartz, and D. B. Stern. However,
Bromberg has been the figure in the forefront as the first current writer to
publish prolifically about the universality of the dissociative mind. Oddly,
however, with a few exceptions, this interest in multiple self-states and dis-
sociation has not included much published writing about DID per se.
I think that, in large measure, DID has been considered rare because of
our need to believe that child abuse is rare. Since DID often results from
severe, chronic, early child abuse, staying unaware of the former leads to
the obfuscation of the latter. As Hegeman (2010) stated, “Disbelief is the
universal Western affective countertransference, both to abuse and shifts
in identity” (p.â•¯99). The idea that DID is rare serves not only to shield from
public consciousness the ugly and painful realities of a high prevalence of
child abuse but also to shield perpetrators themselves. Just as Freud’s social
environment was one in which child sexual abuse was common, so is ours.
Just as Freud may have understandably feared professional shame for his
beliefs and observations, current clinicians face the same dilemma.
Dissociative problems in living have never disappeared among the people
suffering from them. Starting in the late 1700s, clinicians were beginning
to describe, name, and treat dissociated people. For about a century, inter-
est and knowledge continued to develop in Europe and in the United States.
Since the early 1900s, it waned again for almost another century. Now
again, interest in dissociation and dissociative disorders is reemerging both
among clinicians and in the public. Although this reemergence comes from
a confluence of sources, such as increased awareness of the impact of psy-
chological trauma, awareness of the importance of dissociative disorders
in the mental health field can be attributed in large measure to the work of
certain pioneers, who had the insight and courage to recognize and name
DID. Most notable among these is the psychoanalyst Richard Kluft, who
has written prolifically and convincingly about DID. His work in many
ways brings psychoanalysis back to its origins, and he provides an insight-
oriented, somewhat modified psychoanalytic approach to the treatment of
DID. He has given clinicians a roadmap for treating DID. Frank Putnam, in
addition to his clinical contributions, such as the still unsurpassed text, The
Diagnosis and Treatment of Multiple Personality Disorder (1989), has con-
tributed research on the impact of early trauma and dissociation, includ-
ing his Discrete Behavioral States (DBS) model (1997), providing a basis
of knowledge that might have otherwise been unavailable. Colin Ross has
also written prolifically as well as conducted invaluable research on DID.
In addition to Kluft, Putnam, and Ross, other early towering figures in the
treatment of DID include Catherine Fine, Philip Coons, Elizabeth Bowman,
David Spiegel, Onno van der Hart, Jim Chu, Richard Loewenstein, Bessel
van der Kolk, Paul Dell, and Richard Chefetz. This list is by no means
exhaustive, and other towering clinician/writers such as Ellert Nijenhuis,
Kathy Steele, Steve Gold, and Bethany Brand have more recently enriched
and broadened the field with their contributions. 2
In addition to Kluft’s more traditional psychoanalytic orientation, some
relational psychoanalysts, notably Philip Bromberg, are also unearthing
and using the early “pre-psychoanalytic” constructs of psychoanalysis con-
cerning the centrality of dissociation not only in application to explicit dis-
sociative disorders, but also in application to more ordinary problems in
living. Steve Mitchell, the early pioneer in relational psychoanalysis, wrote
presciently and illuminatingly about dissociation and multiple self-states.
This relational perspective that encompasses dissociation and multiplicity
is greatly enriched by drawing explicitly on the dissociative mind of DID.
What is most important, in my view, is that working with DID and under-
standing this basic dissociative structure of the mind, makes it possible for
the clinician to understand the universal dissociative structure of the mind,
including minds that would not be formally diagnosed as having a disso-

ciative disorder. Reasoning backwards, how could it be otherwise? Trauma
is universal; so is dissociation.
This premise that the dissociative mind of DID is the “touchstone,” as
Bromberg (1993) has noted, for understanding other problems in living,
profoundly affects our understanding of general therapeutic action and
efficacy. With respect to extrapolating from work with DID to more usual
constructs of therapeutic action, an important avenue to therapeutic change
is to let other self-states have a voice and not to privilege the powerful over
the less powerful, or the more attractive, i.e., superficially more adaptive,
self-states over the less attractive ones, i.e., those that are more painful,
emotionally intense, and/or more discordant with cultural and/or gender
norms. It is important that the fears and desires of the more pain-ridden
self-states not be denied. This then leads to the importance of encourag-
ing inner dialogue—and eventually mutual acceptance among dissociated
self-states.
So, DID is not so unusual in its structure at all, but is the kernel behind
many other manifestations of psychic life, maladaptive as well as adaptive.
Notes
1. As I noted in The Dissociative Mind (Howell, 2005), Freud’s reconstruction of

the myth of Oedipus retained the traumatic roots of the story:
Even though his new theory seemed on the surface to move away from
themes of child abuse, it was, in fact, embedded in these. In his formulation
of his new oedipal theory, Freud focused only on the part of the story about
the embattled tragic hero who marries his mother, and he “forgot” (in a way
that could be understood as Bartettian reconstruction; see Erdelyi, 1985,
1990, 2001), the beginning framework of the Oedipus story, which had to
do with sexual abuse and pederasty (Devereux, 1953; Fromm, 1980; Ross,
1982; Pines, 1989; Betcher & Pollack, 1993; Brothers, 1995). The reason
for the curse, which was Oedipus’s fate, was that prior to his ascension to
the throne, his father, King Laius, had abducted and raped the teenage son
of the king Polybus, the ruler of a neighboring kingdom. Polybus’s retalia-
tory curse was the one we all know: Laius’s own son would murder him
and marry Laius’s wife, his mother. To avoid the curse, Laius instructed
that his infant son be abandoned to die with a stake pierced through his
ankles (hence the name Oedipus meaning “swollen foot”). Oedipus was
rescued and brought up as the son of a neighboring king. He left home to
avoid the curse prophesied by the Delphic Oracle (Ross, 1982), but met
his fate anyway when he quarreled with and slew another traveler, who,
unbeknownst to him, was Laius, his real father. Thus, Freud’s most famous
myth was framed in themes of child abuse, both pederasty and infanticide;
but he only focused on the tragic adult struggles that were the outcomes of
these early circumstances—as if these meanings could be segregated from

their earlier history. (p.â•¯72)
2. Partly because of the efforts of Kluft and Ross, we have the new Showtime
series, The United States of Tara (Cody & Kaplow, 2009), which has DID as
its topic and follows the fictional life of a woman with DID.
Chapter 3
“The We of Me”
Personality Organization in DID
Due to a simple arithmetical mistake: [People] have failed to notice that

two or three or seventeen selves per body is really not more metaphysi-
cally extravagant than one self per body.
Dennett (1991, p.â•¯419)
Janice, introduced in Chapter 1, refers to herself in her mind as the “We of

Me” and has done so, even though she did not know that she had dissocia-
tive identity disorder (DID), for as long as she can remember. Her phrasing
is extraordinarily apt for others with DID as well. This chapter addresses
the personality organization of that We of Me.
In psychodynamic psychotherapy with a person with DID, just as in less
overtly dissociative or less severe problems in living, the clinician works
with the psychodynamic system of the patient. But in DID, these psychody-
namically interacting parts have their own separate centers of subjectivity,
identity, autonomy, and sense of personal history. What are the different
parts like? How did they develop? What are their functions? How do the
different parts of the system operate together? What are their interrelation-
ships? How is the organization of self-states structured? Did this organiza-
tion work in some way in the family of origin? If so, how? What are the
sources and patterns of antagonism and harmony in the system?
Persons with DID generally experience their different dissociated parts
as different “people.” They do this even when at the same time they con-
sciously acknowledge that their different identities are all part of the same
person. It is also common for clinicians, especially those new to DID, to
on some level subjectively experience different presentations as different
“persons,” especially when there are significant differences in voice tone,
inflection, posture, facial expression, attitude, use of language, and so on.
The clinician must tread a fine line with respect to honoring the patient’s
subjective experience but also always be clear that, even though experien-
tially different, all of the parts participate in one overall personality system,
as well as sharing one body. The different identities are highly interrelated
parts of a system that comprises the total person.
55
The basic organization of the self-states in DID includes those who mostly
operate on the surface and interact with the world, as well as parts less fre-
quently interacting with the outside world, such as those who hold traumatic
experiences. Parts may be differentiated, among other things, by function
and affect state. Enmity, aversion, and opposition to the affect states of other
parts contribute to the continuing separation of parts. For example, some
parts may hold memories of terror, others of fury. The parts who maintain
functionality in the everyday world most often do not want to be affected
by the terror or the fury held by other parts because these affects are likely
to be destabilizing. They are destabilizing with respect to the continuity
of effective functioning in the workaday world and because the traumatic
memories held by other parts are often close to unbearable in themselves.
Accessing these can also be an assault on the sense of continuing selfhood.
There is often antagonism between parts, with different parts holding
different kinds of memories and having opposing views about how best
to manage unmanageable feelings, as well as how to get on with the busi-
ness of daily living. One of the reasons there is such antagonism is that it
was not possible early on for the horrible dissociated experiences to be wel-
comed into dialogue with an affectionate and accepting other person, and
this could not be internalized. Thus, the functional parts are the only ones
accepted and recognized by other people. The parts holding the terrible
memories are exiled and treated as “not-me” (Chefetz & Bromberg, 2004).
In the internal world of the person with DID, a common pattern roughly
conforms to the Karpman drama triangle (1968), composed of parts who
are the suffering victims, the perpetrators, and the rescuers. Victim parts
are often suffering children, and their identities have to do with the rela-
tionships with the abusers, corresponding to certain affective and cognitive
understandings of these relationships, as well as the age of the child at the
time of traumatization. Abuser parts often represent internalizations of the
early persecutors. Rescuer parts are frequently framed around significant
positive, real persons in the patient’s life, and they may also be framed
around restitutive fantasies. The interrelationships among the parts also
repeat the kinds of relationships that the patient experienced and witnessed
in childhood.
A common organization in females with DID is of a somewhat drained,
nonconfrontational, and submissive part who is most often in executive
control, along with dissociative rageful and terrified parts, child parts, and
so on, who are not usually “out front.” Such an organization may well have
worked in the family of origin, protecting the child from knowledge, affects,
and behaviors that would have been dangerous or too disorganizing. As a
result, though, these DID patients often feel chronically victimized and
chronically disempowered. Although cultural gender patterns often allow
more conscious aggression for males with DID, this is not always the case.
And there are females whose host is not drained and depressed: they may
“The We of Me”â•… 57
be angry, compulsively optimistic, or openly guarded, for example. The

important thing to bear in mind is that the part out front most of the time is
not the whole person—there are other identities dissociated from this one.
The number of parts in a DID system usually ranges in the teens. In some
cases, it is only a few, and there are also polyfragmented multiples who
have many, many parts—perhaps close to a hundred or more parts. Many
people with DID have parts with names, but this is not always the case. For
some, the parts do not have names but perform functions or hold emotions.
And, some people may have different parts with names and other parts
who do not have names.
Dissociative identities exist in a third reality (Kluft, 1998, 2000), an
inner world that is visualized, heard, felt, and experienced as real. This
third reality is often characterized by trance logic. In trance logic, ideas
and relationships of ideas about things in reality are not subject to the
rules of normal logic. Because they are kept in separate “compartments,”
contradictory beliefs and ideas can exist together; they do not have to
make sense. In this way, the internal world contains many subjectivities
that experience themselves as separate people. There is a pseudodelusional
sense of separateness and independence (Kluft, 1998). Trance logic is char-
acteristic of dreams and hypnosis. Because of this freedom from logical
critique, identities existing in a person’s third reality may seem fantastical.
However, they are experienced as just as real as are the religious convic-
tions and experiences of some, which might be seen as “fantastical” from
a strictly logical point of view.
Dissociated parts of the person often have different physical images of
themselves and of each other. For instance, Dennis, introduced in Chapter
1, has a female part who has comforted him since childhood. He describes
her as having beautiful black hair. In his third reality (Kluft, 1998), she was
visualized exactly this way and experienced as real.
Corresponding to the trance logic, different dissociated parts often
have different psychophysiological organizations, such as different aller-
gies, taste preferences, handedness, eyesight and glasses prescriptions, and
responses to medications. The organization of self-states is often imagined
in three-dimensional space. The parts are often layered behind one another,
with those representing deeper trauma behind deeper layers of identity
states (Kluft, 1993, 2000, 2009). Frequently, they are grouped or clustered
together (Fine, 1993), for example, with child parts of approximately the
same age together. Or, parts may be contained within another part. For
instance, in drawing the parts in her system, one of my patients drew a
picture of a very fat woman who was fat because she had within her three
other identities.
How do we understand and define these dissociated parts or alters? As
Kluft (2000) noted, “Alters may be understood as rather desperate efforts
to disavow and mitigate the impact of overwhelming life events” (p.â•¯267).

In 1988, Kluft provided a more precise definition of the word alter:
A disaggregate self-stateâ•ƒ.â•ƒ.â•ƒ.â•ƒis the mental address of a relatively stable

and enduring pattern of selective mobilization of mental contents and
functions, which may be behaviorally enacted with noteworthy role-
taking and role-playing dimensions, and sensitive to intrapsychic, inter-
personal, and environmental stimuli. It is organized in and associated
with a relatively stable (but order effect dependent) pattern of neuro-
psychophysiological activation, and has crucial psychodynamic con-
tents. It functions both as a recipient, processor, and storage center
for perceptions, experiences, and the processing of such in connection
with past events and thoughts, and/or present and anticipated ones as
well. It has a sense of its own identity and ideation, and a capacity for
initiating thought processes and actions. (p.â•¯51)
Among the most commonly encountered parts, or alters, are (a) the part
who is in executive control most of the time (i.e., the host); (b) child parts;
(c) abuser or persecutor parts, including parts modeled after the abusers;
(d) differently gendered parts; (e) seductive parts; (f) protector, rescuer,
or soother parts; and (g) a manager. There are also commonly adolescent
parts; angry and terrified parts of different ages; homicidal and suicidal
parts; parts named Satan, Lucifer, Devil, Demon, and such; parts named
No One; mute parts; dead parts; extremely functional and efficient parts;
parts who know a language or a skill that others do not know; gatekeeper
parts who keep other traumatized parts from emerging; parts who have
various other functions such as The One Who Watches and Remembers;
and sometimes animal parts. There are also often parts who are really just
fragments with one isolated function, such as The One Who Cooks, The
One Who Cleans, and so on. Parts may change in the way they function
and in their positions in the system over time.
The Part in Executive Control

Most of the Time
The part of the self who is in executive control most of the time is generally
called the host. I prefer not to use the term host because of the inference
that the person is possessed and that exorcism is the cure and because of the
association of host with parasites. In addition, the association of host at a
dinner party or for houseguests suggests that this part of the person is host-
ing the other parts. The term also conjures up images of pods from science
fiction stories and films. The advantage of the term is that it is one word,
and for this reason, using it is sometimes the best way to be clear. Therefore,
I frequently use other phrases, such as the usually presenting part, the part
who appears most of the time, or the part in executive control most of the
time, but when necessary, I use host. Kluft (1984) has described the host as
“the one who has executive control of the body the greatest percentage of
the time during a given time” (p.â•¯23). This part of the person usually goes
by the name that the patient goes by, the name used socially in the world.
This part is the one out front and actually often functions as a kind of shell,
a front. In accordance with gender, among other things, the presentation
of the host may vary.
Especially in women, the part in executive control most of the time is
likely to be compliant, depressed, depleted, and masochistic. In many cases,
though, this part may be energetic, idealizing, or cheery, while other parts
hold grief, terror, rage, and depression. (Of course, these are not the only
structured patterns; there are many variations and combinations.) What
is constant is that the experience of the part or parts who function and
interact in the world most of the time has been protectively separated from
those of other encapsulated parts who hold powerful emotions such as rage
and terror, as well as memories that would be too destabilizing for the func-
tioning of the person if the host were conscious of them. Thus, the more
depressed, depleted, and masochistic front parts have in their personality
system other parts who hold, for example, rage, anger, terror, pain, and
agency. The energetic front parts are likely to serve in a counteracting way
to the dissociated very depressed and hopeless, and sometimes dead, parts.
Different parts can take over as host at different periods in a person’s life.
They may or may not have coconsciousness with the preceding usually pre-
senting part. One of my patients described how she suddenly “came to” in
class one day when she was about 8 years old, having forgotten everything
she learned the previous year but feeling more in contact with her self of prior
years. Another described how, as an adult, an alter different from the usual
host acted as host for a period over 1 year. Interestingly, this was contextu-
ally bound: She was living in a different location than her usual domicile.
It is frequently noted that the usually presenting part is not the original
personality. Actually, this part could not be the original personality because
no one has an original personality. A person’s sense of self and identity is
built up and synthesized over time (Putnam, 1997). Furthermore, the usu-
ally presenting part is, by definition, a part in relation to and in relationship
with other parts in the total organization of the personality. People do not
start out in life unified but developmentally accomplish the joining and
harmonious functioning of different behavioral and mental states (Putnam,
1997). However, those people who develop DID are likely to have received
much less help from their parents or caregivers in identifying, linking, and
accepting their emotions and thoughts, such that the internal working mod-
els that they developed of relationships are more likely to be contradictory
and segregated.
The part most often in executive control is not necessarily only one part
and may be comprised of various look-alike versions who may or may not
have coconsciousness with each other, and who take over for each other
when one of them gets too tired or is unable to deal with the current situ-
ation. In some cases, no one individual host is in executive control most of
the time because there are so many of them who have ever so slightly differ-
ent important roles to play in daily life. Janice, introduced in Chapter 1, is
often anxious when she thinks about her identity because there are so many
of them who take control when needed—so many “hosts” who fill in for
each other—and she does not know who she is. This is a terrifying thought
to her. Much of the time when she wakes up in the morning, she does not
know who she is. It takes the wearing on of the day, with a pattern of dif-
ferent self-states being triggered by different activities and demands, for her
to begin to feel comfortable in an organization of self.
Another patient discovered that the part of her that most often presented
in the world was primarily a shell that in its own cumbersome way did
conduct transactions with the world but had little vitality or consistent
ongoing perceptions. She described how, when in this self-state, she could
recognize and catalogue events: She would deliberately pull up in her mind
many visual flashes of past situations and events, and then she would regis-
ter current situations by referencing them according to the many different
visual flashes of other similar events of other times. This patient even drew
diagrams in which the outer layers, depicting the surface of interaction
with the world, bore the patient’s given name, while more articulated parts
were on the inside. As she became more integrated, a more vital part of
her who had grown up in the psychotherapy from a young child to an ado-
lescent, decided to take over the role of controlling executive functioning
most of the time. This part, who had originally had a different name in the
system, decided to take the patient’s given name, the name that the previous
host had used.
Child Parts
Most people with DID have at least several child parts. Child parts tend to
hold most of the abuse memories. As a result, they are often exiled in the
system (Schwartz, 1997) and avoided (Van der Hart et al., 2006) by other
parts in the system, including the host, who do not want to be bothered with
their painful feelings. Although it may seem odd to say this, one should keep
in mind that child alters are not real children. Even while speaking in child-
like ways, child alters often understand abstract concepts and long words.
As Shusta-Hochberg (2004) noted: “It is important to remember that the
patient is an adult, despite the childlike ego-states. These parts are not
actual children” (p.â•¯16). This is in agreement with Ross’s (1997) statement
that “child alters are not packets of childness retained in a surrounding sea
of adult psyche. They are stylized packets of adult psyche” (p.â•¯147). The
ages of child parts often correspond to ages at which they were abused, yet
they may also be younger or older. Some may mature and become older in
the treatment, as well as in life, and some may stay the same age.
A child part’s identity often corresponds to particular kinds of relation-
ships with the abuser. Different interpretations of and responses to trau-
matization may be expressed by parts who have different memories of
traumatic experiences and attitudes toward the abuser. For instance, one
incestuously abused adolescent part has great affection for her perpetrator
parent and speaks about the relationship in accepting, even caring, ways,
while another part the same age hates him. Often, there may be twins, in
which one child part is compliant and eager to please, and another child
part is The Evil One. Some child parts hold memories of terror and pain.
Some may be mute, expressing how they have learned that they may not
tell anyone, and some may only be able to whisper, indicating their terror
of being heard or noticed. Behind some traumatized parts, there are often
more traumatized others. Some parts have the job of performing sexually.
Other enraged ones may appear to have identified with the abuser and may
behave in ways that are destructive to the body. Others do not themselves
hold traumatic memories and may be able to enjoy things they actually did
as children, such as play with toys or watch cartoons. Defensive reliance
on child parts who only play can be a problem for an adult who needs to
be engaged in a world of other adults. For instance, Josephine managed to
escape from awareness and memory of her mother’s physical abuse when
she was young by playing and being “happy.” Now, when things upset her,
she frequently reverts to being a playful child, rather than dealing with the
difficult situation.
Rescuer, Soother, and Protector Parts
Rescuer, soother, and protector parts all have different manifestations. These
parts may be overtly protective, as in a caretaking part, often modeled on a
real person. Or, they may be invented. Soother parts are often modeled after
an adult figure, such as a protective and caring grandparent who was a source
of protection and solace for the patient when she was a child. For instance,
there may be a part named after a loving babysitter or a benign grandparent.
In many cases, however, there was no such model, and personified hope
was created in a new part. One patient, who had been brutally abused,
isolated, and often exposed to severe neglect, described how she would
make protectors and friends of the rocks and bushes and believed they
would care for her. A part may be an invented kindly mother figure and
may be named after an important valued attribute, such as Hope or Faith,
or even after a physical thing, such as a hard beautiful rock. For instance,
a patient had a part named Diamond who watched over her. Diamond had
been through the earth’s compression and could now withstand all man-
ner of stresses. Diamond could not be hurt and could therefore be relied
on as a soother/protector. As Ferenczi (1931) wrote, “The man abandoned
by all godsâ•ƒ.â•ƒ.â•ƒ.â•ƒnow splits off from himself a part which in the form of a
helpful, loving, often motherly, minder commiserates with the tormented
remainder of the self, nurses him and decides for himâ•ƒ.â•ƒ.â•ƒ.â•ƒso to speak a
guardian angel. This angel sees the suffering or murdered child from the
outside” (p.â•¯237).
Protector parts may also be fighters. Their job is to protect the patient
from external danger. One of my female patients described how when a
menacing person came into the subway car, a strong male part came out
who was ready to fight. Protector parts may also have had the original
function of anticipation of or identification with the abuser. To preemp-
tively protect the child so that the child may anticipate the abuse rather
than be surprised by it, protector parts become persecutors modeled on
the abusers. Thus, parts who were protectors when the person was a young
child may become persecutors in time, holding anger and rage and meting
out punishments to other parts of the self.
Abuser Parts Are Common
Abuser parts generally hold rage and contempt for the most frequently
presenting part as well as other parts. They are often responsible for self-
injury and may at times be homicidal toward the host or other parts. Often,
they are angry adolescents—or angry children—bent on feeling powerful.
Unfortunately, this can be accomplished without difficulty in the third real-
ity (Kluft, 1998) of the internal system, and these parts may torture or
abuse little child parts in the system who cannot fight back, or they may
abuse the host or other parts. These abuser parts are often named Satan,
Devil, Lucifer, or Demon. Sometimes, they have more esoteric names, such
as those of mythological figures or of powerful gods or goddesses of differ-
ent cultures. Usually, these parts can become engaged in the treatment such
that they become important allies. As this occurs, they bring much more
agency and energy into the person’s conscious life.
Although this may not be initially apparent, most of the time the angry
parts and those modeled after the abuser all function protectively at the
deepest level. These parts live in the past, and they are protecting the per-
son from behaving in ways that would have been dangerous in the past.
For example, Janice, introduced in Chapter 1, has a part called Ereshkigal,
named after the Sumerian goddess of destruction. She believed herself to be
all powerful. She wanted to kill the host, whom she believed to be “wimpy”
and not deserving of life. I was able to engage with her by intuiting her
protective function: “I bet you were very much able to make her behave
perfectly in that family of hers. She should be very appreciative for all the
help you gave her. I think she really needed your help.” Her first response
was, “Yes. I was pretty good at that. But she is still just a piece of crap and
deserved everything that she got.” But soon afterward, she was able to
appear protectively in situations when the patient was the object of some-
one else’s aggression. In time, the patient was able to recognize simply that
she was angry without Ereshkigal’s appearance.
There are, however, some cases in which psychopathic parts are not pro-
tective but wish only for their own power (Blizard, 1997; Bryant, Kessler,
& Shirar, 1996; Rosenfeld, 1971). Working with these parts is much more
difficult. Curtis (1997) reported on a patient with whom he had been work-
ing who had a psychopathic part who committed a serious crime. Since the
whole of him was not psychopathic, he reported this to his therapist and then
turned himself in to the police.
Differently Gendered Parts
Many people with DID have differently gendered parts. These are often
highly stereotyped, not only as gender tends to be but also in accordance
with the fact that young children rely more heavily on stereotypes than do
adults (Bem, 1983). Some of my female patients have male parts who are
strong and can be aggressive. These parts appear when there is a perceived
physical danger. Their presence is a protective comfort, and it can also be a
physical asset, coming in handy when needed, for these parts can be extraor-
dinarily strong, much stronger than the host. For instance, one of my patients
who was going door to door as part of her work, felt threatened at one point.
A male alter emerged who then frightened the threatening person at the door.
Male parts may also represent identifications with male abusers. Often male
parts are more psychologically protective against the stereotyped perception
of female vulnerability. They may believe that if they are boys, then they can-
not be raped as girls are. In addition, the gender of some male parts derives
from the physical circumstance that they were anally raped.
Male patients with DID may also have female parts. Similarly to male
parts of biological females, these parts have various functions. They may
represent the experience of being raped and demeaned by the abuser, who
called the patient “sissy” and “girl.” Or, female-identified parts in male per-
sons may be identifications with a female abuser. Or, female parts may serve
a different function altogether: As stereotypically nurturing females, they
may provide internal comfort to a distraught and traumatized little boy.
Managers
Managers usually have extensive knowledge of events and of the system. They
are often available to explain to the therapist the internal systemic dilemmas
that are not otherwise evident. Generally, they are fairly empty of affect.
Another term for managers has been internal self-helpers (Putnam, 1989).
However, in my experience, so-called managers and internal self-helpers
may have agendas of their own, which may not be best for the well-being of
the person-as-whole. I remember meeting one self-identified manager/helper
who had all the characteristics of knowledge and minimal affect; however,
it turned out what she really represented was a defense against interaction
in the world with other people. She had minimal affect because that was her
defensive style, not because she was a manager or internal self-helper.
Psychotic Parts and Dead Parts
At times, people with DID have parts who are psychotic. This does not
mean that the whole person is psychotic, but that only a part of her is.
As such, when a person with DID presents with psychotic behavior, it is
important to assess whether there is a psychotic part. Another possibility is
that the seemingly psychotic behavior is not psychotic at all but is the result
of flashbacks of experiences that have not been labeled or contextualized.
As a result, the patient cannot explain the bizarre behavior, which from the
outside may appear psychotic (Moskowitz et al., 2009).
The topic of dead parts shares commonalities with psychosis. Some per-
sons with DID have endured such horrific abuse that they believed they
were about to die and that they did die. These dead parts have then been
locked away, only to reemerge when the person experiences extraordinary
stress that brings into question the viability of existence. For instance,
Margaret, introduced in Chapter 1, began to talk about how she was sure
she smelled like rotting flesh and how she thought she was dead and others
around her just did not notice. She wondered how long it would take oth-
ers to realize she was dead. Further exploration revealed that as a child she
had nearly frozen to death, in addition to earlier near-death experiences.
This part of her experience was too much for her to endure and could not
be assimilated. There was no one around who could help her to assimilate
her experience and to recognize that she had lived through it. Although
Margaret managed to survive, the experience of nearly dying and believing
she had died became locked away in her inner world as a dead part.
Animal Identities
Some people with DID have animal parts. While in animal identity states,
they may exhibit animal-like behaviors, such as growling, scratching, or
running on all fours (Goodwin & Attias, 1999; Putnam, 1989). They may
also hear animal calls inside the head (Goodwin & Attias, 1999) or have
visual flashbacks involving animal identities. Other clinical cues that may
indicate the presence of animal identities include excessive fear of animals,
excessive involvement with a pet, and cruelty to animals (Hendriksen,
McCartney, & Goodwin, 1990).
Children often identify with animals and experience them as peers and
friends. Abused children may develop animal parts they experience as pro-
tectors, peers, or both in an environment where there was no protection.
Or, the patient may have identified through loss with a beloved pet that was
lost, innocently killed, or murdered to terrify the child, to demonstrate the
abuser’s omnipotence, or to enforce silence.
Sometimes, parts named after the cat family (leopard, cougar, tiger) may
serve as protector states that are allowed to express the emotion the host
cannot. One of my patients would begin growling and switch into Tiger
when she became upset. On the other hand, the presence of cat-family
parts, or other animal parts, may be more serious and indicate the possibil-
ity of dangerous violence—something that should be assessed.
Animal identities may also be self-representations that are consistent with
the abuser’s treatment and labeling of the child. For example, the child may
have been treated like an animal. Dog parts are not infrequent identifica-
tions. A part named Dog may represent how the patient was treated like a
dog and forced to bark like a dog by her abusers (Bryant et al., 1992). Or,
the child may have been forced into sexual behaviors with animals, leading
to a view of the self as an animal or as bestial and inhuman. Hendriksen et
al. (1990) described a patient who was forced by her parents to eat out of a
dog bowl and to act like a dog. Her father then involved the family dog in
acts of bestiality in his abuse of her. Any reference to sex made her feel as if
she “turned into a dog,” and she did indeed then act like a dog. Further, as
Hendriksen et al. (1990) stated:
Working with animal alters is helpful in addressing the extreme guilt

resulting from participation in acts felt to be inhuman. Because of the
victim’s induction as a co-participant in animal torture, the issue of
responsibility has become even more muddled than in other incest situ-
ations. The animal is often chosen for victimization because it is the
child’s pet. From the patient’s point of view, their pet was victimized
because they loved it. Therefore, the child’s love itself is contaminated
and potentially lethal. This, together with the victim’s extreme guilt
about the seriousness of the infraction, leads to self-esteem deficits at
the level of not experiencing oneself as a member of the human race.
Work with the animal alter can be a pathway to self-forgiveness for
the victim. As therapist and patient begin to understand the animal
alter and its violent propensities as a natural consequence of sadistic
abuse, the patient’s underlying sense of beastliness becomes accessible

to treatment. (p.â•¯221)
Animal parts may also express evaluations of one’s own experience met-
aphorically. My patient Anna experiences herself at times as a fish and as
different kinds of snakes. This probably derives from the fact that she grew
up in a coastal village where many people fished for a living. Sometimes,
she awakens from sleep, feeling that she is wriggling like a fish, and is
unable to use her arms and legs for a few minutes. Perhaps the brutal way
she was treated, often with her arms and legs pinned down, made her feel
like a “beast of prey,” and she understood this feeling in terms of something
with which she was more familiar—as if she were one of the fish that were
so much a part of her home environment. The expectation of ruthless dom-
ination is reflected in her dyadic animal identity constructions: Sometimes,
she is afraid to go into the bathroom because she sees in there a big fish
and a little fish. The little fish is no longer flapping around but is now half-
dead. During the time of her abuse and imprisonment as a household and
sexual slave, she also felt half-dead, with no strength or energy. She also
switches into snake identities, even though she was not familiar with snakes
where she grew up.â•¯One of these is a cobra identity that she experiences as
a protector. Sometimes in the sessions, when she switches to this identity,
her face and chest puff up, almost as one would imagine a cobra. She also
hallucinates snakes that represent her abuser, specifically the penis. Indeed,
she has at times hallucinated her abuser as a 6-foot-long snake in bed with
her. During the time of Anna’s abuse in a strange land far away from her
home, there was no human being—other than another little girl at school,
when she was allowed to go—to whom she could turn for empathic under-
standing or help.
Animal identifications in children and in adult patients without DID also
occur. Goodwin and Attias (1999) comment on the meaning of insects for
Kafka and note that in Freud’s famous case of the Rat Man, the patient was
tormented by the fear that a rat would eat into his anus. As Freud (1909)
noted, “He could truly be said to find ‘a living likeness of himself in the
rat’” (p.â•¯216, cited in Goodwin & Attias, 1999, p. 257).
Different Conceptual Schemes

forÂ€Understanding the Organization
of Parts of the Self
A number of schemes have been introduced that DID therapists have found
helpful in understanding the organization of dissociative parts. As men-
tioned, one such is the Karpman (1968) drama triangle, which consists of
the victim, the abuser, and rescuer. Although not specifically addressing
DID, Davies and Frawley (1994) described the internal psychodynamics

between an adult persona who takes care of daily functioning in the world
and the child personae, who are less adjusted, more demanding, and protest
against the constraints imposed by the adult self. The child and adult selves
feel betrayed and abandoned each by the other.
Davies and Frawley (1994) introduced a useful scheme for understanding
transference and countertransference positions in trauma work as well as
typical associated self states. This includes four matrices encompassing eight
relational positions. These matrices, as described by the authors, include the
following:
• the uninvolved nonabusing parent and the neglected child;
• the sadistic abuser and the helpless, impotently enraged victim;
• the omnipotent rescuer and the entitled child who demands to
be rescued;
• the seducer and the seduced. (pp. 167–185)
More recently, Frawley-O’Dea (1999) added a fifth matrix to the original

four: the certain believer and the chronic doubter.
Several authors in the field of dissociation have offered useful conceptual
schemes for the organization of dissociated parts. Frankel and O’Hearn’s
(1996) ghetto model describes roles of antibonding alters who perform
much like the kapos in concentration camps. His model of antibonding
parts has much in common with Fairbairn’s (1944/1952, 1951) description
of the antilibidinal ego.
Richard Schwartz (1997) introduced his internal family systems model, in
which he outlined the roles of exiles, managers, and firefighters. The exiles
are usually child parts who hold painful memories along with fear, needi-
ness, and shame. Because these memories and feelings, when conscious,
make the person vulnerable, the parts who hold them are banished. The
managers have the job of running the person’s life. (They are distinguished
from the internal managers of the system previously described.) Managers
may have different characteristics, such as being controlling, perfectionistic,
risk avoidant, or caretaking of others, but they all have the job of keeping
the exiles exiled to keep the feelings they hold out of consciousness. There
are times, however, when the exiles will be triggered by life circumstances
despite all of the manager’s best efforts. When the exiles threaten to break
out and flood the person with their feelings, another group of parts, the
firefighters, emerge to put out the fire of these feelings (Schwartz, 1997).
The firefighters are often substance-using or self-harming parts whose pur-
pose is to put out the internal fire of emotions associated with memories
of traumatization. This scheme is close to the experience of many with
DID, and for those who have addictions, it helps to give them a conceptual
handle on their compulsions for extinguishing pain.
Inner Antagonisms: The Theory of the

Structural Dissociation of the Personality
What these models have in common is antagonism between parts, with

different parts holding different kinds of memories and having opposing
views about how to conduct a life and how to manage unmanageable feel-
ings. A comprehensive theory that explains this antagonism between the
different parts of the personality is Van der Hart et al.’s (2006) Structural
Dissociation and the Treatment of Chronic Traumatization. This theory
is synthesized from a number of different sources, including Janet’s initial
observation that dissociation results from trauma and that the effects of
this affect the person’s behavior and thoughts subconsciously; Putnam’s
(1997) discrete behavioral states (DBS) model; evolutionary theories of ani-
mal defense; the thinking of Charles Myers (1940), a World War I physi-
cian/psychologist; neurodevelopmental theories; and knowledge regarding
psychobiological action systems.
These last are innate, self-organizing behavioral systems. Under the
impact of trauma, especially chronic trauma, two types of psychobiologi-
cal action systems—the ones devoted to daily life and the ones devoted to
defense—become segregated and divided against each other (Van der Hart,
Nijenhuis, Steele, & Brown, 2004).
Van der Hart et al. (2006) noted the remarkable correspondences between
these two sets of psychobiological action systems, having to do with daily
life and defense, and the parts of the personality that Charles Myers (1940)
observed in posttrauma patients: the emotional personality and the appar-
ently normal personality. Van der Hart et al. (2006) corrected this termi-
nology to the emotional part (EP) of the personality and the apparently
normal part (ANP) of the personality. According to the theory of the struc-
tural dissociation of the personality, as a result of trauma, the EP remains
fixated in the traumatic experiences, which it often reenacts. It is focused
on a narrow range of cues that were relevant to the trauma. This leaves a
constricted ANP to conduct the daily business of life. To do so, the ANP
must avoid the affect and information held by the EP. It is important to
recognize that this aspect of the personality is only apparently normal;
it is not the same as the personality before the trauma. It is much more
constricted and is subject to intrusions of the EP, including nightmares,
dreams, somnambulism, intrusive thoughts, flashbacks, and somatoform
symptoms.
The ANP is vigilantly avoidant of the information and affect held by the
EP. Indeed, it is likely to be partially or totally amnestic for the trauma.
It is phobic of the memory of the trauma, of cognitions, emotions, as well
sensory memories encoded in the body having to do with the trauma. The
topics of trauma may be passively avoided or actively suppressed. In either
case, over time, the avoidance is likely to become automatic. Because of
the vigilance and constriction required by such avoidance, this aspect of

the self, only apparently normal, does indeed differ substantially from the
premorbid presentation.
The most important point about the ANP and the EP is that they are
dissociated, as separate dissociative parts of the personality. Even though
the ANP may often appear to have a larger scope and greater functional-
ity, once there is an EP, the ANP can only be a part of the personality. It
is not correct to say that the EP is dissociated from the ANP as if the ANP
is whole and unaffected except for those intrusive troublemakers, the EPs
(Van der Hart et al., 2006).
The action systems that correspond to the ANP and the EP are, respec-
tively: (a) action systems devoted to carrying on daily life, such as those
concerning reproduction, childrearing, attachment, sociability, explora-
tion, and play; and (b) defensive action systems and subsystems devoted to
the survival of the individual in conditions of threat. These last defensive
action systems and subsystems of the EP include hypervigilance, fight, flight,
freeze, and total submission. The freeze state is accompanied by analgesia;
the total submission state is accompanied by anesthesia. Related to defense
is a subsystem of recuperation, in which pain perception is reinstated, and
wound care begins (Nijenhuis, 1999; Nijenhuis, Van der Hart, Kruger, &
Steele, 2004; Van der Hart, Nijenhuis, & Steele, 2006). Thus, the EP is fix-
ated in the action system of defense, such as hypervigilance, fight, fright,
freeze, and total submission.
Van der Hart et al. (2006) emphasized that persons with DID are beset
with what the authors called tertiary structural dissociation, which they
contrasted with primary and secondary structural dissociation. Primary
structural dissociation involves one EP and one ANP. An example of pri-
mary structural dissociation is simple posttraumatic stress disorder (PTSD).
Here, the ANP tends to be detached and numb, characterized by partial or
complete amnesia of the trauma, whereas the EP is usually limited in scope
but is hypermnestic, reexperiencing the trauma (Van der Hart et al., 2004).
Secondary structural dissociation involves one ANP and more than one EP.
Examples of secondary structural dissociation are complex PTSD and dis-
sociative disorder not otherwise specified (DDNOS). Secondary structural
dissociation is characterized by dividedness of two or more defensive sub-
systems. For example, there may be different EPs who are devoted to flight,
fight, freeze, total submission, and so on (Van der Hart et al., 2004). In
tertiary structural dissociation, there are two or more ANPs as well as two
or more EPs. There may be different ANPs who perform aspects of daily
living, such as work in the workplace, childrearing, and playing.
For example, my patient Anna, who has DID and was frequently raped
and used as a prostitute by her caretakers, at times wakes up from sleep as
if fighting someone off with her flailing arms and legs. This activity, over
which she has no control, is the intrusion of an EP of her personality. When
she began treatment, Anna had florid DID and intrusive and reenactive
PTSD symptoms but lacked coherent memories of the causes of many of
her symptoms. In treatment, she has been recapturing and piecing together
memories of her early adolescence by means of flashbacks and somatic
reenactments. Sometimes, these relived traumatic experiences have taken
hours or even days to unwind—like an unstoppable film, from beginning to
end. She has been, in effect, spellbound to watch and participate in, again,
the horrors that have already happened. However, unwelcome as they
have been, many of these memories have now become narrative memories.
Horrible as they were to experience, she now has the memory, a memory
that is autobiographical, because she was truly “there,” as she was not in
the first experiencing, in the reexperiencing. These lengthy flashbacks can
be understood as the intrusions of different EPs. Like many of the vic-
tims of child sexual abuse, Anna did not initially remember these events as
narrative memory but initially experienced them as flashbacks, dissociated
visual imagery, and somatic, motor reenactments.
The Closed System, the Self-Care

System, and the Third Reality
The organization of self-states in highly dissociative people is a partially

closed system, which has elements in common with the self-care system
and the third reality (Kluft, 1998). An open system allows interaction with
the outside and transformation of the individual through interactive inter-
change with others. It assumes interaction with, and influence from, the
outside. A whole is more than the aggregate of its parts because it is in
constant interaction with, and thus continually transformed by, the envi-
ronment. Fairbairn (1958) contrasted the closed system of internal objects
and the parts of the self that are attached to them, to an open system that
allows for interaction with the outside. He noted:
A real relationship with an external object is a relationship in an open

system; but, insofar as the inner world assumes the form of a closed
system, a relationship with an external object is only possible in terms
of transference, viz., on condition that the external object is treated as
an object within the closed system of inner reality. (p.â•¯381)
Fairbairn (1958) described how the terror of psychic disintegration

contributes to the maintenance of the closed system of internal objects.
Fairbairn’s model of endopsychic structure, involving the interdynamics of
exciting object, the rejecting object, the libidinal ego, and the antilibidinal
ego (or internal saboteur) describes some of the alters we see in DID. Alters
who bond with the good (“exciting”) aspects of perpetrators are much like
libidinal egos, and contemptuously abusing, rejecting alters are very much
like internal saboteurs, responsive to and modeled after rejecting objects.
“Fairbairn saw that psychic structure is the personification of failed experi-
ences with objects” (Grotstein, 2000, p.â•¯177).
Under conditions of abuse, neglect, or gross insensitivity, an inordinate
degree of self-sufficiency is required of the young child. Because this is gen-
erally too much to muster, the child may invent an omnipotent protector,
helper, or inner caretaker (Beahrs, 1982; Bliss, 1986). In such a situation,
self-care is provided by parts of the self, not by the outside interpersonal
world. Kalsched (1996) described the self-care system as a way for a child
to manage traumatic attachments and as a way to provide from within the
self a supplement to the scarce supplies available in the interpersonal envi-
ronment. The threat of “unthinkable” agonies and the terror of going mad
activate the self-care system, which not only restores missing aspects of the
needed attachment relationships as aspects of the self but also uses such
quasi-delusional methods as perceptually “blanking out” threatening fig-
ures. The self-care system generates a sense of psychic stability by creating
illusory sources of protection and comfort, and it provides an effective and
often lifesaving coping strategy in a frightening or abusive interpersonal
environment. The self-care system generates a sense of psychic stability by
creating the illusion of sources of protection and comfort. It gives a particu-
lar meaning to “pulling yourself up by your bootstraps.”
The closed self-care system has some elements in common with the third
reality, described by Kluft (1998). The third reality can be an immense
internal world with, for instance, castles, dungeons, fields, and so on
(Oxnam, 2005). In the creation of this world, there can be much playful
creativity. Unless there can be some real connection of inside parts with
the outside world, the inside cannot grow because it remains more of a
closed system. As long as these parts remain segregated from each other,
contradictions in their beliefs, wishes, and motivations will not be expe-
rienced as problematic or conflictual. Inviting the parts into interaction
with the therapist and to share their third reality with the therapist is,
then, integrative. The therapist operates as a relational bridge (Bromberg,
1998) for self-states to share more aspects of their segregated experience
with each other.
Chapter 4
DID Is a Trauma Disorder
The basic problem for a traumatized individual becomes his own self-cure.
Bromberg (1994, p.â•¯538)
Dissociative identity disorder (DID) is an outcome of psychological trauma

that was early, chronic, and severe. A history of sexual, physical, or emo-
tional abuse has been found in the vast majority of people with DID. In
this sense, it is a chronic trauma disorder (Ross, 1989). In 1986, Putnam
et al. found in their study of 100 subjects that 85–95% of the respondents
reported a history of sexual or physical abuse. In later studies, Ross (1997)
found that 88.5 to 96% of patients with DID in three large studies reported
a history of sexual or physical abuse. Anderson and Alexander (1996) found
that, as opposed to adult female incest survivors without DID, those with
DID reported significantly more severe and earlier sexual abuse as well as
more physical abuse. Brand, Classen, McNary, and Zaveri (2009) found
that, in a sample of patients with dissociative disorders, 86% and 79% had
suffered sexual and physical abuse, respectively.
Psychological trauma and dissociation are inextricably linked. Trauma,
especially psychological trauma that is early, severe, and chronic, has a pro-
found effect on personality development. This effect is much more complicated
than the arrest of a particular phase of development. A typical understanding
of child development in the last century was that it involved the mastery of
developmentally relevant tasks, whether we call these psychosexual stages,
psychosocial stages, stages of interdependence, or the developmental epochs
of infancy, childhood, preadolescence, and adolescence. Far beyond arrest
of a particular phase of development, trauma in childhood changes brain
structure, increases stress hormones, affects the endocrine system, numbs the
self, makes the world unsafe, interferes with attachments, and causes the dis-
sociation of certain areas of experience from consciousness—as well as other
detrimental effects. All of these are interdependent to varying degrees and,
depending on other life events and circumstances, may become compounded.
What is the meaning of the relationship between trauma and dissociation? In
what ways is problematic dissociation linked with trauma?
73
What Is Psychological Trauma?

Objective Versus Subjective Trauma
A central dilemma that is often discussed in the trauma field concerns the
distinction between so-called objective trauma (sometimes called massive
trauma) and subjective trauma. A condition for the diagnosis of posttrau-
matic stress disorder (PTSD) in the the fourth edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric
Association [APA], 1994) is that the “person experienced, witnessed, or
was confronted with an event or events that involved actual or threatened
death or serious injury, or a threat to the physical integrity of self or others”
(p.â•¯467). However, not everyone who has been subjected to what can be
viewed as objective or massive trauma—as specified in DSM-IV—actually
develops PTSD. Not only that, but various kinds and severities of traumatic
events affect different people in different ways. As a result, many trauma
experts prefer to define as traumatic that which is overwhelming to the
individual or to the individual’s defenses rather than what may be viewed
as an objective trauma. Others dispute this approach, noting that without
an objective measure of trauma, anything that is merely upsetting might be
described as traumatic. In such a case, the word trauma may be so diluted
that it loses its meaning. One result of this dilemma is that the current con-
notations of the word include both these meanings: Trauma may refer both
to an objectively catastrophic event and to something that feels subjectively
upsetting. This dual meaning creates confusion. Some (e.g., Shapiro, 2001)
have dealt with this dilemma pragmatically by dividing traumatic events
into Big “T” (big trauma) versus small “t” (small trauma) ones. Although
useful in a practical way, in the sense that it gives us a basic language for
talking about the dimensions and expected impact of a traumatic event,
this distinction does not address the objective-versus-subjective dilemma.
How, then, do we resolve these confusions and contradictions in definition?
One useful approach lies in a description of the specific effects of the trauma-
tizing event on the person. For example, as Spiegel (1990a) explained:
Trauma can be understood as the experience of being made into an

object; the victim of someone else’s rage, of nature’s indifference, or
of one’s own physical and psychological limitations. Along with the
pain and fear associated with rape, combat trauma, or natural disaster
comes a marginally bearable sense of helplessness, a realization that
one’s own will and wishes become irrelevant to the course of events,
leaving either a view of the self that is damaged; contaminated by the
humiliation, pain, and fear that the event imposed; or a fragmented
sense of self. (p.â•¯251)
DID Is a Trauma Disorderâ•… 75
In the same vein of thought, Herman (1992) noted, “At the moment of
trauma the victim is rendered helpless by overwhelming force” (p.â•¯33).
Horowitz (1976) also emphasized the individual’s helplessness in the face
of trauma and pointed to the importance of the degree to which the trau-
matic event could be assimilated into the person’s cognitive framework.
Unbearably intense affect overwhelms the person’s ability to organize
information and even to think. As a result, the traumatic events or circum-
stances cannot be assimilated or taken in. The neurobiological result is the
sensorimotor, rather than narrative, registration of the unendurable experi-
ence. This lack of assimilation results in vulnerability to flashbacks as well
as a deficit in narrative memory with regard to the event.
This deficit in memory has been compared to “an irreversible negative—
a photographic negative that cannot produce a positive image.â•ƒ.â•ƒ.â•ƒ.â•ƒWithin
the shape of the trauma, there is only a negative, a blackness that cannot be
cognized” (Raine, 1999, p.â•¯114). In the language of Jacques Lacan, this is
the Real, the traumatic, the unknowable. As Boulanger (2007) explained,
“The Real is the unsymbolizable and unbridgeable gap at the heart of
traumatic experience. The Real is ineffable; by definition it can neither be
captured nor be given meaning” (p.â•¯55). In verbal terms, trauma is itself
unknowable and unrepresentable. One could say that trauma punctures the
psyche, and that hole or lack is in of itself unknowable, unsymbolizable—
we can only infer it in terms of its aftereffects. It is unformulated, and
importantly, it is dissociated.
Following from the descriptions of the authors just mentioned, one can see
how the most fundamental effect of trauma is dissociation. Accordingly, we
might best define trauma as “the event(s) that cause dissociation” (Howell,
2005, p.â•¯ix). People vary so much in their resilience to so-called objec-
tively traumatizing events that it does not make sense to speak of trauma
as defined by objective trauma. It also does not make sense to classify as
traumatic that which is merely upsetting. We cannot quantify trauma, but
we can define it conceptually in terms of its effects on individuals.
Thinking of trauma as the events that cause dissociation makes irrel-
evant the confusing discussions about objective trauma (which does not
necessarily result in posttraumatic stress to all who are exposed to it) versus
subjective trauma (which may run the risk of categorizing anything merely
distressing as traumatic). It also supersedes the question regarding whether
the event is a big T or a small t trauma. Defining trauma as an event that
causes dissociation focuses on the “fault lines” or “fissures” in the mind
rather than on the external event. If an event is so overwhelming that it
cannot be assimilated, it cannot be linked with other experience, resulting
in gaps in memory and experience. This is a description of dissociation.
As a result of the trauma, there is a change in the structure of the person’s
psyche. There is now a structural dissociation: Parts of experience have
become structurally separated from other aspects of experience.
Although this definition suggests that the concept of trauma requires

dissociation, the reverse is not true. Dissociation, which is a more inclusive
concept, refers to many kinds of phenomena, processes, conditions, and abil-
ities, such as absorption and hypnosis, as well as posttraumatic responses.
The statement is not tautological because trauma does not define dissocia-
tion. What requires emphasizing is that trauma implies dissociation.1
Dissociation as a Response to Trauma
Dissociation Is Initially Adaptive

Problematic or maladaptive dissociation is often a rigidified outcome of
repeated psychological trauma. However, dissociation is often initially
adaptive, protecting the traumatized person from unbearable knowledge,
preserving sanity, and even fostering survival. In a general sense, disso-
ciation refers to a separation of experiences, feelings, memories, and so
forth that would normally be connected. The capacity for dissociation is an
aspect of human nature that can be of great value. For instance, by use of
dissociation, psychological trauma that might otherwise completely over-
whelm a young child and lead to a breakdown of functioning can be encap-
sulated in subconscious parts of the mind, allowing the child to continue
functioning in the day-to-day world. The capacity for dissociation can be
soothing in times of unbearable stress. For example, many highly dissocia-
tive patients report that they have found ways to voluntarily “disappear”
from traumatic experiences by going into a trance state, becoming lost in
the wallpaper, or mentally going into a mouse hole in the wall.
Dissociative ability serves as a means to survival in life-threatening cir-
cumstances as an aspect of biological endowment. People may use disso-
ciation to trance out, go into neutral gear (Terr, 1994), develop psychic
numbness (Lifton & Markusen, 1990), mentally float to the ceiling or sky,
and so on. Such responses are commonly reported by victims of rape, near
drowning, serious automobile accidents, building collapses, natural disas-
ters, and wartime disasters, to name a few. At such times, dissociation
allows people to separate themselves from the experience of the trauma. As
Van der Kolk (1996b) noted, “During a traumatic experience, dissociation
allows a person to observe the event as a spectator, experience no, or only
limited, pain or distress; and to be protected from awareness of the full
impact of what has happened” (p.â•¯192).
Dell (2009b) has synthesized and reformulated much of what is known
about the kind of dissociation that often occurs in such extreme circum-
stances and has marshaled an impressive array of research documenting the
phylogenetic roots of what he called “evolution-prepared survival-oriented
dissociation” (p.â•¯764). He noted in particular that the response to near-lethal
falling likely has the longest phylogenetic history—that is, that adaptive,
survival-oriented responses are likely to have evolved by natural selection.
He suggested that life-threatening falls represent the prototypical danger for
humans in the physical world.
To further elucidate this point, Dell (2009d) cited and quoted from the
research of Heim, an avid mountain climber who summarized reports of
the experiences of dozens of mountain climbers who experienced poten-
tially lethal falls but survived:
There was no anxiety, no trace of despair, no pain; but rather calm

seriousness, profound acceptance, and a dominant mental quickness
and sense of surety. Mental activity became enormous, rising to a hun-
dred-fold velocity or intensity. The relationships of events and their
probable outcomes were overviewed with objective clarity. No con-
fusion entered at all. Time became greatly expanded. The individual
acted with lightning-quickness in accord with accurate judgment of
his situation.â•ƒ.â•ƒ.â•ƒ.â•ƒMen who had fallen from great heights were unaware
that their limbs had been broken until they attempted to stand. (Heim,
1892, as cited in Dell, 2009d, p.â•¯761)
As Dell (2009b) noted, almost 95% of the victims Heim studied had simi-
lar experiences, and other investigators of near-fatal falls have reported simi-
lar instances of people feeling calm, detached, depersonalized. Dissociation
helped the people who had near-fatal falls to manage the trauma of falling.
In their research, Shilony and Grossman (1993, as cited in Dell, 2009b) in
fact reported that those who failed to experience depersonalization during
trauma reported significantly greater psychopathology.
Although depersonalization that occurs at the time of the trauma is nor-
mal and often beneficial, it is the persistence of depersonalization over time
that becomes problematic.
Persistent and Automatic

Dissociation Is Maladaptive
The value of the capacity for dissociation is inestimable. That said, if
this dissociation is maintained for too long or becomes automatic, it then
becomes maladaptive. If a person’s way of life becomes organized around
dissociative avoidance of any reminders of trauma, this also is problematic.
The problem is that automatic dissociation does not work: Continuously
avoided overwhelmingly painful experience cannot be integrated and will
therefore intrude into the person’s life.
An important issue in understanding dissociation and its potential to
maladaptively impact one’s life is whether the dissociation is or is not under
voluntary control. For example, consider the phenomenon often called
highway hypnosis, which is not hypnosis at all, by the way, but involves the
ability to dual task: attend to one’s thoughts and the road simultaneously
when the road is a familiar one. Because we can do things that are familiar
fairly automatically, we are often surprised on arrival at our destination
that we do not remember all the turns and stops we made in the process.
Highway hypnosis would be extremely dangerous, however, if we could
not return attention to the road when necessary. Problematic dissociation
is that way: Once it has been put on automatic, it is hard to stop.â•¯I ntrusions
cannot be controlled. Reality cannot be reattended to at will. Often, when
triggered, highly dissociative people cannot control the switching between
self-states. In all forms of problematic dissociation, too much of the disso-
ciative behavior is involuntary.
Complex PTSD and Disorders of Extreme

Stress Not Otherwise Specified
It is important to explore and understand the other ways in which dissocia-
tion is part of the concept of trauma-related disorders. DID is considered
to be a form of complex PTSD (Courtois, 1999, 2004; Ford & Courtois,
2009; Herman, 1992; Van der Kolk, 1996b). Although PTSD has now
become a culturally accepted concept as well as a much-used diagnosis,
it only partially describes the most predominant forms of posttraumatic
problems as reflected in everyday living (Herman, 1992). The diagnosis of
PTSD was originally developed in response to the symptoms displayed by
large numbers of returning Vietnam veterans. Previously described as bat-
tle fatigue and shell shock, these symptoms included amnesia; somatoform
and hysterical presentations such as contractures, tics, tremors, and stut-
tering; as well as symptoms of intrusion, constriction, and numbing. An
existing problem in the original formulation of PTSD in the third edition of
the DSM (DSM-III; APA, 1980) was that to qualify as traumatic, an event
had to be out of the ordinary. Indeed, a prime example was the horrors of
war. Traumatologists Brown (1991) and Herman (1992) noticed, however,
that in contradiction to the DSM-III requirement, many traumatic experi-
ences occur with such frequency that they are not necessarily “out of the
ordinary.” In certain times and cultures, war is itself ordinary. In addition,
posttraumatic symptoms characterized not only soldiers but also cut across
a much larger swath of the population, characterizing people who had suf-
fered chronic posttraumatic stress from such events as rape, battering, and
childhood sexual abuse. These events are severe and expectably traumatiz-
ing, and to many of the people who suffer from them, they are not neces-
sarily out of the ordinary at all. By the time of DSM-IV (APA, 1994), the
out-of-the-ordinary requirement was dropped.
In the late 1980s and the 1990s, and following the formulation of PTSD,
the concept of psychological trauma was becoming more thinkable, and
the atrocity of child abuse (especially child sexual abuse) was becoming
less deniable. However, a conceptual model for peoples’ posttraumatic
responses to such events did not yet exist. Modeled as it is on the effects of
exposure to single-incident traumas such as combat fatigue and disaster,
the diagnosis of PTSD does not describe the effects of prolonged and
repeated relational trauma and victimization that occurs early in life. There
are important differences between childhood-onset trauma and adult-onset
trauma (Boulanger, 2007). Trauma, especially psychological trauma that is
early, severe, and chronic, has profound effects on development. It affects
brain structure, the endocrine system, and stress hormones, as well as
makes the world in general feel unsafe, and creates dissociative experiences.
Indeed, Van der Kolk (2005) and others have proposed a new diagnosis
of developmental trauma disorder for children with histories of complex
trauma because of the awareness that the current diagnosis of PTSD is not
developmentally sensitive.
Judith Herman (1992) coined the term complex PTSD because the criteria
for PTSD alone do not adequately describe the kind of suffering and life prob-
lems characteristic of a great many chronically traumatized people. Complex
PTSD originates in relational trauma: the often early, severe, and chronic
traumatic mistreatment by family members or others entrusted with care of
the child. As opposed to single-event trauma, complex relational trauma is
likely to result in alternating dissociated self-states with contradictory, ideal-
izing, and devaluing relational patterns. The symptom presentation involves
damage to relationships and identity, a potential for revictimization, and
emotional dysregulation. Both PTSD and complex PTSD affect the psycho-
biological systems, but in complex PTSD, these disruptions and deficits are
more pervasive, chronic, and often more severe and more conducive to per-
sonality fragmentation than in simple PTSD. Complex PTSD includes DID as
well as other trauma-based disorders, such as borderline personality disorder
(BPD). Howell and Blizard (2009) have proposed chronic relational trauma
disorder as a term and concept that encompasses both DID and BPD.
Complex PTSD was reformulated as a proposed new diagnosis, disorders
of extreme stress not otherwise specified (DESNOS), by the working group
(Luxenberg, Spinazzola, & Van der Kolk, 2001) for the DSM-IV (APA,
1994). This proposed diagnosis has focused on different problem areas that
research found to be associated with this kind of trauma (Van der Kolk,
1996b). These areas include (a) affect dysregulation, including impulse con-
trol, self-destructive behavior, and dyscontrol of anger; (b) disturbances
in attention or consciousness; (c) somatization; (d) alterations and distur-
bances in self-perception; (e) alterations and disturbances in relationships;
and (f) alternations and disturbances in meaning systems.
Although it is not an official diagnosis, the DESNOS syndrome has
been the subject of much research, and it has been proposed for inclusion
in the DSM. Many clinicians find the concept of complex PTSD and the
description of DESNOS extremely useful for their thinking and clinically

attributable to their patient population.
The following lists Luxenberg et al.’s (2001) diagnostic criteria for the
proposed DESNOS syndrome:
I. Alteration in Regulation of Affect and Impulses
A. Affect Regulation
B. Modulation of Anger
C. Self-Destructive
D. Suicidal Preoccupation
E. Difficulty Modulating Sexual Involvement
F. Excessive Risk-Taking
II. Alterations in Attention or Consciousness (A or B required):
A. Amnesia
B. Transient Dissociative Episodes and Depersonalization
III. Alterations in Self-Perception (Two of A–F required):
A. Ineffectiveness
B. Permanent Damage
C. Guilt and Responsibility
D. Shame
E. Nobody Can Understand
F. Minimizing
IV. Alterations in Relations with Others (One of A–C required):
A. Inability to Trust
B. Revictimization
C. Victimizing Others
V. Somatization (Two of A–E required):
A. Digestive System
B. Chronic Pain
C. Cardiopulmonary Symptoms
D. Conversion Symptoms
E. Sexual Symptoms
VI. Alterations in Systems of Meaning (A or B required):
A. Despair and Hopelessness
B. Loss of Previously Sustaining Beliefs (p.â•¯375)
Note the many times the word alterations is used in the criteria for
DESNOS. This highlights how important psychological fragmentation
and lack of self-coherence are in this syndrome. One way to understand
such alternations—although not specifically stated here—is as a change or
a switch of self-state. As noted, these criteria are not specific to DID but
apply to other trauma-based disorders, such as BPD (Howell, 2002a), as
well. What needs emphasizing here is that DID falls within the domain of
trauma-based disorders, and that dissociation in some manifestations is an
integral aspect of trauma-based disorders.
The Dissociative Nature of PTSD

Many clinicians and researchers view PTSD as a dissociative disorder and
believe that it should be included in the DSM under the category of dissocia-
tive disorders rather than under anxiety disorders (Brett, 1996; Chu, 1998;
Van der Hart et al., 2006). Indeed, “many writers argue that dissociation
is central to the development and maintenance of PTSD, and that dissocia-
tive symptoms are important to both the diagnosis and conceptualization
of PTSD.â•ƒ.â•ƒ.â•ƒ.â•ƒDissociation has repeatedly been found to be related to the
severity of chronic PTSD” (Waelde, Silvern, Carlson, Fairbank, & Kletter,
2009, p.â•¯449). Not only are dissociation scores of people with PTSD higher
than those without PTSD (Bremmer et al., 1992), but also a recent meta-
analysis by Ozer, Best, Lipsey, and Weiss (2003) found that peritraumatic
dissociation (i.e., dissociation that occurs at the time of, or immediately
after, the stressful event) was the most predictive of PTSD when measured
along with variables such as prior trauma exposure and current stressors.
Briere, Scott, and Weathers (2005) have clarified this finding: By distin-
guishing between acute dissociation at the time of the trauma and persist-
ing dissociation afterward, they found that the greater risk for PTSD lies in
dissociation that persists over time.
Onno van der Hart and his colleagues (Nijenhuis et al., 2004; Van der
Hart, 2000; Van der Hart, Van Dijke, Van Son, & Steele, 2000) elegantly
formulated an explanation of how PTSD is dissociative. They emphasized
that the alternations between intrusions and numbing in the PTSD con-
struct are in themselves manifestations of dissociation:
[T]raumatic intrusions are positive dissociative phenomena, and com-

plex traumatic re-experiences are also dissociative. It follows that all
phenomena that are manifestations of trauma re-experiences (reacti-
vated traumatic memories), such as flashbacks, should be seen as posi-
tive dissociative symptoms. To the extent that this theoretical position
can be accepted by students of trauma, they cannot but consider the
re-experiencing phenomena in PTSD, such as “recurrent and intrusive
recollections of the event, including images, thoughts, and perceptions”
(APA, 1994, p.â•¯428) as positive dissociative phenomena. The same is
true of Acute Stress Disorder (ASD). (Van der Hart et al., 2000, p.â•¯51)
In their landmark article, “Trauma-Related Dissociation: Conceptual

Clarity, Lost and Found,” Van der Hart et al. (2004) noted that intrusion,
which is a key diagnostic feature of PTSD in the DSM-IV (APA, 1994),
should be understood as dissociative: “Intrusions imply a lack of integra-
tion of the part(s) of the personality that remain fixated in traumatic events,
thus a lack of integration of the personality. Positive dissociative symptoms,
including intrusions, are common in trauma-related disorders” (p.â•¯908).
Similarly, Ginzburg, Butler, Saltzman, and Koopman (2009) stated that,

“PTSD hyperarousal symptoms (i.e., hypervigilance, exaggerated startle,
sleep disturbance, concentration difficulties, and anger) may be viewed
as manifestations of dissociative processes. Hyperarousal symptoms may
reflect the anxiety attached to the dissociated fixed ideas” (p.â•¯462).
The positions of Nijenhuis et al. (2004) and Ginzburg et al. (2009) are
accepted by many (myself included), but that is not to say that those in
the PTSD field and the dissociative disorders field are always in agreement
in how research is interpreted. The dissociative nature of PTSD is a con-
troversial topic, with some researchers and theorists taking the position
that PTSD does not necessarily inherently involve dissociation but may
instead have dissociative subtypes (see Waelde et al., 2009, for a discus-
sion on dissociative subtypes). These theorists concentrate more on the
hyperarousal aspects of PTSD, such as elevated heart rate and blood pres-
sure. For example, David Spiegel, in his electronic “Expert Commentary:
Dissociation and ASD and PTSD—DSM-V Considerations” (featured
in the Members’ Clinical Corner, International Society for the Study of
Trauma and Dissociation in January 2009) noted that many of those work-
ing in the PTSD field have focused not so much on the dissociative aspects
of PTSD but more on anxiety and arousal, and in particular
on a model of hyperactivation of the noradrenergic system, both periph-

erally and in the brain (e.g., in the locus coeruleus). Irritability, increased
heart rate and blood pressure associated with trauma reminders, flash-
backs, and nightmares have been key symptoms targeted for treatments
such as exposure, cognitive restructuring, and coping skills training.
Whether PTSD is inherently dissociative or has dissociative subtypes, and

how much of a role dissociation plays in PTSD, remains a sometimes highly
controversial issue among traumatologists. To some degree, it can even
seem as if the field itself is dissociated into a split awareness about the reali-
ties of trauma and its impact.
Professional Confusion About the

Effects of Trauma and Dissociation
on Problems in Living
Partly because the phenomenon of dissociation has been so “dissociated”

within the mental health field, the DSM itself is full of inconsistencies with
regard to the influence of dissociation and the definitions of its impact. For
example, Van der Hart et al. (2006) have observed that in the DSM-IV
(APA, 1994), intrusive PTSD symptoms are called dissociative flashback
episodes, while flashbacks of acute stress disorder (ASD) are not considered
dissociative. Even though the numbing and avoidance symptoms of ASD are
considered dissociative, the same symptoms are not identified as dissocia-
tive in PTSD. Adding to the commentary on the inconsistencies and confu-
sions about trauma disorders and dissociative disorders, Colin Ross, in his
electronic “Expert Commentary: How the Dissociative Structural Model
Integrates DID and PTSD, Plus a Wide Range of Comorbidity” (featured
in the Members’ Clinical Corner, International Society for the Study of
Trauma and Dissociation in May 2009), observed that “the structure and
rules of the DSM result in many people meeting criteria for numerous dif-
ferent disorders. This is routinely the case in DID and PTSD.” In addressing
the presence of dissociative features in many disorders, Ross added:
When the intrusion is a physiological sensation, in DSM-IV-TR lan-

guage we call that somatization. When the intrusion is an impulse to
pluck hairs out of your head, or a sudden intrusion of a rage state,
we call that an impulse control disorder. However when the intrusion
is an impulse to wash your hands repeatedly, we call the impulse a
compulsion and diagnosis OCD. The intruding affect is anxiety rather
than rage. When a flashback episode intrudes, we call it a dissociative
flashback episode and diagnose an anxiety disorder. When the intru-
sion is an auditory hallucination, we call that psychosis according to
DSM-IV-TR. When the same symptom occurs in DID, we call it a dis-
sociative symptom.
Similarly, when traumatic affect is withdrawn from the apparently
normal part (ANP) of a Vietnam veteran, we call that numbing and
make it a symptom of PTSD. If the same symptom occurs in someone
with BPD, we call it emptiness, but if the diagnosis is schizophrenia,
we call it a negative symptom of schizophrenia. When a man perceives
a threatened abandonment by his wife, flies into a rage, and beats her
to control her and maintain his insecure attachment to her, we call
this intermittent explosive disorder. The original trauma was failure
of secure attachment by his primary female attachment figure in child-
hood, and the trigger in the present causes a reaction far out of propor-
tion to the realistic threat in the present. The intruding affect is rage,
but the underlying affect is fear and annihilation anxiety.
When the trigger in the present is a news helicopter flying overhead,
the original trauma was combat in Vietnam, and the intruding affect is
fear, we call this a “dissociative flashback episode” and diagnose PTSD.
It would seem simpler and far clearer to note the underlying importance
of trauma and dissociation in many disorders that are otherwise classified.
And yet, as Luxenberg et al. (2001) explained:
Trauma-related disorders, including dissociative disorders, continue to

be grossly underdiagnosed. This underrecognition can be best under-
stood in light of the multiplicity of symptoms with which these patients
present that may not be readily recognized as being related to their trau-
matic experiences. (p.â•¯377)
Note
1. In a field such as the trauma and dissociation field, it is important to be precise

as much as we can. One common problem is that the words trauma and abuse
are often—although incorrectly—used interchangeably. Abuse, however painful
and horrible, is not necessarily affectively or cognitively overwhelming of itself.
Unfortunately, too many studies and reviews on the topic fail to make this dis-
tinction and end up observing that since the documented or recalled abuse did
not correlate highly with dissociation, this means that traumatic events do not
necessarily imply dissociation. Trauma may be conflated with abuse, and then
when a person does not respond posttraumatically, it is erroneously concluded
that trauma did not result in dissociation. An individual can endure terrible cir-
cumstances, even life-threatening events, but they are not necessarily perceived
or experienced as traumatic to that person. Many variables may be at stake,
including past history of trauma, overall resilience, and the social context, to
name a few. For example, if one has the opportunity and ability to communi-
cate emotions about the event to another person who is responsive and caring,
it may link the traumatic event with one’s ongoing life experience and with
interpersonal connection, thus lessening the extent to which the experience is
overwhelming and making it more tolerable. This does not mean that abuse
is not bad. Abuse is terrible and unacceptable, but it does not always result in
trauma. When it does, in my view the effect of that trauma is dissociation.
Chapter 5
Dissociated Self-States, Trauma,

and Disorganized Attachment
[T]he essential experience of trauma [is] an unraveling of the relation-

ship between self and nurturing other, the very fabric of psychic life.
Laub and Auerhahn (1993, p.â•¯287)
Attachment theory, which assumes a two-person or even a multiperson psy-

chology (Cortina & Marrone, 2004; Cortina & Liotti, 2010), has been a
contributor to relational psychodynamic theory. This is especially true for a
relational psychodynamic theory that encompasses dissociative processes.
This chapter explains why a trauma theory is not enough to understand
the origin and persistence of dissociated self-states—and why the theory
and knowledge base must include attachment, specifically disorganized
attachment (DA). The chapter includes key aspects of attachment theory
as well as functions of the attachment behavioral system, internal working
models (IWMs), and attachment classifications, along with an emphasis on
DA. The links between DA, incompatible, segregated IWMs, and dissoci-
ated self-states are described.
Disorganized Attachment Predicts

Later Dissociation Better Than
Does Documented Trauma
The high correlations between dissociative disorder diagnoses and ante-

cedent child abuse, notably physical and sexual abuse, are well known.
However, careful studies (Carlson, 1998; Lyons-Ruth, 2003, 2006; Ogawa,
Sroufe, Weinfield, Carlson, & Egeland, 1997) have revealed that, statisti-
cally, DA is a better predictor of later dissociation than is discernable and
known abuse or specific instances of childhood trauma. Why should this
be? Certainly, the kinds of family environments in which abuse occurs are
also characterized by emotional abuse and neglect. Poor psychological inte-
gration follows from family environments characterized by combinations of
abuse, trauma, deprivation, and neglect (Allen, 2001) and from attachment
85
dilemmas, particularly DA. In this sense, the antecedents of dissociative

identity disorder (DID) stem not only from trauma (Gold, 2000) but also
from other factors, such as severe neglect and attachment dilemmas in the
context of early environments (Liotti, 1999).
It is not only the “traumatic event” in isolation but also the context of
the event that makes something traumatic. It can make all the difference if
a traumatized child can tell a sympathetic caregiving figure what happened
and receive support. The child is then not alone with the trauma and is
given the opportunity to connect the terrifying moment with a comforting
one and reassure herself of general safety and of the reality of her percep-
tions. On the other hand for example, if the child is told he or his loved
ones will die if he reveals what happened, then the child ends up bearing
the terror in isolation. The child’s affective state may be so unbearable that
it rises to the level of the traumatic and cannot be managed in awareness.
A child may be sexually and physically abused by his or her father only to
be disbelieved and rejected by his or her mother. In many cases, the latter
may be more unbearable than the former. Add to that the reality that the
mother who permits abuse of a child may be the same mother who was
highly misattuned, unresponsive, or neglectful when that child was a baby;
these qualities can well contribute to DA. With such a parent, there may
be hidden trauma as well: Parental behaviors that are highly neglectful or
grossly misattuned can be traumatizing to an infant even if they might not
be traumatizing to an older child or to an adult (Howell, 2008).
Clearly, there are difficulties in predicting which situations will end
up being traumatic as well as determining which ones will be labeled so,
but what is it about DA that predicts dissociative disorders? This chapter
addresses the meaning of the findings that show DA as the best predictor
of later dissociation.
The Trauma Model of DID
A prototypical example of the trauma/abuse model of DID is that of a little

girl who is “on the ceiling” watching another little girl below as she is raped
by her father (Ross, 1989). A traumatically abused and terrified child may
well deal with overwhelming affect and pain by distancing herself from
this experience to such a degree that she disidentifies with the experience
and becomes an observer (rather than an experiencer) of the event. In this
depersonalized state, she then pseudodelusionally (Kluft, 1984) views this
as happening to another child. This “other child” then “holds” the affects
and memories that are unbearable to the little girl watching from above.
This separation protects the child from being continually overwhelmed and
safeguards the ability to function.
Dissociated Self-States, Trauma, and Disorganized Attachmentâ•… 87
But now, there are at least two little girls—the conscious little girl who
is up on the ceiling watching another little girl suffering and the little girl
who is suffering, experiencing the rape. The first little girl may go to school
the next day knowing nothing of the one who was raped by her father.
Thus, parts of the self who in effect hold some terrible information and
unbearable emotions are not known by other parts who must go on living,
go to school, to work, and so on. In psychological trauma, particularly at
the hands of a person on whom one is dependent, dissociation allows a
sequestering of the traumatic experience so that it allows the traumatized
individual to continue functioning in a double-bind relationship (Spiegel,
1986), often without having to notice the inherent contradictions.
A child who is subject to sexual abuse in the home may “forget” the
night’s events during the day and use all her resources to “be like a nor-
mal person” during the day. In her stunning book, Miss America by Day
(2003), Marilyn Van Derbur, who was Miss America in 1958, described
how she was both a “day child” and a “night child.” The day child knew
nothing of the night child until she became older and began psychotherapy.
This dynamic by which the victim bonds with the idealized aspects of the
abuser while tuning out the abusive aspects along with the terror has also
been called traumatic bonding (Dutton & Painter, 1981). Often applied to
battered spouses or to those with Stockholm syndrome, it also character-
izes victims of child abuse.
In cognitive psychological terms, Jennifer Freyd (1996) has described this
sort of situation leading to dissociation as betrayal trauma. An aspect of
betrayal trauma theory is betrayal blindness, in which mechanisms of trust
and distrust become confused. Here, the capacity to dissociate may be life
preserving for such a child might not be able to go on living were she aware
of continual abuse in this way. Some children who are too aware of their
situation and for whom dissociation was not adequate do attempt suicide.
Others just wish that they could die. In psychoanalytic terms, Ferenczi (1949)
and Fairbairn (1952) have also articulated forms of dissociative adaptations
to attachment dilemmas. Dissociation can literally save the child from the
intolerable.
A Previously Whole Personality Is Not Shattered

So far, we are discussing two dissociated identities: the one who knows
and suffers and the one who stays connected in an idealizing way with the
caregiver. One might think of the little child on the ceiling as splitting off
the identity of the child below, but that is not exactly what happens, at least
not usually on a one-time basis. In a one-time event that is overwhelming
and inconsistent with already existing reasonably good attachment and in
which there are no precursors for a differently personified identity, such as
DA, the traumatized person would more likely develop posttraumatic stress
disorder (PTSD), including anxiety or depersonalization symptoms, but not

dissociated identity states. This would be in contrast to the chronic abuse
cases, in which there are early and continuous attachment dilemmas.
So, in this prototypical model of the little child on the ceiling, we need to
consider (a) how trauma impedes the linking of self-states (since a familial
environment that is abusive or neglectful fails to facilitate the child’s abil-
ity to link and integrate experiences) and (b) as a result of early traumatic
attachment dilemmas, how the child had to develop contradictory, segre-
gated models of attachment that involve alternating activation of the attach-
ment system with the fear system, otherwise known as DA. In essence the
substrate for the separation of the little girl on the ceiling and the other
little girl whom she watches being raped (as well as possibly additional
parts who are needed in other times and other ways) is already there in
the child’s inner world. This ongoing separation was “called forth” by the
impossible dilemma of the rape by the caretaker.
The Nonfacilitative Environment and Trauma

Impede the Normal Linking of Experience:
Putnam’s Discrete Behavioral States Model
Rather than resulting from a “shattering” of a previously intact and uni-
fied identity, the formation of day and night children (and other internal
identities) stems not only from trauma but also from “a developmental fail-
ure of consolidation and integration of discrete states of consciousness”
(Putnam, 1997, p.â•¯176). Putnam’s discrete behavioral states (DBS) model
of the personality emphasizes that rather than starting out as a unity,
the human personality must become integrated over time. Psychological
trauma and neglect impede the process of integration. In his DBS model,
Putnam (1997) describes how mental states, or states of consciousness, are
the building blocks of human behavior and consciousness. For example,
behavioral states, such as deep sleep, rapid-eye-movement (REM) sleep,
and awakening, which were discrete in infancy, become linked over time in
sequences. Infants go through orderly transitions, or switches, that involve
discontinuous jumps from one state to another, for example, from sleep to
wakefulness to fussiness to crying. While at first these are clearly biologi-
cal states involving such biological activity as eating and elimination, they
begin to succeed each other in orderly sequences so that the transitions
between them become regularly linked. The linking of affective/biological
states occurs similarly. As these linkages become more complex, the child
gains greater control and ability to self-regulate.
One of the important effects of trauma and neglect is that the expected
linking of associative pathways among states is impeded. For example,
states of terror are not linked with other states of mind. This is particularly
likely in a neglectful environment in which the parents or caregivers cannot
or will not attune to or help label the child’s emotions to help them to con-
nect these emotional states to other emotional states. This is in contrast
to ways that more helpful caregivers assist in emotion regulation, such as
downregulating overarousal, minimizing negative affect, and assisting a
child to transition from negative to positive states (Tronick, 1989) as well
as promoting integration by facilitating the child’s reflective functioning,
for example, letting the child know that she is in the caregiver’s mind in
an empathic way (Fonagy, Gergely, Jurist, & Target, 2002). Trauma also
interrupts metacognitive, self-observing, self-reflective functions, which
can facilitate the integration of states. As a result of trauma, the child is
then left with overwhelming affect without context and without soothing,
resulting in disjointed, out-of-context states.
Originally, behavioral/mental states are not linked. It is in the course of devel-
opment, in a facilitative interpersonal environment, that they become linked.
Relational Trauma, Attachment,

and Dissociation
Relational trauma is profoundly about attachment. As Laub and Auerhahn

(1993) so cogently said, “The essential experience of trauma [is] an unrav-
eling of the relationship between self and nurturing other, the very fabric
of psychic life” (p.â•¯287). When it comes to dissociated self-states, even
though the trauma/dissociation field and the field of attachment studies
developed separately and use somewhat different languages, incompatible
segregated IWMs and dissociated self-states describe basically the same
phenomena.
Bowlby’s Relational Attachment Theory

John Bowlby’s (1969/1983) first revolutionary insight concerned the evolu-
tionary survival benefits of attachment, thus grounding attachment behav-
ior in the science of ethology. It became a scientific underpinning for the
relational theories of human development and of psychotherapy and, among
others, of Fairbairn, Guntrip, and Winnicott. Bowlby’s second major con-
tribution was his concept of IWMs, which involves expectations regarding
the availability of the attachment figure, the mental representations of the
self and the attachment figure, and the affects about them. Bowlby proposed
that difficult attachment conditions could foster the development of mul-
tiple, segregated IWMs. Inconsistent and segregated IWMs are especially
characteristic of a later-identified attachment style, DA. Both segregated
IWM and DA have direct relevance to our understanding of dissociated
self-states. Specifically, it appears that the segregated IWMs of DA are the

precursors and substrates for a great portion of dissociated self-states.
Bowlby (1969/1983) was proposing a new instinct theory (Bretherton,
1992)—a theory of an evolutionary origin and biological basis for attach-
ment behavior—when he presented ethological and observational evidence
that infant primates, including humans, are hardwired for attachment in
the service of survival. Based on his study and observations, he postu-
lated that proximity to the mother provided protection against predators.
Inasmuch as it increased the chances of survival, physical closeness was
understood to be the goal of the attachment system. This theory contra-
dicted the then-prominent Hullian learning theory, which classified attach-
ment behavior as a secondary drive, derivative only of the primary drive of
hunger. Attachment theory also contradicted Freudian dual-instinct theory.
As a result, Bowlby’s assertion of the primacy and the reality of attachment
relationships—beginning with the mother—was not immediately accepted
into psychoanalysis. So much so that Bowlby, asserting the importance of
the real interpersonal environment as opposed to an exclusionary empha-
sis on fantasies, once stood up at a psychoanalytic meeting, emphatically
insisting to the audience, “But, there is such a thing as a bad mother”
(Mitchell, 2000, p.â•¯84; italics in text).
Bowlby came to understand attachment, which was often indicated by
infant behaviors such as clinging, crying, and following, as a behavioral
system. A behavioral system is a motivational system that is not secondarily
derivative of more primary drives, but a primary one by its own right. The
attachment system is not the only behavioral system but is one among oth-
ers, such as those that control mating, feeding, fear, exploration, caregiv-
ing or parenting, and dominance (Bretherton, 1992). Behavioral systems
may operate sequentially, and they may also activate or inhibit each other.
For example, the attachment system and the fear system work in tandem,
and fear often activates the attachment system. The exploratory system is
activated and enhanced by the attachment system; conversely, the infant’s
exploratory behavior is inhibited in the absence of the attachment figure.
Notably, the attachment system is regarded as
preemptive when aroused, since it mobilizes responses to fear or threat.

In that sense, the quality of regulation of fearful affect available in
attachment relationships is foundational to the developing child’s free-
dom to turn attention away from issues of threat and security toward
other developmental achievements, such as exploration, learning and
play. (Lyons-Ruth, 2003, p.â•¯885)
Importantly, the attachment system does not operate only in infancy.

Attachment is intrinsic to emotional security, and the need for it pertains
to us throughout the life cycle. As Bowlby (1984), now famously, said, “All
of us, from the cradle to the grave, are happiest when life is organized as
a series of excursions, long or short, from the secure base provided by our
attachment figures” (p.â•¯11).
Current attachment theorists have further developed Bowlby’s initial
observation about the importance of proximity to the caregiver by identifying
additional functions of attachment, such as the infant’s reduced anxiety and
enhanced feeling of security (Fonagy, 2001). Most important, attachment
helps regulate affect. Lyons-Ruth (2001, 2003) further articulates Hesse and
Main’s (1999) observation concerning the importance of the attachment fig-
ure as a solution to fear and stresses that the attachment system modulates
psychological fear and distress. She views the attachment system as analo-
gous to the immune system: Just as the biological immune system modulates
physical disease, so does the infant’s attachment to the caregiver modulate
and reduce fearful affect. This emphasis on reduction of fearful arousal is a
large departure from libidinal and aggressive drives as motivational systems.
Instead, attachment theory “regrounds clinical theory in the developmental
dynamics of fear” (Lyons-Ruth, 2001, p.â•¯40). However, she more recently
specified that regulation of fearful arousal is not only dependent on such
parental behaviors as soothing but also depends on positively toned intersub-
jective exchanges between infant and caretaker that contribute to the infant’s
felt security: “Therefore, there is now a convergence of developmental,
behavioral, biological, and evolutionary arguments for enlarging our model
of the attachment motivational system to include positive components of the
infant–caregiver relationship, components that also serve to down-regulate
fearful arousal in early life” (Lyons-Ruth, 2006, p.â•¯601).
Internal Working Models

As Bowlby’s thinking evolved, it became less behavioral and more focused
on mental processing. Although his first revolutionary insight concerned the
survival benefits of attachment, an equally important concept in Bowlby’s
attachment theory is that of IWMs, which organize the child’s cognitions,
affects, and expectations about attachment relationships. IWMs appraise
and predict attachment emotions of self and others. As such, they guide
attachment behavior. They generalize from past experience with the attach-
ment figure (Bowlby, 1973) in a way that is similar to Daniel Stern’s (1985)
conceptualization of representations of interactions that are being general-
ized (RIGs). They are “superordinate structures that combine numerous
schemas ‘of being with.’â•ƒ.â•ƒ.â•ƒ.â•ƒT hey regulate the child’s behavior with the
attachment figure” (Fonagy et al., 1995, p.â•¯235).
Bowlby (1973, 1980) noted that babies and children develop multiple
IWMs that may be unintegrated and contradictory. Bowlby addressed
defense against the child’s interpersonal attachment dilemmas (such as
unavailable, intermittently available, or intrusive caretakers) in terms of
what he called “defensive exclusion.” Here, the child may either deactivate
attachment or disconnect her perceptions and emotions, a style that allows
the child to stay attached but to disconnect observations and feelings that
are contradictory to her attachment.
The IWMs in infancy are aspects of implicit memory. Initially, they
operate subsymbolically. As the child grows older, the IWMs become
more explicit and may become verbally coded as part of autobiographi-
cal memory. These IWMs represent unconscious procedural knowledge
of being with another person that reflect implicit models of relationships
and are often adaptations to the parents’ inadequacies, inconsistencies, and
defenses (Lyons-Ruth, 1999, 2001). When these implicit procedural ways
of being with another are contradictory—for example, “Mother is safe and
protective, and I am safe” versus “Mother is dangerous, and I am endan-
gered and terrified”—or when implicit procedural knowledge contradicts
seemingly clear explicit information (e.g., a physically violent parent insists
that there has never been abuse), the contradictions can set the stage for
conflicting and segregated IWMs.
Segregated and incompatible IWMs can be the precursors for milder dis-
sociative disorders as well as ordinary problems in living. One IWM may
become dominant in its way of regulating emotions and interpersonal per-
ceptions, while others may become segregated from ordinary experience
as aspects of not-me (Sullivan, 1953). This may be the case in avoidant or
resistant attachment. For example, a person we will call Sarah, who is pri-
marily characterized as having a preoccupied attachment (corresponding to
resistant attachment of childhood), would often find herself in relationships
in which others cannot see her needs, realities, and contributions as valid.
In spite of that, she keeps trying to get these people’s positive attention,
mostly unsuccessfully and only on occasion successfully. As a result, she
has frequently been extremely distressed. In therapy, she has become more
aware of a main cause of her distress (her own expectations) as well as the
fact of her distress and the accompanying feeling of the injustice of it. This
IWM became more linked with the rest of her ongoing consciousness; as a
result, she has learned to increasingly assert herself. She was risking discon-
nection—but fortunately without that outcome, thus redefining the attach-
ment parameters of her relationships. In addition, she has been increasingly
able to extricate herself from interpersonal situations that were intractably
similar to her early attachment dilemmas, with the result that she is now in
more relationships in which she feels valued and noticed. Her problematic
IWM is still there, but because she has worked with her feelings about it
and linked it with her ongoing experience, it no longer defines her life as it
had in the past. She has become aware of it, understands it, and has learned
to apply new models that support healthier relationships.
In a general sense, a child who is put in situations in which only the
subjectivity of the caregiver matters is unable to express thoughts and
feelings that conflict with those required by the caregiver and therefore
may keep contradictory implicit knowledge segregated from the accept-
able “factual” view. The child might have a split-off knowledge about her
own needs while simultaneously convincing herself that her needs are what
her caregivers need from her. Here, the distinction between implicit, pro-
cedural memory and explicit, declarative memory is especially relevant.
Procedural memory pertains to things like “how to ride a bike” or “how
to interact with Mommy.” Certain procedural memories, which may not
be conscious, may exist in contradiction to conscious declarative memory,
which may contain autobiographical episodes of memory (called episodic)
or informational propositions about the self and others (called semantic).
Although procedural memory is not lost or changed, declarative memory
changes with experience. Thus, a person may have certain kinds of rela-
tional procedural “knowledge” that is enacted. This knowledge may not
be consciously known. Indeed, early schemata that contributed to DA are
encoded in implicit memory and “are too complex and intrinsically contra-
dictory to be later synthesized in a unitary, cohesive structure of explicit
semantic memory. In this sense the IWM of early [disorganized] attachment
is intrinsically dissociative” (Liotti, 2004, p.â•¯479). For example, the person
may have been told that the abusing parent was a wonderful person, or that
parent may have represented him- or herself to the world as such. This sets
up at least two conflicting IWMs and ways of relating to the world, which,
especially if there is amnesia for abuse, may be extremely confusing to the
person. If there is no collaborative relationship within which to work out
these contradictions, these patterns remain deeply segregated systems of
attachment.
These incompatible, segregated IWMs can be understood as dissociated
self-states. There is a striking similarity between the concept of segregated,
incompatible working models and that of dissociated self-states. Indeed,
inasmuch as IWMs involve an expectation of a particular kind of relation-
ship that involves the person, expectations of the other, and affects about
these expectations, one could say that IWMs are self-states, and that seg-
regated, incompatible IWMs are dissociated self-states (see Forrest’s 2001
work, which provides a neuroscience view and focus on these expectancies
as the important cross-temporal contingencies that infants must learn to
mediate if they are to cohere an integrated self).
Attachment and Attachment Classifications

Mary Ainsworth and her colleagues (Ainsworth, Blehar, Waters, & Wall,
1978) began a classification of infant attachment to the mother by means of
a procedure called the strange situation. This involved the mother leaving
her baby (aged 12 to 18 months) in an unfamiliar situation for a few min-
utes and then returning twice; an observation and coding were made of the
baby’s style of response to both being left and to being reunited. Ainsworth
et al. described three types of attachment: secure attachment and two inse-
cure attachment types—anxious avoidant and anxious resistant. A little
over half of the babies studied were found to be secure. Next in frequency
was avoidant attachment, followed by resistant attachment.
Babies who were securely attached cried and showed other signs of being
upset by the mother’s absence, but they were quickly comforted when the
mother returned. Avoidantly attached babies did not show behavioral dis-
tress in the mother’s absence and actively avoided contact with her when
she returned. A smaller third group of infants was classified as anxious
resistant. These babies were distressed in the mother’s absence, but they
were not comforted by her return. Rather, they continued to be distressed
and resisted being comforted. (This group has also been called anxious
ambivalent.)
Securely attached babies develop IWMs that are coherent and consistent.
The self is regarded as lovable, and others are regarded as trustworthy and
available. In contrast, insecure attachment classifications are also coherent,
but they are more problematic. They are coherent because they comprise
an organized pattern of attachment that includes contradictory conscious
and unconscious components. This organized pattern works as a defensive
system that is adaptive to the early interpersonal environment and operates
as a form of self-regulation and affect regulation.
Wallin (2007) understood these insecure patterns to involve two or more
contradictory working models. With regard to the avoidant/dismissing
classification, he wrote:
These “minimizing” or “deactivating” strategies are woven through

the contradictory models—conscious and unconscious—that shape
the inner and interpersonal experiences of avoidant/dismissing indi-
viduals. One model is consciously embraced and involves the sense that
the self is good, strong and complete, while others are untrustworthy,
needy, and inadequate. The second model which is unconscious and
feared, entails a disturbing sense that the self is flawed, dependent, and
helpless, while others are likely in response to be rejecting, control-
ling and punitive. Deactivating strategies support the first model as a
defense against the second (Mikulincer & Shaver, 2003). More specifi-
cally, these strategies promote distance, control, and self-reliance (the
essence of the conscious model) while inhibiting emotional experience
that might activate the attachment system (as it is dispiritingly repre-
sented in the unconscious model). (pp.â•¯90–91)
This defensive organization works as a response to an intrusive, misat-

tuned, rejecting and/or distant mother. It works to tamp down emotional
yearning for attachment. The parasympathetic nervous system can be
activated to cut down on experienced emotional reactivity, even though

physiological measures indicate that the distress has been felt. Avoidantly
attached children may also be thought of as repressing the affects of attach-
ment (Liotti, 1999). Later in life, avoidantly attached children may idealize
the parents (Liotti, 1992), thus contributing to the contradictions in the
IWM. In short, in avoidant or dismissing attachment style, deactivation of
attachment and devaluation are used as defenses—although idealization is
also used defensively. Here, the experienced reactivity of the self is over-
regulated (Wallin, 2007).
In contrast, there is the anxious resistant attachment classification (or
corresponding adult “preoccupied” classification). These children
were understood to inhabit a representational world shaped by mul-

tiple, unintegrated working models. These models were thought to be
the outcome of contradictory experiences with unpredictable attach-
ment figures.â•ƒ.â•ƒ.â•ƒ.â•ƒPresumably closeness was associated with favorable
experiences that generated the model of a distressed self in interaction
with a sometimes responsive other—while abandonment was linked
to problematic experience that resulted in a model of an autonomous
self in interaction with an unresponsive other (Mikulincer & Shaver,
2003). (Wallin, 2007, pp.â•¯92–93)
This overall organization views the self as close and connected to the
other, but the self is stressed, and the other is unpredictable. Here, there is
hyperactivation of the sympathetic nervous system. Emotions are turned
on, and the person is consciously aware of them. Resistantly attached chil-
dren may also be thought of as denying one side of an ambivalent attitude
(Liotti, 1999). This attachment style is often adaptive to an interpersonal
environment in which the caregiver is unreliably responsive.
Liotti (personal communication, December 2010) notes that securely
attached infants expect “well,” while avoidant ones expect to be rejected,
and resistant ones do not know what to expect. It should be noted here that
these categories are in a certain sense oversimplifications: Not everyone
fits into such neat categories; and, additionally, a child can have differ-
ent attachment styles with different attachment figures. However, what is
important to remember is that the secure, avoidant, and resistant strategies
are all identifiable organized patterns. They are not all necessarily happy
ones (especially with respect to the insecure strategies), but they represent a
purposeful pattern that has developed that enables the child to stay attached
and to self-regulate in the best possible way given the interpersonal envi-
ronment to which they have adapted.
It is only in later years into attachment research that a fourth attach-
ment pattern, called disorganized/disoriented, was identified (Main &
Solomon, 1986, 1990). (The corresponding adult attachment style is called
unresolved.) Disorganized attachment (DA), which affects about 15% of

infants (Van Ijzendoorn et al., 1999, as cited in Liotti & Gumley, 2008),
is associated with maltreatment or gross insensitivity on the part of the
caretaker. When the child faces the dilemma of both seeking safety from
and fearing the caretaker at the same time, the child’s attachment strategies
are likely to become disorganized. As a consequence, multiple, segregated,
incompatible working models of attachment may develop.â•¯T hese “multi-
ple and dissociated mental structuresâ•ƒ.â•ƒ.â•ƒ.â•ƒcontrol the child’s actions. These
structures may be related to incoherent, simultaneous representations of
the self and the attachment figure” (Liotti, 1995, p.â•¯348).
In the strange situation, babies with disorganized attachment (DA) will
do such things as run in circles, run toward and then run away from the
caregiver, have a facial expression in which one side is eager to greet and
another is terrified, or even just collapse in a heap.â•¯On videotape, they
appear to simultaneously approach and withdraw or to do both things in
quick succession (Jacobvitz, 2000; Lyons-Ruth, 2003). The attachment
system is activated, but the fear system is also activated in what is a repeti-
tive approach–avoidance conflict. The infant approaches the attachment
figure, governed by the attachment system, but then retreats as the fear
system takes over. This may become a positive-feedback loop, intensifying
the distress. “Caught in this loop, the child will experience such an over-
whelming flow of contradictory affects as to exceed his or her capacities for
a coherent, or even an ambivalent, organization of behavior and attention.
Therefore, his or her attachment behavior will become disorganized and
disoriented” (Liotti, 1999, p.â•¯764). Neither approach nor avoidance works
as a means of self-organization or as a way to alleviate fear. As a result,
disorganized children have a collapse of their defensive or coping strategy.
As babies and young children, they have not been able to find a way of
regulating affect. Although this disorganization is classified as a kind of an
attachment style, one could argue that it is less an attachment style than it
is an unresolved conflict about the viability of attachment.
Liotti (2011) puts it this way:
Being exposed to frequent interactions with a helplessly frightened, hos-

tile and frightening, or confused caregiver, infants are caught in a rela-
tional trap, created by the dynamics of two inborn motivational systems,
the attachment system and the defense (fight-flight) system. The attach-
ment and the defense systems normally operate in harmony (i.e., flight
from the source of fear to find refuge in proximity to the attachment fig-
ure). They, however, clash in such a type of infant-caregiver interaction
where the caregiver is at the same time the source and the solution of the
infant’s fear (“fright without solution”: Main & Hesse, 1990, p.Â€163).
The consequence of the simultaneous activation of the defense and the
attachment system is the “failure to terminate attachment interactions,
due to the fact that fear is in itself a powerful activator of the attach-
ment system. (Solomon & George, 1999, p.Â€385)
This pattern of DA is predicted by maltreatment and neglect (Carlson,

1998) and has been found to occur in about 80% of maltreated infants
(Carlson, Cicchetti, Barnett, & Braunwald, 1989). Maltreatment and
severe neglect, however, are not the only path to DA. About 15% of the
infants of low-risk families, in which the infants did not appear to have
been abused, are also disorganized (Liotti, 1999; Lyons-Ruth, 2003). What
then precipitates the DA in this group?
Hesse and Main (1999) hypothesized that frightening or frightened (FR)
parental behavior could lead to disorganized attachmenmt (DA) in the
absence of overt maltreatment. With reference to the first, they described
some of the mothers of these “low-risk” disorganized infants: Offering
none of the metasignals of play, these mothers teased their babies by spon-
taneously entering into predatory, animal-like behavior—growling, hiss-
ing, baring their teeth, stalking their infants on all fours, in one case mock
mauling the baby, with fingers extended like claws. The authors explained
as follows:
[F]rightening parental figures put their offspring in an irresolvable and

disorganizing paradox in which impulses to approach the parent as the
infant’s “haven of safety” will inevitably conflict with impulses to flee
from the parent as a source of alarm. Here, we argue that conditions of
this kind place the infant in a situation involving fright without solu-
tion [emphasis added], resulting in a collapse of behavioral and atten-
tional strategies. (p.â•¯484)
From studies such as these, we learn that infants are particularly sensi-
tive to instances when they are presented with conflicting needs (such as
approaching or fleeing), even if these instances are not perceived by the par-
ent as traumatizing or maltreating. The parents might have been meaning
to play with the infant, but they were not attuned to the child’s experience,
affect, or needs, resulting in the infant experiencing fright without solution.
Repeated exposure to such experiences might well result in DA even when
the parent is not abusive but is sufficiently out of tune with the infant and
the infant’s needs.
The Intergenerational Transmission of Attachment

Style and the Adult Attachment Interview
The scary and misattuned mothers who hissed at their babies and crawled
on all fours described by Hesse and Main (1999) were not overtly abu-
sive and were not consciously intending to harm their children. It is likely
that they were transmitting unresolved trauma from their own histories.
Because of their own unresolved traumas, they tended to reenact their dis-
connected procedural relational models of how to do things with another
(inconsistent and segregated IWM), resulting in serious misattunement
and varying degrees of neglect. Hesse and Main (1999) documented a
correspondence between the attachment styles of the infant and those of
the mothers. Secure, autonomous parents tended to have secure babies;
dismissing parents, avoidant babies; and preoccupied parents, anxious,
resistant babies. In addition, behavior of parents classified as unresolved/
disorganized corresponded to that of their disorganized infants. (However,
the unresolved category will also be given a secondary category, and if
the second category is secure, then there is less likelihood of having an
infant with DA.) The authors coded the parents’ attachment classifications
using the Adult Attachment Interview (AAI), an interview developed by
Main and her colleagues in which respondents are asked to describe and
evaluate some of their own early attachment experiences. Rather than life
history, coherence and collaborativeness of discourse are key criteria for
coding these interviews. The parents’ ability or lack of ability to speak
coherently and collaboratively, while describing their own life events and
early attachment experiences in the context of an interview that activates
the attachment system, predict their infant’s attachment style, suggesting
a source of intergenerational transmission. The ability to think about and
describe personal experience in a coherent way and to empathically think
about what others are thinking fosters the child’s emotional development.
The lack of opportunity for narration of self-experience with important
figures (the very narration that secure attachment allows) is detrimental
to the development of integrating capabilities. Thus, a parent’s unresolved
trauma—as can become manifest in brief moments during the AAI—would
be expected to affect the coherence and collaborativeness of their discourse.
Liotti (2004) noted that parents with unresolved traumatic memories are
likely to have their attachment system activated along with their caregiving
system when they engage in caring for their own children. The activation of
the attachment system arouses strong emotions, including fear and anger,
and these emotions are likely to show even as they attempt to soothe their
babies. Although they are not overtly maltreating their babies, such parents
may be unwittingly frightening them.
Main’s development of the AAI connected the related themes of trauma,
IWMs, DA, and coherence of narrativity. The AAI, in a sense, scores unre-
solved trauma—although it should be noted that the coding of the unre-
solved classification does not depend on the veridicality of the reports of
trauma. Unresolved trauma leads to dissociated mental structures, whether
we call these structures self-states or an IWM. Not surprisingly, the par-
ents of dissociative patients are more likely than others to have experi-
enced a major loss around the time of the patient/subject’s birth. Liotti,
Intreccialagli, and Cecere (1991), cited in Liotti (2006), found that a large
portion (62%) of parents of 46 patients with dissociative disorders had
suffered a serious loss either 2 years before or 2 years after the birth of the
baby. In contrast, only 16% of parents of psychiatric patients without dis-
sociative disorders had suffered such a loss.
Fright Without a Solution

The concept of fright without a solution (Hesse & Main, 1999) describes
the prototypical dilemma of the child who develops DA. However, this
may be more complicated than directly frightening or frightened parental
behavior. Noting that she and her colleagues had found that “absence of
caregiver responses will also lead to infant disorganization,” Lyons-Ruth
(2006) suggests that “the more general caregiving mechanism related to
disorganization may be the lack of effective caregiver regulation of fear-
ful arousal, rather than explicit fear of the caregiver herself” (p.â•¯610). In
the course of a 19-year longitudinal study, Lyons-Ruth and her colleagues
(Lyons-Ruth, 2001, 2003, 2006) found that overall disrupted attachment
was highly associated with DA: “Both in our own work and in the work of
three additional laboratories, these disrupted affective communication pro-
cesses at 12 to 18 months of age are related to the extent of the infant’s dis-
organized attachment behavior” (Lyons-Ruth, 2006, p.â•¯606). Lyons-Ruth
and her colleagues (Lyons-Ruth, 2006) examined five broad forms of dis-
rupted parental affective communication with the infant: withdrawal, neg-
ative-intrusive responses, role-confused responses, disoriented responses,
and affective communication errors. The last included the mother’s failure
to respond to the infant’s affective signals and giving simultaneous con-
flicting cues to the infant—for example, a mother laughing at her baby’s
distress while picking up the baby.
Although the developmental pathway from DA to DID is not clear, DA
has been linked to the development of dissociative symptoms (Carlson, 1998;
Liotti 1992, 2004, 2006; Lyons-Ruth, 2001; Ogawa et al., 1997). In fact, DA
was noted as a better predictor for dissociative experiences than documenta-
tions of abuse. In a longitudinal, prospective study extending from infancy
to late adolescence, Ogawa et al. (1997) found that DA and proneness to dis-
sociation were significantly related. In longitudinal studies involving disorga-
nized infants, Lyons-Ruth (2003, 2006) found that contrary to expectation,
maltreatment and trauma per se did not predict later dissociative symptoms.
Instead, “maternal disrupted communication at 18 months made a strong
contribution to the prediction of dissociative symptoms at age 19” (p.â•¯610).
The researchers found no prediction from factors of poverty, single parent-
hood, early history of maltreatment, or the mother’s dissociative sympto-
mology up to age 7. None of these predicted the incidence of dissociative
symptoms in the adolescent at 19 (Lyons-Ruth, 2006).
What then in unrepaired maternal disrupted behavior is traumatic? As

previously noted, neglectful or grossly misattuned maternal behavior that
would not be traumatizing to an older child or an adult might well be so for
an infant. This may lead to DA. As Liotti (2011) observes:
The interaction between a frightened/frightening, helpless or abdicat-

ing caregiver and a disorganized infant experiencing fright without
solution is an extreme example of emotional misattunement, that is,
of threatened failure in the intrinsic intersubjectivity of human experi-
ence (Stern, 1985, 2004). Instead of preserving secure intersubjectivity,
the infants’ experience is alike to feeling utterly alienated from one’s
own primary relatedness, that is, to feeling alone while being in the
perceptual (as opposed to communicational and affectional) presence
of another person. This experience may be understood as a type of
early relational trauma, that exerts an adverse influence on the develop-
ment of the stress-coping system in the infant’s brain. (Schore, 2009,
pp.Â€385–386)
Is Disorganized Attachment Inherently

a Dissociative Process?
Disorganized infants exhibit trancelike and disconnected behaviors
(Jacobvitz, 2000; Lyons-Ruth, 2003). They often exhibit stilled behavior
and appear to be staring into space. Many of the behaviors displayed by
infants with DA are phenotypic of dissociation (Main & Morgan, 1996),
and Liotti (1992, 1995, 1999) has proposed that DA may be considered a
prototype for dissociative disorders.
The disorganized infants who are caught in fright without a solution have
highly conflicting and segregated IWMs that, by the nature of the interper-
sonal situation in which the attachment figure is traumatizing, dangerous, or
feared, cannot be linked. Therefore, these working models are dissociated.
Disorganized Attachment: Hypnoid States in Babies

One may understand DA as the result of early trauma—trauma in the sense
of something that exceeds the integrative capacity of the infant or young
child’s consciousness—and that these early contradictory IWMs in DA are
the result of dissociative processes (Liotti, 2006). Based on observations
that these babies, like dissociative adults, go into trancelike behaviors, one
could also say that these traumatized babies exhibit hypnoid states.
Liotti (2006) suggests that the emotionally shifting, frightening, or vio-
lent interpersonal environment to which these disorganized infants are sub-
ject simply cannot be assimilated and organized for use by the infant in
any coherent fashion: “The simultaneous emotional perception of self and
the caregiver in DA could exceed the integrative power of consciousness in

this developmental period” (p.â•¯58). Referring to Bower’s (1971) early work,
which found that, in contrast to younger infants, those over 20 weeks old
responded with alarm when presented with multiple perceptual images of
the mother, Liotti (2006) infers that this means that the infants’ integra-
tive powers have increased by 20 weeks: Because the older infants expect
continuity, they are alarmed at the lack of it. Liotti (2006) notes that this
is significant because this is the same period that the attachment bond is
developing. Second, he suggests that this unintegratable confusion puts the
infant into an altered state, a trance—as can happen with adults (i.e., with
confusional techniques in Ericksonian hypnosis).
In other words, with regard to DA, the basic substrates that may later
develop into dissociated parts of the self are already there—in infancy.
These substrates probably also set the stage for developing self-hypnotic
abilities of the person with a dissociative disorder.
Dissociative Disorders May Develop

From Disorganized Attachment
Liotti (1992) has proposed that the development of DID depends on an ear-
lier development of DA in which the baby has many disconnected, contradic-
tory IWMs, and that it is only this, in combination with severe and repeated
trauma, that yields DID. He has developed a compelling model by which
DA may develop into either less-serious problems in living or full-blown dis-
sociative disorders, depending on whether later events in the child’s life are
mitigating (allowing an opportunity for synthesis of dissociated structures)
or further traumatizing (which would prevent such synthesis).
A child who had reparative stabilizing attachment experiences subsequent
to early experiences yielding the DA might be prone to dissociative experi-
ences such as daydreaming and may have a high score on the Dissociative
Experience Scale (DES) (see Chapter 8 on Assessment) but would otherwise
be relatively unimpaired. A child who had fewer reparative experiences but
had not experienced serious trauma and maltreatment might develop a mild
dissociative disorder. But, a child with DA who was subsequently subjected
to serious abuse would be likely to develop DID.
How then would this come about? Following Edelman (1989), Liotti
(1992) suggests a process by which DID may develop and by which the
switch process occurs. Edelman’s (2004) theory of consciousness assumes
that information is processed in a parallel distributed way with respect to a
primary form of consciousness (PC) that is shared by humans and certain
other higher-developed mammals. “Primary consciousness is the state of
being mentally aware of things in the world, of having mental images in
the present” (Edelman, 2004, p. 9). This develops from an ongoing match-
ing and evaluation of information about the biological self to information
outside that self—to the outside reality. PC is the basis for the emergence of
higher-order consciousness (HOC), which is a conceptual memory of self
and nonself linkages. HOC precedes the development of logical and verbal-
izable thoughts. According to Liotti:
The working model of self and the attachment figure is an early aspect
of the conceptual memory of self-not self. In order for the process of
HOC to proceed properly, the matching of ongoing environmental
information with a coherent (if not unitary) conceptual memory of self/
not-self is necessary. If the conceptual schemata of the self/not-self dis-
tinction against which the ongoing environmental information is at a
given moment matched, are multiple and incompatible, HOC will tend
to collapse. It is likely that, in that particular moment, the subjective
experience of the person will tend to be reduced to the PC. An altered
state of consciousness will be experienced, inside which the non-con-
ceptual, non-verbalizable aspects of the biological self (visceral and
emotional information) will be confronted with stored and ongoing
information concerning outside reality. If two or more of the incom-
patible conceptual models of self/not-self alternate rapidly during this
altered state of consciousness, dissociated actions (each related to one
of these incompatible models) such as those observed in D babies dur-
ing the SS [strange situation] may make their appearance. If one among
the competing conceptual models (let us label it CM1) is then selected
for matching with ongoing environmental information, the altered
state of consciousness will come to an end, and HOC will be resumed.
An amnesia barrier, however, will separate the information pertaining
to CM1 from that pertaining to other models (CM2, CM3, etc.) when
they will be eventually called into operation by new configurations of
environmental stimuli. Until the process of switching from one CM
to another in matching environmental information is completed, an
altered state of consciousness (that is, a lapse of HOC and a resurgence
of PC) will be subjectively experienced. (p.â•¯201; italics in original)
The Karpman “Drama” Triangle

ofÂ€Victim, Persecutor, and Rescuer
Along with Ross (1989) and Putnam (1989), Liotti found the Karpman
drama triangle a helpful heuristic model for understanding the dissociated
self-states of DID. The Karpman drama triangle (1968) includes the help-
less suffering victim, the powerful abuser, and the powerful rescuer. Liotti
linked the origin of the identities specified in the Karpman triangle to the
infant’s experience of frightening or frightened parents. As noted, the IWM
of DA expresses multiple, segregated, and dramatically different expecta-
tions of the attachment figure (Liotti, 1999, 2004, 2006). In particular, the
child may display incompatible attitudes involving care-seeking, caregiv-

ing, and fight-flight, and display shifts between these. This kind of dra-
matic shifting from one attitude to another—from helplessness to hostility
to caregiving—is also characteristic of adults who report histories of abuse
and traumatic attachments. Referring to Main and Hesse’s (1990) studies
of disorganized children who suffered fright without a solution with regard
to parents who tended to be frightening or frightened, Liotti suggested ways
that these identities of victim, persecutor, and rescuer may develop.â•¯I n the
first case of the frightening parent, the children will have an IWM in which
they experience themselves as helpless victims of a persecutor. In the latter
case of the frightened parent, the children might erroneously see themselves
as the source of the parents’ fright and construe themselves as persecutors.
Linked to this self-view, they may also see themselves as blameworthy. In
response to a parent’s inversion of the attachment relationship, these chil-
dren may also develop an additional role: They may see themselves as the
parent’s rescuer and comforter. In addition, with reference to a frightened
as well as a frightening parent, inasmuch as their own attachment needs
for modulation of fear are not being met, the children may also experience
themselves as helpless victims.
These roles, developed early into identities in the infant’s experiences
with the caregiver, function as substrates that underpin later identities and
roles that are variants of caregiving, perpetration, and victimization.
Disorganized Attachment Precedes

a Wide Array of Disorders
It is important to note that attachment disorganization has been linked not
only to dissociative disorders but also to a wide range of difficulties and
diagnoses. Sequelae of early DA include deficiencies in reflective, mentaliz-
ing capacity (Fonagy, 2001; Fonagy et al., 2002) include increased aggres-
siveness with peers (Lyons-Ruth, 1996) and general difficulties with affect
dysregulation (Liotti, 2006; Lyons-Ruth, 2003; Schore, 2003a, 2003b).
These deficits following DA make it a general risk factor for a number of
psychiatric diagnoses. Inasmuch as DA is essentially a dissociative process,
this would be true: Dissociation underlies many diagnoses and problems in
living, including neurotic, superego, and trauma-based difficulties (Howell,
1997a); personality disorders (Bromberg, 1993, 1995, 1998; Howell,
2002a, 2003); and psychoses (Liotti & Gumley, 2008; Moskowitz, 2008;
Read, Perry, Moskowitz, & Connolly, 2001). However, DA is most directly
and clearly linked to disorders characterized by splitting and dissociation,
such as borderline personality (Liotti, Cortina, & Farina, 2008; Lyons-
Ruth, 2001, 2006), narcissistic psychopathology (Lyons-Ruth, 2001), and
psychosis (Liotti & Gumley, 2008) in addition to dissociative disorders.
It should be noted that DID has frequently been misdiagnosed as border-

line personality disorder (BPD). BPD is also often diagnosed as comorbid
with DID. I have previously outlined why I believe that BPD is dissocia-
tion based (Howell, 2002a). Howell and Blizard (2009) proposed a new
diagnostic term of relational trauma disorder that would encompass BPD.
In these last conceptualizations, BPD is not comorbid but is an aspect of
dissociative psychopathology.
Sequelae to DA: Controlling Strategies

How do the later-developing aspects of DA manifest themselves? Often,
as these disorganized babies and young children grow older, they develop
an organizing strategy (Liotti, 2006; Lyons-Ruth, 2001, 2006). By 3 to 5
years old, many of these formerly disorganized infants and young children
have reorganized their attachment strategies in such ways that they began
to control their mothers and other people in particular ways: They became
either compulsive caretakers of their parents or aggressively bossy and hos-
tile. Lyons-Ruth (2001) concludes:
The developmental transition from disorganized behaviors to controlling

forms of attachment behaviors over the preschool period supports the
notion that one “grows into” a borderline or narcissistic stance through
a complex series of alternative developmental acquisitions.â•ƒ.â•ƒ.â•ƒ.â•ƒThe child
in a disorganized attachment relationship appears to use emerging devel-
opmental capacities to construct increasingly polarized coercive or role
reversed “false-self” relations with the parent. (p.â•¯45)
While Lyons-Ruth (2006) views this reorganization as due to the chil-

dren having “given up turning to the parent to help regulate their security
and stressful arousal, [instead becoming] immersed in maintaining the par-
ents attention” (p.â•¯608), Liotti (2006) suggests more specifically that these
strategies inhibit the attachment system, substituting other motivational
systems, such as an inverted caretaking behavioral system or a competitive,
hierarchy-based behavioral system. Furthermore, these strategies work as a
defense against “the unbearable feeling of disorientation and disorganiza-
tion linked to fright without a solution” (p.â•¯68). The problem is, however,
that when the attachment system is activated in these now seemingly orga-
nized older disorganized children, they lose their organization derived from
the substituted behavioral system and become vulnerable. In testing situa-
tions in which separation anxiety is invoked by such things as the presenta-
tion of pictures of a child being left alone, these children suddenly become
anxious and helpless, sometimes expressing catastrophic fantasies about
what will happen to the pictured child who has been left alone (Liotti,
1999). In these instances, their organization falls apart: “Whenever mental
pain activates the attachment system, the dissociative processes linked to

the disorganized IWM emerge in consciousness, and disrupt the integrative
powers of consciousness, as a consequence of the collapse or failure of the
defensive controlling strategies” (Liotti, 2006, p.â•¯68). As long as the attach-
ment system is not activated, they are relatively anxiety free, but when the
attachment system is activated, they become highly symptomatic. Clearly,
people who have not had the opportunity to integrate conflicting and dis-
sociated IWMs but who could only sidestep them by invoking other behav-
ioral systems are poorly equipped to handle new trauma.
Defense
According to Liotti’s (2006) conceptualization (with which I agree) in
the above instances, the organizing controlling strategy, that is, the side-
stepping of the attachment system and the engagement of an alternative
behavioral system, is the defense. The underlying dissociative organiza-
tion is not understood to function defensively. Rather, the emergence of
the unresolved dissociative structure is the result of attachment dilemmas
that could not be resolved and synthesized. Because the underlying dis-
sociative structure, which does not contain in itself an adequate psychic
defense, has been exposed when the attachment system has been activated,
the attachment-related anxieties and catastrophic fantasies emerge. This
is in contrast to saying that the dissociative structure is being used defen-
sively in these instances. This is not to gainsay that dissociative processes
once established may later be used defensively. However, it is fundamen-
tal to understand that, in contrast to the insecure styles of avoidant and
resistant attachment, which integrate the discordant IWM into an overall
defensive style, DA, with its segregated, incompatible IWM (and the corol-
lary, dissociated self-states), is not a defensive style. The existence of these
segregated IWMs should not be misinterpreted as defense, such as splitting.
To the contrary, the emergence of the dissociated IWMs may result as a
failure of defense. As Liotti (2006) noted, the extreme separation anxiety
and catastrophic fantasies of these children whose attachment system was
suddenly activated appears “as a consequence of the collapse or failure of
the defensive controlling strategies rather than as a primary defense against
mental pain” (p.â•¯6).
People With Disorganized Attachment

Are Poorly Equipped to Deal With Painful
Attachment Dilemmas and Relational Trauma
The disorganized children who developed controlling strategies that side-
stepped the attachment system become symptomatic when the attachment
system is activated. The person with DID may switch between activation
and deactivation of the attachment system, but the dissociation is a short-

term solution, not a cure for the unresolved attachment traumas. When the
attachment system is activated, separation issues can be extremely painful.
The psychotherapy relationship is a key arena in which the attachment sys-
tem is activated.
What does this have to do with our work clinically? What I have real-
ized and what needs emphasizing here is that these disorganized children
and later unresolved adults (the adult counterpart to DA) can only regulate
themselves by regulating others. They are hyperalert to the mental states of
others but less to their own. In contrast to the insecure attachment styles,
in which there is a defensive, not entirely happy, but workable organizing
strategy for regulating affect and for coping with the interpersonal situa-
tions that they have faced, in DA the child and later the adult has not been
able to develop a coherent strategy for self-regulation. As a consequence, the
only way to develop a unitary strategy is to control others. But, when this
strategy fails, they become disorganized. And, when trauma strikes anew,
they do not have a means to self-regulate, to recover, or to handle it.
This has several implications for clinical work. One is that it gives us,
as clinicians, a better conceptual sense of how our patients feel when their
attachment system is activated in psychotherapy, as it will be. For instance,
our patients with DID (and those with an unresolved attachment style)
may frequently make intrusive demands on us in the therapy (e.g., many
and lengthy messages, many requests for callbacks, or other extra-session
attention, or even, sometimes jokingly, the request to move in). If we keep
in mind that this is how they are regulating themselves and that they have
not learned other ways, we can mitigate problematic countertransferen-
tial responses. Then, there is the additional problem that rejection of these
attachment bids is shaming. What are we to do? I suggest bearing in mind,
or perhaps even saying, something like the following:
I know that you may be hurt when I am unable to [return the phone call as
quickly as you would like, or give you extra time, etc.]. And I know that you may
be especially hurt because you don’t know what else to do, and also because it
is painful [shameful] to ask. But part of our job is to work on this problem from
your childhood: that you were deprived of being able to develop good ways of
self-regulation. We will work together on your learning how to do this. I hope
that knowing this will help you not to be so hurt or to feel so abandoned when I
am not able to do these things.
One might include things that are specific to the patient’s situation, such
as, “You can remember that I have told you that I will call you back when
you call me,” or “If you are just wanting contact, you can call and listen to
my voice message. Leave a message if you wish, but be sure to tell me if you
need me to call you back.”
The Care-Taking Controlling Strategy May

Also Preserve the Capacity to Love
I would like to offer a somewhat different perspective on the care-taking/
controlling strategies emanating from disorganized attachment on the basis
of my experience with DID patients who have developed this strategy. I
am not in disagreement with the general formulations provided by Liotti
and Lyons-Ruth. What I would like to add (with recognition of Kernberg’s
[1975, 1984] similar stance with regard to the role of splitting in protect-
ing the good from the bad) is that the caretaking strategy, in conjunction
with the dissociation of rageful and terrified self-states, can facilitate the
preservation of the capacity to love. Although this capacity to love may
be infiltrated with other motivations such as need to please and primitive
idealization, I believe that in many cases of DID, the preservation of this
capacity is a kind of “digging-in-one’s heels” insistence on the potential for
a loving orientation to life. The opportunity for this insistence is provided
by some aspect, no matter how small, of a loving relationship in the per-
son’s experience.
For example, recall the case of Janice presented in Chapter 1: Janice was
a thoroughgoing caretaker to her mother, providing her mother with her
own daily tea, massages, as well as providing family meals, sewing, and
party clean-up. She was tuned in to her mother’s chronic depression, and
hoped to help heal her with her attentions. Even though Janice also had
dissociated rageful self-states, in most other self-states she cared about her
mother’s comfort and well-being. Her dissociation, stemming from her dis-
organized attachment, allowed her a way to preserve her ability to love.
Albeit, this is an extremely high price to pay, it is better than the possible
alternatives of psychosis or psychopathy.
In another case, Violet, who was severely terrified, neglected, and abused
as a child, clung to the task of rescuing and loving her mother into health,
even as a young child. Her belief in her power to restructure her mother’s
psyche through her love provided a mainstay to her psychic equilibrium.
In her household her father was unpredictably violent and aggressive in
his behavior, corroborating his frequent verbal threats to murder his chil-
dren and his wife. Violet’s mother acquiesced to his domination, was highly
self-absorbed, and was unable to defend her children. Not only was she
unable to defend them, but it seems that she was envious of their potential
to escape his domination. Violet’s childhood was one of being constantly
under siege, but with no respite, no comforting other presence, other than
an older brother who was available to her some of the time, who could
provide her with even temporary solace. She longed for her mother to be
well and stronger than she was, really did care about her, tried hard to
get through her mother’s barrier to receive her help and to reach her, and
was able to help her to some degree. While one could say that this was a
controlling/caretaking behavior stemming from disorganized attachment,
her fiercely held belief that she could help and transform her mother pre-
served her ability to believe in human goodness. Her ability to love and to
truly care about certain others became expanded in her inner-oriented as
well as her in outer-oriented psychic landscape. However, her entrenched
belief in the power of her love operated defensively to take the focus off her
own personal daily terror. This illusion that the power of her love could
restructure her mother and her brother became an aspect of her identity.
Today the prospect of giving up that illusion of power is a huge shift for her,
and especially for one of her self-states. This is especially powerful because
the Inner Violet believed that she was responsible for protecting the Outer
Violet at age 3 from her father’s abuse. Although such a shift is severely
disequilibrating and brings on annhiliation anxiety, it does not mean the
loss of her capacity to love.
Chapter 6
Some Neurobiological
Correlates of the Structure
and Psychodynamics of
Dissociated Self-States
Introduction
The neurophysiology of self-states is a complex and fascinating subject that

is in its infancy. Regardless, there is hope that an understanding of the
physiologic basis of self-states, combined with our already existing more
developed knowledge of psychodynamics, will eventually lead us to craft an
even more powerful approach to treatment. In this chapter, I explore ways
in which our increasing knowledge base of the neural processes related to
dissociative experience can support our potential for healthy living and
potentially improve the psychotherapy of the chronic complex trauma,
posttraumatic stress disorder (PTSD), and the dissociative disorders. First,
I focus on how a traumatic experience is processed in the brain. In the sec-
ond part of this chapter, I focus more on the importance of depersonaliza-
tion and hypoarousal and ways that different physiological organizations
of self may develop, including DID.
Traumatic Experiences Are

Processed Piecemeal
Over a century ago, Pierre Janet (1907) described how “vehement emotions”
evoked by trauma can prevent the integration of traumatic memories. Because
they cannot be assimilated, aspects of these experiences became separated
from ordinary consciousness. As subconscious fixed ideas, the residues of the
traumatic experience continue to intrude into experience. Today, we know
more of how traumatic experience is processed in the brain differently from
nontraumatic experience. One way the processing differs is that traumatic
experiences are often encoded in procedural repertoires and somatosensory
modalities rather than in declarative memory, where nontraumatic memories
are commonly encoded (Courtois, 1999; Levine, 1997; Scaer, 2001, 2005;
Terr, 1990, 1994; Van der Kolk, 1996a, 1996c). By definition, traumatic
experiences come with high levels of emotional arousal, and there is cause to
109
believe that extremely high levels of emotional arousal cause a deficiency in

declarative and narrative memory.
There are two basic memory systems: declarative, also known as explicit
memory, and nondeclarative, which is also known as implicit memory or
procedural memory. Declarative memory, which relates to facts and events,
refers to the “what” of experiences (e.g., “What did I do? I know that I
rode a bike; I know it was red”). Autobiographical or narrative memory
is a form of declarative memory. Procedural memory, which has to do
with motor skills, habits, conditioned emotional responses, and emotional
memories, refers to the “how to” (e.g., “I know how to ride a bike—my
body knows to remain balanced, my legs know how to alternate,” etc.).
There are many things that a person knows how to do procedurally—ways
of moving, talking, responding to others—that are difficult to put into the
language of facts.
Dissociated memories are evoked in procedural, sensorimotor, somatic
formats that will emerge when the person enters the mental state in which
the trauma was originally salient. For example, Bruce Perry (1999) wrote of
a little boy he met in a residential treatment center who persistently refused
to eat his hot dog unless it was cut up, a matter that caused escalating con-
flicts with the staff. Perry’s inquiry revealed that the child had been forced
to perform fellatio on his father and other men until he was 6 years old.
The oropharyngeal patterns of stimulation of eating things like hot dogs
evoked state memories of the abuse, involving terror and confusion. Until
this discovery, no one knew why this child was being so “difficult” (and it
is likely that the child would not have been able to explain his reaction).
Survivors of sexual abuse often describe repeated vaginal and rectal pain;
survivors of physical abuse often describe back pain that corresponds to
the location of previous injuries, even though there is no current medical
explanation for such continual experiences. The persistence of intrusive
physical reactions linger long after actual traumatic injuries have physically
healed is often termed somatoform dissociation. In many cases, the simplest
explanation of somatoform dissociation could be that the trauma prevented
the experience from being processed in a way that it could become narra-
tive memory; instead, the “memory” remained an aspect of sensorimotor
memory only. Indeed, common symptoms of hysterical shell shock among
soldiers in World War I were paralysis, mutism, anesthesia of a limb, and
other somatosensory functional losses. Amnesia for the event almost always
accompanied these symptoms.
As Van der Kolk (1996a) eloquently noted: “The body keeps the score”
(p.â•¯214). Localized yet otherwise inexplicable body pain may be a reactivation
of a traumatic memory reexperienced in a body part that was injured during
the trauma. Terr (1990), writing of her work with children, demonstrated the
effect of procedural, implicit, somatic nonverbal memories powerfully. She
described the behavior of a 5-year-old patient who had intensely inappropriate
Structure and Psychodynamics of Dissociated Self-Statesâ•… 111
fears of projectile objects and who was inordinately protective of her upper
abdomen. As an even younger child, she had often pointed to this area. As
a toddler, and unlike most other children this age, she had screamed while
being diapered. This child drew age-inappropriate pictures of anatomically
correct naked people. When she was 5 years old, photographs surfaced that
showed the girl at 18 months of age being pinned down on the diaper table by
a man’s hard, erect penis, exactly in the location of her upper abdomen. Terr
(1990) called this kind of an event “psychophysiologic reenactment” (p.â•¯271)
and noted that often the part of the body that was injured or hurt during the
trauma manifests or “recalls” the pain.
What are the psychophysiological processes that bring about such
events? According to Van der Kolk (1996c), extremely high levels of emo-
tional arousal lead to inadequate evaluation of the sensory information in
the hippocampus. Van der Kolk described a basic model for the processing
of traumatic experience: Sensory information is partially processed by the
thalamus, which then passes along raw sensory information to the amygdala
(which is involved in evaluating emotion) and to the prefrontal cortex. From
the amygdala, this emotionally evaluated information is passed on to areas
in the brain stem that transform it into hormonal and emotional signals, as
well as to the hippocampus (which is involved with the organization and
integration of information). The strength of the hippocampal activation has
an inverted U-shaped function: Up to a certain point, the stronger the sig-
nificance conveyed by the amygdala, the stronger the memory consolidation
into declarative memory will be. This may explain how we tend to remember
significant events such as births and adventures more vividly and often with
more narrative detail than the less emotionally charged day-to-day events.
However, too much stimulation interferes with hippocampal function. The
result of such interference with the integrative function of the hippocampus
is that memories may be stored in nonintegrated sensorimotor modalities,
affective states, visual images, and somatic sensations.
The experience is laid down and later retrieved as isolated images, bodily
sensations, smells, and sounds that feel alien and separate from other
life experiences. Because the hippocampus has not played its usual role
in helping to localize the incoming information in time and space, these
fragments continue to lead an isolated existence. Traumatic memories
are timeless and ego-alien. (Van der Kolk, 1996c, p.â•¯295)
Van der Kolk noted that what is important about the processing of trau-
matic experience is that, because the sensory information from the thalamus
reaches the amygdala first, “preparing” it for evaluation by later-arriving
information from the cortex, the emotional evaluation of this information
ends up occurring in advance of the conscious evaluation. The result is that
stress hormones and the sympathetic nervous system (SNS) are activated
before the person understands the cause for this activation.
Because traumatic memories have been incompletely processed (i.e., inte-
grated) in the hippocampus, they are experienced as isolated somatic and
sensorimotor experiences and can “make themselves known” piecemeal and
often through strange and terrifying contents. When a memory emerges in a
flashback, it is frequently expressed in a sensory way that then requires cog-
nitive interpretation to understand because contextual pieces are missing.
For example, Brenmer (2002) described a patient who was locked in a closet
as a child. She recalled the smell of old clothes but had no visual memory of
the closet or an affective memory of fear. Nijenhuis et al. (2001) found that
somatoform dissociation was best predicted by physical abuse and threat to
life by another person. In many cases it seems that the simplest explanation
of somatoform dissociation could be that the trauma prevented the experi-
ence from being processed in a way that would have it become a narrative.
In response to stressful situations that require an effective emergency
action, the body releases endogenous stress hormones: norepinephrine and
cortisol. Norepinephrine (adrenaline) causes heightened alertness and focus,
increases heart rate and blood pressure, and facilitates memory at lower lev-
els by making the brain more efficient. However, norepinephrine levels that
are too high cause the brain to shut down (lowering and hindering effec-
tive action). In stressful circumstances, the HPA (hypothalamic-pituitary-
adrenal) axis also goes into action and regulates the response of the body to
stress. The response to stressful circumstances activates a complicated circuit
of reaction and feedback loops that involves the hypothalamus, the pituitary,
and the adrenal glands, and that among other chemical reactions prompts the
production of the hormone cortisol by the adrenals (Yehuda, 2000). Cortisol
increases survival functions by shutting down systems that are not immedi-
ately necessary in time of danger: immune function, digestion, and pain per-
ception. Although helpful in a sporadic emergency, long-term effects of high
cortisol secretion are harmful to brain function and health. Indeed, PTSD
has repeatedly been associated with HPA dysfunction, and early life stresses
may have a long-term effect on its development and function (Bremner &
Vermetten, 2007; Simeon & Abugel, 2006; Yehuda, 1998, 2000).
An additional problem related to incomplete processing by the hippocam-
pus is that procedural memories of the threatening event continue to operate
as if the danger is still present. A positive-feedback loop of stress reactions may
ensue, so that sensitized neurons continue to resensitize each other, continu-
ally activating neuronal pathways independently of external cues for current
danger. This can result in a automatic overactivation of a person’s arousal sys-
tem, which in turn leads to too frequent activation of the HPA axis, overpro-
duction of cortisol, and even subsequent hippocampal damage (Scaer, 2005).
When the stress response is activated too often, the hippocampus
may suffer damage and decrease in size (Bremner & Vermetten, 2007;
Nijenhuis, Vanderlinden, & Spinhoven, 1998; Perry, 1999; Van der Kolk,
1996b). A number of studies have found decreased hippocampal volume
in adults with dissociative identity disorder (DID) and PTSD (Nijenhuis,
2003). Vermetten, Schmal, Linder, et al. (2006) found that women with
DID had 19.2% less hippocampal volume and 31.6% less amygdalar vol-
ume than healthy controls. Ehling, Nijenhuis, and Kirkke (2003) found
that patients with florid DID had 25% less hippocampal volume than
controls, whereas patients with dissociative disorder not otherwise speci-
fied (DDNOS) had 13% less hippocampal volume compared to controls,
suggesting a dose effect: Hippocampal volume may correlate with sever-
ity of posttraumatic stress and dissociation. Such reduction in size need
not be permanent. In fact, after successful integrative treatment, patients
with DID recovered considerable hippocampal volume (Nijenhuis, 2003).
It should be noted that these effects on hippocampal and amygdalar size
and volume are not specific to trauma and dissociation but occur in other
disorders as well. Interestingly, administration of antidepressants has also
been associated with restoration of hippocampal volume in traumatized
persons (BremnerÂ€& Vermetten, 2007).
Until fairly recently PTSD has mostly been understood in terms of over-
arousal and anxiety—involving hyperactivation of the noradrenergic sys-
tem, with symptoms of increased heart rate and blood pressure. However,
it has been proposed more recently that there are two types of PTSD, one
involving hyperarousal, and one involving hypoarousal (Bremner, et al.,
1999; Perry, 1999; Frewin & Lanius, 2006a).
Bruce Perry (1999) has described these two PTSD patterns—posttrau-
matic neurodevelopmental processes of hyper- and hypoarousal, in trau-
matized children. The patterns become more pronounced with more severe,
chronic, and early trauma. The hyperarousal pattern involves “fight or
flight” reactions, including elevated heart rate, vigilance, behavioral irritabil-
ity, increased locomotion, and increased startle response. The hypoarousal
(dissociative) pattern involves symptoms such as numbing, analgesia, dere-
alization, depersonalization, catatonia, and fainting, along with low heart
rate, bradycardia. The hypoaroused children exhibited robotic compliance,
glazed expressions, and passivity, a response more characteristic of infants,
young children, and females. This pattern is adaptive to immobilization or
inescapable pain. Although these patterns are interactive and most people
suffering from such altered neurobiology use combinations of these two
patterns, the boys’ posttraumtic responses tended to be more hyperaroused
and the girls’ more hypoaroused. Perry speculated that these gender pat-
terns were evolutionarily adaptive in that invading tribal warriors would
be more likely to kill the men, but capture the women and young children.
Thus, fight or flight would be the men’s best defense, while being still and
quiet would be the best survival behavior for women and young children.
This attention to hypoarousal is extremely important to our clinical

work. When, for instance, the patient’s eyes glaze over or it there appears to
be a sudden bodily collapse, this likely heralds important material—either
something internal from the past or perhaps something in the interpersonal
interaction that is evoking it.
Secondary PTSD, Hypoarousal,

and Depersonalization
Clinical experience suggests that most patients with DID go through life
much of the time in varying degrees of a chronic hypoarousal and deperson-
alized state. This has also been described as secondary dissociative PTSD.
The depersonalization response is initially adaptive because it blunts the ter-
ror response that the person would otherwise feel and thereby allows the per-
son to continue attending to the functions of daily living. There is increasing
evidence to indicate that such a depersonalization response may be involved
in the creation of the distinct identity states of DID. Thus, while in the past
clinical attention leaned toward noting hyperarousal in patients, now there is
an understanding of the need also to check for hypoarousal as part of what is
being reenacted. Similarly, there is the need to look for underlying fear states
whenever the patient talks about depersonalization (i.e., if there was a need
to depersonalize, then there likely was fear as well).
The following is a brief vignette of a patient indicating this line of thought:
Janice: I wonder who I am. That person who came out and taught that wonderful
class—she did it, it was great! Everyone loved what she did. But then she
went away. Is she real? Is she me? I don’t know. It is so weird. I want to be
able to wake up in the morning and know who I am. But I don’t.
Me: What you say makes me think that the one who taught the great class—yes,
she is you. She is real. It is just as if you took a medication, propanolol—
which some people take to alleviate performance anxiety—to teach the
class. Propanolol blocks the effect of norepinephrine, a hormone that is
released in response to stress. Norepinephrine makes the brain hyper-
alert, but sometimes it causes too much anxiety. So, by blocking the effect
of the norepinephrine, the propanolol helps the person perform without
anxiety. The brain can do something similar to alleviate terror.
Janice: Okay. It’s as if I took a propanolol, but I don’t know where she went. I
imagine most people have a reservoir of who they are. I would like to have
a reservoir of me.â•ƒ.â•ƒ.â•ƒ.â•ƒI always lived in terror. I was always terrified that I
would get in trouble. I was afraid to be me.
I responded as I did to Janice (uncharacteristically lecturing because I

was preparing this chapter) as a way to normalize her feelings—and sug-
gested an integration with normal life by linking her nonstressed teacher
identity to an analogous physiological response of secondary dissociative
PTSD and depersonalization. That is, the nonstressed teacher may have
been nonstressed as a result of being emotionally blocked and depersonal-
ized—simply unaware of any emotional turmoil. The teacher part might
have appeared to be a more evolved and healthy aspect of self, but she was
in fact a part of the self that was able to teach without terror because the
turmoil was kept out of awareness. Following my “tutorial,” my patient
correctly reminded me that I had not explained the dissociation: Where
did the teacher part come from, and where did she go? The comparison
to propanolol only goes so far—in reality, the evolutionarily adaptive
depersonalization/dissociation response plays for higher stakes and has a
much longer-lasting effect than the several hours of a propanolol-induced
response. That said, the analogy did launch an investigation of strategies
for relinking mental states as well as a discussion about depersonalization
as a way to go on functioning in the face of constant terror. What are the
physiological circuit breakers that operate in the background and contrib-
ute to Janice’s experience? If we could understand this mechanism better,
perhaps we could speak to it psychodynamically or influence the process in
some other useful manner.
Another important question concerns why Janice does not have a reser-
voir of experience. How do we understand this lack of integrative experience
neurophysiologically, and how can we use our understanding to foster more
of an experience of personal “reservoir” for people who have DID?
The following section describes some of the neuroscience relevant to
the problems of posttraumatic and dissociative disorders, in particular the
importance of depersonalization and hypoarousal and the ways that differ-
ent physiological organizations of self manifest and may come about.
Two responses to traumatic stress have traditionally been noted in the
literature (Frewin & Lanius, 2006a, 2006b; Nijenhuis & Der Boer, 2007;
Simeon & Abugel, 2006; Van der Kolk, 1996b, 1996c). One is the better-
known PTSD reaction of hyperarousal, characterized by heightened anxi-
ety, elevated heart rate, increased electrical skin conductance, along with
intrusions, such as flashbacks. This reaction, which characterized about
70% of individuals diagnosed with PTSD in the studies of Frewen and
Lanius (2006b), has been called “primary dissociation” by Van der Kolk
(1996b). The other response, known as peritraumatic dissociation, is a
depersonalized, numb reaction in which anxiety, heart rate, and electric
skin response do not rise, and the person becomes “detached,” observing
events as if from a distance from the self, often feeling separated from the
body. Van der Kolk (1996b) called this “secondary dissociation.” These
last symptoms are also prominent in depersonalization disorder (Simeon
& Abugel, 2006). The hyperarousal aspect of PTSD has been overempha-
sized in the psychophysiological and mental health literature, somewhat to
the detriment of recognizing the importance of hypoarousal (Neijenhuis &
Den Boer, 2009; Porges, 2003; Schore, 2009); which is linked to experi-
ences of both depersonalization and shame and is a significant problem for
many with dissociative disorders.
The psychological distancing of depersonalization protects against the
heightened arousal of the trauma and has an anesthetizing effect. It is an
invaluable bodily resource in times of extreme danger and emergency,
allowing the person to manage attending to the tasks that are necessary
to continuing life and to function through the traumatic event without the
derailing and disabling neurological messages of terror. However, if relied
on chronically, this process results in the person living much of his or her
life in a depersonalized state.
Depersonalization relegates overwhelming traumatic experience to the
realm of “Not-Me” (Sullivan, 1953). For example, during an EMDR (Eye
Movement Desensitization Reprocessing) session a highly dissociative
patient was describing an assault by her father when she was a young ado-
lescent in which he cut the flesh near her eye with his fingernails, endan-
gering her vision. The patient recalls at first saying to herself, “Oh, No!”
However, as soon as the actual physical attack toward her started, both
in the EMDR session and in her memory of the event, she suddenly went
into a peaceful state, feeling nothing and could not visualize anything any-
more. This is a kind of depersonalization response. It is a type of response
that is part and parcel of the hypnoid state described by Breuer and Freud
(1893–1895a,b), by Pierre Janet (1907, 1925) and by 19th-century French
psychological writers. Given our increased understanding of neurophysi-
ological processes, can we now better understand the biological patterns
of such provocative experiences, and will this understanding help us better
define how to work with depersonalization in psychotherapy?
Taken together, various positron emission tomographic (PET) scan and
functional magnetic resonance imaging (fMRI) studies indicate that in
secondary dissociative PTSD and in depersonalization disorder, certain
parts of the brain that are involved in emotional response are inhibited by
several other higher cortical areas. Frewin and Lanius (2006b) reported
that fMRI studies of people with secondary dissociation responses to
trauma-script imagery showed increased activity in the ACC (anterior
cingulate cortex) and mPFC (medial prefrontal cortex), compared with
nonpsychiatric controls. These areas, the ACC and mPFC, are involved
in cognitive processing, modulating emotional response, and inhibition of
the activation of the limbic system (the “emotional brain”). The authors
noted that the increased activity in these two cortical areas indicates “a
possible enhanced suppression of limbic emotion circuits in secondary dis-
sociation” (p.â•¯117). Most of the same brain regions that are involved in
secondary dissociation are also implicated in depersonalization disorder

(Nijenhuis & Der Boer, 2007).
Philips, Medford, Senior, Bullmore, Suckling, Brammer, et al. (2001)
used fMRI to track changes in brain activity to neutral and aversive-dis-
gusting pictures in patients with depersonalization disorder in comparison
with controls. While in response to the aversive pictures, the controls had
greater activity in emotion-sensitive areas, such as the insula (a limbic area
involved with disgust perception), and these areas were not activated in the
depersonalized patients. Only in response to the neutral stimulus did the
depersonalized patients show activation in the insula. At the same time, the
depersonalized patients did have heightened activity in the prefrontal cor-
tex in response to aversive stimuli: “Only in the depersonalized patients,
however, did activation in the right ventral prefrontal cortex occur in the
absence of activation in the insula response to these scenes” (p.â•¯157). The
depersonalized patients understood that the aversive pictures were sup-
posed to evoke disgust, but they did not experience this emotion. In fact,
they did not differentiate neutral and aversive pictures in their ratings of
their own responses. In summary, these authors stated, “Our findings
indicate that a core phenomenon of depersonalization—absent subjective
experience of emotion—is associated with reduced neural responses in
emotion-sensitive regions, and increased responses in regions associated
with emotion regulation” (p.â•¯145). Consistent with these findings, Simeon
et al. (2001) found that in people with depersonalization disorder, the
amount of norepinephrine in urine was inversely related to the severity of
depersonalization disorder. (This is also consistent with the vignette at the
beginning of this section in which I compared the action of depersonal-
ization to the effect of taking a drug that blocks norepinephrine.) Simeon
and Abugel (2006) noted that the Phillips et al. fMRI research on aversive
versus neutral images suggests that:
Depersonalized individuals hypo-activate limbic regions, the emotional

regions that are important for processing emotions, and conversely,
that they hyper-activate higher cortical areas. Ultimately, this suggests
a brain mechanism that may underlie the emotional inhibition, numb-
ness, and sense of unfamiliarity experienced by chronically deperson-
alized people. (p.â•¯116)
The Body Anchors States of Mind

In secondary dissociative PTSD and in depersonalization, one feels separated
from one’s body. It appears that the areas of the brain that are responsible
for an integrated body schema are the ones that have functional abnormali-
ties in depersonalization disorder (Nijenhuis & Den Boer, 2007; Simeon
& Abugel, 2006). Noting that the secondary dissociative response, like
depersonalization, entails an experiential separation of mind from body,

Frewin and Lanius (2006a) emphasized the role of altered body perception
in secondary dissociative PTSD. For that, they pointed to the association
of depersonalization disorder with somatoform dissociation as observed by
Nijenhuis et al. (1999). Somatoform symptoms have been significantly cor-
related with peritraumatic dissociation (Nijenhuis, 2000; Nijenhuis, Van
Engen, Kusters, & Van der Hart, 2001).
Noting the possible role of altered body perception in secondary PTSD,
Frewin and Lanius (2006b) suggested that “disconnection of neural path-
ways normally linking self-awareness with emotional body-state perception
could occasion the development of dissociative identities in traumatized
children” (p.â•¯113). Continuing this line of thinking about the linkage of
secondary dissociative PTSD and depersonalization with the creation of
the dissociative identities in DID, they also emphasize alexithymia (no
words for emotion).
We believe deficits in the conscious awareness of bodily states are inte-

gral to the alexithymia construct because the substance that is felt dur-
ing an emotional feeling seems inherently to be a particular body state.
Associations between trait alexithymia and secondary dissociative
states may develop over the course of chronic childhood physical and
sexual abuse. Specifically with increased repetition and automatization
of secondary dissociative processes during situations of long-standing
abuse, the priming of the dissociative state may become sensitized
and increasingly automatic and unconscious. In addition, repetitious
entry into secondary dissociative states may produce progressively
more marked departures from external reality and consciousness for
self. As dissociative individuals become increasingly less aware of and
connected with their identity, feelings, body, and surroundings, they
may become alexithymic and thereby deficient in how much they are
able to cognitively understand their emotional experiences. In addition,
with little cognitive insight about their emotional feelings, dissociative-
alexithymic individuals are correspondingly unable to regulate their
affective responsesâ•ƒ.â•ƒ.â•ƒ.â•ƒin an adaptive coping manner. (pp.â•¯120–121,
emphasis added)
Secondary Dissociative PTSD and Depersonalization

in Terms of the Structural Theory of Dissociation
Van der Hart et al. (2006) and Nijenhuis et al. (2004) (see summary of
the structural theory of the dissociation of the personality in Chapter 3)
described the effects of primary and secondary dissociative response to
PTSD in terms of the structural dissociation of the personality. The appar-
ently normal part (ANP) of the personality is focused on performing
functions of daily life, and the emotional part (EP) of the personality
is focused on response to physical defense to threat. The ANP may be
described as chronically depersonalized: “Patients in their ANPs indeed
report low body awareness and feel generally more or less detached from
their body” (Nijenhuis & Den Boer, 2007, p.â•¯228).
These ANPs and EPs have at least a rudimentary sense of self that is accom-
panied by distinct differences in psychobiological function: “Traumatized
individuals tend to alternate between re-experiencing traumatic events and
being more or less detached from these painful memories on account of not
integrating such experiences into their personality. Moreover, the survi-
vor’s sense of self typically changes with these alternations” (Nijenhuis &
Den Boer, 2007, p.â•¯219). In fact, it was found that EP and ANP responses
differed markedly in heart rate and facial expression when exposed to a
small object that was moved in the direction of the face (Nijenhuis & Den
Boer, 2007).
In people who have been subjected to early chronic stress or have been
abused early in life, we might expect to see the appearance of separate
phenomenological-physiological self-states as evoked by differing contexts.
Two ingenious studies by Reinders et al. (2003, 2006), summarized in the
following discussion, demonstrate this.
One Brain, Two Selves

Dennett (1991) commented that having 2, 3, or 17 selves per body is really
“not more metaphysically extravagant than one self per body” (p.â•¯419).
In DID, different identity states are characterized by different memories,
affects, behaviors, sensations, perceptions, postures, and so on. In particu-
lar, patients with DID often have amnesia for traumatic memories when
in the nontraumatized identity state, which is also the one often in execu-
tive control and is generally an ANP. In the first of two fascinating stud-
ies, titled “One Brain, Two Selves,” Reinders et al. (2003) documented
the cerebral correlates of two autobiographical selves. Using functional
neuroimaging (PET scan), the authors demonstrated particular changes in
localized brain activity—two different cerebral blood flow patterns—that
occurred in accordance with the presence of a traumatic personality state
(also known as an EP) versus a neutral personality state (also known as an
ANP). The research participants in both the first and second study were
11 persons with DID who had the ability to switch at will between a trau-
matic state and a neutral one. These participants were asked to listen to
an autobiographical trauma script and an autobiographical neutral script
while in both personality states. Among the four conditions, the trauma
script elicited blood flow changes only in the traumatic personality state. In
the neutral personality state, the participants did not recognize the trauma
script as a personally relevant narrative and responded to it in a way that
was similar to the way they responded to the neutral script. Likewise, no
significant differences were found between the two personality states in
response to the neutral script.
The EPs (or TPs, traumatized personality) states presented data that sup-
ported the presence of a network of deactivated brain areas; including the
mPFC, which is involved in conscious processing of experience. In contrast,
patterns in the ANP states (neutral personality states, NPS) showed distur-
bances in the parietal and occipital blood flow and were indicative of an
inability to integrate visual and somatosensory information. The results of
the 2003 study suggest that when patients with DID are in neutral person-
ality states there is a “blocking” of trauma-related information that
prevents further emotional processing, which reflects the defense sys-

tem, as applied by DID patients, to enable them to function in daily
life (Nijenhuis, 2002). Thus, the NPS, as compared to TPS, shows dis-
turbances of parietal and occipital blood flow, suggesting a relatively
low level of somatosensory awareness and integration (Simeon et al.,
2000), by suppression of the (re-)activation of these areas. These results
match the clinical depersonalised features of NPS (Nijenhuis et al.,
2002) as well as their subjective responses in the current experiment.
(pp.â•¯2122–2123)
In the 2006 study, Reinders et al. found that in response to listening to a

trauma script, the EPs, but not the ANPs, showed increased heart rates and
blood pressure, as well as reported strong emotions and sensory remind-
ers of the traumatic event. In response to the neutral script, neither EP nor
ANP displayed elevated heart rate or blood pressure. The EPs (or trauma-
tized identity states) showed more activity in the amygdala and other areas
relevant to defensive motor activity, as well as reduced activity in prefron-
tal areas. In comparison, the ANPs (or the neutral identity states) showed
more activity in the ACC, which is involved in inhibitions of emotional
responses, as well as more activity in other frontal areas involved in self-
awareness and planning. In sum, Reinders et al. (2003) stated:
We have shown that these patients have state-dependent access to auto-

biographical affective memories and thus different autobiographical
selves.â•ƒ.â•ƒ.â•ƒ.â•ƒOur results indicate the possibility of one human brain to
generate at least two distinct states of self-awareness, each with its own
access to autobiographical trauma-related memory, with explicit roles
for the mPFC and the posterior associative cortices in the representa-
tion of these different states of consciousness. (p.â•¯2124)
The Polyvagal Theory

As noted, PTSD presentations are not uniform: As a case in point, Frewin and
Lanius (2006b) described highly differing PTSD responses in a husband and
wife who had been in a car accident. The husband presented with the more
typical pattern of elevated heart rate, anxiety, and posttraumatic intrusions.
The wife, however, described herself as “frozen” and did not have an elevated
heart rate. We may be able to understand more of this “frozen” hypoarousal
response—as well as learn more about the possible pathways to the one brain/
two selves phenomenon by turning to Porges’s polyvagal theory.
Porges (2001, 2003) advanced the polyvagal theory of the phylogenetic
substrates of the social nervous system. According to this theory, there have
been three primary adaptations and changes in the neural regulation of the
autonomic nervous system (ANS) that in humans are arranged in a hierar-
chical organization of response patterns. The first of these response pat-
terns is characteristic of reptiles, fosters digestion, and responds to threats
by depression of metabolic activity, thus conserving oxygen and energy. The
associated behavior of this response is immobilization. Porges called this the
dorsal vagal complex, the DVC. The second stage of response is character-
ized by the sympathetic nervous system, the SNS, which can increase meta-
bolic output, thus enabling “fight or flight.” The third stage, which is unique
to mammals, is characterized by the ability to regulate as well as increase
metabolic output. This is the ventral vagal complex, the VVC, and involves
a social engagement system, including social signaling systems for motion,
emotion, and communication as well as self-soothing. This last stage includes
what Porges called a “vagal brake” that inhibits the SNS, regulating the
heart. Porges stated: “As the autonomic nervous system changed through
the process of evolution, so did the interplay between the autonomic nervous
system and other physiological systems that respond to stress, including the
cortex, the hypothalamic-pituitary-adrenal axis, the neuropeptides of oxy-
tocin and vasopressin, and the immune system” (p.â•¯123). Although the poly-
vagal theory has some similarities to the triune brain proposed by McLean
(1990), it emphasizes the phylogenetic changes in structure and function.
This theory presents an evolutionarily progressive design, a design in which,
when the more advanced strategies fail, the organism falls back on the next
most recently phylogenetically developed organization.
The polyvagal theory proposes that during danger or threat, the older,
less social systems are recruited. The older systems, although functional
in the short term may result in damage to the mammalian nervous sys-
tem when expressed for prolonged periods. Thus, the stress and coping
neurophysiological strategies that are adaptive for reptiles (e.g., apnea,
bradycardia, immobilization), may be lethal for mammals. (p.â•¯130)
Porges (2001) emphasized that for over a century researchers have oper-
ated according to an arousal theory involving sympathetic activation. (This
coincides with the overemphasis on the hyperarousal aspect of PTSD.)
He noted that the arousal theory overlooked the importance of the dor-
sal ventral complex and described an experiment by Richter (1957) that
was meant to demonstrate the arousal theory. The experiment tested how
long rats would be able to continue to swim before they drowned. It had
been supposed that they would die from overactivation of the SNS, lead-
ing to increasingly rapid heartbeat and death in systole. Instead, the oppo-
site happened. The rats died a vagus death resulting from overactivation
of the parasympathetic nervous system and overengorged hearts. The rats
reverted to the most primitive system, of immobilization, designed to con-
serve resources. The most stressed of the rats, in accordance with DVC acti-
vation, simply dove to the bottom of the tank, instead of trying to swim,
and died most rapidly.
One of the important implications of the polyvagal theory is that in situ-
ations of extreme terror humans also can revert to dorsal vagal activation.
Nijenhuis and Den Boer (2007) suggested that the woman in Frewin and
Lanius’s (2006b) husband-and-wife case may have been immobilized and
paralyzed in a dorsal vagal response. This dorsal vagal response appears to
be related to the secondary dissociative PTSD as well as to the hypoaroused
“dissociative” response described by Schore (2002a, 2002b, 2003, 2009)
and Perry (1999, 2001); “tonic immobility” (TI; Marx, Forsyth, Gallup,
Fusé, & Lexington, 2008; Moskowitz, 2004); and the “total submission”
response described by Van der Hart et al. (2004).
Animal Defense States Responsive

toÂ€Predation: Fight/Flight, Freeze, and
Tonic Immobility or Total Submission
A number of writers have addressed the correspondence between the more
general animal defense states responsive to predation and the human post-
traumatic and dissociative responses (Marx et al., 2008; Moskowitz, 2004;
Nijenhuis, Vanderlinden, & Spinhoven, 1998, 2004; Perry, 1999, 2001;
Sapolsky, 2004; Schore, 2002, 2003a, 2003b, 2009). Nijenhuis et al. (2004)
and Van der Hart et al., in their landmark book The Haunted Self (2006),
noted the similarity between human behavior following exposure to ter-
ror and various animal states, including fight/flight, freezing/analgesic, and
hypoaroused states that they called “total submission.” Humans may have
inherited a repertoire of discrete behavioral states that have been adaptive
to conditions of predation. For instance, bodily symptoms such as stiff-
ness, analgesia, and high muscle tension may all represent a human freez-
ing response. Total submission involves anesthesia and low muscle tension.
These animal defense states may also underlie different dissociative parts of
the personality (Nijenhuis, Spinhoven, Vanderlinden, Van Dyck, & Van der
Hart, 1998).
In many species, freezing is the dominant response after a predator is
encountered. Because flight might be dangerous at that moment, the animal
“freezes” on the spot, becoming almost completely motionless. Freezing is
adaptive in the sense that it increases the chances of survival by eliminat-
ing the motion cues that allow the predator to detect the animal and acti-
vate the strike response of the predator (Nijenhuis, Spinhoven, et al., 1998;
Nijenhuis, Vanderlinden, & Spinhoven, 1998; Van der Hart et al., 2006).
It may also create the impression that the prey is dead and therefore less
desirable meat (Scaer, 2001).
Although freezing is characterized by stilled movement with motor
actions inhibited, it involves increased rapid heartbeat, rapid breathing,
high muscle tone, high blood pressure, and analgesia, all of which ready the
animal for an explosion into the actions of fight or flight. The autonomic
patterns of the freeze response are complicated. Freezing involves activa-
tion of the SNS and appears to be mediated by the loss of the ventral vagal
parasympathetic brake on the SNS (Van der Hart et al., 2004).
Van der Hart et al. (2000) link forced helpless immobility and a con-
comitant freeze response, with somatoform dissociation. The helpless
immobility of situations of terror appears to be prominently linked to the
development of PTSD. These authors note that there was an especially high
incidence of shell shock among World War I veterans as a result of fight-
ing in the trenches, a situation in which the soldiers were simultaneously
immobilized and terrified for long stretches of time. The authors suggest
that the “high rate of somatoform dissociative symptoms in World War I
combat soldiers was, at least in part, due to forced immobility in the face of
threat to bodily integrity, thereby evoking chronic animal defensive states,
in particular, freezing, with concomitant somatoform manifestations” (Van
der Hart et al., 2000, p. 53).
Similarly, Scaer (2001) notes that whiplash patients of auto accidents, in
contrast to racecar drivers and football players who are frequently subject
to impacts of much greater force and velocity, were relatively helpless and
immobilized at the time of the accident. The incidence of “whiplash syn-
drome” is much higher than would be expected on the basis of organic injury.
He views “whiplash syndrome” as a prototype for somatoform dissociation
and PTSD, as a “model of traumatization with long-standing and at times
permanent neurophysiological and neurochemical changes in the brain that
are experience-based rather than injury-based” (p. 33). This is based on the
hypothesis that many whiplash patients may have entered a freeze state and
dissociated the frightening experience at the moment of the accident.1
Another defensive response to predation is what Van der Hart et al.
(2006) called “total submission,” similar to tonic immobility (TI). This
involves a different kind of physiological activation—including that of the
parasympathetic nervous system—in which the animal in effect “plays

possum.” In this response, heart rate drops, including at times syncope
(fainting); there is low heart rate variability, loss of muscle tone, emotional
and bodily anesthesia, eye aversion from threat cues, and defocusing. This
appears to be mediated by the dorsal vagal branch of the parasympathetic
nervous system (Van der Hart et al., 2004). Total submission involves body
paralysis, or at least low muscle tension, and can also involve being out of
the body. People often report being paralyzed, unable to move or to think,
in the face of extremely terrifying circumstances, such as a robbery, rape,
or a reminder of such an event.
Tonic Immobility
Marx et al. (2008) have linked the literature on TI as an evolved response
to predation to the hypoarousal states often reported by sexual assault sur-
vivors. Some of the evolutionary advantages of TI involve its potential to
inhibit aggression of predators due to decreased visibility and possibly less-
ening the bleeding that occurs when injured. TI has been found in many
animals: from insects and fish to primates (Marx et al., 2008). (It is inter-
esting to note that some predators, such as orca whales against sharks, have
reportedly found ways to use the TI reflex of the prey to their advantage.)
Marx et al. (2008) compare TI to “rape-induced paralysis,” in which sexual
assault victims lose the ability to move or to call out during the assault.
They refer to a study by Heidt, Marx, and Forsyth (2005), in which 52% of
the participants reported TI in response to child sexual abuse, and note that
the conditions for TI of fear and restraint are the same ones that have been
found to be risk factors for PTSD following sexual assault. Fear in and of
itself is insufficient, they say, but must be coupled with circumstances that
prevent an escape. Similarly, Moskowitz (2004) notes that in TI “it is the
perception of entrapment, with or without physical restraint, that is most
important” (p.â•¯986). The authors state that depersonalization may be a by-
product or component of TI, including a sense of “self” detachment.
Marx et al. (2008) describe the stages that lead up to TI. The first stage is
the preencounter stage in which the predator has not yet been encountered.
The next stage is the encounter stage in which a predator has been detected:
The immediate response is for the prey animal to cease all movement
(freeze). Additional responses during this stage include focused atten-
tion, sustained cardiac deceleration, defensive analgesia, and potenti-
ated startle. These responses orient the animal toward potential threat
and prepare it for action.
Continued approach by the predator sets in motion a sequence of
active defensive postures (e.g., flight or fight) that characterize the post-
encounter, or circa strike, stage. Here, most prey will first attempt to
escape. When escape is not possible or thwarted (as indicated by tac-

tile contact with a predator), a prey animal will subsequently fight or
resist. Clear evidence that the organism has changed to a defensive pos-
ture is first seen in the startle reflex response, a response that is often
potentiated during this stage, coupled with rapid acceleration in heart
rate and electrodermal activity. These behavioral action tendencies are
associated with the multicomponent emotional response known as fear
(LeDoux, 2000).
Unsuccessful escape or resistance typically results in the prey enter-
ing a state of TI. The most obvious feature of TI is profound but revers-
ible physical immobility and muscular rigidity. This immobilized state
includes a sustained and largely involuntary pattern of neuromuscu-
lar activity (i.e., cataleptic-catatonic) and sympathetic and parasym-
pathetic responses. Additional characteristics of the response include
intermittent periods of eye closure, fixed, unfocused gaze or stare,
Parkinsonian-like tremors in the extremities, suppressed vocal behav-
ior, analgesia, and waxy flexibility. (p.â•¯75)
The authors (Marx et al., 2008) emphasized that TI needs to be distin-

guished from freezing behavior, the latter of which is characterized by alert-
ness, responsivity to stimuli, and the capacity for voluntary action. In contrast,
TI involves unresponsiveness and catatonic-like motionlessness. They also
distinguished it from learned helplessness, which is a learned response during
which the animal can move.
Both Moskowitz (2004) and Marx et al. (2008) linked catatonia to TI.
The activation of the DVC and the SNS may be one reason that rape victims
were unable to move or to cry out. Writing of catatonia, which he charac-
terized as “scared stiff,” Moskowitz (2004) explained:
Engagement of the SNS in catatonic excitement or stupor may also

affect the type of communicative behavior available to an individual.
According to Porges’s polyvagal theory of emotion and defensive
behavior (so-called because he believes mammals have evolved two
dissociable vagal systems; Porges, 1995, 1997, 2001), sympathetic acti-
vation results in an inhibition of the ventral vagal complex (VVC), a
parasympathetic component of the autonomic nervous system unique
to mammals that allows for rapid and subtle cardiac modulation in
situations perceived as safe and innervates the muscles of the face and
vocal system. Thus, inhibition of the VVC results in a decreased capac-
ity to use sophisticated forms of communication with words and ges-
tures—the first line of defense in situations of conflict. The loss of such
capacity would be consistent with the mutism frequently seen in cata-
tonia as well as symptoms such as negativism, automatic obedience, or
echolalia and echopraxia. In addition, several of these behaviors (waxy
flexibility, automatic obedience) appear submissive, which would also

be consistent with a defense reaction. (p.â•¯994)
Allan Schore, Dissociation, and the Developing

Brain, Especially the “Right Brain”
Allan Schore has synthesized a great store of knowledge about the types
of posttraumatic responses and their interactions, making it easier for the
nonmedical clinician to grasp the significance of these neurophysiological
processes for clinical work. He explains the relational unconscious, which
involves communication between the interacting unconscious minds, in
terms of right brain implicit processes. Noting that “Studies show that
60% of human communication is non-verbal” (2008, p. 24), Schore has
grounded the increasing awareness in the mental health field of the cen-
trality of affect and the importance of affect regulation in the language
of the brain—especially the right brain. This neurophysiological knowl-
edge of right brain processes works interactively with our psychodynamic
knowledge, complementing the relational trend in our field and the greater
emphasis on intersubjective communication. As we become more aware of
the nonverbal, relational unconscious, we are more cognizant of the effects
that we have on our patients, and they on us.
Schore’s work on the influence of the early environment on brain develop-
ment has been especially important for alerting clinicians and researchers
to the effects of the early social environment and relational trauma on the
developing brain structures of the infant and young child. Contextualizing
the dorsal vagal response described by Porges within a vast body of new
research, he brought its meaning into more clinical specificity.
Schore (2009) describes the infant’s two psychophysiological responses
to trauma—hyperarousal and dissociation—but he emphasized that the
two responses are interrelated: “Hyperarousal is the infant’s first reaction
to stress. Dissociation is a later reaction to trauma, wherein the child dis-
engages from the stimuli of the external world” (p.â•¯111). In the first phase,
the infant’s alarm activates the right hemisphere, which activates the SNS,
which releases stress hormones and increases heart rate, respiration, and
blood pressure. Following this phase of mounting distress and overarousal
is dissociation, in which the child disengages from stimuli. “The child’s dis-
sociation in the midst of terror involves numbing, avoidance, compliance
and restricted affect (the same pattern as adult PTSD)” (p.â•¯111). Schore
notes that in the dissociation response infants seem to be staring off into
space with a “glazed look.” This is a parasympathetic mechanism of con-
servation. However, Schore (2002a) elaborates, if this
primary metabolic shutdown becomes a chronic condition, it will

have devastating effects on the morphogenesis of limbic structures.
Dissociation and conservation-withdrawal, functional expressions of

heightened dorsal vagal activity, induce an extreme alteration of the
bioenergetics of the developing brain.â•ƒ.â•ƒ.â•ƒ.â•ƒA n infant brain that is chroni-
cally shifting into hypometabolic survival modes has little energy avail-
able for growth.
Despite the drawbacks, “this intensified parasympathetic arousal
allows the infant to maintain homeostasis in the face of the internal
state of sympathetic hyperarousal.” (p.â•¯452)
As we have seen in Chapter 5, abuse, severe neglect, massive misattune-

ment, and lack of regulation of the child’s affective distress on the part of
caregivers may result in attachment trauma—and disorganized attachment.
Attachment trauma, if chronic, may lead to “characterological use of prim-
itive autoregulation—that is, pathological dissociation, during subsequent
states of development” (2009, p.â•¯114). This defense is maladaptive not only
because it becomes chronically used, even in low-stress circumstances, but
also because it is difficult
to exit this state of conservation-withdrawal. During these episodes,

the person is impermeable to attachment communications and interac-
tive regulation. This deprives the person of input that is vital to emo-
tional developmentâ•ƒ.â•ƒ.â•ƒ.â•ƒ[and] social intimacy is habitually deemed to be
dangerous. (p.â•¯115)
Schore (2009) cited a number of studies that together indicate that, espe-
cially in the right hemisphere, the prefrontal cortex and limbic areas are
central to dissociative response. Schore noted that the right brain is more
involved with nonverbal and emotional communication and processing of
experience that is not always conscious, while the left brain is more dedi-
cated to verbal and logical processing of conscious experience. He pointed
out that the right brain is also involved in implicit information processing,
and that this is linked to the right lateralized amygdala. This is relevant to
the fact that while PTSD research has previously focused more on deficits
to declarative memory associated with hippocampal function, this research
is now “shifting from the hippocampus to the amygdala, from explicit
memory of places to implicit memory of faces” (p.â•¯124). Emphasizing how
crucially the right hemisphere is involved in these dissociative responses,
he even stated, “The symptomatology of dissociation reflects a structural
impairment of a right brain regulatory system and its accompanying defi-
ciencies of affect regulation” (p.â•¯126, emphasis in original).
Schore (2009) noted that the right brain of the infant and young child
matures earlier than does the left, and that it is more deeply interconnected
with the limbic system, which myelinates in the first year and a half. As a
result, early attachment experiences, including relational trauma, especially
have an impact on the right brain and limbic system. In particular, trau-
matic attachment experiences are “burned into” the “limbic-autonomic cir-
cuits of the cortical and subcortical components of the right brain during
its critical period of growth” (p.â•¯130).
Schore (2009) further suggested that the dissociative response, as a kind
of primitive form of affect regulation, is “best understood as a loss of verti-
cal connectivity between cortical and subcortical limbic areas within the
right hemisphere” (p.â•¯117). Dissociation appears before the myelination of
the cerebral cortex or the development of functionality of corpus callosum
connectivity. This contributes to the disconnection of higher cortical func-
tion from subcortical function and negatively affects the ANS/CNS (central
nervous system) links, which are more extensive in the right hemisphere.
Schore’s (2009) work helps to explain how early abuse leads to disorganized
attachment—that abuse and severe neglect are associated with deficiencies in
brain development, notably that the capacity for affect regulation is impaired.
(As we know, disorganized attachment and the accompanying affect dys-
regulation and risk for psychiatric disorders carries over into adolescence and
adulthood.) In particular, there is an “impairment of higher corticolimbic
modulation of the vagal circuit of emotion regulation on the right side of the
brain that generates the psychobiological state of dissociation” (p.â•¯130).
Schore (2009) said the foregoing most simply:
From a developmental neuroscience viewpoint, early abuse and neglect

have immediate impact on the developing right brain during a critical
growth period; this produces an immature right brain that has limited
ability to regulate intense affective states. (p.â•¯130)
The good news, according to Schore (2009), is that psychotherapy heals

in the context of the mind-to-right brain connection, and that it can
positively alter the developmental trajectory of the deep right brain

and facilitate the integration between cortical and subcortical right-
brain systems. This enhanced interconnectivity allows for an increased
complexity of defenses of the emotional right brain—coping strategies
for regulating stressful affect that are more flexible and adaptive than
pathological dissociation. (p.â•¯140)
So how does the clinician help with this? Schore (2009) explains, quoting
from his 2003b work,
“the psychobiologically attuned therapist acts as an interactive affect

regulator of the patient’s dysregulated state. The model clearly suggests
that the therapist’s role is much more than interpreting to the devel-
opmentally disordered patient either distortions of the transference,
or unintegrated early attachment experiences that occur in incoherent

moments of the patient’s narrative.” Even more than the patient’s late-
acting rational, analytical and verbal left mind, the growth-facilitating
psychotherapeutic relationship needs to directly access the deeper psy-
chobiological strata of the implicit regulatory structures of both the
patient’s and the clinician’s right minds. (p. 25)
The Orbitofrontal Cortex

Schore emphasized the importance of the maturation of the orbitofron-
tal cortex, which acts as executor of the right cortex and is influenced by
dyadic interactions between caregiver and child. The orbitofrontal cortex,
located between cortical and subcortical structures, is connected to the
hypothalamus, the amygdala, and the brain stem, from which point it regu-
lates the ANS. Schore (2002a) wrote:
The highest level of the right brain that processes affective information,
the orbitofrontal cortex.â•ƒ.â•ƒ.â•ƒ.â•ƒT he maturation of this prefrontal system
overlaps and mediatesâ•ƒ.â•ƒ.â•ƒ.â•ƒthe developmental achievement of “the sub-
jective self.” This cortex functions to refine emotions in keeping with
current sensory input, and allows for the adaptive switching of internal
bodily states in response to changes in the external environment that
are appraised to be personally meaningful.â•ƒ.â•ƒ.â•ƒ.â•ƒT he orbitofrontal system
thus acts as a recovery mechanism that efficiently monitors and auto-
regulates the duration, frequency, and intensity of not only positive but
negative affect states. (p.â•¯4 47)
Drawing on Schore as well as many others, Kelly Forrest (2001) has con-
tributed a brilliant, synthetic integration of neuroscience and attachment
literature, outlining a neurodevelopmental approach to the etiology of
DID. Forrest emphasized the role of the orbitofrontal cortex in the inhibi-
tory control of information. In her “orbitofrontal model,” she proposed
the following:
The experience-dependent maturation of the orbitalfrontal cortex in

early abusive environments, characterized by discontinuity in dyadic
socioaffective interactions between the infant and the caregiver, may
be responsible for a pattern of lateral inhibition between conflicting
subsets of self-representations which are normally integrated into a
unified self. The basic idea is that the discontinuity in the early caretak-
ing environment is manifested in the discontinuity in the organization
of the developing child’s self. (p.â•¯259)
Forrest (2001) observed that in contrast to insecure attachment, in which

there is an underlying pattern of responsiveness, albeit suboptimal, in dis-
organized attachment, there is no underlying pattern. The fact that there
is a pattern in insecure attachment makes it possible for the child to build
a Me-in-relation conceptual system for organizing behavior that is context
independent. The orbitofrontal cortex then facilitates this in part by bias-
ing toward sympathetic high arousal or parasympathetic hypoarousal. In
contrast, disorganized children, who have less consistency in their dyadic
interactions, have less-integrated conceptual systems. The subset of disor-
ganized children who go on to develop DID has not been able to experience
relationships and thus basic Me concepts as continuous. Because of this
high degree of unpredictability, the orbitalfrontal cortex cannot
organize a context-independent regulatory system which anticipates

parental responsiveness, such as is organized in securely attached
infants. The only remaining option for organizing behavior available
to the orbitofrontal system in these circumstances is to organize state
and later self-functioning according to the immediate context. My con-
tention is that the orbitofrontal system resorts to regulating autonomic
functioning based predominantly, if not solely, on the immediate con-
text. (p.â•¯280)
Forrest (2001) further postulated that
The orbitalfrontal region, based on chronic experiences of extreme

environmental discontinuity, idiosyncratically develops a pattern of
increased lateral inhibition sufficient to create relative isolation between
conflicting, context-driven subsets of Me concepts such that dissoci-
ated Me concepts emerge. (p.â•¯282)
Forrest’s work lends neurophysiological support to Kluft’s (1988) rec-

ommendations that in the interests of promoting integration, the therapist
maintain a basically consistent stance toward all of the alters; the therapist
should avoid a “multiple therapist disorder.”
Note
1. Levine (1997) Scaer (2001, 2005) and others have written about the impor-
tance of “discharge” of the freeze response. Despite being apparently motion-
less, the animal in “freeze” and with the massive amount of norepinephrine
that has been released in the body, rapidly increasing heart rate and blood
pressure, is physiologically ready to flee at the moment that it becomes safe or
necessary. Indeed, when animals can finally flee, they may exhibit stereotyped
shaking patterns, so that they seem to be completing the action of the escape
that had been in progress before it became necessary to freeze. Levine, who has
studied the process of discharge from freeze states, concluded that in contrast
to domesticated or zoo animals that did not have a freeze discharge, undomes-
ticated animals that were allowed to exhibit the freeze discharge of shaking,
running, and/or continuing to do what they were doing just before the freeze,
showed no signs of future impairment.
Scaer (2005) cited the study by Ginsberg (1974) in which the length of
time that groups of chicks could delay drowning was measured. In one group
immobilized chicks were allowed to discharge the freeze; and in another they
were prevented from doing so. Those chicks who had the advantage of the
freeze discharge survived the longest.
Levine (1997) believed that posttraumatic responses are “fundamentally,
incomplete physiological responses suspended in fear” (p. 34) and that humans,
like other animals, need to feel and then to release the pent-up energy in their
bodies in order to heal. It should be noted that this is another version of the
old abreactive theory of Breuer & Freud (1893–95). In addition, there is a
distinction between “freeze” in one-time traumas and the effects of multiple
traumas that have not been resolved. While important, such release, in itself,
is often not sufficient to process the trauma, possibly especially so in people
whose traumas were early and chronic, resulting in reduced ability to utilize
discharge effectively.
In humans, abreaction (discussed in Chapter 9) involves the expression of
intense emotion, often using words, but frequently accompanied by expressive
motoric behaviors. The important thing for humans is the ability to communi-
cate this emotion in a way that is not re-traumatizing, such that the listening
and empathetically connected other can help to de-traumatize the experience,
allowing it to become part of narrative memory.
Chapter 7
Dissociated Self-States
Creation and Contextualization
To put it as simply as possible, I argue that there is no such thing as

an integrated self—a “real you.” Self-expression and human relatedness
will inevitably collideâ•ƒ.â•ƒ.â•ƒ.â•ƒbut health is not integration. Health is the abil-
ity to stand in the spaces between realities without losing any of them.
This is what I believe self-acceptance means and what creativity is really
all about—the capacity to feel like one self while being many.
Bromberg (1993, p.â•¯166, emphasis in original)
In the first book of his science fiction trilogy, Out of the Silent Planet, C. S.
Lewis has his main character, Ransom, begin to refer to himself as “We”
when he is feeling completely alone and overwhelmed by the demands
of the horribly harsh extraterrestrial climate and his uncertain fate in it.
Ultimately, he sees what he is doing and pulls himself together as “I” to
complete his coming adventures on this forbidding planet. Similarly, a
mildly troubled patient begins to speak of herself as We when, in the course
of an affectively heated-up eye movement desensitization and reprocessing
(EMDR) session, she encounters awareness of extremely painful attach-
ment dilemmas that she has always had. In short, many people who are not
technically “dissociative” do at times refer to themselves as We as a mild
and temporary verbal multiplication of self in response to aloneness and
stress. None of the aspects of the plurality are personified or differentiated.
Somehow, though, the plural self is comforting, and I suspect that it has to
do with the fact that another part of the self can, or is imagined to be able
to, provide support in times of stress and isolation.
Kluft (1985a, 1985b), who has addressed the creation of alters in great
depth, spoke to the issue of the creation of alters in dissociative identity
disorder (DID) more specifically:
Understood in terms of their raison d’etre, the alters may be under-

stood as rather desperate efforts to disavow and mitigate the impact of
overwhelming life events. They express the wish, the fantasy, of sup-
planting an intolerable reality with a more tolerable one. In fact, it
133
has been my experience that the core of DID is the establishment of

a “multiple reality disorder”â•ƒ.â•ƒ.â•ƒ.â•ƒfor which the alters are an embodied
and personified delivery system.â•ƒ.â•ƒ.â•ƒ.â•ƒT here is a need to disidentify with
the unacceptable experience (although after the first dividedness, the
disidentification may be with an attitude, a wish, or an affect, etc.), a
repudiation of empathic connectedness with one’s state of mind during
the unacceptable experience, and the formation of a boundary that
maintains the disconnections noted above.â•ƒ.â•ƒ.â•ƒ.â•ƒT herefore, a fantasized
personified adaptation that serves and maintains these adaptations is
formed. (p.â•¯267)
Kluft (2000) demonstrated how different alters exemplify different cop-

ing strategies of belief, such as, “I would be safe if I were a boy,” hence a
male alter, or “I wish someone would comfort me,” leading to the creation
of a protective alter named Angel (p.â•¯267).
Similarly, Shusta-Hochberg (2004) described how “the creation of
another self-state enables the core of the traumatized child to avoid experi-
encing the abuse.” She continued:
Dissociation offers an immediate escape through the perception of hav-

ing another self-state occupy the body, so that the other self-state—often
referred to by clinicians as an alter—experiences the pain, suffering
and terror of the trauma. This results in the core self-state—usually
referred to as the host—subjectively perceiving the trauma as happen-
ing to the alter, and the host may even have amnesia for the event. From
an external point of view, the child, in its alter self-state, may appear to
observers to be conscious and even cooperative, and may be mistaken
for the host, but will tend to be more restricted in emotions and person-
ality traits, with limited access to abilities and memories.
Repeated traumas are likely to elicit repeated emergence of the alter
state. The more this happens, the more of the child’s autobiographical
memory will be stored in the alter state and the greater will be the host’s
amnesia, leading to an inability to recall significant parts of the past,
which is consistent with theories of state-dependent memory. When
trauma is complex and repeated over an extended portion of the child’s
life, this process may recur repeatedly, resulting in numerous alter states,
each containing certain autobiographical memories, skills, procedural
and general knowledge, behavioral patterns, physical sensations, and
emotions. These are the building blocks of DID. The host, and subse-
quent alters as a whole—if integrated—constitute a fully cognizant and
functioning human being. The various parts taken separately have major
deficits in self-awareness and functioning. (pp.â•¯14–15)
Dissociated Self-Statesâ•… 135
Dissociated and segregated states of mind are also less likely to be linked
because trauma causes a decrease in metacognitive and reflective ability.
Things become concrete, and it is hard to think about thinking. It is also
important to remember that the inception of disorganized attachment is
likely characterized by a trance state (Liotti, 2006). In a trance state, things
do not have to make the kind of sense that they usually must. This is no
inductive logic. In normal logic, Dangerous Mommy is an upsetting contra-
diction to Nice Mommy. However, in trance logic Dangerous Mommy and
Nice Mommy can exist together. There is no contradiction. Their coexis-
tence does not have to make sense.
Children have considerably greater self-hypnotic abilities than do adults,
especially during late childhood, peaking around age 12 (Maldonado &
Spiegel, 1998; Bernstein & Putnam, 1986). High dissociative ability con-
tinues into adulthood only in situations of ongoing traumatic abuse (Kluft,
1984). Thus, people who encounter even extreme trauma in adulthood do
not develop extreme, florid symptoms of DID (Chu, 1998) unless they were
highly traumatized in childhood.
Origins of Dissociative Identities:

TheÂ€Karpman Drama Triangle of Victim,
Persecutor, Rescuer—Redux
In Chapter 5, I described one of Liotti’s views of how the child develops

dissociative identities in terms of the Karpman triangle and the attachment
relationship: The child becomes victim, persecutor, and rescuer in relation-
ship with the parents and “knows” these roles implicitly as a result. From
this point of view, each of these identities emerges from real interpersonal
experience: The child is the victim of the frightening caregiver, the child is
the rescuer and comforter of the frightened caregiver, and the child perceives
himself to be the persecutor of the frightened, withdrawn, or preoccupied
caregiver.
However, it is also the case that these identities come about in ways that
are not direct replications of the roles and experience that the child actually
enacted vis-à-vis the caretaker. For instance, when the parent is too fright-
ening to be regarded as in need of comfort or does not seem frightened, the
child may develop these identities in the context of trauma. In this case,
although the internal working models containing the substrates for these
identities must precede their creation and development, these identities are
not created solely in the context of interactions with frightened caregivers.
The Karpman triangle is still aptly descriptive (although it certainly does
not cover all the varieties of dissociative identities). Apart from the identity
who manages to function in the world with at least a fair degree of deper-
sonalization and with some degree of amnesia (usually the “host”), variants
on these three characters populate the inside. Most often, people with DID
have dissociated victim identities, usually inner children who continue to
suffer from the abuse. In addition, internal persecutors, some of whom may
function in some ways like an exceptionally harsh, archaic superego, are
created by a procedural enactive “identification with the aggressor” that
occurs in response to trauma. Finally, internal rescuers are created. Similar
to rescuers are dissociative identities who in the child’s mind would be safe
from the abuse.
The Victim Identity

Let us begin with the victim identity. If the attachment figure is over-
whelmingly frightening or abusive, and if there is a history of disorganized
attachment, then the segregated systems of attachment are invoked. In
peritraumatic dissociation, people experience themselves as detached and
distant from the event. Emotion-processing parts of the brain are damped
down (Frewin & Lanius, 2006a, 2006b), and the person may feel like a
calm observer while going through a situation of extreme terror. A child
who is being raped by her father, for instance, may go into a detached state
and experience herself as rising to the ceiling. Given her state of mind, she
may literally see the child below as another child. Thereby, this child who is
being subjected to terrifying abuse at the hands of a caregiver may be calm,
not feeling the fear, and have some analgesia to the pain. If this were a case
of simple posttraumatic stress disorder (PTSD), then fragmented memories
of the traumatic experience would not become part of the memory system
of another identity but would later intrude into consciousness, probably in
fragmented ways. But, if this happens again and again, especially if this
is in the context of earlier disorganized attachment, the detachment may
become chronic as a way of escaping unendurable experience that is incom-
patible with attachment.
DID generally represents a very high magnitude of traumatization. For
example, it is well known that a single rape for an adult can be a very trau-
matic experience, requiring months or years of recovery. For this, even the
word “recovery” may be a misnomer, considering that one is almost never
the same afterwards. In DID, a speculative multiplication factor (Kluft,
1993c) applies: Imagine a child misused by a trusted, loved and/or needed
adult 2 times a week for 10 years. This is more than 1000 times, and it is
a child.
If there is a preceding disorganized attachment, then the child watching
from above embodies one self-state of calm who may be able to engage in
an attachment relationship, but there is another child, another self-state,
who is utterly terrified. Since these systems of experiencing are separate
and unlinked, only one has executive control of the body at a time, and the
calm, depersonalized one does not know about the other states of mind.
The Persecutor
Now, let us consider the persecutor/aggressor identity in relation to the
previously discussed situation of a daughter’s rape by a father. In the trau-
matic moment, the child will often become highly absorbed in a trancelike
state with the problem of the persecutor. Self-hypnotic dissociation is the
“escape when there is no escape” (Putnam, 1992). But in this situation, the
child is likely to intently focus on the matter of most relevance, which is the
abuser. Trance logic prevails, and there is an unclear distinction between
self and other. In addition, the child, as a result of being intensely focused
on the abuser, is likely to automatically mimic the aggressor’s behavior.
Through a process of identification with the aggressor, a part of the child
may begin to feel that she is the aggressor. Once created, this identity state
may become increasingly utilized in the service of predicting the aggressor’s
behavior, consequently avoiding some harm and preempting the aggressor’s
perceived power and threat.
Mirroring, Imitative Behavior, and Procedural,

Enactive Identification With the Aggressor
It has long been known that infants, even soon after birth, are capable of engag-
ing in what appears to be mimicry (Meltzoff & Moore, 1977; Trevarthen,
2009). Gallese, Fadiga, Fogassi, and Rizzolatti (1996) have documented
“mirror neurons” in monkeys, finding that the same premotor neurons fire
when the monkey performs an action, such as eating a peanut, and observes
another monkey performing the action. Gallese (2009) and his colleagues
have also documented what they considered “the likely human homologue
of these monkey areas in which mirror neurons were originally observed”
(p.â•¯522). Gallese further stated, “Watching someone grasping a cup of cof-
fee, biting an apple, or kicking a football activates the same neurons of our
brain that would fire if we were doing the same” (p.â•¯522). Gallese, however,
emphasized that these neurons function via integration with other parts of
the brain, in particular via integration with the motor system. All of this
underscores the social design of our brains.
Recently, the activity of specific mirror neurons in the human brain have
been discovered. According to ScienceDaily (http://www.sciencedaily.com/
releases/2010/04/100412162112.htm, April 13, 2010), the April 2010 edi-
tion of Current Biology reported that Dr. Itzak Fried and his colleagues
have made a direct recording of mirror neurons in the human brain, show-
ing that these neurons fired and were most active when both executing an
action and observing it. “Piggybacking” on a situation in which patients
were being treated for epilepsy, they recorded activity of 1,177 neurons in
the 21 patients. The researchers recorded both single-cell and multiple-cell
activity, but interestingly the location of the neurons they recorded were in
the medial frontal cortex and the medial temporal cortex, where this activ-
ity had not been previously observed, even in monkeys.
Colwyn Trevarthen noted (2009) that although we do not fully under-
stand it, the interaction of mother and infant somatic and visceral processes
gives the infant a “means of expression and access to the other anticipatory
‘motor-images’ and ‘feelings’ and permits direct motive-to motive engage-
ment with a companion” (p.â•¯70). Trevarthen also highlighted another
aspect of this mirroring and imitation: The baby not only imitates but also
anticipates. He (2003) described how after watching the baby imitate a
parent or the researcher, if the researcher waited, the baby would repeat
the same sound and behaviors that had been imitated as an aspect of a
dance of intentional elicitation of the same response from the adult. This
is a “protoconversation.” Emphasizing the role of expectation, Trevarthen
(2003) wrote:
The classical way of diagramming the human cerebral cortex indicates

that it processes sensory information coming in at the back and sends
it forward to the “pre-central” motor system. In fact, all information
that is perceived is expected by the brain. There is a process seeking in
the other direction, first setting up a motor plan, then looking for the
sensory information needed. The motor or “executive” action is lead-
ing to the cognitive experience, so the initiative is actually frontal in
origin. It has got to do with initiating voluntary activity and then the
experience comes about. (p.â•¯12; emphasis in original)
Given that humans not only imitate but also anticipate, as part of rela-
tional neurological design, we can think in more detail about the process
of “identification with the aggressor” in the formation of abuser and per-
secutory self-states in the persons with DID. In the process that is often
termed “identification with the aggressor” (e.g., Ferenczi, 1932/1949),
abuser and victim self-states become partially or entirely dissociated. (See
Chapter 11 for more description of identification with the aggressor.) As
a result perhaps of mirror neurons as well as imitative/anticipatory pro-
cedural enactment, a part of the child may behave like the abuser or even
experience the self as the abuser in the internal world of the “third real-
ity.” The omnipotence and devaluation with which the abuser has treated
the victim is automatically enacted. In the traumatic moment of being
terrified and abused, the child cannot assimilate the events into narrative
memory and goes into a trancelike state. In this state, the child focuses
intently on the source of the danger, the abuser, including the abuser’s
postures, motions, facial expressions, words, and feelings but does so in a
depersonalized and derealized way. Thus, identification with the aggres-
sor relies on processes that Lyons-Ruth (1999) described as “enactive
procedural representations of how to do things with others” (p.â•¯385). In
contrast to relationships of mutuality in which there is much validating

and mirroring of the other’s experience, in traumatic procedural learn-
ing, there is no opportunity for interchange of perspectives. In this way,
these aggressor-identified, grandiose, and dominating abuser self-states
that often embody rage, contempt, and omnipotence may arise procedur-
ally and imitatively.
If in a situation of interpersonal terror the child has a dissociative
hypoarousal response as described by Schore, or a secondary dissocia-
tive PTSD response (as described by Frewin & Lanius, 2006b, and by the
Reinders et al. articles, 2003, 2006), to protect the ability to survive and
to function, then we can add the procedural process of identification with
the aggressor to this. Another part of the self that is disconnected from this
depersonalized, functioning apparently normal part may be automatically
imitating and anticipating the abuser’s behavior. I am suggesting that, along
with mimicking of the aggressor, in the context of such a depersonalized
state the situation is ripe for the creation of aggressor-identified alter. Recall
Frewin and Lanius’s (2006b) statement that “disconnection of neural path-
ways normally linking self-awareness with emotional body-state perception
could occasion the development of dissociative identities in traumatized
children” (p.â•¯113). Also recall these additional words:
Specifically with increased repetition and automatization of second-

ary dissociative processes during situations of long-standing abuse, the
priming of the dissociative state may become sensitized and increasingly
automatic and unconscious. In addition, repetitious entry into second-
ary dissociative states may produce progressively more marked depar-
tures from external reality and consciousness for self. (pp.â•¯120–121)
Although the human brain and nervous system are designed to be social,
procedural enactments are not always happy affairs.
The Rescuer
Finally, also, in a hypnotic state traumatized children can create protectors,
as noted. In his phrase “dissociative multiplicity,” O’Neil (2009) empha-
sized that people with DID do not just dissociate but also creatively multi-
ply themselves. Grotstein (2000), speaking of Fairbairn’s schizoid position
and the “phantasmal accommodations for survival” that the infant must
make in situations of danger, observed “thus, in withdrawing, the infant
becomes his own imaginary parent” (p.â•¯138). Under conditions of abuse
and neglect, an inordinate degree of self-sufficiency is required of the young
child. Because this is generally more than can be managed, the child may
invent an omnipotent protector, helper, or inner caretaker (Beahrs, 1982;
Bliss, 1986). For example, Julie, a person with DID who had been brutally
sexually abused, isolated, and periodically subjected to severe neglect and

terror as a young child, described how she would make friends and protec-
tors of the rocks and bushes, convincing herself that they would care for
her. Since inner protectors are experienced as real, frightened parts may
become highly attached to them. Thus, the attachment system character-
izes the inner world as well as the outer one, and this sets the stage for what
Kluft (2000) called “the third reality,” the internal world of trance logic
and multiple personifications.
The Third Reality

The third reality is in some ways like an interior dream world that has its
own structure and consistent cast of characters. There is much playful cre-
ativity in this world. However, the third reality to some extent relies on a
psychic system that is relatively closed. The closed system is contrasted to
an open system that allows interaction with the outside and transformation
of the individual through interactive interchange with others. This closed
system makes for problems in living, and to the extent that this system is
closed, it cannot grow.
The Self-Care System

Related to the third reality is what Donald Kalsched (1996) called “the self-
care system.” As we have seen, the attachment system can be understood
as a psychological system for combating stress and modulating stressful
arousal (Lyons-Ruth, 2001). It fails to work adequately in traumatic attach-
ments, in which the attachment figure is dangerous or fails to provide a
protective shield against the dangers of the environment. The effects of
the failure of the attachment system, then, are profound. Kalsched (1996)
described how the “self-care system,” which operates by using dissociative
defenses, such as psychic numbing, trance states, and self-hypnosis, defends
the self against traumatic attachments and supplements the scarce supplies
available in the interpersonal environment. However, the self-care system
also results in the closed system:
The self-care system is self-protective and compensatory rather than

relational. As such, it cannot gain understanding from experience
(Kalsched, 1996). Because it functions protectively to prevent retrau-
matization, the self-care system strenuously resists transformation. The
illusions of the self-care system are only temporarily helpful and must
be continuously replenished. Without a benign-enough connection to
the interpersonal world, hope cannot last. (Howell, 2005, p.â•¯221)
Connecting Dissociated Self-States:

Contextualization
Kelly Forrest’s (2001) attachment-centered, neuroscience analysis of the

processes probably involved in the origin of the dissociated identity states
of DID emphasized how these states become and remain context bound.
Following from her analysis, part of the healing process will involve pro-
moting intercontextualization among these dissociated self-states. Forrest
referred to Putnam (1997), whose discrete behavioral states (DBS) model
of the personality emphasizes that rather than starting out as a unity, the
human personality must become integrated over time. Originally, discrete
behavioral and mental states are the building blocks of human behavior
and consciousness. As the linkages between them become more complex,
the child gains greater control and the ability to self-regulate. One of the
important effects of trauma and neglect is that the expected linking of
associative pathways among states is impeded. In this way, self-states stay
bound to the original context.
As self-states become more aware of their contextual interrelatedness to
each other, the increasing aggregates become more context independent.
An example of being bound by context would be: A child part who remem-
bers being beaten by a tall man may feel all the old terror when tall men are
seen in reality. Such an occasion of seeing a tall man could re-evoke the old
terror and be experienced as flashbacks, or it could be marked by a switch
in which this terrified part appears. When they are context bound in this
sense the separate parts are too responsive to the pulls, associations, and
contextual elements of events and circumstances that were too overwhelm-
ing to assimilate in the past. As the alters are each separately working on
how to avoid land mines—or stepping on them, they are less available to
coconsciously empathize or be supportive to each other.
As self-states become more aware and accepting of their contextual inter-
relatedness to each other, the increasing aggregate of self becomes more con-
text independent, with respect to vulnerability to being triggered by outside
context. As this happens, the dissociative barriers diminish. For example,
Little Denny, a terrified child part of Dennis (introduced in Chapter 1)
lives in terror. When a sudden threat of abandonment evoked his terror,
Little Denny became uncontrollably rageful and verbally destructive with a
person that the host loved. Following this, Little Denny’s guilt and despair
permeated the whole aggregate personality, contributing to extreme insta-
bility that the host then tried to manage. This could be comparable to a less
dissociative person experiencing an almost unmanageable rage, and per-
haps expressing it, and then feeling shaken. An important difference is that
the less dissociated person can recover more easily from being shaken—
because other aspects of memory and more stable and confident self-states
are contextually available. Likewise, Little Denny becomes less upset when
he can receive some support from another alter who has more experience
and comfort with rage. And he is also less upset when he can feel more
empowered by being less alone, experiencing himself as standing next to
the host, who can comfort and protect him.
Intercontextualization is also promoted in the relationship with the ther-
apist. Inviting the parts into interaction with the therapist and to share
their third reality with the therapist is integrative in the sense of binding
together. The therapist operates as a relational bridge (Bromberg, 1998) for
self-states to share more aspects of their segregated experience with each
other.
Mitchell’s (1993) statement about working with dissociated self-states in
people who do not necessarily have DID applies to DID as well:
Is the degree of discontinuity among different versions of the self a

measure of the degree of psychopathology? Does the analysand end
treatment with a more unified, homogeneous self? Certainly psychopa-
thology might well be measured by degrees of dissociation of impor-
tant versions of self. Yet it seems mistaken to assume that a digestion
and blending of different versions of self is preferable to the capacity to
contain shifting and conflictual versions of self. (p.â•¯105)
Similarly, Watkins (1992) states:
Integration means making the barriers between various alters more

permeable, increasing communication and cooperation, then returning
the various subpersonalities to the status of “covert” ego-states which
cannot be contacted except under hypnosis. We feel it is unnecessary to
fuse them into a unity since this is not a part of the “normal” personal-
ity. (cited in Phillips & Frederick, 1995, p. 166)
However, integration is a tricky concept. Of course, integration, along

with less fragmentation, is usually a general goal in psychotherapy, includ-
ing for people who do not have dissociative disorders. In a general sense,
integration may be a lessening of separateness and an increase of perme-
ability of internal boundaries between self-states, distinguishing this from
the idea of the person becoming one seamless unit. Rivera (1996) suggests a
continuum on which the robust multiplicity is at the healthy end of the con-
tinuum, and a fragile self, which can be characterized by either pathologi-
cal dissociation or pathological association is at the other end: “Defensive
association pretends to simple unity to hide fragmentation, suppression,
and complex humanity in all its contradictory manifestations. Defensive
dissociation acknowledges the depth and complexity of the human condi-
tion through the interplay of a multitude of self-states, but denies it utterly
at the same time through disconnection” (p. 34). Similarly, Gold (2004)
states that “‘normal’ people maintain a sense of integration and continu-

ityâ•ƒ.â•ƒ.â•ƒ.â•ƒby systematically and routinely invoking processes that enable them
to ignore the glaring gaps, inconsistencies, and lack of continuity in their
experiences and behavior.”
People with DID frequently express fears of integration because their
alters are afraid that they will die or be eliminated. While they do not die,
what the parts do lose is their redundancy: There are often too many parts
who are doing the same things, without the knowledge of the others who
are also doing the same things. They are unaware of how many feelings and
thoughts they actually share. As a result, there is much time wasted, and it
is inconvenient, destabilizing, and sometimes disastrous to not know what
one said or did. In addition, the dissociative separation of self-states and
affect schemas, which resulted from unbearable affect, also impairs current
affect regulation.
One of the problems is the word, integration, and the concept behind
it. According to Wikipedia, the word, integer, from the Latin means
untouched, hence, whole. The implication is of a unit or a unity. In this
way, integration is also a one-person concept. However, the organization of
self-states can differ in different relationships and interactions. There is not
only the contextualization of self-states within the individual personality,
but also the contextualization of each person’s self-states within the dyad.
The concept of contextual interdependence avoids the problems in the
often implied opposition between dissociation versus unity. And, it explic-
itly allows for intersubjectivity of parts in the internal world. As the dif-
ferent subjectivities can increasingly recognize that they can utilize their
connectedness to each other, they are in a better position to bear their
overwhelming affects.
Rather than a monolithic integration, a better ideal might be not only
harmonious interaction among the multiple self-states but also an appre-
ciation of contextual interdependence. I agree with Bromberg’s (1993)
statement at the beginning of this chapter: “To put it as simply as pos-
sible, I argue that there is no such thing as an integrated self—a ‘real you’”
(p.â•¯166). Integration can mean different things. For me, an ideal integration
would allow the different “voices” of different self-states to retain their
own tenor although increasingly less dissociated, and in harmony or in
conscious conflict, as the case may be. In other words, integration need not
cover over multiplicity or even the capacity for dissociation.
I propose that contextualization might be a more fruitful way of thinking
about our psychotherapeutic goal. Subselves within the context of the whole
aggregate, when separate but not highly dissociated, add perspective and
internalized multiple viewpoints. However, if viewed in three-dimensional
space as Putnam (1997) did in his DBS model, each self-state looks differ-
ent from the particular vantage point of the others. But, most important,
as one self-state or group of self-states takes on different functions, such as
executive or experiential functions, the relationships to other states change.

This reorganization of internal relationships and points of view has the
potential to release logjams. When these changes become more available
to thought, through interaction with another person or another part of the
self, therapeutic action has occurred. However, this is movement not only
toward integration but also toward greater contextualization. That is, the
different self-states become increasingly aware of how they are contextually
related to each other. In so doing, they become, as a group or as groups,
more independent of specific contexts and thus less vulnerable to being trig-
gered by specific contexts.
While the contextualized self is one that can, in Bromberg’s (2003)
wonderful phrasing, “stand in the spaces between realities without losing
any of them” (p.â•¯166), it also encompasses an awareness of all of the parts
together. From this perspective, we can take a different view of the concept
of unity. Bromberg (2003) described his view of how the continuity of “I”
must depend on human relatedness:
“Unity” is a shorthand term for the experience of feeling fully in life,

and “life” is the experience of our connection with the rest of human-
ity. That is, unity is the connection to mankind and other people. In
analytic treatmentâ•ƒ.â•ƒ.â•ƒ.â•ƒwhen the therapistâ•ƒ.â•ƒ.â•ƒ.â•ƒis able to relate to each
aspect of the patient’s self through its own subjectivity, each part of the
self becomes increasingly able to coexist with the rest, and in that sense
is linked to the others. It is an experience of coherence, cohesiveness,
and continuity, that comes about through human relatedness. (p.â•¯704)
Part 2
Treating Dissociative
Identity Disorder
Chapter 8
Assessment and
Diagnosis of DID
Diagnosis has great meaning to our patients. While diagnosis should

inform treatment, for the patient, it may be the first time they have
“stopped to notice” that they have a mind that does not work like other
people’s minds.
Chefetz (2005a, p.â•¯661)
This chapter describes basic assessment methods to identify the presence of

dissociative identity disorder (DID) and dissociative disorder not otherwise
specified (DDNOS). These methods include diagnostic face-to-face inter-
views, screening instruments, and assessment instruments. Most patients
with DID have spent years in the mental health system with incorrect pri-
mary diagnoses, such as schizophrenia, bipolar disorder, and anxiety dis-
orders, before being correctly diagnosed. The primary reason for this is
that most clinicians have not been adequately trained in graduate school or
medical school to recognize dissociative disorders, if they have been trained
for this at all. Frequently, the training they have received has included a
bias against recognition of the existence of DID; furthermore, those who
are willing to consider DID as a diagnosis have often been taught that the
presentation of DID is florid, with switching that is easy to spot. To the
contrary, “only 6% make their DID obvious on an ongoing basis” (Kluft,
2009, p.â•¯600). Also, the result of poor clinical training, but much less fre-
quent, is false-positive diagnoses. Clinicians who have not been adequately
trained in differential diagnosis (including dissociative disorders) are more
likely to make mistakes in either direction.
Because of this general lack in training, as well as because of the amnesia
and hiddenness that so often characterize DID and DDNOS, I recommend
that all incoming patients be assessed for dissociative disorders.
147
Amnesia for Amnesia: DID Is a

Disorder of Hiddenness
There are important differences in the presentation of those with DID and
DDNOS from other groups of psychotherapy patients. Whereas people who
suffer primarily from anxiety or depression can tell you straightforwardly the
nature of their problem, patients with undiagnosed DID usually cannot tell
you that their primary problem is that they switch, have frequent intrusions
into their experience, and have amnesia for large segments of their lives. In
essence, they have amnesia for amnesia. Although prospective new patients
who turn out to be highly dissociative will occasionally tell their clinicians
that they have been previously diagnosed with a dissociative disorder or that
they themselves suspect it, it is much more common that patients enter psy-
chotherapy for some other concern, such as anxiety, depression, addictions,
posttraumatic stress, or relationship problems. These multiple symptoms
often accompany dissociative disorders and may themselves, in large mea-
sure, be the result of the unseen trauma-driven dissociation that governs the
patients’ lives. As Luxenberg et al. (2001) noted: “Yet trauma-related disor-
ders, including dissociative disorders, continue to be grossly underdiagnosed.
This underrecognition can be best understood in light of the multiplicity of
symptoms with which these patients present that may not be readily recog-
nized as being related to their traumatic experiences” (p.â•¯377).
People with DID often do not know about their dissociative identities.
Or, they may “sort of” know: They have an inkling, but they do not have
the conceptual or emotional language yet to spell it out to themselves.
Sometimes, if they do know, even sort of know, they may assume that every-
one else is similar. Living in such a haze, people with DID often find it dif-
ficult even to think about, much less communicate about, their dissociative
problems. Moreover, even when they know they have dissociative problems,
they are often, for good reason, loath to reveal it: They fear being regarded
as “crazy” and of being “put away.” They also fear they are crazy. As a
result, the assessment must be conducted with great care and sensitivity.
Diagnostic Constructs
Another contribution to the difficulties of accurate diagnosis has to do

with our diagnostic constructs. There are two primary constructs: switch-
ing and intrusions/withdrawals of experience. However, both the current
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,
Text Revision (DSM-IV-TR; American Psychiatric Association [APA],
2000) and the proposed criteria for the fifth edition (DSM5; with a pro-
posed publication date by APA in 2012) place the emphasis on the switch-
ing aspect of DID as well as DDNOS.
Assessment and Diagnosis of DIDâ•… 149
Switching
The DSM-IV-TR (APA, 2000) provides the following diagnostic criteria
for DID (300.14):
A. The presence of two or more distinct identities or personality
states (each with its own relatively enduring pattern of perceiv-
ing, relating to, and thinking about the environment and self).
B. At least two of these identities or personality states recurrently
take control of the person’s behavior.
C. Inability to recall important personal information that is too
extensive to be explained by ordinary forgetfulness.
D. The disturbance is not due to the direct physiological effects of
a substance (e.g., blackouts or chaotic behavior during Alcohol
Intoxication) or a general medical condition (e.g., complex partial
seizures). Note: In children, the symptoms are not attributable to
imaginary playmates or other fantasy play. (p.â•¯529)
Notice that Criteria A and B are vague about whether the clinician must
witness the switches in identity states or whether the patient’s self-report
is adequate.
The reader may find the new proposed diagnostic criteria for DSM5 (expected
publication date is 2012) at http://www.dsm5.org/ProposedRevisions/Pages/
proposedrevision.aspx?rid=57. An important difference is that the new cri-
terion A specifies that the client’s self-report with respect to disruption of
identity states is considered adequate: It is clear that the clinician need not
witness such disruption. Another important difference is that in the new
DSM5 criteria somatic symptoms are given diagnostic importance. The
amnesia requirement that is specified in DSM-IV-TR continues in DSM5.
Dissociative Disorder Not Otherwise Specified

DDNOS (APA, 2000, 300.15) is used when there are predominant dissocia-
tive symptoms that do not meet the full criteria for DID or for any other
DSM dissociative disorder. It is a frequently used category because many
highly dissociative patients are “almost DID,” in accordance with Example
1 of the DDNOS criteria. Example 1 of DDNOS refers to “Clinical presen-
tations similar to Dissociative Identity Disorder that fail to meet the full
criteria for this disorder. These include presentations in which there are not
two or more distinct personality states, or amnesia for important personal
information does not occur” (APA, 2000, p.â•¯242). Thus, those severely dis-
sociative patients who do not have amnesia between identity states should
be diagnosed, according to the current and the proposed future criteria, as
having DDNOS. This is despite the fact that they may have dissociated iden-
tity states; that these identity states function as autonomous, personified,

separate subselves; and that they benefit from treatment designed for DID.
Some clinicians use the DDNOS category when the patient has not
displayed obvious switching to the diagnosing clinician, although the
patient may have reported it. Because of the ambiguity of Criterion B in
the DSM-IV-TR (APA, 2000) regarding whether the clinician must have
been in communication with alternate identities, many clinicians will take
a more conservative approach and use the DDNOS designation for those
severely dissociative patients they have not personally witnessed switching.
However, if the proposed (2012) DSM-V goes into effect, this will no lon-
ger be an issue: These patients will be diagnosed with DID.
Additional examples for DDNOS given in DSM-IV-TR (APA, 2000)
also include derealization without depersonalization, dissociative states
due to brainwashing, dissociative trance disorder, loss of consciousness not
attributable to medical disorder, and Ganser’s syndrome. The most com-
mon reason, however, for the diagnosis of DDNOS is for reasons similar to
Example 1 (International Society for the Study of Trauma and Dissociation
[ISST-D], in press).
Other categories of dissociative disorders listed in DSM-IV-TR (APA,
2000) are dissociative amnesia (300.12) in which “the predominant experi-
ence is one or more episodes of inability to recall important personal infor-
mation, usually or a traumatic or stressful nature, that is too extensive to be
explained by ordinary forgetfulness” (p.â•¯239); dissociative fugue (300.13), in
which the “predominant symptom is sudden or unexpected travel away from
home or one’s customary place of work, with inability to recall one’s past”
(p.â•¯240); and depersonalization disorder (300.6), which is characterized by
persistent or recurrent “experiences of feeling detached from, and as if one is
an outside observer of, one’s mental processes or body (e.g., feeling like one is
in a dream),” and in which “reality testing remains intact” (p.â•¯241).
Intrusions and Withdrawals, Partial Dissociation

Although important, the phenomenon of switching occurs with relatively less
frequency and may be less characteristic of DID (Dell, 2001, 2006a, 2006b,
2009a, 2009d) than the phenomenon of intrusion of other identity states
into current experience. Examples are flashbacks, intrusive thoughts, intru-
sive emotions, and “made” behaviors. The importance of these intrusions
for DID was first identified by Kluft (1987a). In his landmark study, Kluft
found that patients with DID endorsed 8 of the 11 Schneiderian (Schneider,
1959, as cited in Kluft, 1987a) first-rank symptoms that had been considered
indicative of schizophrenia. These symptoms were voices arguing, voices
commenting on one’s action, influences playing on the body, thought with-
drawal, thought insertion, made impulses, made feelings, and made voli-
tional acts. Kluft observed that while it is no longer generally accepted that
these first-rank symptoms are diagnostic of schizophrenia, they are in fact

characteristic of DID. He further specified that the hallucinated voices and
the made actions were due to the activities of an alternate identity. Following
Ross (1989) and Putnam (1997), who also observed that dissociative distur-
bances have often been misunderstood for schizophrenia, Dell (2001, 2009a,
2009d) described in depth how the preponderance of dissociative symptoms
reported by patients with diagnosed dissociative disorders are these subjec-
tively experienced made thoughts, emotions, or behaviors. He distinguished
between full dissociation, which is characterized by amnesia, and partial
dissociation, which includes such symptoms as flashbacks, hearing voices in
the head, passive influence symptoms, and intrusions of dissociated expe-
rience. In partial dissociation, Dell (2001, 2009a, 2009d) noted that there
is either subjectively experienced or objectively observable discontinuity in
thought, affect, or behavior, without amnesia for behavior or identity. He
incorporated these symptoms of partial dissociation in his Multidimensional
Inventory of Dissociation (MID; Dell, 2006a) diagnostic questionnaire.
In practice, assessment questions and instruments incorporate both
models: Many of the questions that are asked in the following assessment
methods, which include diagnostic interviews as well as formal assessment
instruments, rely on both switching and intrusions/withdrawals from dis-
sociative identities.
Assessment Interviews
An important proviso for any of these approaches to assessment is that

if severe cognitive or memory problems seem to be present or if the pre-
sentation does not seem to make sense, neuropsychological testing may
be indicated (Brand, Armstrong, & Lowenstein, 1996). In addition, severe
somatoform problems should also be addressed with a physical examina-
tion to rule out or assess medical contributions.
An additional proviso is that although this chapter covers the screening
and assessment tools I use most frequently in private practice, it is not an
extensive review of all of the relevant instruments. Selection of the best
screening and assessment instruments will vary with treatment setting and
the purpose of assessment. For more information on assessment, see the
ISST-D Guidelines (ISST-D, in press), the work of Bethany Brand and her
colleagues, and that of other clinicians in the field of dissociative disorders
who are expert in assessment.1
Face-to-Face Interview: Basic Diagnostic Indicators

Although the inexperienced DID clinician is unlikely to detect overt switch-
ing in the first interviews, be alert to some basics. These include large gaps
in autobiographical memory, logical inconsistencies in narrative, history of

abuse, experiences of depersonalization and derealization, affective dysregu-
lation, and somatoform dissociation. Large gaps in autobiographical memory
and history of abuse are red flags. Experiences of depersonalization and dere-
alization are important to inquire about as many patients with DID live a
good portion of their lives in such states. One may ask something like, “Does
it ever seem to you that things are not real?” or “Do you sometimes feel that
you are not in your body?” Dissociative patients will often answer in the affir-
mative. They may think that this is normal, and as result, they do not notice
this as something meaningful about themselves. Furthermore, they may rely
on these ways of experiencing as a way to decontextualize experience and to
continually damp down affect. Does intense affect bring on subjective shifts?
One might also ask about thoughts and ways of thinking that come into the
mind and do not seem like one’s own. Chefetz (2000b) described the result of
an instance when he asked his patient if she had ever noticed other, competing
streams of thought in her mind: “She looked confused again. Suddenly she
brightened, ‘Oh, you mean my People! Sure, they’ve been there as long as I can
remember! How did you know about that? Nobody ever asked’” (p.â•¯308).
Topics for Inquiry

The following discussion conveys a brief description of important topics
for inquiry during the clinical interview. For more comprehensive informa-
tion, refer to an excellent, highly informative, and classic article by Richard
Loewenstein (1991) on assessment via an office mental status examination.
This thorough examination inquires after many of the symptoms of DID
and is organized according to categories of evidence of (a) alternate iden-
tities, (b) amnesia, (c) autohypnotic phenomena, (d) posttraumatic stress
disorder (PTSD), (e) somatoform symptoms, and (f) affective symptoms.
In addition to the standard questions of an initial interview, patients
should be asked about memory and amnesia and experiences of depersonal-
ization, derealization, identity confusion, and identity alteration (Steinberg,
Cicchetti, Buchanan, Hall, & Rounsaville, 1993); somatoform experiences
(Nijenhuis, 1999); intrusions/withdrawals into conscious experiences, such
as passive influence symptoms (Dell, 2009a; Kluft, 1987a); and other conti-
nuities and discontinuities in their experiences and behavior.
Inquiry regarding child abuse has not always been included in standard
initial interviews. Because early traumatization is usually a part of the his-
tory of those with DID, and because the rate of child trauma is higher for
DID than any other diagnostic group (ISST-D Guidelines, in press), if I hear
about prolonged severe abuse in childhood, my antennae are up for the pos-
sibility of a dissociative disorder. However, asking questions about abuse
requires a great deal of care. If the person seems upset at all by the question,
I generally indicate that we do not have to talk about that now. Premature
detailed investigation could trigger an overwhelming and retraumatizing

flood of memories and bring on decompensation.
With regard to memory, inquiries should address the continuity of child-
hood memories after the age of 3 or 4. Because the hippocampus, which
categorizes and processes memories, does not come online until around
the age of 3, narrative memory is generally lacking before this age. Large
gaps, such as not remembering the seventh grade or not remembering any-
thing until the age of 9, for example, signal cause for further investigation.
Memory gaps in the present or recent past are also important. Does the
person lose time, (that is) seemingly “coming to” and not knowing what she
did for the last few hours or days? Does the person remember what she did
last night or yesterday morning? Is there evidence of fugues, in which she
finds herself in unexpected places and does not know how she got there?
I often ask patients if they remember anything about our last session.
If they do not remember, does prompting bring the memory back? Many
patients who are not highly dissociative may not remember the last ses-
sion, but the memory usually begins to emerge with prompting. Ever since
I began routinely asking this question, I have been surprised at how often
highly dissociative people do not remember the last session and at how
often prompting fails to bring back the memory—indicating that different
dissociative parts of the person have been “out.” I also check for memory in
the session: Is the person aware of what we were discussing earlier?
The quality of memories is important as well. Perhaps most important is
whether the memory is episodic (concerning personally remembered autobio-
graphical episodes). For instance, a dissociative patient of mine told me, “I
know that I graduated high school, because I was told I did, but I don’t remem-
ber being there.” Such an answer suggests the strong possibility that a different
part of the person than the one currently speaking attended the graduation.
It is especially important to inquire about somatoform symptoms as
these may represent bodily sensations related to past trauma (Nijenhuis,
1999). For instance, my patient Anna sometimes feels intense pain on the
top of her shoulders, the point from which she as a young adolescent was
forced down onto her knees, despite her resistance, to perform fellatio on
her abusers. This is an aspect of dissociated memory from past trauma.
The clinician should be alert to changes in appearance or behavior.
For instance, does a person’s dress style change from session to session?
Sometimes, a unisex hairstyle and clothing style on a woman may indicate
that she has found a more comfortable way to switch to differently gen-
dered identities. Does a person’s voice change markedly in the session? Are
taste preferences consistent? For instance, Dennis, introduced in Chapter
1, brought a cup of coffee into the session, opened the lid, and exclaimed
in disgust, “Ugh! I hate black coffee! Sophia must have bought this.” With
regard to the body, the clinician should inquire about handedness, eye-
sight, allergies, and reactions to medications. People with DID may be
right-handed in one self-state and left-handed or ambidextrous in others.

Many highly dissociative persons will have parts whose visual acuity is
quite different from others, or they will have different allergies and highly
differing reactions to medications.
Does the person report having had the experience of meeting people she
does not know but who seem to know her, perhaps by a different name?
Often, those with DID are thought by others to be lying because different
parts will say different things of which the host has no knowledge. Does
the person appear to be going in and out of trance, report autohypnotic
experiences or out-of-body experiences? How does the person handle emo-
tions? Generally, the host will not express intense anger. I have often been
surprised when inquiry about affects yields responses like, “I feel noth-
ing.” Painful as it is for their therapists to hear, many, if not most, highly
dissociative people go through life feeling depersonalized and with highly
damped down affect a great deal of the time.
Does the person hear voices? If so, are they perceived as originating from
inside the mind or from outside the head? This may help to differentiate
a psychotic disturbance from a dissociative one: Kluft (1999a) noted that
in 80% of those with DID, voices are heard from inside the head, while
in 80% of psychotic disorders voices are heard from outside the head.
However, making this discrimination is not foolproof for highly dissocia-
tive persons also hear voices from outside their heads (Moskowitz, 2008).
Useful distinctions include whether the communications are bizarre and
whether the person can hold the tension of knowing that voices are being
heard in her head without attributing additional meanings to this.
Consider language: Does the person refer to herself or himself as “we”?
Is the patient’s spouse ever referred to as “her husband” or “his wife”?
Are parents or other significant people referred to as “the parents,” “her
parents,” “his friend,” and so on? Are body parts ever deprived of the pos-
sessive pronoun, for example, “the hand hurts”?
What about PTSD symptoms such as visual, auditory, or somatic flash-
backs or intrusions of intense affect or memories? Does the person have
passive influence symptoms such as made experiences, thoughts, emotions,
or behaviors (Dell, 2001; Kluft, 1987)? For example, the person might say,
“It felt like the hand picked it up; I didn’t.”
I have one more diagnostic indicator. Even though it is not in my office
for the purpose of assessment, I have a dollhouse visible on my bookcase.
On more than several occasions, a person has revealed dissociativity by
asking to see the dollhouse. Inevitably, as soon as the dollhouse is taken
down, the patient has switched into a child part as she begins playing with
the dollhouse.
Formal Screening and

Assessment Instruments
Before assessing for dissociative disorder, it is often helpful to gently intro-

duce the patient to the subject of investigation and to normalize dissociation
as a trait and a defense, as something that everyone does to some extent
(Nijenhuis, Spinhoven, Van Dyck, Van der Hart, & Vanderlinden, 1996).
For instance, the Dissociative Experiences Scale (DES) has its title written
at the top, as does the Somatoform Dissociation Questionnaire (SDQ).
I discuss four screening tools first: the DES, developed by Bernstein and
Putnam (1986) and updated by Carlson and Putnam (1993); the Adolescent
Dissociative Experiences Scale (A-DES; Armstrong, Putnam, Carlson,
Libero, & Smith, 1997); the Child Dissociative Checklist (CDC) developed
by Putnam (1997); and the SDQ-5. Following this, I discuss several assess-
ment instruments: the SDQ-20 (Nijenhuis, Spinhoven, Van Dyck, Van
der Hart, & Vanderlinden, 1997); the MID (Dell, 2006a); the Structured
Clinical Interview for DSM-IV Dissociative Disorders–Revised (SCID-
D-R) developed by Steinberg (1994a, 1994b, 1995); and the Dissociative
Disorder Interview Schedule (DDIS) provided by Ross (1997). More detailed
information about screening and assessment instruments can be found on
the ISST-D Web site under the heading “Professionals” and the subheading
“Education and Treatment” (http://www.isst-d.org/).
Screening Instruments
Frequently used screening instruments include the DES, the A-DES, the
CDC, and the SDQ-5. The DES, the A-DES, and the CDC are available in
the public domain and are available at http://www.isst-d.org.
The Dissociative Experiences Scale

The most widely used standard screening tool is the DES, a self-report
measure developed by Bernstein and Putnam (1986) and further developed
by Carlson and Putnam (1993) as the DES-II. In addition to clinical screen-
ing, the DES is an extremely popular measurement instrument in research.
Usually the first diagnostic instrument to be used, this 28-item question-
naire asks about the extent of the presence of dissociative symptoms. It
can usually be filled out in 20 minutes or less. It is scored by adding the
total scores and dividing by 28 (Carlson & Putnam, 1993). Scores above
30 indicate the high possibility of DID and that further inquiry about this
possibility should be conducted (Carlson & Putnam, 1993).
The DES correlated .78 with the SCID-D-R (Boon & Draijer, 1993),
which is considered the “gold standard” of assessment instruments.
However, it is important to remember that the DES is a screening tool, not
an assessment instrument. Low scores do not rule out the presence of a dis-
sociative disorder, and high scores (especially for people who may have a
reason to want the diagnosis) do not indicate its presence. In fact, caution
is advised, especially in research, for using the DES score as a cutoff that
precludes further assessment for dissociative disorders. In their study of the
prevalence of DID in psychiatric outpatients, Foote et al. (2006) noted that
had they used the DES score as a cutoff, they would have missed a number
of patients who were identified as having DID by formal, but more time-
consuming, assessment measures.
Regardless of whether scores are high or low, taking the DES may bring up
thoughts or associations the patient would like to discuss. These may become
a meaningful part of both the diagnostic interview and the psychotherapy.
The DES-T
A shorter version of the DES is the DES-Taxon (DES-T). The DES taps into
several dimensions of experience, including ordinary ones such as absorp-
tion, as well as the more clearly dissociative experiences such as amnesia,
switching, depersonalization, and derealization. In addition, it is based on
the concept of a continuum of dissociation. In contrast to the continuum
model, Putnam (1997) found that a relatively small subgroup of subjects
whose abuse was earlier, more chronic, and severe fit into a taxon or per-
sonality classification. Eight of the DES items, taken together, are taxonic
for DID (Putnam, 1997; Waller, Putnam & Carlson, 1996). This group of
eight specific items—3, 5, 7, 8, 12, 13, 22, 27—comprise the DES-T. The
scoring program for the DES-T is available on the ISST-D Web site under
the heading “Professionals,” subheading “Education and Treatment”
(http://www.isst-d.org/). As with the DES, a cutoff score of 30 indicates
the high possibility of DID (ISST-D, in press).
Advantages for use of the DES-T are that it can be completed more
quickly than can the DES, and especially in research studies, it is used with
the hope that it will be more accurate. However, the view that the DES-T is
more accurate has become controversial. More current research (Dalenberg,
2004) indicated that absorption is just as highly correlated with physical,
sexual, and emotional abuse, as well as depersonalization, as are the taxonic
criteria themselves. Several aspects of dissociative abilities and tendencies,
such as absorption and detachment, appear to be functionally interlinked
as well as highly intercorrelated. Thus, the conceptual and practical divide
between normal and pathological dissociation is often left blurry.
The Adolescent Dissociative Experiences Scale

Although the DES and the DES-T are designed for people over 18, the A-DES
(Armstrong et al., 1997), a 30-item self-report instrument, is designed for
people aged 11 to 18. Adolescents with DID typically score between 4 and
7. A score of 4 or higher generally warrants further evaluation.
The Child Dissociative Checklist

The CDC, designed by Putnam (1997), is a 20-item checklist. It is scored
by summing the item scores. Scores can range from 0 to 40; a cutoff score
of 12 or more may tentatively indicate sustained pathological dissociation,
indicating that further evaluation should be conducted.
The Somatoform Dissociation Questionnaire

The SDQ-5 (Nijenhuis et al., 1997) was developed as a self-report screening
instrument for DSM-IV (APA, 2000) dissociative disorders. It addresses
several somatic experiences, such as urinary pain, paralysis, and body stiff-
ness. Having only five questions, it can be completed rapidly. It is scored on
5-point Likert scale, with possible scores of 5 to 25, which are obtained by
summing the scores. A score greater than 7 indicates the high possibility of
a dissociative disorder, which should then be addressed by formal assess-
ment instruments. The SDQ-5 correlates well with the SDQ-20.
Nijenhuis, Spinhoven, Vanderlinden, Van Dyck, et al. (1998) have
observed that somatic dissociation is commonly experienced by people with
dissociative disorders, but that there has been a problem with diagnostic
concepts. According to the DSM-IV-TR (APA, 2000), the “essential feature
of Dissociative Disorders is a disruption of the usually integrated functions
of consciousness, memory, identity, or perception” (p.â•¯477). However, if
the traumatic experience has been too intensely overwhelming to be assim-
ilated into ordinary consciousness, it may be encoded in somatosensory
modalities rather than as narrative memory. According to Nijenhuis (2000)
and Van der Hart et al. (2006), our diagnostic system repeats the ages-old
Cartesian dualism, in the form of a mind–body controversy with respect to
the “location” of dissociation: Although the DSM-IV-TR (APA, 2000) cat-
egorizes the cognitive and affective aspects of dissociation as dissociative
disorders, somatically experienced dissociative processes, such as motor
control and sensation, are classified as somatoform. The only DSM-IV-TR
dissociative disorder that even remotely refers to bodily symptoms is dep-
ersonalization disorder, in which the person feels detached from or outside
the body. Nijenhuis, Spinhoven, et al. (1998) observed that major somato-
form dissociative symptoms bear much similarity to animal defensive reac-
tions to threat, including, notably, freezing and anesthesia/analgesia. (For
additional discussion of this topic, see Chapter 6.)
More information on both the SDQ-5 and the SDQ-20 can be found
in Nijenhuis’s (2004) book, Somatoform Dissociation: Phenomena,
Measurement, and Theoretical Issues.
Self-Report Assessment Instruments

The Somatoform Dissociation Questionnaire
The SDQ-20 (Nijenhuis et al., 1996), which includes the five SDQ-5 ques-
tions, is a measure of the severity of somatoform dissociation. It addresses
such issues as tunnel vision, pseudoseizures, and psychogenic blindness.
The SDQ-20 correlation is .85 with the DES (Nijenhuis et al., 1996, 1999)
and .75 with the MID (Dell, 2006a, 2006b). Also scored on a 5-point
Likert scale, it has possible scores from 20 to 100, which are obtained by
summing the scores. The cutoff score of greater than 28 indicates the pres-
ence of somatoform dissociation, and scores increase with the severity of
the dissociative disorder diagnostic category, such that those with DID may
have scores over 50 (Nijenhuis, 2009).
The Multidimensional Inventory for Dissociation

The MID, developed by Dell (2006a, 2006b), is a sophisticated, comprehen-
sive, 218-item self-report assessment instrument. With its 23 dissociation
scales, the MID provides a multiscale measure of pathological dissociation.
The premise of the MID is an important one: Having tested hundreds of
patients with dissociative symptoms, Dell (2001) came to understand the
intrusions of dissociated self-states into ordinary consciousness as more
characteristic of DID than the more dramatic switching that is the primary
phenomenon on which the DSM criteria are based. He also distinguished
between full dissociation, characterized by amnesia, and partial dissocia-
tion, which includes such symptoms as flashbacks, hearing voices in the
head, passive influence symptoms, and intrusions of dissociated experience.
Administration of the MID usually takes about 1 hour. The MID has high
correlations with other measures of dissociation: Its correlations are .90
with the DES, .75 with the SDQ-20, and .78 with the SCID-D-R (ISST-D,
in press). It is the only measure of the dissociative disorder screening or
assessment instruments discussed here that has a validity scale and screens
for defensiveness, rare symptoms, attention-seeking behavior, factitious
behavior, and neurotic suffering. The test also yields information about the
prominence of certain kinds of identities, such as persecutor identities or
child identities. I have found this a useful measurement, especially when I
needed to provide documentation of a diagnosis on such things as patients’
disability applications.
One caution, however, about the use of the MID, as well as any other
questionnaire that refers to traumatic experiences, is that in my experience,
it can be triggering to fragile patients.
Structured Interviews
Structured Clinical Interview for DSM-IV
Dissociative Disorders-Revised
The SCID-D-R, developed by Marlene Steinberg (1994a, 1994b, 1995),
is considered the diagnostic gold standard for DID. This is a 277-item
interview that assesses five symptoms of dissociation: amnesia, deperson-
alization, derealization, identity confusion, and identity alteration. The
SCID-D-R diagnoses the four DSM-IV-TR (APA, 2000) dissociative dis-
orders and DDNOS. It usually takes between 45 minutes to 3 hours to
administer. However, proper administration of this scale requires consider-
able familiarity with dissociative symptoms, and it generally requires spe-
cific training in its use.
The Dissociative Disorder Interview Schedule

Another excellent structured interview, the DDIS, was developed by Ross
(1997). It has the advantages of easy access and requiring less training, and
it takes less time to administer (usually between 30 and 45 minutes) than
the SCID-D-R (it can be downloaded at http://www.rossinst.com). It is a
132-item structured interview that also assesses the symptoms of the five
DSM-IV-TR (APA, 2000) dissociative disorders. In addition, it assesses
somatization disorder, borderline personality disorder (BPD), major depres-
sive disorder, and substance abuse. Ross (1997) reported a sensitivity of .95
for the diagnosis of DID using the DDIS.
The Minnesota Multiphasic Personality Inventory 2

Many people ask about the use of the Minnesota Multiphasic Personality
Inventory 2 (MMPI-2) in diagnosing dissociation. This, along with other
instruments such as the Rorschach (Brand, Lowenstein, Armstrong, &
McNary, 2009), can yield useful information when properly understood.
Often, patients with DID have elevated F (validity scale, indicating exagger-
ation of symptoms) and Sc (schizophrenia) scales due, in part, to trauma and
dissociation-linked questions. Without the advantage of knowledge of dis-
sociative disorders, these scores can indicate a different degree of and type
of disturbance than is the case (Brand, Armstrong, & Lowenstein, 2006).
Factitious and Malingered DID

A factitious disorder involves a person’s intention to take on a sick role; a
malingered disorder, on the other hand, requires motivation by an external
goal, such as getting disability payments or staying out of prison. For both
of these reasons, there are some people who would like to falsely appear to
have DID. I have met several such patients who seemed to have a desperate
need for the diagnosis to give them license to behave aggressively, errati-
cally, or selfishly as a way to justify a pathological relationship or as a way
to claim entitlement. The diagnosis may also be sought as part of applying
for disability, avoiding pending legal charges, or staying out of jail (Coons,
1991; Coons & Milstein, 1994; Draijer & Boon, 1999; Thomas, 2001).
Especially if there is an issue of homicide, a false-positive diagnosis can be
dangerous (Coons & Milstein, 1994).
While careful psychological testing is a requirement for making any offi-
cial determination, there are some notable red flags in factious and malin-
gering persons’ presentations in the interview. Examples of red flags include
(a) the person’s open broadcast of the diagnosis (people who have DID tend
to try to hide it rather than to flaunt it); (b) continuity of memory, in partic-
ular, being able to narrate a chronological life story without gaps; (c) affect
tolerance, in particular, being able to express strong negative affect (people
with DID are unlikely to move easily in affective range without dissociat-
ing; especially in the host presentation, it is unusual for people with DID
to display intense anger); (d) telling of abuse without shame (people with
DID are ashamed of their abuse and are generally loathe to tell about it); (e)
reporting abuse that is inconsistent with medical history; (f) reporting dis-
sociative symptoms but not having PTSD symptoms; (g) bringing “proof” of
the diagnosis to the interview; and (h) dramatic and exaggerated presenta-
tion of symptoms (Coons, 1991; Coons & Milstein, 1994; Thomas, 2001).
(For an especially informative discussion of this topic, see Thomas, 2001.)
Although such red flags are helpful, it is important to be aware that given
increased Internet information and dissemination of knowledge, people are
becoming more and more sophisticated in their ability to dissemble.
The fact that these people are not as highly dissociative as they claim
does not mean that they do not have serious emotional problems. For a
more comprehensive evaluation of malingered or factitious DID, the use of
the measures of dissociation discussed here, as well as measures of malin-
gering and other standard psychological tests, are recommended.
Differential Diagnosis, Misdiagnosis,

and Comorbidity With an Emphasis on
Psychosis, Borderline Personality Disorder
As previously noted, the possibility for misdiagnosis works both ways.

Other disorders can be misdiagnosed as DID, as well as the reverse. This is
in part because dissociative symptoms are found in a number of disorders,
for example, PTSD, eating disorders, and even schizophrenia.
Psychosis
Dissociative disorders have historically been conceptualized as, and con-
fused with, schizophrenia (Kluft, 1987a; Moskowitz, 2008; Moskowitz et
al., 2009; Putnam, 1989; Ross, 1989, 1997). In 1939, Schneider (1939/1959)
described a set of symptoms, including audible thoughts, somatic passivity,
“made” feelings, impulses, and behaviors, thought withdrawal, and thought
insertion, as pathognomonic of schizophrenia. Kluft (1987a) observed
that it is no longer generally accepted that these first-rank symptoms are
diagnostic of schizophrenia; they are in fact characteristic of DID. To wit:
Although some of these symptoms are often classified by the observing cli-
nicians as psychotic, they may simply be posttraumatic intrusions attesting
to an earlier real-life occurrence. What might appear to an outside observer
to be psychotically hallucinatory or delusional may in fact be a reliving of
an unassimilated aspect of traumatic experience that has an ever-present,
vivid, and terrifying reality to the patient when it occurs. Many dissociative
patients are subject to terrifying flashbacks, which may be visual, auditory,
or somatic. If the patient can hold the tension between the posttraumatic
“hallucination” as well as the awareness of present experience—basically
maintaining a foot in both worlds simultaneously, with the ability to stay
interpersonally connected, despite the terror—would we call this psychotic?
Is this psychosis in the eye of the observer, or is it “in” the patient?
Seemingly psychotic symptoms and behaviors often accompany the pre-
sentation of highly dissociative patients. One of the reasons stems from the
dissociation of memory itself. When a dissociated experience is triggered,
the patient may be aware of only body sensations, sounds, sights, or vehe-
ment emotions such as terror or rage. If a patient begins writhing on the
floor, flailing arms and legs, a dissociative part of the patient, for example,
may be reliving the experience of trying to fight off a rapist. Without the
wherewithal to make an inquiry about what the experience represents, a
clinician may view such a patient as simply psychotic. Often, dissociated
experiences do not manifest themselves as one whole experience but are
instead revealed as sensory fragments, in accordance with the way they
were stored. If the experience was too overwhelming to be processed by
the hippocampus, where the experience may be synthesized with its audi-
tory, visual, haptic, and other sensory components (and thus be too over-
whelming to become part of narrative memory), only isolated aspects of the
experience may intrude into the patient’s consciousness. Yet, because the
context is unknown, the patient may appear to be psychotic.
Hearing voices is for many clinicians, right away, an indication of psy-
chosis, and the DSM specifies this. In fact, a patient who hears voices in
conversation meets a criterion for schizophrenia. However, many people
with DID hear voices a great deal of the time inside their heads. These are
the voices of other parts, who comment on the patient’s behavior or want
their thoughts to be heard. A differentiation may be made by asking the

patient if the voices are heard inside or outside the head. However, many
dissociative patients also hear voices outside the head (Moskowitz, 2008).
Useful distinctions are as follows:
• The degree to which the messages of the voices are, as a pattern,

bizarre. With respect to the Schneiderian symptoms, those indicative
of schizophrenia are more bizarre.
• Whether the patient has the ability to think about his or her psychotic
thinking. For instance, if someone with the delusion that his or her
body is disintegrating or that he or she is dead, unbeknownst to oth-
ers, can say that he or she knows this is not true but cannot help feel-
ing this way—that is, psychotic thinking in the context of dissociative
thinking—does this merit a diagnosis of unqualified psychosis? It
may of course be indicative of the need for hospitalization.
• Dissociative patients may have parts who are truly psychotic. When
such a part appears, it is important to understand that this is a part, not
necessarily a breakdown or regression of the whole person.
A study by Brand, Loewenstein, Armstrong, and McNary (2009) of per-

sonality differences between patients with DID, psychosis (PSD), and BPD
as shown on the Rorschach found that that patients with DID had both a
higher level of traumatic associations and more logical reasoning than did
the psychotic patients.
Taken together with the results for BPD, this Brand, Loewenstein, et al.
(2009) study found the following:
Individuals with DID showed greater capacity to be self-reflective, to

modulate affect, and to see others as potentially helpful. These abili-
ties may contribute to some individuals with DID being able to more
easily develop a working alliance than some patients with BPD and
PSD. The patients with DID were able to think relatively clearly com-
pared with the other patients, despite having high levels of traumatic
flooding. These personality characteristics may contribute to patients
with DID being able to engage in, and benefit from, insight-oriented
therapy. (p.â•¯203)
Borderline Personality Disorder

Frank Putnam’s (1997) review of studies showed that 30 to 70% of those
diagnosed with DID also met criteria for BPD. Sar et al. (2003) found that
64% of subjects with BPD had a dissociative disorder. A nationwide ran-
dom sample study found that 53% of patients treated for BPD also had
diagnoses of a dissociative disorder, 11% of these DID (Zittel Conklin &
Westin, 2005, cited in Brand, Classen, Lanius, et al., 2009). Is this comor-
bidity, or does it indicate a diagnostic sharing of a common dissociative
spectrum (Howell, 2002a; Howell & Blizard, 2009)?
Misdiagnosis and Comorbidity

The issue of comorbidity is a complicated one. If BPD and DID/DDNOS are
understood as both existing on the dissociative spectrum, they would not
necessarily be comorbid. Or, is this dissociative spectrum concept poten-
tially misleading, obscuring ways that the two disorders are distinguish-
able (Brand et al., 2009)? In addition, patients with dissociative disorders
have often been misdiagnosed as having BPD because the clinician does not
know how to make sense of the patient’s dissociative symptoms, behavior,
and reported experience.
The issue of psychosis just discussed bleeds into that of BPD even though
the two are two different diagnostic categories (see Howell, 2008, which
addresses dissociation, BPD, and psychosis). BPD was originally conceived
of as a kind of “borderland” or a disorder lying on the borderline between
neurosis and psychosis. Initially, this made sense in that there were a num-
ber of patients who presented as neurotic, but under stress or in situations
of intimacy would appear to become psychotic. And, they did not improve
in the psychoanalytic therapies that neurotic patients did. Replacing such
earlier terms as pseudoneurotic schizophrenia, ambulatory schizophrenia,
and psychotic character, the term borderline personality disorder became
for a while a kind of wastebasket category (Millon, 1981). In time, BPD was
understood as both a personality disorder and a separate category (bor-
derline personality organization [BPO]; Kernberg, 1975) in developmental
diagnosis. It was characterized by the person’s reliance on the defense of
splitting, and other lower-level defenses associated with it, such as projec-
tive identification, denial, primitive idealization, devaluation, and omnipo-
tence, rather than on repression and its associated higher-level defenses,
such as reaction formation, projection, and negation (Kernberg, 1975).
It is not uncommon for patients with DID to be misdiagnosed as hav-
ing BPD on the basis of their clinicians’ misunderstanding of dissociative
presentations. For example, a clinician unfamiliar with switching may mis-
understand this phenomenon as borderline splitting. Or, when different
identity states convey contradictory information and then have amnesia
for what the other identity states said, the patient may be thought to be
lying. This can appear to be characterological mendacity when it is not.
Poor affect regulation characterizes both BPD (Linehan, 1993) and DID
(Chefetz, 2000a, 2010). Likewise, disorganized attachment, correspond-
ing to the unresolved attachment category in the adult attachment scale,
is often understood to precede both BPD and DID (Blizard, 2003; Fonagy,
2000; Liotti, 1999, 2006; Liotti et al., 2008). Finally, the symptoms of
BPD are more and more understood as being trauma based (Allen, 2001;
Gunderson & Sabo, 1993a, 1993b; Herman, 1992) and as dissociation
based. The last criterion for BPD refers to dissociation directly, and all of
the DSM criteria can be understood as stemming from underlying dissocia-
tion (Howell, 2002a).
An additional problem with the diagnosis of BPD is that so many dif-
ferent presentations and organizations of symptoms can receive the same
diagnosis. The terms complex PTSD and DESNOS (disorders of extreme
stress not otherwise specified), proposed by Herman (1992), Van der Kolk
(1996b), Courtois (1999, 2004), and Courtois, Ford, and Cloitre (2009),
include both DID and BPD. A partial remedy to the overlap of BPD and
DID diagnoses and the overapplication of BPD is the proposed diagno-
sis of relational trauma disorder (Howell & Blizard, 2009). In contrast to
borderline personality, the term relational trauma disorder is less pejora-
tive, more accurate, and more experience-near for those who manifest the
trauma symptoms consistent with the diagnosis of BPD.
What I suggest (Howell, 2008) is that BPD and DID are both based in
dissociation, but often, what we call BPD (preferably chronic relational
disorder), in contrast to DID, results from a more massive and less intri-
cately compartmentalized avoidance system for terrifying and overwhelm-
ing affects, emotions, and memories. Because the splitting is more massive,
there is less of the self or ego—what Fairbairn called the central ego—avail-
able for reflection, resulting in the wild affective swings we often see (see
Celani, 2001). In essence, it is sometimes more difficult to treat this par-
ticular dissociative pattern than it is to treat DID. Interestingly, the study
by Brand, Loewenstein, et al. (2009) of personality differences shown on
the Rorschach found that patients with DID had a greater capacity for self-
reflection, greater social interest, greater capacity for accurate perception,
and more logical thinking than those diagnosed as borderline.
Bipolar Disorder, Obsessive Compulsive Disorder,

Eating Disorders, and Substance Abuse Disorders
Another disorder that is often misdiagnosed when the patient has DID is
bipolar disorder. DID is not uncommonly misdiagnosed as bipolar disorder.
On the other hand, mood changes that are part of bipolar disorder may
be misunderstood as dissociative symptoms. Careful diagnostic assessment
with a knowledge of dissociative disorders is crucial. Of course, a number of
disorders, such as bipolar disorder, as well as eating disorders and substance
abuse disorders, are all often comorbid with dissociative disorders as well.
In particular, rapid mood swings in DID patients are often diagnosed
as rapid-cycling or Bipolar II. These rapid mood swings may be due to
posttraumatic intrusions or a switch of identity. Bipolar disorder has not
been found to be more common among patients with DID than in the
general population (ISST-D Guidelines, in press). Patients who have com-

plex PTSD, of which DID is one variant, have problems with affect regula-
tion; and chronic depression, as well as mood swings, is likely to be part
of the symptom picture. Because of the substantial traumas that could not
be assimilated and accompanying enormous emotional pain that could not
be alleviated, substance abuse is not an uncommon outcome. Substance
abuse may indeed mask the dissociative disorder, until abstinence or con-
trol has been achieved or the disorder has otherwise been diagnosed. Those
with complex PTSD are also likely to have substantial body image prob-
lems, including somatoform dissociation. Eating disorders, including binge
eating, bulimia, and anorexia are frequently comorbid with dissociative
disorders. Furthermore, it appears that along with body dissatisfaction,
the somatic symptoms of dissociation contribute to defects in body-based
awareness, as manifested in binge eating (Fuller-Tyszkiewicz & Mussap,
2009). Obsessive-compulsive spectrum disorders have also been linked to
dissociative disorders (McNevin & Rivera, 2001; Shusta, 2001). Shusta
(2001) has reported on a case in which her patient’s obsessive-compulsive
symptoms that had been previously resistant to therapy were actually the
result of intrusions of an alter; only following the correct diagnosis (DID)
was treatment able to resolve these symptoms.
Diagnosing dissociative disorders can be a daunting task. Many clini-
cians have not been trained to diagnose dissociative disorders and are thus
prone to misdiagnosing DID or DDNOS as something else or to misdiag-
nosing other disorders as DID. When this happens, it is regrettable for the
patient is not receiving the correct treatment and may be harmed by incor-
rect medications and treatments. There are notable points of similarity—
and difference—between DID and psychosis and between DID and BPD,
as well as other disorders. These should be understood so that a correct
diagnosis can be made.
Note
1. See Armstrong and Lowenstein (1990); Bernstein and Putnam (1986),

Berstein and Putnam (1993); Brand, Armstrong, and Loewenstein (2006);
Brand, Armstrong, Loewenstein, and McNary (2009); Brand, Classen, Lanius,
Loewenstein, McNary, Pain, and Putnam (2009); Brand, Classen, Zaveri, and
McNary (2009); Brand, McNary, Loewenstein, Kolos, and Barr (2006); Boon
and Draijer (1993); Courtois (2004); Courtois et al. (2009); Dell (2006a, 2006b,
2009a, 2009c, 2009d); Ellason and Ross (1997); Foote et al. (2006); Foote and
Park (2008); Loewenstein (1991); Nijenhuis (1999); Nijenhuis, Spinhoven, Van
Dyck, Van der Hart, and Vanderlinden (1996, 1997); Putnam (1989, 1991,
1997); Ross (1997, 2007); Ross, Heber, et al. (1989); Ross and Keyes (2004);
Ross et al. (1992); Steinberg (1994a, 1994b, 1995); Thomas (2001); and Waller
and Ross (1997).
Chapter 9
Phase-Oriented Treatment
The core experiences of trauma are disempowerment and disconnection

from others. Recovery, therefore, is based on the empowerment of the
survivor and the creation of new connections.
Herman (1992, p.â•¯133)
The phase-oriented treatment model requires that careful stabilization

and ego building precede any work with traumatic memories. Originally
formulated by Pierre Janet (1919/1976) in the early 1900s, phase-oriented
treatment has become increasingly advocated by clinicians in the field of
dissociative disorders. It is now considered the standard of care in the
treatment of complex posttraumatic stress disorder (PTSD) and dissocia-
tive disorders (Brand, 2001; Chu, 1998; International Society for the Study
of Trauma and Dissociation [ISST-D], in press; Steele, Van der Hart, &
Nijenhuis, 2005).
The phase-oriented model is especially important because of the dangers
of opening up traumatic memories before a patient is ready. Exposure to
dissociated memories and affects that is too rapid or poorly handled can be
retraumatizing. For example, following the successful use of exposure tech-
niques with traumatized Vietnam veterans in the 1980s and 1990s, some
trauma therapists used the same treatment models with patients with com-
plex PTSD and dissociative disorders. Too often, the unfortunate result was
that, rather than being helped, many of these patients were retraumatized or
required hospitalization. Unlike the Vietnam veterans who had suffered their
trauma as adults and were more likely to have an underlying solid and fairly
integrated personality structure, those traumatized in childhood may not be
able to endure the destabilizing effect of reencounters with dissociated trau-
matic memories in the initial phase of treatment. As Chu (1998) explained:
The pervasive myth that aggressive abreactive work will lead to rapid
improvement in most patients has its origin in treatment models devel-
oped for combat-related posttraumatic stress disorder (PTSD) (Foa,
Steketee, & Rothbaum, 1989; Keane, Fairbank, Caddel, & Zinering,
167
1989). These models emphasize flooding patients with stimuli that trig-
ger reexperiences of the traumatic events that are then abreacted in the
context of highly interpersonal support. The applicability of these tech-
niques early in the treatment of those patients with severe childhood
traumatization and complex posttraumatic and dissociative disorders
is limited. (pp.â•¯76–77)
Janet’s (1919, 1925) early model of phase-oriented treatment outlined

three basic stages: (a) stabilization and symptom reduction, (b) treatment
of traumatic memories, and (c) personality integration and rehabilitation
(Van der Hart et al., 2006). Following Janet, writers such as Putnam (1989)
and Herman (1992) have modified some specific emphases and language
but have retained the three basic stages. I find Herman’s articulation of the
stages of recovery especially useful:
• establishing safety
• remembrance and mourning
• reconnection with ordinary life
Subsequently, over the past decade or so, a number of writers in the field,
including Chu (1998); Courtois (1999, 2004); Courtois and Ford (2009);
Kluft (1999a); Steele et al. (2005); Van der Hart, Van der Kolk, and Boon
(1998); Van der Hart et al. (2006); and others, have further elaborated on
the use of these phases in the treatment of chronically traumatized people,
some with expanded phases and different emphases but with basically the
same format. The ISST-D guidelines (in press) also outlines three phases:
• establishing safety, stabilization, and symptom reduction

• working directly and in depth with traumatic memories
• promoting identity integration and rehabilitation
I also adhere to these three phases in this chapter. However, I believe, along
with Herman (1992), that Phase 2, working with traumatic memories,
implicitly requires much mourning.
The phases of treatment are a basic model, not a rigid timetable. Although
theoretically described in a linear way as proceeding from one phase to the
next, in practice there is always a backward-and-forward progression, as is
the case in standard psychodynamic psychotherapy. Some have compared
this back-and-forth movement stabilization and trauma processing to an
upward moving spiral that continually revisits old issues but with increasing
levels of complexity (Courtois, 1999; Steele et al., 2005; Wheeler, 2007).
Safety issues, which are characteristic of the first phase, are likely to come
up from time to time in the second or even third phase. In addition, flash-
backs, disturbing memories, or abreactions may well erupt in the first phase
Phase-Oriented Treatmentâ•… 169
(Chefetz, 1997a), but here the task is to help the patient contain and modu-
late the intensity of the affect rather than to explore the memories (ISST-D,
in press). The pace and intensity of the treatment must be in tune with the
patient’s current vulnerabilities and resilience. With patients with dissocia-
tive identity disorder (DID), it is important to remember that different self-
states are likely to be in different phases of the treatment simultaneously.
Some, such as more apparently adaptive parts, may appear to be moving
toward Phase 3, while other parts may still be in Phase 1 and in need of
stabilization. It is hard to know the extent to which reports of oscillating
stages represent this kind of isolated and staggered self-state growth.
Kluft (1994a) has distinguished between high-functioning, middle-
functioning, and low-functioning DID patients. There are some patients who
have been so damaged and who have so few resources with respect to social
support, mobility, financial resources, and intelligence as well as a paucity
of early positive experiences to draw on that moving to the second phase
of treatment is not realistic or helpful. These patients will continue to need
primarily supportive work to help them to manage their lives. Although this
may seem sad, these patients benefit enormously from this support because
it enables their lives to be more stable. Also, sometimes after years of what
looks like a low-level treatment, a person may graduate, so to speak, and
begin to do trauma work, with the accompanying gains in life satisfaction.
Phase 1: Establishing Safety
The focus of the first phase is the establishment of safety, stabilization,

and reduction of symptoms. Before I begin this section, I want to insert the
proviso that much of what follows is an ideal. A good number of patients
with DID enter treatment by hitting the ground running. They do not nec-
essarily know or tell you that they have DID. They do not necessarily want
to—or are able to—deal with their trauma slowly. They may enter with
florid PTSD. Once they discover that they have parts, they may want to
get to know them all at once. Or, a traumatic transference may begin right
off the bat. Therefore, the clinician’s job in this initial phase is usually no
paint-by-the-numbers affair. We do our best to contain, explain, and pro-
mote as much trust as possible.
Kluft (1993b) noted that his research indicates that “those patients who
accept and endorse the approaches that are designed to slow and pace the
treatment make more rapid progress and have many fewer crises than those
who do not; i.e., ‘the slower you go, the faster you get there’” (p.â•¯146).
Chu (1998) has proposed the mnemonic SAFER (self-care and symptom
control, acknowledgment, functioning, expression, and relationships) as a
summary of the Stage 1 tasks. More specifically, this means that responsi-
bility of self-care and symptom control, acknowledgment of the reality of
the abuse and the fact that it was not the patient’s fault, continued func-
tioning in the context of treatment, support for the expression of feelings,
and the establishment of models of relationships that are collaborative and
mutual are all emphasized.
People with complex PTSD and DID have developed their dissociative
structure for good reasons. Many, such as Janice, Dennis, and Margaret,
who were introduced in Chapter 1, have been severely and chronically trau-
matized in childhood. Often, the self-view of people with complex PTSD
and DID is suffused with shame and a conviction of defectiveness. As a
result of early abuse or severe neglect, they have considerable difficulties
with affect regulation, self-soothing, and trust. Because the external world
was often dangerous and frightening in the past, they (or many parts of
them) expect the present to be dangerous as well. Because their internal
world often reenacts the earlier external one, it is likely that they may have
been or are currently enmeshed in abusive or violent relationships. They
often lack effective skills to help themselves confront and deal with their
problems. As Forgash and Knipe (2008) commented, “Many of our clients
describe trying to function in adult life without the blueprints” (p.â•¯36).
To help with their chronic terror, sense of deficiency, and poor affect
regulation, people with complex PTSD and DID have often developed eat-
ing disorders, substance abuse, sex addictions, or severe masochistic prob-
lems, manifesting as self-punishment or in harmful relationships (Howell,
1996). In the latter case, they may have flown into the arms of someone
from whom they sought love and protection only to come under the influ-
ence of an abusive relationship.â•¯T hese solutions only work in the very short
term; in the long term, they decrease a person’s ability to negotiate life’s
problems. As a result, the person is left with not only the original problems
unsolved but also additional ones.
The intense distress of all of these situations coupled with poor affect
management may lead to frequent dangerous and self-destructive behav-
iors, such as unsafe sex, reckless driving, and medical self-neglect, as well
as self-mutilation and suicidality. In addition to self-mutilation, for which
Brand (2001) cited an incidence of 34 to 48% for DID, there is the danger
of suicidality, which has an incidence of 61 to 72% for attempted suicide; in
addition, 1 to 2.1% of patients with DID have completed suicide.
Brand (2001) identified five reasons that severe trauma survivors are
especially likely to be self-destructive:
First, ambivalence about self-care is to be expected in patients who

came to believe they were worthless due to chronic childhood abuse
and who have no concept of self-care, much less methods for health-
fully caring for themselves (Herman, 1992; Chu, 1998). Second, there
is frequently an element of reenacting abuse dynamics through self-
destructiveness. These reenactments may feel “normal” to the client
because they mirror their early experiences. Third, the self-destructive

behaviors may have developed because the person had no support
group, no words, or other holding environment in which to express
distress. Self-destructiveness may be a primary form of communica-
tion for those who do not yet have ways to tame their excruciating
inner conflicts and feelings and who cannot yet turn to others for sup-
port (Chu, 1998). Fourth, there may be a physiological basis associated
with early abuse and poor attachment which contributes to acting on
affect rather than verbalizing it (Van der Kolk et al., 1991; Van der
Kolk, 1996). Fifth, the process of therapy may challenge defenses that
have served to distract the traumatized patient from painful feelings
and memories. The weakening of outmoded defenses can result in an
increase in attention to exceptionally painful childhood experiences.
Thus, some patients become self-destructive when they attempt to pro-
cess memories of trauma, especially if the timing of trauma work is not
carefully planned (Courtois, 1999). (p.â•¯138, emphasis added)
I would like to elaborate on Brand’s (2001) second reason as it pertains

specifically to DID. Persecutor or abuser parts often torture or punish other
parts for various things, such as telling about the abuse, which the abuser
had required kept secret, or for other activities that were forbidden dur-
ing childhood. For example, one of my patients, Rosemary, has on several
occasions been punished by an internal persecutor with self-injury for tell-
ing me of her abuse. Similarly, Anna was forbidden to eat by an internal
persecutor as punishment for eating good food in her current home. This
was in accordance with the fact that her abusers forbade her to eat anything
other than peanut butter sandwiches when she was growing up and bru-
tally beat her if they caught her doing so.
The Development of Trust and Establishment

of the Treatment Alliance
One of the most important tasks of the first phase is the establishment of
trust—something not to be taken for granted with chronically traumatized
people. Kluft (1993b) noted that genuine trust in early treatment is rare,
and that the early appearance of trust in DID
is usually a leap of faith, a wish, an enactment of a fantasy, an expres-

sion of hope, or telling a potential aggressor, the therapist, what the
patient thinks he or she want to hear.â•ƒ.â•ƒ.â•ƒ.â•ƒA more operational definition
of what appears to be early trust is enough hope, curiosity, or despera-
tion to return for the next session. (p.â•¯149)
It is especially true of traumatized patients that trust cannot be taken for

granted and must be earned. Persons with DID have often had the experi-
ence of their boundaries being violated early in life, situations in which they
have been powerless before someone else’s demands or desires. Chu (1998)
described this as chronic disempowerment. At least some of the patient’s
dissociated identities expect to be violated again. Not only do parts of the
patient expect to be violated again, but also violations may not be viewed as
unacceptable, and the very topic of boundary violation is often unexamined
in the patient’s mind. Therefore, the establishment of proper boundaries
at the outset and throughout the treatment is of utmost importance. Such
things as beginning and ending on time, returning phone calls in a timely
manner, announcing vacations and absences with adequate warning, and
a clear cancellation policy are all reassuring. Looseness of these technical
boundaries may be interpreted as a sign of potential boundary crossings or
violations from the patient’s perspective. It is also important for the therapist
to protect his or her boundaries, including the setting of appropriate limits.
This also reassures the patient that she will not be able to easily harm the
therapist. It is also good modeling for the patient. As in any psychotherapy,
the therapist must be trustworthy. People who have been betrayed through-
out their lives are sensitive to issues of honesty and dishonesty. Thus, with
chronically traumatized patients, Ben Franklin’s aphorism, “Honesty is the
best policy” (i.e., it is better not to lie to the patient), is generally appropri-
ate. The importance of admitting a mistake is crucial—even if it hurts the
therapist’s self-esteem to admit a mistake or a failing.
Complex and difficult-to-manage transference and countertransfer-
ence patterns constantly emerge (Davies & Frawley, 1994; Loewenstein,
1993; Pearlman & Saakvitne, 1995). Traumatic transferences, in which
the patient experiences the therapist as the abuser, are common (Herman,
1992; Loewenstein, 1993; Spiegel, 1986). It is important to be aware that
traumatic transferences may be hidden. While the therapist may be in overt
communication with a trusting host (the part who is usually in executive
control), who is trusting, beneath the surface some parts of the person who
have not made themselves known expect to be betrayed and abused. For
example, in the case of a recent new patient, following a pleasant and reas-
suring discussion with the part usually in executive control, suddenly a
child alter emerged and asked if I intended to abuse her. The result was that
we then talked about her fears. It turned out that she, like many chronically
traumatized patients, had in the past been abused by one of her therapists.
(See Kluft, 1990, for a description of the “sitting duck syndrome.”)
It is often useful to ally with the patient’s distrust. As Kluft (1993b) said:
Rather than confront, explain, or reassure in response to the patient’s

mistrust, I encourage my patients to value mistrust as an important
warning sign. I indicate that since the patient has been hurt quite deeply,
the development of apprehension, suspicion, and misgiving are natural

and essential protections against further traumatization. (p.â•¯149)
The language one uses is important; for instance, using words like
“parts,” or “different ways of being you,” instead of “alters” is helpful.
Chefetz’s (2005a) felicitous phrase, “different ways of being you” (p.â•¯661),
is both nonchallenging and inviting. It is also an integrative metaphor that
allows for the individuality of parts in the context of the whole person.
The Establishment of the Treatment Alliance

With Multiple Different Dissociated Self-States
An important aspect of the development of trust in Phase 1 work is the
establishment of the treatment alliance, which when working with DID
can be quite complicated. One should be prepared for such events as a new
patient telling you one day about horrifying parental abuse, only to tell you
in the following session or sessions that her parents were wonderful, and she
was a very bad child. This then becomes an opportunity for the therapist to
explore whether “different parts of you may feel differently about that.”
It is ideal to establish an alliance with as many parts as possible in the
beginning stages of treatment. However, one must also be sensitive to the
strong possibility that the diagnosis has not yet been accepted. Therefore,
the therapist should be careful not to put pressure on dissociative parts who
are not ready to come forward. Speaking to dissociative parts should be
done in a way that does not feel over-exposing or shaming to the patient.
One way of doing this, unless otherwise indicated, is to address comments
to the system as a whole. This avoids putting any particular part on the
spot and may soften the patients’ reluctance to expose their multiplicity.
Safety Agreements
Because patients with complex PTSD and dissociative disorders are espe-
cially vulnerable to suicidality and dangerous behaviors, safety agreements
are helpful for maintaining safety in DID trauma treatment. Often, safety
agreements will include a series of constructive alternatives to self-harm
to be taken if the patient begins to feel endangered. The agreement may
spell out a hierarchy of actions, such as reaching out to supportive others,
various forms of self-soothing such as relaxing activities, relaxation exer-
cises, or exercise itself—all of which are to be implemented before calling
the therapist or going to the emergency room. This supports patient self-
responsibility and avoids putting the therapist in the position of rescuer
(Courtois, 1999). Safety agreements also usually include calling the thera-
pist and being in voice contact with the therapist before any action is taken.
The topic of safety agreements is discussed in more detail in Chapter 14.
Psychoeducation
Psychoeducation contributes to the development of the treatment alliance,
but it is often useful throughout the treatment. For starters, the patient needs
to be informed about how treatment is expected to progress, including that
treatment is likely to bring about emotional pain in its course, and that
the patient and parts of the patient may become intensely angry or disap-
pointed with the therapist at some points in the work. Psychoeducation may
include information regarding what trauma is and how it has an impact on
the personality, how dissociation works, and why the person has developed
dissociative problems. Patients with complex trauma may at times develop
extreme reactions to something the therapist has said or not said, done or not
done. It is often wise to anticipate this in advance, and perhaps to note this
anticipation in initial communications with the patient. For example, one
may say something like, “It is likely in our work together, there will be a time
or times when you will feel angry with me, disappointed with me, or that I
have failed you. We should expect this and not be surprised if and when it
happens, which it probably will.” It is also vital to emphasize to the patient
that despite the diagnosis and experience of dividedness, the whole person is
responsible and will be held responsible for the acts of any part.
Other aspects of psychoeducation include relaxation and breathing tech-
niques, grounding techniques, and methods of self-soothing. Breathing
exercises often facilitate a mood of calm and focus. Because unmodified
instructions to do deep breathing can induce hyperventilation, I prefer
breathing exercises that require mental focus and discipline as the person
performs and notes inhalations and exhalations. One exercise that I like
is taking a breath in to the count of 4, holding for 4 counts, breathing out
for 6, holding for 2, and repeating a number of times. Often, patients may
indicate that just breathing makes them feel silly, and they doubt it will do
any good. In such cases, I may volunteer to do the breathing with them or
just ask them to try it. In one case, I invited a new patient, who had had
multiple hospitalizations and was currently on many medications, to try
a simple breathing technique. Initially, she pooh-poohed it, saying, “I am
someone who has taken very heavy medication. A breathing technique will
not touch the problems I have.” To my great pleasure and surprise, the
next day she called and left a message for me, saying that she was amazed
that the breathing techniques worked, and she felt much less anxious.
Conscious breathing is also grounding as it creates contact with the body
and the senses. In addition, the buildup of carbon dioxide in the blood-
stream, along with inadequate oxygen that occurs with shallow breathing,
potentiates anxiety, which is relieved by the deeper breathing.
Because chronically traumatized patients may lose touch with their sur-
roundings when anxiety is evoked, methods of grounding are helpful. In
addition to breathing, these may include turning on the lights, stamping one’s
feet, touching one’s face, or intently looking around the room to mentally
describe the objects in it. Steven Gold’s book, Not Trauma Alone: Therapy
for Child Abuse Survivors in Family and Social Context (2000), is an
excellent resource, as is Chu’s Rebuilding Shattered Lives: The Responsible
Treatment of Complex Posttraumatic and Dissociative Disorders (1998).
In addition, see Boon, Steele, and Van der Hart’s Coping With Trauma-
Related Dissociation: Skills Training for Clients and Therapists (2011).
Getting to Know Alters and Working

toÂ€Improve Internal Communication
Another important aspect of the initial phase is getting to know the dis-
sociative parts of the person and their internal structuring (i.e., their rela-
tionships and interactions with each other on the inside). However, this
should be done without undue anamnesis. As Kluft (2000) stated: “It is
neither necessary nor advisable to bring all parts into co-consciousness all
the time early in treatment. There is considerable virtue in allowing per-
missive amnesia for traumatic material until given personalities are able to
tolerate the material under discussion” (p.â•¯272). This is not always easy to
do. For example, early in treatment, Janice, introduced in Chapter 1, began
to become acquainted with some of her parts. Despite the fact that some
of this information had emerged in her hospitalization, she was amazed
at the result of our work with her parts in therapy and became enthusias-
tic, especially as her seemingly always known phrase for herself, “the We
of Me,” now made sense. However, as more parts emerged, they shared
their intense sadness and grief with Janice. Since she had built so much
of her public, as well as her subjective, life around being cheerful, we had
to quickly slow this process of meeting new parts as the experience was
becoming upsetting and almost overwhelming to her.
Other ways of becoming acquainted with the parts in the initial phase
are mapping of the system and journaling, by which parts make entries that
are then available to other parts to read. Mapping is discussed in greater
detail in Chapter 10.
Phase 2: Working With Traumatic

Memories and Enabling Traumatic
Memories to Become Narrative Memories
The second phase of treatment involves working directly and in depth with
traumatic memories (ISST-D, in press). Herman (1992) stressed how trauma
deprives the survivor of a sense of control over her life and of connectedness
with others: “Recovery, therefore, is based on the empowerment of the sur-
vivor and the creation of new connections” (p.â•¯133). The purpose of PhaseÂ€2
memory work in mitigating the trauma, then, is to bring more control over
one’s life and increased connection with other parts of the self and other
people. This is best accomplished by reducing dissociative barriers between
parts so that traumatic memory may become continuous narrative memory.
As the traumatic memories become more resolved and integrated, they are
less likely to derail the person via sudden intrusions or switching.
Contraindications to initiating this second phase of trauma work include
severe limitations of the patient’s capacity for reflection and self-control,
pervasive psychosis, malignant regression, extremely unstable lifestyle,
ongoing abuse, and uncontrollable rapid switching (Van der Hart et al.,
2006). For those patients who have the skills and the resilience to tolerate
work on memories, an important proviso remains that it is retraumatizing,
rather than helpful, to the patient simply to relive a traumatic memory. Any
reexperiencing is best done in a protective context that links the past ter-
rors with current safety and that therefore indicates the past horrors are, in
reality, over. The patient’s communication must be in the context of safety
and acceptance: The other listening person is a secure base and a safe place.
In this way, safety is connected with the traumatic event.
This section has three parts: specific ways of working with traumatic
memories; reconceptualizing abreaction; and understanding the central
conflict. While they are interrelated, I deal with them separately.
Approaches to Working With Traumatic Memories

Phase 2 work involves working with traumatic memories. How this work
is understood depends on one’s theoretical model. Core aspects of this
work have been described in different terms, ranging from “abreaction,”
to “guided synthesis,” and “realization of traumatic memories” (Van der
Hart et al., 2006, p.â•¯322). Kluft (1993a), Fine (1993), and others emphasize
abreaction. Herman (1992) emphasizes remembrance and mourning. Van
der Hart et al. (2006) emphasizes synthesis and calls this phase “overcom-
ing the phobia of traumatic memories” (p.â•¯319).
Although traumatic memories will emerge spontaneously in the treat-
ment as a result of organic forces within the system, work with these mem-
ories is often carefully planned by the therapist in collaboration with the
patient. The purpose of planned work with traumatic memories is to avoid
uncontrolled eruptions of triggered affect and behavior that may be dam-
aging and unnecessarily painful to the patient. However, it is important
to be aware that we cannot always plan for work on traumatic memories
in an ordered and systematic way, for intense affect will emerge spontane-
ously. As Chefetz (1997a) maintained: “The abreaction of intense affect is
not a goal of psychotherapy; it is an inevitable concomitant experience in
the history of persons with posttraumatic histories, physical and/or sexual
abuse, neglect, and related intense experiences” (p.â•¯209). The primary
issue is that the therapist know how to handle it when it does emerge or
erupt (Chefetz, 1997a).
Planned approaches that reduce the dangers of triggered affect from
becoming overwhelming often involve working with memories in a sys-
tematic fashion, explicitly implementing certain titration strategies to keep
the affect about the memories manageable (Fine, 1993; Kluft, 1994, 1998,
1999b; Putnam, 1989; Ross, 1989; Van der Hart et al., 2006). This may
include use of fractionated abreactions (Fine, 1993), which involves delib-
erately dividing the memories into sections so that only pieces of the entire
memory are experienced at one time as a way of protecting the patient from
becoming overwhelmed.
In addition to fractionating techniques, muting techniques are useful for
a therapist to know as a way to help with the patient’s frightening memories
that emerge. Muting techniques include such things as suggesting to the
patient that she imagine she has a remote and is watching the memories on
a television screen. With the remote, he can turn the sound down, slow the
action, drain the picture of brightness, or make the images smaller so that
they seem farther away; and he can also turn the television off. Although
the image of the remote is visual, the same concept can be applied to a vir-
tual affect dial or rheostat, perhaps with a dimmer switch. The patient may
use this to lower or even turn off affect that is too intense. Sometimes, ther-
apists will ask the patient to imagine a picture in a picture, or split screen,
in which a frightening memory is playing on one screen while on another
screen is a calming scene (Twombly, 2000). The calming screen can be a
resource when the frightening memories feel too painful to bear in their
full intensity. These help to give the patient a sense of control. Incompletely
processed disturbing memories and feelings that were worked on in the ses-
sion may be left in a virtual locked vault in the office until the next session
(Kluft, 1989). These metaphors are generally compelling to patients with
DID because of the pervasiveness of the trance logic. Finally, in addition to
the above, to decrease the danger of retraumatization as well as fear of it, it
may be suggested to the patient that intense traumatic affect may be shared
across dissociative boundaries slowly over time (Kluft, 1989). For example,
one of Kluft’s metaphors is “the slow leak” (1988).
The Relational Perspective:

Reconceptualizing Abreaction
Abreaction is both a pivotal and a highly controversial concept with
respect to Phase 2 work. As indicated at the beginning of this chapter,
phase-oriented treatment is so important because patients with complex
trauma and dissociative disorders are highly vulnerable to triggering and
to spontaneous abreactions, which may carry a risk of retraumatization.
Furthermore, as indicated, in some of the mental health literature from
early psychoanalysis to new age therapy, including primal scream ther-

apy literature (Janov, 1970/1999), there has been much emphasis on the
expected healing benefits of abreactions. The idea behind abreaction is
that emotional discharge of affects connected with traumatic memories is
healing. But, is it so? Or, if it is so, how do we understand it? What does
abreaction mean, anyway?
In their well-known and relied-on dictionary of psychoanalytic terms,
Laplanche and Pontalis (1973) defined abreaction as follows:
An emotional discharge whereby the subject liberates himself from the

affect attached to the memory of a traumatic event in such way that this
affect is not able to become (or to remain) pathogenic. Abreaction may
be provoked in the course of psychotherapy, especially under hypnosis,
and produce a cathartic effect. It may also come about spontaneously,
either a short or a long interval after the original trauma. (p.â•¯1)
The terms abreaction and catharsis have often been used interchange-
ably. They are distinguished only in that abreaction refers to mental reliv-
ing, whereas catharsis refers to bodily physical expression (Cameron &
Rychlak, 1985). My primary disagreement with the definition provided
by Laplanche and Pontalis (1973) has to do the idea of discharge, which
derives from a one-person psychology as well as from quasi-neurological
(Van der Hart & Brown, 1992) 19th-century models of psychics and neu-
rology. Importantly, these models of mind do not encompass a two-person
psychology or a multiple-self perspective.
This idea of discharge or release, with all of the ambiguities in language
and conceptual interpretation, is a source of confusion that continues to
plague us. Understandably, patients and therapists may often endorse the
wish to “get it all out,” as if that will simply make the problematic feel-
ings go away. Understandably, the dissociative parts who hold these terrible
memories are shunned by the rest of the system because they are protecting
the rest of the system from memories that have been unbearable. Thus, the
part who is usually in executive control, and other parts who have been
shielded from these affects and memories, may often wish they would just
go away. But then, one might ask, where would those affects go? It is an
illusion to think that these affects are actually disposed of. To the contrary,
they can only be redissociated. The therapeutic goal is for the affects and
memories to be shared across dissociative barriers, so that, in this way, they
become narrative memories—that is, memories that are accepted markers
of past experience, that are recalled as part of a continuous narrative, and
that can be tolerated and mourned. If the affects were simply gotten rid of,
the memories could not be mourned, which is a core part of healing.
In contrast to older, solely cathartic concepts of abreaction, I suggest
that it is not the discharge of tension, the getting it out, that is helpful,
but the communication of emotion and memory to another person (i.e., a

two-person psychology)—and other parts of the self—that is healing. In
the most literal sense, tension refers to bodily tension. The body tension
relief aspect of abreaction is not unimportant, but it is intertwined with
the emotional, including intrapersonal and interpersonal, meaning of the
situation and occurs in large measure as a result of these.
As opposed to the idea that one unified person just gets rid of all the bad
stuff, I propose that the therapeutic action of abreaction derives from the
trusting and sharing of affect and knowledge among parts of the self and
with another person. Here, the therapist’s compassion and sensitivity to
the patient’s pain serves as a model for the kind of response that alters can
learn to give to each other. Even without specific reference to DID, I find
that this multiple-self perspective is the most promising for trauma work. A
two-person psychology applies not only to the genesis of intrapsychic diffi-
culties but also to their resolution. A multiple-self perspective is compatible
with the idea that, in a general sense, integration, or synthesis, is a goal in
the healing of trauma, as in psychotherapy in general.1
Chefetz (1997) observed that affect is the centerpiece of experience. By
this, he meant that affect is the most potent contextualizer of experience,
and that without knowing the emotional dimension of experience, personal
narrative may remain incoherent or bereft of meaning. The sharing of dis-
sociated affect between parts of the self and between persons may feel like
a release or discharge because it is no longer being kept locked down and
hidden from the part usually in executive control, from some other parts of
the self, and from other people. However, in my view, it is more properly
understood as a kind of sharing that is intersystemic and interpersonal.
The expressed affect does not go anywhere but becomes part of a person’s
accepted and conscious repertoire of experience. The formerly unbearable
affect is now tolerable as an aspect of narrative memory. Chefetz (1997)
provided a more precise definition of abreaction: “the verbal or non-verbal
expression of intense affect, which when associated with a coherent narra-
tive of experience, may provide relief of chronic anxiety states” (p.â•¯203).
Abreactive experiences can be powerful and healing. The therapist
should bear in mind that intense affect may be expressed, and unusual
behavior may be enacted. People may scrunch their bodies, flail about, roll
into a ball, roll on the floor, and so on. The healing effect of abreactions
derives from strangulated affects (Breuer & Freud, 1893–1895a) becoming
expressible and from previously untellable experiences being brought to
the light of day in the context of an interpersonal environment that allows
these to feel real. In all phases, but especially in Phase 2, the affective com-
munication is often intense in abreactions, and it may be painful for the
therapist to hear and witness.
The Central Conflict: Silencing Versus

the Eagerness to Be Known
When working with traumatic memories, it is useful to bear in mind what
I call the central conflict. An advantage for using the concept of the cen-
tral conflict for doing memory work is that it is not mired in a one-person
psychology. A key problem with solely cathartic techniques (i.e., “getting it
out”) is that they do not take into account the complexities of the intraper-
sonal and the interpersonal systems.
As the integrative work of sharing painful memories and affect across
more parts of the system occurs, a central conflict often emerges: The parts
who hold the unbearable painful affect are often desperate to share and
express their pain and to be known. And, they want to do it now. Other
parts are equally desperate to keep them silent. This means that some parts
feel that they cannot wait. Moreover, not having formulated that this is
how they feel, they cannot easily examine their impulses to make everyone,
including the part usually in executive control, other parts of the system,
and the therapist, acquainted with it immediately. This may occur in the
form of flashbacks, terrifying emotions, and the like. At the same time,
other parts, also not having had a chance to formulate their feelings and
thoughts, impulsively say, “Never!” The gradual resolution of this conflict
enables mourning for the recognition of terrible traumatization as well as
mourning for the losses of previously needed psychic illusions. (I must note
that this model of the central conflict is oversimplified. For example, parts
holding painful memories often feel that it is their job to contain them.)
It is important to be alert and to become informed regarding what knowl-
edge may be too much for the usually presenting part or other dissocia-
tive parts to handle. Often, dissociative parts will tell me spontaneously if
they think the usually presenting part can or cannot handle certain knowl-
edge. Out of respect to the likelihood that they may be correct as well as
out of safety concerns that might arise from a part feeling betrayed, I will
often ask a dissociative part who has shared information with me if it is all
right if I share this with the usually presenting part. However, such mat-
ters should always be handled judiciously. Safety concerns can work both
ways. Sometimes, the usually presenting part needs to know of imminent
threats and unresolved difficulties that may have been communicated by
another part who does not want the usually presenting part to know about
them (Van der Hart et al., 2006). In such a case, one may request that the
dissociative part share the information with the usually presenting part
of the person. It is important for the clinician to strive to avoid becoming
part of a reenactment of a neglectful, unseeing parent who stands idly by
(Davies & Frawley, 1994) and allows the child to be harmed. Such issues
can be complicated. For example, there may be sexual reenactments by
adolescent parts who want to keep these behaviors hidden from adult parts
in the system. In the interests of general safety, the part who is usually in
executive control must know. However, such information may need to be
sequestered from some child parts. Thus, negotiating this conflict about
sharing information and affect, in which, in simplified form, some parts are
desperate to share and express their pain while others are equally desperate
to keep them silent, requires careful clinical judgment.
Emotional safety is a pertinent matter: The parts need to feel safe enough
to share, knowing that their concerns about other parts knowing are
respected. However, it is not always easy for the therapist to keep so much
in mind. On one occasion, a tough, protective female part, who always
clenched her fists, had told me about the patient’s brutal abuse by an uncle
when she was a little girl. The host did not know about this abuse, and this
part had told me the host did not and should not know yet. Shortly there-
after, I was speaking to an adolescent part who had some coconsciousness
with the host and forgot myself, making reference to the abuse. Suddenly,
the tough, protective female part who had originally informed me of the
abuse appeared before me, fists clenched and clearly annoyed with me for
exposing the adolescent to information prematurely. The switch happened
so suddenly that the adolescent part did not hear what I had said.
In the approach, I describe, the traumatic memories and affects are
revealed and shared in dialogue between separate dissociative identities and
the therapist—and among each other. This involves not only a two-person
psychology but also a multiple self or multipart dissociative psychology. It
includes collaborating with the system to work on memories in an organic
way. This is further complicated and aided by the multiple self-states of the
therapist. As Bromberg (1998) noted: “Therapeutic action depends on the
freedom of the analyst to make optimal use of dissociation as an interper-
sonal process that includes the analyst’s dissociative experience as well as
the patient’s” (p.â•¯288).
Often, dissociative parts will let me know, sometimes in oblique ways,
when the patient is ready. In the work that Janice and I have done together,
there was a time that the parts had alluded to some extremely horrifying,
demeaning, and sadistic abuse the patient had suffered as a child at the
hands of some boys, in what she referred to as the Torture Room. They
also alluded to a mute, ugly little girl called The Little Girl in the Torn
Dirty Slip, who had been locked up and was not allowed to speak. When
I asked why she was forbidden to speak, I was told that it was because the
knowledge of her story would be too much for the part who is usually in
executive control to handle. These allusions had gone on for a long time,
and I kept getting reports that The Little Girl in the Torn Dirty Slip would
not be allowed to come out, despite my requests and statements of concern
for her: She was “locked up” and forbidden to speak. As the sessions pro-
gressed, however, it became clear that parts who were out in the session
were telling a hidden part to “shut up.” The following is part of a session
in which this previously off-limits aspect of her unspoken memories begins

to be revealed; here, one of the dissociative parts (DP), rather than the part
who is usually in executive control, is speaking:
DP: [Turning her head to the right as if speaking to someone.] Shut up!
Me: Why are you telling someone to shut up? Who are you telling to shut up?
DP: The Little Girl in the Dirty Slip.â•¯She is supposed to be locked up.
Me: What does she want?
DP: She wants to come out and tell you all about it. But if she knows what’s good
for her, she’ll stay where she is and keep her mouth shut. Nobody else wants
to know about her pain.
Me: Why does she need to keep her mouth shut and stay put?
DP: Because that’s where she belongs, and it is our job to keep her there. There
are others, the soldiers. I don’t know what they’ll do if we let her out.
Me: How do you feel about keeping her locked up?
DP: Actually, I feel sorry for her. She’s not a bad kid. Sometimes she cries, and I
wish I could help her, but it is my job to keep her where she is.
Me: So you actually have sympathy for her?
DP: Yeah, I gotta go now.
Me: [It was time to stop this conversation because the session will soon come to an end.] I
just want to say before we stop that I am thinking about how The Little Girl in the
Torn Dirty Slip feels, even though she can’t talk, and I will be thinking about her. I
am aware of her pain and how awful this is for her.
In a later session, The Little Girl in the Torn Dirty Slip did come out and
speak to me. She told me a horrifying story. This story also enabled us to locate
the traumatic events in time and place, and it gave us more information about
what was going on and not going on with the parents that this was allowed
to happen. The part usually in executive control was informed and became
coconscious about the event. Nobody crumbled. But, the system had time to get
used to the idea that this part wanted and needed to share her story. The alters
whose job it was to keep her locked up had some time to think about whether
this was really necessary and whether it was what they really wanted.
This vignette illustrates a way of working with the central conflict and of
achieving a successful integration of memories.
Phase 3: Reconnection With Everyday Life:

Identity Integration and Mourning
As Van der Hart et al. (2006) noted: “There isâ•ƒ.â•ƒ.â•ƒ.â•ƒthe persistent myth
that merely integrating traumatic experiences is sufficient for overcoming
traumatization. In fact, Phase 3 may contain some of the most difficult

work yet” (p.â•¯337). In addition, third-phase work may reopen second- and
first-phase issues. As a result, vigilance for suicidality should be main-
tained, even in Phase 3.
The third phase of treatment resembles in many ways work with less-
traumatized and less-dissociative persons. This makes sense because by the
third phase, the patient has gotten better and is less dissociative and less
prone to react to triggers of past trauma. However, there are important
differences. Because the dissociative personality organization has entailed
avoidance of many life issues, the healing of dissociation can leave the
patient with many previously unconfronted but daunting issues. As patients
shift their focus from their traumatic pasts to their current lives, many core
beliefs emerge and need to be reexamined. These may include such things
as continuing to feel and believe that one is worthless, continuing to believe
that comfortable intimacy is not possible, facing existing unhappy relation-
ships and work problems, as well as learning some of the “blueprints” for
adult life for the first time. Perhaps even more painfully, these core issues
also include facing the narcissistic personality structure that is often the
residue of the dissociative personality structure (Howell, 2003; Schwartz,
1994, 2000). As Kluft has frequently said, following work on the problems
posed by DID, patients increasingly must deal with the everyday problems
of “unitary personality disorder.”
Conflicts about getting better are also likely to surface in the third phase
of work. These conflicts may include fears of becoming independent and
losing the therapist or having to become completely self-reliant (Van der
Hart et al., 2006).
The profound mourning that comes with assimilating painful memories
in Phase 2 continues in Phase 3, but with more finality. The quality of grief
work continues to mature. Rage about the recognition that life is not fair
and that one has suffered many extreme injustices may eventually become
mature acceptance. Gradually, patients begin to relinquish the role of the
victim. Chu (1998) recounted an anecdote one of his patients told to him:
I once read a story about a man who had been a political prisoner. For
years he was kept in a cell that was 5 feet wide and 9 feet long, sepa-
rated from anyone else. His routine was the same each day—he got up
at 6 each morning, ate twice a day, and was allowed to bathe once a
week. The rest of the time he spent walking up and down the 9 feet of
his cell, back and forth, back and forth. As an old man, after almost
30 years, he was released and went to live with relatives. For the rest of
his life, he got up at 6 each day, ate twice a day, bathed once a week,
and spent his time walking back and forth in his bedroom—up 9 feet,
and back 9 feet. I realize that’s what I’ve done most of my life—living
in captivity although I’m no longer a captive. I now know I don’t have
to stay in my cell. My life has been ruled by fear, but I finally feel as
though I can escape and be free. (p.â•¯89)
Note
1. As I indicated at the beginning of this chapter, in some of the mental health lit-
erature from early psychoanalysis to new age therapy literature, there has been
much emphasis on the expected healing benefits of abreactions. For instance,
“primal scream” (Janov, 1970/1999) therapy was popular in the 1970s.
This idea was extended to interpersonal relationships. Soon, however, it was
noticed that indiscriminantly venting one’s feelings toward other people was
often destructive rather than helpful to relationships and therefore ultimately
destructive to the person venting.
In an evaluation of abreactive techniques used in World War II, Horowitz
(1976/1986) wrote the following:
Abreaction led to more abreaction, to seemingly endless accounts.â•ƒ.â•ƒ.â•ƒ.
Abreaction may relieve anxiety, but this effect can be non-specific and tran-
sient. To obtain durable improvement, it seems necessary to understand
the individual patient, the meaning of the experienceâ•ƒ.â•ƒ.â•ƒ.â•ƒand to revise dis-
crepancies in self-object representations and other organizing constructs.
(p.â•¯119)
I have suggested that the reason that “abreaction led to more abreaction, to
seemingly endless accounts” is that the expected benefit was misunderstood as
“getting rid of it” as opposed to integration.
Some aspects of the problematic attitudes regarding the indiscriminant use
of cathartic and exposure techniques in inappropriate circumstances trace back
to Breuer and Freud, whose writings contained the germ of the controversy: In
Studies in Hysteria, “Preliminary Communication,” Breuer and Freud (1893–
1895a) linked psychological trauma and dissociation. The basic strategy described
by Breuer and Freud can be understood within the dissociative framework.
In this treatise, Breuer and Freud (1893–1895a) compared the memory of
the trauma to a “foreign body which long after its entry must continue to be
regarded as an agent that is still at work” (p.â•¯6). The reason that the traumatic
memory acts as a foreign body is that it has been isolated from the person’s
other memories. Noting that hysterical reactions corresponded to traumatic
memories, they said, “It may therefore be said that the ideas which have
become pathological have persisted with such freshness and affective strength
because they have been denied the normal wearing-away processes by means
of abreaction and reproduction in states of uninhibited association” (Breuer
& Freud, 1893–1895a, p.â•¯11). Breuer and Freud further noted that when the
isolated “strangulated affectâ•ƒ.â•ƒ.â•ƒ.â•ƒcan find its way out through speech” (p.â•¯17),
it becomes associated with normal consciousness, and the symptom recedes.
Breuer and Freud stated that while they had not found the etiology of hysteria,
their new discoveries had yielded the mechanism of hysterical symptoms—and
their cure. The cure was remembrance and abreaction. In short, they found that
symptoms disappeared when the memory and its affect could be discharged
(abreacted), expressed in words, or both.
With regard to this, Freud emphasized the discharge of affect, while Breuer
emphasized the verbally communicative aspect (Van der Hart & Brown, 1992).
Dell (2009d) noted that the “Preliminary Communication” reads between the
lines like an argumentative dialogue between Freud and Breuer. According to
Hirschmuller (1978, as cited in Van der Hart & Brown, 1992), who was Breuer’s
biographer (and importantly, his biographer with respect to the famous case
of the highly dissociative Anna O.), the “talking cure” did not require Anna
O. to discharge affect. Citing Hirschmuller, Van der Hart and Brown (1992)
observed that in his initial descriptive notes Breuer did not stress emotional
expression. According to these authors, Breuer emphasized verbal, more than
emotional, expression of feelings, and Freud added emotional expression in
1895 in Studies on Hysteria.
The problem, according to Van der Hart and Brown (1992), arose with
Freud’s introduction of the constancy principle, according to which
the nervous system endeavors to keep constant something in its functional
condition that may be described as the “sum of excitation.” It seeks to
establish this necessary precondition of health by dealing with every sen-
sible increase of excitation along associative lines or by discharging it by
an appropriate motor reaction. Starting from this theorem, with its far-
reaching implications, we find that the psychical experiences forming the
content of hysterical attacks have a common characteristic. They are all of
them impressions that have failed to find an adequate discharge. (p.â•¯130)
The idea of catharsis (“getting it out”) in abreactive treatment followed
from this “quasi-neurological model” based on the constancy principle. The
implications of this model are different from the implications of “working
over” and sharing between parts. While these two models of treatment are
different, they are not always distinguished. According to Van der Hart and
Brown (1992), the “key problem here is to relate the latter abreaction-catharsis
model based on the discharge of excitation and the principle of constancy with
the association-reintegration therapeutic model based on the concept of dis-
sociation” (p.â•¯131).
In contrast to the quasi-neurological concepts of abreaction, Van der Hart
and Brown (1992) emphasized the importance of integration, or resynthesis, in
the healing of trauma. Van der Hart and Brown were emphatic that “since Janet,
it has been repeatedly demonstrated that in most cases of posttraumatic stress,
particularly chronic disorders, treating the traumatic memories alone (whether
by abreaction or by any other approach) is insufficient” (p.â•¯136). Integration of
memories, followed by their acceptance and mourning, is needed.
Chapter 10
Facilitating Coconsciousness
and Coparticipation
in the Treatment
Paradoxically, the more one is prepared to see the DID patient as an

aggregation of alters that is capable of coordination and cooperation,
the more effectively one can approach the DID patient as a single indi-
vidual. Far from reifying the alters, it usually erodes their separateness
quite aggressively.
Kluft (2000, p.â•¯264)
Coconsciousness refers to two or more alters sharing the same mental,

affective and/or perceptual space at the same time. Each may be aware of
the other’s presence and have ongoing memory of the situation. This does
not mean, however, that they are behaving as one. Generally, one part is
in executive control, while one or more others are watching, listening, and
thinking about what is happening. The achievement of coconsciousness is
a necessary step toward greater harmony and cooperation in the system, as
well as toward integration.
By coparticipation in the treatment, I mean participation in treatment on
a level of not only one person but also multiple subjectivities. While not all
of the alters necessarily see themselves as participants in treatment, the goal
is to enlist them in the process. Encouraging the different parts to partici-
pate together furthers the treatment in many ways:
• More information essential to healing and enhanced functioning is

shared among dissociative parts.
• Dissociative barriers are lessened.
• The different parts feel less isolated, exiled, or unwanted as they engage
more in communication with each other and with the therapist.
• Functioning is more effective when relevant information and affect
are available to the one in executive control.
• Switching is exhausting and derailing.
Achieving coparticipation is a formidable task for the patient, and fos-

tering it can be formidable for the therapist as well. The stability of the
187
system, unwieldy though it may be, depends on the dissociative structure

that developed to protect the person’s survival and sanity. This means that
many parts may enter treatment with a substantial commitment to the sta-
tus quo in the system. The psychodynamics of this status quo are intricate
and usually difficult to decipher completely. Multifarious issues involve
(a) commitment to hiddenness, (b) complicated but often minimally suc-
cessful efforts at affect regulation, and (c) variations on aspects of self-
punishment. Parts who have been hidden want to remain hidden because
so much shame, terror, and realistic circumspection have been associated
with the multiplicity being found out.
Often, there are parts who torture the host or others on the inside because
they believe this is necessary for the person’s safety and protection. In the
original family environment, often it was not safe for the patient to express
feelings of dissatisfaction or anger. In fact, in environments in which poten-
tially deadly parental rage could easily be set off, the expression of true
affect had to be extremely curtailed. As a result, the system has depended
for its safety on the inhibition of expression or the exclusion from con-
sciousness of powerful overwhelming affects, such as terror and rage.
The system works in a certain way to contain affects and thoughts that
feel unbearable and that were at one time unexpressable. When the person
is no longer in an abusive environment, this dissociative organization is no
longer necessary or efficient. Information and affects that may be relevant
to a given situation are often unavailable to the part of the personality in
executive control. It would be so much more efficient if this part could, for
instance, instead of dissociating, access anger and the ability to say “no,”
when the patient is being abused. For instance, when Janine’s husband was
verbally abusive to her, she was unable to access appropriate feelings of
anger and self-defense. The anger was held by another part who had sel-
dom seen the light of day because it would have shattered her belief in her
parents’ goodness as well as having gotten her into a great deal of trouble
as a child. As a result, Janine maintained the dissociative barriers, with the
result that current abuse caused her to switch into a helpless child state. To
say the least, this did not help her to resolve this situation; indeed, it only
rewarded the sadism of the abusive husband.
For coparticipation of parts to occur, the therapist must be willing to
acknowledge the subjective existence of all of the dissociative parts, that is,
the alters. As Richard Kluft (Kluft & Fine, 2009) noted, not to acknowl-
edge their presence is simply rude. Since alters are already present with
their own experiencing and acting subjectivities, there is no danger of the
iatrogenic creation of these alters via acknowledgment of what the patient
has already presented.
One must be aware in the therapy session that other parts who are behind
the surface and not currently out can be and often are listening. When
one sees the evidence of an alter coming through, it is often, although not
Facilitating Coconsciousness and Coparticipation in the Treatmentâ•… 189
always, helpful to acknowledge this. When patients become comfortable

with the idea that they have dissociative parts, it is helpful to encourage the
participation of other parts who are listening to share their observations
and concerns. However, all interventions must be done with extreme care.
It is generally helpful to ask the host and the parts if it is safe or if it is all
right with them to ask for information or to speak to a part who has been
hiding. Parts who are beneath the surface may be encouraged to share their
thoughts with the part who is out.
On a practical basis, the dissociative parts, as an aggregate, know much
more than the therapist knows, and they know more than the host knows. It
is important to develop an attitude of “We’re all in this together” (Itzkowitz,
2010). One important caveat: There are no “good” and “bad” alters. The
therapist must never play favorites. There is an important psychic reason
for the existence of each alter. They are all of equal importance.
In this chapter, I discuss some ways, by no means exhaustive, of inter-
acting with the dissociative parts to (a) facilitate coconsciousness and
coparticipation, (b) increase empathy among the parts, and (c) increase
knowledge across the system. This includes engaging directly with parts,
talking through, and asking inside. I also cover negotiating the time that
parts have out in the session, helping the parts to differentiate themselves
so that they are not so enmeshed in maladaptive patterns with each other,
the integrative benefits of paying attention to perceptions of the body, and
specific visualization techniques. The approaches I describe are not exhaus-
tive. I refer the reader to the Journal of Trauma & Dissociation for a wealth
of articles on this topic. What I consider most important is the principle
behind the “technique.”
Many therapists, including myself, who work with highly dissociative
patients find hypnosis and eye movement desensitization and reprocessing
(EMDR) invaluable tools in the work. In many of the vignettes that follow,
the operation of hypnotic processes is assumed. For more discussion of
hypnosis and EMDR, see the end of this chapter.
Interacting With Dissociative

Parts of the Person
There are several ways of interacting with dissociative parts of the person:
asking to speak with them directly, talking through, and asking the host
to ask inside.
Working Directly With Dissociative Parts

It can be helpful to engage with the different alters directly to find out how
they are feeling, what they need, and what problems they are experiencing
in the system and in life. Not only is this helpful to them individually in feel-
ing understood and in facilitating better adaptation to life circumstances
both inside and out, but also it enlists their support in what must be a
joint effort for the patient to get better. Most of the time, they will simply
appear naturalistically when they have something to communicate or when
they are triggered by something that has occurred in the session or in the
inner world. However, they are also often shy, reluctant, or afraid to come
forward. If it is relevant to the clinical work—for instance, a hostile alter
causing trouble or an alter behaving unsafely—the clinician may choose to
invite such an alter to come forward. If a dissociative part is having trouble
emerging, the clinician might ask the host to “step back” and to allow the
designated part to “step forward.” Sometimes, especially if it is the first
time, hypnosis helps parts who are otherwise unable to come forward to do
so. Generally, however, hypnosis is not required.
Sometimes, clinicians will schedule “roll calls” and call out the known
alters to see who is present (ISST-D Guidelines, in press). However, the cli-
nician should be respectful of the patient’s energy and the alters’ subjectivi-
ties and should not call them forth without clinical reasons.
Talking Through
Because switching takes energy and working with parts separately takes up
session time, it is often most effective to interact with the alters as an aggre-
gate or without a switch of executive control. One method of doing this is
talking through (Putnam, 1989). Talking through is a way of speaking to
parts who are more withdrawn and beneath the surface. The therapist in
effect talks past or through the host to those who are beneath the surface,
sharing thoughts, or giving important information. This is especially useful
when alters do not come forward or when there is limited time. For exam-
ple, if the therapist is going on vacation, the therapist may say, “Please,
everyone listen. I want to remind you that I will be away next week, and I
want to make sure every one of you who might be responsible for getting
here is aware of this. If any one of you has feelings about this, I really want
to know.” Often, there will be a part who will speak up with feelings of
abandonment. Or with a safety contract, the therapist talks through to
all of the alters after a contract has been negotiated with the host, saying
something like, “This is what has been agreed on. I am assuming that all
parts are in agreement with this unless you speak up now.”
Talking through is particularly useful when the dissociated self-states are
so locked down that they are unable to come forth (or the host may feel
unable to let them do so). For example, Anna’s parts are resistant to coming
forward. Rather than direct interaction, the best approach with her has been
talking through. She exhibits distinct changes in animation, facial expres-
sion, voice tone, and body posture when I am talking through to different
parts of her. For example, there is a part who calls himself Lucifer and often
engages in self-injury. While Lucifer has never come out directly to talk to
me, there have been times when I have made contact with Lucifer by talking
through, with good results. On one occasion when I was talking through to
Lucifer, suddenly Anna’s face changed dramatically, and she looked furious.
Then, just as suddenly, she switched back. The next day, she called and left a
message that she was completely without self-injury and felt wonderful—like
she had not felt for many years. She added that she hoped it would continue.
Because she almost always feels terrible, this was quite a change.
In one particular session with Anna, a child alter naively and delusionally
wanted to go to the ocean to be carried away by the waves to go back to her
mother, from whom she had been separated as a child, not realizing that
such an act would drown her. I talked through to her in the following way:
Me: [Talkingto little girl.] You have been through unimaginable horrible things.
Of course, you wanted to find a way to get home. That was very active
thinking—to be wanting to get out. But you know of course that you
can’t really get home that way. And you know that your mother is dead,
and the rest of your family is now here in the United States. Your mother
isn’t there anymore. The ocean can’t take you to your mother because
she isn’t there. It is proactive to be thinking of how to get home, though.
You have been through so much, and you are thinking so hard. But we
can’t solve that problem in Chicago now. We will work on it. Right now,
you need to take a rest. Is that okay?
Anna: [Her face shows much emotion. Talking to the little girl inside is bringing up
a great deal of emotion. Informed by the child self-state that had clearly been
touched, she, Anna says] I am so angry with myself.
Me: For what?
Anna: I should have figured out a way to get home.
Here, the result of talking through is like what Greenson (1967) has
described as the result of a good interpretation: It brings up more informa-
tion and more important material for the work of therapy. The seemingly
suicidal alter (who mostly just wanted to go home) was engaged, oriented
to the present, and then presented with her self-blame, which was another
problem to be handled, but it was far better than suicidality.
Asking the Host to Ask Inside

Another way of encouraging coparticipation is to encourage the host to
listen inwardly and to ask inside. Encouraging the host to help the parts to
become more coconscious and mutually participative on the inside helps
the host to do so on a regular basis on his or her own, continually break-

ing down dissociative barriers. Asking inside and listening inwardly may
become necessary when the alters do not want to come forth, but there is
clear evidence of their presence through some crisis. For example, some-
times in cases of self-injury, when the host seems not to be aware of any
precipitant and no other parts are volunteering any information, asking
the host to ask inside does have fruitful results, with either an alter offer-
ing information to the host or with a switch in which the alter comes forth
directly to discuss the situation.
Sometimes, asking the patient to ask inside brings forth images, words, or
fleeting thoughts. In the following report of part of a session, I asked Janice,
introduced in Chapter 1, to ask inside because it was a telephone session. I
use this example to show how asking inside can effectively bring forth much
inside information. However, please be aware that the session may sound a
little confusing because there were many parts contributing to the conversa-
tion. In addition, while the alter who is speaking is not the usual host, she is
functioning as host. The usual host did not speak during this session. Many
other parts of Janice did speak. Rather than arriving in person, Janice called
on the telephone to say she did not feel stable enough to drive:
Me: How are you? What is going on?

Janice: I’m just doing what has to be done. The Girl in the Torn Dirty Slip still
has a hold right now. She is very powerful. She doesn’t speak. She is in
their head.â•ƒ.â•ƒ.â•ƒ.â•ƒI was so frozen. I felt like the person I had been before is
just gone. [In other words, the presence of The Girl in the Torn Dirty Slip was
intensely felt by other parts.]
Me: What happened?
Janice: My husband was horribly yelling at me for about an hour. And then he felt
better, and said “Isn’t it wonderful being married to me?” I have been in
a fetal position. Someone said, “We have taken her to a place where it
doesn’t hurt.” Can you explain what has been happening to me?
Me: I don’t know. But let’s try this. This is on the phone. So, it is not the same
as in person, but can you ask inside of The Little Girl in the Torn Dirty Slip
what is going on now?
Janice: I think she wants—I keep hearing, “total power and control”—like she
does another’s bidding, although she feels the pain. I just had images of being
tied up—maybe in the torture room. I roll myself into a ball. All I want to
do is sleep. [The Girl in the TDS feels the pain of intolerable situations, and
memories of the torture room are brought forth.]
Me: Can you ask her what she is feeling?
Janice: Rage. She can’t scream. That’s why they took her mouth away—because
she screamed so much.
Me: When?
Janice: A long time ago. That’s when she learned to be quiet and invisible. She is
who they bring out to take it when I can’t take it anymore.â•ƒ.â•ƒ.â•ƒ.â•ƒShe says the
slip act is getting old. She wants to make an appearance in something else.
She is sick of the brown dirty slip.
Me: What would she like to appear in?
Janice: Something fresh. Whoa! She just said a lot. She is a combination of things—
scared and power—changing her clothes, a new dress.
In this session, The Girl in the Torn Dirty Slip was accessed and able to
speak through the part in executive control. In a later session, because of the
work in this phone session of asking inside, The Little Girl in the Torn Dirty
Slip, who had always been locked away, did finally come out in session to
share her story, a story that was horrifying, a story that most people would
not want to know if they had endured it. The result of her coming out in
many later sessions was that her suffering was much diminished; she became
aware that these events were in the past, that it was not her fault, and that
she is not bad, unworthy, or unlovable because of what was done to her. This
leads into another important issue, that of encouraging empathy among dis-
sociated parts of the self.
Helping Dissociated Parts of the Person

Have Empathy for Each Other
In the example just discussed, The Little Girl in the Torn Dirty Slip had
been kept in lockup because other parts feared that her telling her story
would fill them with dread and horror. They were afraid to feel what she
feels and to know what she knows. And, they have come to rely on this
system of defense, fearing that everything will fall apart if they do not. The
other parts who keep their distance from The Little Girl in the Torn Dirty
Slip, excluding and denigrating her, also rely on her denigration for some
of their self-esteem.
As one of the parts said in the phone session just described (the following
vignette is a continuation of the session just described but illustrative of a
different topic):
Janice: [Her voice deepens considerably as she switches.] That girl with the slip! She
is such a pain!—a downer! I am here to speak for myself.
Me: I understand you feel she is a pain.
Janice: When she was little, she crawled into the slip.â•¯Really gross! Gotta go now.
Me: Glad to talk to you.
Janice: [Voice higher.] I’m back now. That was too funny! That is exactly what I did
when as a little girl Janette [ Janette is both a child alter and what Janice was
called as a little girl.] had her “tired spells,” you know, when she couldn’t
move? I just could not go on anymore—could not do anymore.
Me: I have a suggestion. She said she wanted something fresh. Could you get
her something fresh?
Janice: That would really be self-care! I don’t know. I order from catalogues for
everyone else. I got a beautiful sweater for L, and etc. for others.
Me: And have you gotten anything for yourself? You could in those catalogues
get something for her and for yourself.
Janice: That would be in the same category. Self-care. I don’t think we can do that.
The whole structure is built a certain way. Best not mess with it! No. She
is the indentured servant. We all need a bottom of the heap, and she’s
ours. She has to stay there. None of us are [sic] going to go down there. I
have to stop talking now.â•ƒ.â•ƒ.â•ƒ.â•ƒ[ Janice switches back to the part who had called.]
There are a lot of soldiers here. [Sympathetically.] She has been locked up
her whole life. That is sad for her. She is happy being not locked up now. It
is sad, though. We are going to have to rebuild the structure again. This is
tiring for all of us.
In this example, by the parts talking with me, they were increasing cocon-
sciousness. As a result of clearly stating the reasons for the rejection of The
Little Girl in the Torn Dirty Slip, the parts who had rejected her began to
see that this was an unacceptable way to behave. By being free to express
their hostility and their fears, they became less hostile and less fearful. The
Little Girl in the Torn Dirty Slip is okay now, and she helps others inside
who have been exiled and denigrated.
Helping People With DID

toÂ€Remember: Asking Inside
Another important function of asking inside is to restore memory. Dennis,
introduced in Chapter 1, came into his session distraught and disoriented.
He had just made a deadline for his job despite the fact that his computer
had broken (his work required a computer). He had purchased a new com-
puter, but he did not know how he had done this. Some part of him had
done the work required for the job task, but he knew that he had not, and
he did not know who had. He was filled with feelings of terror and confu-
sion about the whole thing.
In this case, the immediate benefit of remembering was that he would
feel less confused and less disoriented. And, he was in great distress. First,
I inquired about the situation in general terms. What had happened? What
was at stake? What did he remember? His first response was that all he could
remember was that he had a deadline of Sunday night, and his computer
had frozen on Friday night. Our current meeting was on a Thursday night,
following the Sunday. He was anxious beyond measure, and it was hard for
him to be able to talk about it at all.
The most important thing for me as a therapist for dissociative identity
disorder (DID) was to be aware of the fact that Dennis had many different
parts who were working together, despite their narcissistic disharmony, to
help him to stay alive and financially solvent.
When I asked about the status of his job, the first thing Dennis told me
was that he was supporting his mother who has had debilitating rheumatoid
arthritis and cannot work at all now and who lived in a separate city, sev-
eral hundred miles away. He loves his mother very much. She was the only
parent who had raised him. And, she had raised him alone, emotionally
and financially. Neither her family nor her deceased husband’s family had
been available to help.â•¯As noted previously, there was often little money,
and there were many times Dennis and his mother were completely without
food. It is these kinds of experiences that would intrude on Dennis’s mind
when he thought about the terrors of not being able to keep his own job.
Thus, I knew how intensely important it was for Dennis to be able to
keep his job—if he lost his job, this whole house of cards would fall apart.
His mother, basically helpless, would be without resources and in danger
of receiving zero or, at best, inadequate, medical care and starving as well.
Living in a different city, Dennis was of course in similar danger, but he
was younger and stronger. Most important, he was impaired in his own
ability to tell past from present: Yes, if he loses his job, it is a problem, a
big problem, but it is not exactly the same as his mother losing hers when
he was a child.
The next thing I asked was an open-ended inquiry into who it was that
saved the day. Who bought the new computer? Who did the final work that
resolved the situation? I wondered if it might have been Sophia, a maternal
figure who Dennis states is often much better with numbers than he is and
would have been in a better position to resolve the situation. At first, he did
not remember. Then, I specifically requested that he ask inside who had
bought the new computer and where. First, he told me that he had checked,
and there were no credit card records of any transaction. It must have been
in cash. There were some cash stashes unknown to Dennis but known to
some of the other parts. So, I persisted with the question and the request
that he ask inside—specifically of Sophia. Finally, he told me that the com-
puter had been bought on Saturday at a particular store in Manhattan, and
that Sophia had indeed finished the work. I asked why she had not put it
on the credit card. His answer was that Sophia had known that he would
“freak out” with the knowledge of such an expense. It was a very good
(and comparatively expensive) computer, and although he needed it for his
job, it was something of an anathema for him to have purchased it: Could
he really be that important? Implicitly, “No.” Thus, Sophia, along with
others, kept the information from him so that the project could be finished
and so that he, Dennis (but truly, all of them), could keep his job.
As the two of us addressed the intensity of his emotions about this sit-
uation, he volunteered that if he had been in a different, but at present
unimaginable, state of mind, he might have been able to tell his boss that
his computer had broken, and that he needed more time. He said this in
the mode of self-criticism. I echoed the same sentiment with more sup-
port, considering all of his fears, many of which had never been publicly
expressed: A reasonable boss would understand the situation, and as a
result, he would not have had to feel so terrified.
One striking and notable thing about this incident was the revelation of
how lovingly interconnected his parts can be. Because they did not want
him to be too distraught to be able to finish the project, together they found
a way to buy him a new computer with stashed cash, and they kept the
information from him so that the project could be finished.
At the end of the session, Dennis felt much better. He had reclaimed
this aspect of his memory thanks to the collaboration of Sophia and
other parts, who, in the protective framework of the therapy session,
felt that it was safe to let him know what had happened. He then said,
“I would feel so lonely without them.â•ƒ.â•ƒ.â•ƒ.â•ƒI n such a desolate world, they
keep me company.”
Negotiating the Time Specific Parts Have

in the Session and Getting Parts Who Have
Come Out in the Session to Go Back Inside
Generally, it is not difficult to get dissociative parts who have come out in
the session to go back inside. Usually, they are cooperative and understand
that the session must end at a specified time, or if they are young, that they
are too young to drive or to take care of themselves outside without the
copresence of a more grown-up part. However, especially if these parts
have not been out before or have only rarely been so, it may be difficult.
They enjoy being out and interacting with a human being who is interested
in them, and they may not want to go when it is time for them to go. I often
reassure them, especially if they are child alters, that I will look forward to
meeting with them again in the future. If they indicate that they have not
had enough time, I may promise to make time for them in another session.
While I do not want a child part leaving the office for reasons of safety,
and the parts know this, sometimes they like to feel grown up and try to
trick me. When I catch them and say, “You are not so-and-so,” I get a
sheepish look and an agreement to go back inside. This may have to be
repeated again, but usually they go back, even if grudgingly.
However, reluctance or inability of an alter to leave can sometimes be
a serious matter. Sometimes, an emergency extension of a session may be
required. This is difficult when sessions are scheduled back to back. There
have been occasions when I have had to call for a spouse to come and get
the patient. In the case of my patient Anna, whose alters are generally rigidly
locked inside, communication with alters has at times resulted in extreme
disorganization. Sometimes, when parts have emerged in her session, she
has become wobbly on her feet, and I have to walk her down to the lobby.
On one occasion, when I was trying to talk to an aggressor part, a child
part was thrown out instead. After some conversation with the child part, I
asked her to leave so that the Anna could return. Unfortunately, Anna did not
return. Half an hour later, with no success, I called her husband to explain to
him that Anna was in a child state and asked him to take her home. I phoned
her in the evening, and when she got on the phone, she said in a child’s voice,
“Who are these people? What a nice house! Can I stay here?” I asked her
husband to watch her vigilantly, especially to make sure that she did not leave
the house. Fortunately, by the following day, the host had returned.
Asking One Part to Step Aside

This approach of asking a part to step aside for the betterment of the system
of the overall person derives from the work of Richard Schwartz (1995).
Schwartz was a family therapist who became involved in the treatment of
eating disorders. As a good family therapist would, he began to notice that
the index patient (the eating-disordered patient) was often forced by the
family dynamics to be compliant with the most powerful forces in the fam-
ily system, and that the most powerful players were motivated to block the
improvement of the patient. Following from this observation, he learned to
ask the person who was most dominating and interfering to step outside
so that he could learn what the interpersonal dynamics would be between
the remaining parties without that person present. For example, Schwartz
might notice that a father would intervene in a negative way every time a
mother and daughter would try to resolve something between themselves.
The father would make it impossible for the mother to be heard by her
daughter. When Schwartz realized that all of these family dynamics had
been internalized, he developed the internal family systems approach. The
internal family systems approach encompasses work with all levels of dis-
sociative problems, from ego state dissociation to DID.
As have DID therapists, Schwartz (1995) noticed that often there are
parts who are punishing, criticizing, or dominating the part who is in exec-
utive control most of the time. It is not necessarily that these parts enjoy
the activity, but that they have just always done it this way because it has
worked in the past as a means of maintaining system stability and keeping
the patient out of trouble—or so they believe.
One of Margaret’s sessions may illustrate: Margaret, introduced in
Chapter 1, always had to be the “Good Girl” to survive. In the family of her
upbringing, there was no room for her to have any feelings about how she
was treated. She was repeatedly raped by her father since she was a girl and
sadistically and repeatedly raped by her stepfather when she was an adoles-
cent. Her father, who was often full of booze and drugs, tried to drown her
when she was 8. When Margaret was 12, he shot at her with a rifle, missing
her head only because of the intervention of her stepmother, who moved his
hand. On another occasion, after knocking out her front tooth in a beat-
ing, he tried to strangle her. Had she been anything other than the Good
Girl, her tenuous safety in the family would have been extremely endan-
gered. Not surprisingly, she is a hard-working and conscientious employee,
spouse, and mother. Her lessons in being the Good Girl were hard-learned,
and in many cases, they illustrated the principle of one-time learning.
Having always played the Good Girl, she quickly takes the other person’s
point of view. The problem is that she has no validated stance from which
to care about herself and take her own point of view.
In this session, Margaret reported that she was feeling depressed, frus-
trated, and stuck. She was feeling exploited by a coworker, and while she
acknowledged feeling angry, she also felt helpless. She experienced somatic
symptoms in which she felt that her throat was closing, and she could not
breathe. In addition, her heart was hurting her, another symptom that she
develops at times when she is under extreme stress. Inquiry into her somatic
symptoms yielded the fear that she would be strangled if she failed at her
task, one in which she (a) was being taken advantage of, (b) was put in the
position of taking the blame for someone else’s mistakes, and then (c) was
being forced to do extra work because of this other person’s mistakes. She
said that she was feeling extremely frustrated and hated having to be the
Good Girl. I then asked her more of how she was feeling:
Me: How are you feeling toward the Good Girl?

Margaret: I am feeling murderous toward the Good Girl. I am also feeling frus-
trated with being stuck and with only having her to work with.
Me: She’ll get strangled if she fails at being good?
Margaret: Yes.
Me: The Good Girl was so important to you when you were younger. She
did keep you safe to the extent that that was in your control when you
were younger. I shudder to imagine what would have happened if you
would have indicated outrage at the way you were treated. The Good
Girl enabled survival.
â•… Would it be all right for The Good Girl to step aside so that I could
talk to the one who was frustrated and angry with her?
Margaret: [Her response is unexpected; initially, she did not want the Good Girl to step
aside.] It is terrifying to the rest of me. I did not expect this. But I am
completely terrified. I don’t know if I want this, or if I am ready for her

to step aside.
Me: Even if it is only for a minute? Could she step aside just for a minute,
and then could she step back?
Margaret: This is absolutely terrifying. But, OK, if it is only for a minute.
Margaret: [Continues.] I am enraged at the people who won’t take the responsibil-
ity. I am angry that they won’t take responsibility and fix their mistakes.
I feel that I have to fix everything.
Me: What would you like to say?
Margaret: Look, Winston, we have all the coding done! Everything is set to go
into production. Someone in your department made a big mistake in
coding, and now production will be slowed down. You are causing us to
lose sales. You need to fix this problem.
Me: That sounds like a strong place to be standing in.
Margaret: It does not sound like a crazy person, and it does not sound out of
bounds.
Me: Maybe the Good Girl can have a friend from you in this?
Margaret: [Correcting me.] Maybe I can be the grown-up that the little (good) girl
never had.
Me: The Good Girl was great to be willing to step aside. I see that she has
been very powerful and in many ways dominant in the system.
Margaret: She is bossy! She has been the boss of me! I feel so liberated. I could
only do this if she weren’t around!
Me: She’s around. It is wonderful that she could concede your having more
space.
â•… But how did this feel to you?
Margaret: I have had strong images. There is a way that I felt—on top of a moun-
tain. The air is clear and feels good. I have a cape.
Me: A cape?
Margaret: Like Superman’s cape.
A week later in her next session, Margaret reported that the changes in her
mood and her feelings of competency had remained, and while she did not
necessarily feel like Superman, she continued to feel powerful and good.
Working With Dissociative Parts’

Experience of the Body
It is often integrative to help patients with DID connect to their bodies
and, specifically, to help parts to notice the body. Child parts, for instance,
often do not realize that they are in a grown-up body. Specifically noticing
the body often helps them to gain coconsciousness and to accept that they
share the body with other parts. The therapist may ask them to notice such
things as how tall they are, what their body looks like to them, and so on.
This might include asking child alters to do such things as to stand up and
note their height against the size of the room, against the furniture, or in
comparison to the therapist’s height. I have often found it helpful to ask the
part who is out to look at the hands. Whose hands do they see?
The following vignette is a section from a session with Shirley, who had
just been triggered and frightened by an event at work that reminded her
of her childhood trauma. When she came into the session, she was still
agitated and upset about it. I began by asking her who was upset and in a
general sense what was going on inside her.
Me: Who is upset?

Shirley: Sam [a protective male alter] is very upset. He could have hurt somebody.
He was so upset he might have punched somebody—or worse. I had to
physically stay away from the situation in order to control him.
Me: [Realizing that Sam is starting to speak.] How old are you?
Sam: I’m 8. I have to protect Shirley. I have to watch all the time.
â•… [Sam has to watch because the danger to Shirley as a child was almost constant
from perpetrating family members and from perpetrators in the environment.]
Me: That’s a big job. That must be so lonely.
â•… [Sam nods.]
Me: I bet Shirley appreciates how you have protected her.
Sam: No, she runs away. She is only 5. She is not there enough to know what I
do. I don’t need any appreciation.
Me: Oh, the little Shirley runs away. And you, you just do your job? You don’t
need appreciation.
â•… [Sam nods.]
Shirley: [Intercedes.] Things are not dangerous now like they once were. Sam is
contemptuous of the little one.
Me: Yes, I can understand that he would be. It has been all up to him to protect
the body. You are right though that the constant danger is past. Sam does
not need to be so vigilant and on edge all the time. The traumas of the past
are over.
Shirley: Maybe he will let me sleep tonight! That would be wonderful!
Me: Yes, it would. How does that feel to Sam?
Shirley: [Visibly becoming very anxious.] Something is wrong. He is so separate. I can
feel him, but he is so disconnected. I see things through his eyes, but it is
disconnected from me. Help me. Something is not working. This is very
upsetting.
Me: Sam, through your eyes, please look at the hands.

â•… [Sam looks at the hands.]
Me: What do you see?
Sam: [At first, I am not sure whether it was Sam or Shirley speaking.] I see two hands.
Me: What do they look like?
Sam: One is old, and one is a hand. They are very unconnected. [Sam is upset.]
Me: How old is the hand that is not old? Is it a child’s or a grown-up’s hand?
Sam: It is a child’s.
Me: I would like to ask you to put your hands together and twist your arms
together at the same time, like this. [I demonstrate.]
â•… [Sam does this. Suddenly, there is a switch to Shirley, who now feels and
understands Sam, and she is very moved. She stays with her arms entwined for
several minutes.]
Shirley: Oh, it is connecting. They are connecting. This is amazing. Sam is not so
separate. He understands that he does not have to be constantly on the
defense. He is more connected.
Shirley: Sam likes you.
Me: I like Sam, too.
Shirley contacted me the next day to tell me what a powerful session it had
been for her.
Sheldon Itzkowitz (personal communication, 2010) has described a tech-
nique that a patient of his devised to help her in sharing memories between
dissociative parts. The patient discovered that while imagining that each of
her hands was a different dissociative part, one of them the host, she could
put her fingers together and enable the host, who had been amnestic of
memories to be given those dissociated memories. The host then confronted
a significant and painful task of mourning, but at least she now knew more
of the life that she had actually led.
Mapping the Organization

ofÂ€Dissociative Identities
Mapping “can be understood as an introduction to the personalities on the

patient’s own terms.â•ƒ.â•ƒ.â•ƒ.â•ƒT herefore, the therapist is empowering the patient
and respectfully supporting the patient’s involvement in the therapy pro-
cess” (Fine, 1993, p.â•¯142). The creation of a map of the patient’s internal
world often helps therapists in learning their way around the system. The
map represents the patient’s current understanding of their dissociative
system, indicating the identity of the parts, their relationships with one
another, their ages, their genders, often their appearances and personal
styles, when they came into being, and their particular function. Maps can
also provide the clinician with clues regarding hidden influences and poten-
tial danger from the inside. Maps are often worked on throughout the first
phase of treatment as more parts are identified and more information about
the ones already identified is revealed. An initial map may function as a
baseline against which subsequent ones can be compared (Fine, 1993).
Mapping the patient’s organization of self-states can take many differ-
ent forms. Fine (1993) described a user-friendly format for mapping that
requires no drawing skills. The patient is invited to place the name of the
part in usual executive control, which is generally the name the patient goes
by, in the center of a large piece of paper and then to meaningfully indicate
the position of each dissociative part in this representation of psychic space
to indicate how similar or dissimilar the parts are to each other. The map
may reveal ways that certain parts are clustered together or separated and
in this way may help to elucidate the relationships and the conflicts that the
parts have with each other.
Sometimes, a patient simply makes a list of dissociative parts and provides
descriptions. Often, the patient may prefer to draw some form of visual dia-
gram of the different parts and their functions and interrelationships. Some
patients have used pie charts. One of my patients mapped her alters onto
a picture of the brain. Others may visualize houses with individual and
special rooms for everyone. Sometimes, people visualize tree houses, with
separate places for the different parts. There may be landscapes, castles,
moats, and so on. Those with some drawing skills may spontaneously draw
pictures of the cast of characters on a piece or pieces of paper.
Maps can be telling in terms of what they leave out as well as what they
include. Maps reveal an organization of affects, as well as the way parts
are interrelated and work together. For example, one person’s map had sig-
nificant parts arranged around an empty center, where often the part who
is most frequently in executive control is placed. In this case, the part who
bore the patient’s given name not only was not in the center but also was
not listed at all. Here the part who acknowledged depressive affect was left
out, revealing a clue to one particular way that the system was organized
defensively to avoid depressive affect.
FigureÂ€10.1 is a map that Dennis drew of his system. This map is a struc-
ture hanging in space, called the Onyx House. Dennis is in the center. He
has a two-way, often reciprocating, interaction with a part he grew up with
as a child, who is now an adult, Sophia. This is a strong connection. Sophia
is connected to a child Little Sophia. Part of Sophia grew up, and part of
her did not. There is a partial amnesia between these two parts. A male
child part, named Denny, is the counterpart to Little Sophia. Denny holds
an enormous amount of pain and longing for nurturance from Dennis. He
can also be impulsive. Dennis holds him close to his heart and loves him,
even though he often also is annoyed by his behavior—and even though
Mnemosyne
Little Sophia
Klixcilitep
-
-
Figure 10.1â•‡Dennis’s map.
he often cannot hear him because of the amnesia barrier. Denny and Little
Sophia are in communication with each other, as two main child parts of
the system. Then, there is Mnemosyne, who is pictured as above Dennis,
as a highly developed part, who has a strong influence, even though it is
an influence with a good deal of amnesia, on Dennis. Mnemosyne is brutal
and cruel and contains pure rage—hot, bloody, bone-crunching rage. She
enjoys her fury, and this gives energy to Dennis. Mnemosyne is the per-
sonification of memory in Greek mythology. She is the daughter of Gaius
and Uranus and, as consort to Zeus, the mother of the nine muses. At the
very bottom of the structure is a sentry, defined mostly by her function,
named Sheila. Dennis says, “Sheila feels cold and lonely when I touch her.
She feels unrelated to us. I suspect she holds something more terrible than
any of us, but she won’t talk to me or let me see.” On the right-hand side
of the map is Sage, a somewhat less-known part, who will at times impart
valuable wisdom to Dennis. His responsibility is to tell the truth when any
of the parts ask. Then there is Klixcilitep, who is a nonhuman part and is
more like a machine that sits deep under the roots of the pylon on which the
Onyx House sits. According to Dennis:
Klixcilitep’s purpose is to keep the Onyx House stable and organized. It acts as a
medium for memory and experience and has access to every memory and every
thought of everyone in the Onyx House, except for Sheila. It has no personality
of its own and doesn’t talk or listen, but its presence is felt everywhere in the
house, almost as if the entire thing is of Klixcilitep’s own design.
Mapping often occurs naturalistically as alters come out and indicate

their concerns and relationship to others in the system. The map may
consist only of the patient’s verbal communications of how they visualize
the organization of the dissociative parts of the system. For example, one
patient had a tree house that she described. If the patient does not explic-
itly communicate it, the map may have to be constructed in the therapist’s
mind. The main point is that the therapist should be getting to know the
cast of characters and their interrelationships. Just as technique should not
be privileged over purpose, creating a map of the different parts should not
take precedence over sensitivity in the clinical work. For example, parts
should not be called out for the sake of a map (International Society for the
Study of Trauma and Dissociation, in press).
The Use of Visualization and Metaphor

to Increase Coconsciousness:
Visualizing Other Parts
Most patients with DID have a good ability to visualize aspects of their
inner world as well as the appearance of other parts on the inside. People
with DID often visually imagine houses and other lodging places, which are
divided in particular ways to accommodate the occupancy of different parts.
They may visually imagine special rooms, landscapes, even seascapes. They
also visualize each other’s physical appearance. This ability enables them
to utilize visual metaphors and guided imagery therapeutically. Therapists
often devise metaphors and images that are custom made for their particu-
lar patients. However, some that have broad utility I mention here. Kluft
(1989, 1993b, 1999b, 2009) has suggested a number of visualizing and
metaphoric techniques, such as suggesting that parts impart information to

each other through means of a slow leak or a dripping faucet. This allows
for the information to be imparted by one part to another but in a way that
is not overwhelming. Another of his metaphors is of irrigation ditches from
a river-fed lake that may overflow.
George Fraser (1991, 2003) has offered the dissociative table technique,
a guided imagery or, more specifically, inner-guided imagery technique.
The dissociative table technique generally utilizes an image of a table sur-
rounded by empty chairs in a safe room. Parts are then invited to enter the
room and to sit in the chairs around the table and share their concerns.
However, other images, such as sitting around a rock at a beach, may be
utilized just as well. After important preliminary work, the therapist may
say something like the following:
“I want you to imagine yourself in a safe room. In this room is a table.

Around this table are chairs. One chair is for you, the other chairs are
for those others who play a role in your internal life,” or if the internal
parts are better known, “The chairs are for you and those you are
aware of who are inside.” (2003, p.â•¯13)
It is emphasized that it is a safe room in which no one gets hurt, and that
the purpose is for the parts to get to know each other better. The dissociative
parts are then invited to speak with each other or through the host. To aid in
the process, Fraser (2003) suggested use of a virtual spotlight or microphone
to help individual parts to speak. Next, he suggested saying something like,
“OK, now I want you all to listen when someone else speaks so you can all be
aware of what is said in therapy” (p.â•¯16). As this is a powerful technique that
may tap into hypnotic phenomena, Frazier recommended that those using
the table technique should either have formal training in hypnosis or have
supervision for their first few cases in which it is used.
Shielagh Shusta-Hochberg (2004) has proposed the window-blind tech-
nique, which also involves visualization of other parts. First, the person
visualizes a window with the blinds drawn closed and is told that other
parts of the system are on the other side. When ready, the patient is invited
to slightly and slowly twist the virtual wand of the blind and describe what
she sees. Shusta-Hochberg offered the following vignette:
A patient with persistent adult-specific denial of the existence of other

parts continued to take issue with the assessment that she suffered from
DID. Review of her high DES [Dissociative Experiences Scale] score
and some of her answers failed to convince her. I would again and
again relate to her what I observed in session to support the diagno-
sis, including childlike behaviors, affective tone, vocabulary and vocal
tone and pitch. I also reported to her that she would gather up stuffed
toys and interact with them very much as a child would. My reports
of these observations seemed to do little to satisfy her that my diagno-
sis was correct. Eventually we tried the window-blind technique using
guided imagery. I started by addressing the issue with her child parts.
One of her childlike parts looked through the window and saw adult
alters “moping,” appearing depressed, with shoulders stooped and
heads hanging down, defeated, hopeless, and alone. Tears rolled down
her face as she said, “It’s so sad.” Then, one of her adult parts looked
through the partially opened blinds and glimpsed a group of little girls
playing a colorful children’s board game, having fun down on the floor.
Seeing them, she suddenly grasped the concept of not knowing as being
part of the disconnection of dissociation. Following this exercise, she
found tears on her cheeks and wondered why. She was told that one of
the child parts had seen her and felt compassion for her pain. She was
amazed. This was a very difficult but invaluable turning point in this
treatment. The technique was used several subsequent times with this
patient to help her view her dissociation more objectively. This seems
to accomplish in part what videotaping can do, without presenting the
dilemmas videotaping can entail. (p.â•¯18)
Other Approaches to Facilitating

Coconsciousness
Many people with DID have successfully used written venues as ways for
parts to share information with each other. One of these is a group jour-
nal in which parts make entries that are then available to other parts to
read. This is an invaluable tool for achieving coconsciousness. Some people
will use an actual journal; others will use a computer. Putnam (1989) has
described a specific form of this: a bulletin board on which dissociative
parts may post notices to each other and to the system. The general prin-
ciple is to offer suggestions and support for the parts to share experiences
and be in communication with each other.
Throughout each session, Kluft’s (1993a) “rule of thirds” is important to
bear in mind: Uncovering or intensely emotional work should be completed
by the time 2/3 of the session is up, allowing the remaining 1/3 to wrap up
and restore equilibrium.
Hypnosis and EMDR

Both hypnosis and EMDR are adjuctive modalities in DID therapy, not
treatments in themselves. Clinicians who use these modalities in work with
highly dissociative patients should have received, not only the appropriate
training to use these modalities, but also the specialized training requisite
for use with highly dissociative patients. In addition, patients should be

carefully informed about the possible risks as well as the benefits they may
expect. Therapists should receive from the patient the appropriate informed
consent for use of these modalities.
Hypnosis
With regard to the usefulness of hypnosis in DID treatment, there is no
substitute for reading the works of Richard Kluft. He has written prolifi-
cally on this topic and has formulated a great number of hypnotic interven-
tions. To learn more about these interventions and to understand how he
uses hypnosis, I refer the reader to his many edited books and widely placed
articles. Fortunately a number of his articles may be found in the journal,
Dissociation, electronically retrievable at https://scholarsbank.uoregon.edu.
Kluft (1982, 1991, 1994b) noted that hypnosis has been a controversial
issue in the treatment of DID. Arguments that have been made against the
use of hypnosis include the claim that DID may be iatrogenically induced,
and the claim that hypnosis can be harmful. With regard to the first argu-
ment, he observed that “personalities” created under experimental hypno-
sis are highly limited, do not have a center of subjectivity, initiative, and
personal history, and they don’t last. In addition, in DID treatment, the
number of alters usually decreases. If the therapist were creating alters,
their number should increase. With regard to the second argument, Kluft
noted that there is little firm evidence that hypnosis in itself is damaging. As
with many interventions, the problem arises from a therapist’s lack of skill,
rather than from the use of the intervention. Finally, people with DID tend
to be highly hypnotizable (Bliss, 1984; Frischholz, Lipman, Braun, & Sachs,
1992). Trauma, especially repeated trauma may spontaneously induce self-
hypnosis. Trauma victims have often unwittingly learned autohypnosis as a
way to avoid or buffer the full impact of traumatic experiences. As a result,
the patients’ developed autohypnotic techniques may permit much hypnotic
work to be done without the induction of a formal trance. Thus, it is likely
that the treatment is suffused with hypnotic phenomena even if the therapist
does not believe that he or she is employing hypnosis (Kluft, 1994b).
Hypnosis has many uses in psychotherapy with highly dissociative
patients: relaxation, grounding, self-soothing, enhanced coping skills,
increased sense of self-efficacy, creating safe places, and help with the
reduction of emotional pain, to name a few. It is an excellent way to con-
tact alters who have otherwise been reluctant to appear. While Kluft has
described numerous hypnotic techniques, a few that are illustrative include
the provision of sanctuary, bypassing time, distancing maneuvers, bypass-
ing affect, and alter substitution (Kluft, 1994b). The provision of sanctu-
ary involves the creation of a safe place for alters whose affect has become
unmanageable. Safe place work is used in other modalities of therapy, such
as EMDR. However, in DID treatment a safe place must be created for

every known alter: Different alters are unlikely to have the same perspec-
tive on safety. Bypassing time may be achieved in at least two ways: (1) hyp-
notically helping overwhelmed alters to go their safe place or to go to sleep
until the next session; (2) hypnosis may be used to assuage a patient’s terror
that may be evoked by certain dates, such as Halloween, or an abusive par-
ent’s birthday. In this second technique of bypassing time, Kluft suggests
to the patient that he or she is currently looking backward in time and is
feeling good about how well he or she had handled it. An example of a
distancing maneuver is the library technique, in which the patient envisions
a trip to a library where there are fascinating volumes, “some of which we
will study together and close whenever we have read as much as we can
absorb” (1989, p. 95). This method allows the exploration of memories in a
setting that is safe and circumscribed, and provides a distance from poten-
tially overwhelming memories. Bypassing affect may be achieved by sug-
gesting that the patient put the overwhelming affect in a time-locked vault
that will only open a few minutes before the session. Another technique is
alter substitution—used when a key alter who has usually shouldered the
major responsibility for managing daily life becomes exhausted and over-
whelmed. Rather than let this situation devolve into retraumatization and
the patient’s experience of failure, the overwhelmed alter will be replaced
by another alter who is not exhausted, with the consent of the patient. Such
hypnotic methods teach skills of affect management, alleviate suffering,
and give the patient a greater sense of self-efficacy—highly relevant because
helplessness is generally at the root of DID.
Hypnosis may also be used for retrieval of memories (Kluft, 1994b;
Maldonado & Spiegel, 1998), but Kluft teaches that great care must be
used: “I avoid asking leading questions or dropping hints that I anticipate
finding an abuse historyâ•ƒ.â•ƒ.â•ƒ.â•ƒI treat any technique, including hypnosis, as
having potential for both desirable and undesirable outcomes and so inform
the patient. I encourage the patient to regard all recovered material as tenta-
tive, and deserving consideration in depth and at length before action might
be taken on its basis” (1994b, p. 210).
EMDR
Eye Movement Desensitization Reprocessing (EMDR) is also often used
adjunctively in DID treatment. EMDR helps to heal trauma and dissociation,
restoring associative pathways within neural networks. However, because
EMDR intensifies painful affect in the process of resolving it, it should be used
with great care in DID treatment. Generally, the sets should be shorter than
those used with less dissociative patients, and there should be heightened vigi-
lance for the possibility that affect may become unmanageable. There is a vast
literature on EMDR, starting with Francine Shapiro’s (1995) Eye Movement
Desensitization and Reprocessing (EMDR): Basic Principles, Protocols, and

Procedures. However, there is less literature on the application of EMDR with
highly dissociative patients. Catherine Fine is notable for her work in this area.
One particularly excellent article, authored by Fine and Berkowitz (2001),
describes a Wreathing Protocol for the imbricated use of EMDR and hypnosis
in the treatment of highly dissociative patients. The authors noted that pre-
mature abreactive work can promote regression and decompensation, which,
when it occurs, gives “the message to the DID patientâ•ƒ.â•ƒ.â•ƒ.â•ƒthat past experiences
contained within parts of the mind remain overwhelming and unmanageable,
and that they should continue to be avoided at all cost. Therefore, because of
the easy affective destabilization of the DID patientâ•ƒ.â•ƒ.â•ƒ.â•ƒgreat caution should
be exercised in the use of EMDR because it is such a powerful methodology”
(p.Â€277). In the Wreathing Protocol, hypnosis renders the heightened affect
more manageable, but the benefits of EMDR, which works faster than hyp-
nosis does, are retained.
Chapter 11
Working With Persecutory

Alters and Identification
With the Aggressor
Persecutor parts function as trauma shields (Putnam, 1989) to protect the

person from horrifying memories and defending against feelings of helpless-
ness. Having persecutory and abuser identity states is like having an internal
Al Qaeda or Taliban that punishes you for the slightest infraction of bizarre
and arcane rules. It involves being emotionally attached to inner and per-
haps outer persecutors, even though you were tortured by them. It is in part
this relational configuration that gives the persecutor parts their power.
Abusive parts often engage in self-harm and self-sabotage, and they may
be aggressive and frightening toward other people and destructive of prop-
erty. These parts may also do such things as cut or burn the body, hit the
face or other parts of the body, put the person in physical danger, and
behave homicidally toward other parts in the system. They may instruct
the part who is in executive control to commit suicide, engineer falls down
stairs or on the pavement, or cause a person to fall out of bed. They may
call the part in executive control denigrating names, tell that part that he or
she is worthless, and so on. Although abuse of other people is less frequent,
these parts may also behave in threatening and dangerous manners toward
the therapist and other people. Abusive and persecutory alters are common
in people with dissociative identity disorder (DID). Ross, Norton, et al.
(1989) found 84% of a sample of 236 cases of DID had such parts.
Why do these persecutor and abuser parts behave as they do? In the most
general sense, they are usually modeled after a caretaker who was abusive.
However, their psychology is complex. The parts who punish, hurt, and tor-
ture the host or others on the inside often do so because they believe this
is necessary for the person’s safety and protection. In the original family
environment, it was often not safe for the patient to express feelings of dissat-
isfaction or anger. In fact, in environments in which potentially deadly paren-
tal rage can easily be set off, the expression of true feeling must be extremely
curtailed. As a result, the system depends, for its safety, on the inhibition of
expression or the exclusion from consciousness of powerful overwhelming
affects, such as terror and rage. For example, Margaret’s (Chapter 1) father
was an unpredictable alcoholic who knocked out her front tooth because
211
his football team lost. After his team lost, he found a quarter in the carpet
that he claimed she had let fall out of her pocket. He said to her, “I told you
not to let any money fall into the carpet!” and then began beating her. It
eventually involved her teeth being knocked out, her bedroom dresser being
knocked on top of her, and her entire face being bloodied. It would not have
been safe for Margaret to express any feelings about the way she was being
treated—especially when her mother’s only concerns were that she would
not be able to get the blood out of the shirt and that she would now have to
take Margaret to the dentist. Thus, the development of a part who oversees
and preemptively curtails thought and behavior by intuiting and predicting
the frightening parents’ behaviors is a great asset to the child in this environ-
ment. In a way, it is like a preemptive strike; this part’s control of the person’s
behavior often mimics that of the original aggressor.
The purpose and activity of abuser parts has much in common with what
Bromberg (1996) called an early warning system, a fail-safe security system
that is always hypervigilant for trauma. Although the part of the self that
functions as the early warning system is also motivated in people without
DID, in people with DID this part is personified with its own sense of purpose
and subjectivity. This dissociative vigilance of being on alert, which I believe is
part of the underlying reason for the reliability and speed with which abuser
parts can appear, is highly protective of sanity. As Bromberg (1996) stressed,
this dissociative vigilance “doesn’t prevent a harmful event from occurring
and, in fact, may often increase its likelihood. It prevents it from occurring
unexpectedly” (p.â•¯230). In this sense, it safeguards an ongoing sense of subjec-
tivity and protects against emotional deregulation and annihilation anxiety.
Thus, the vigilant intention to avoid current and future trauma ends up as a
continual internal reenactment of the past traumatic situations.
In addition to preserving safety and sanity, the persecutor part has the job
of protecting the child’s attachment to the abusive caretaker. Attachment
serves survival (Bowlby, 1969/1983) and buffers fear (Lyons-Ruth, 2001).
Because proximity to an attachment figure provides protection to the infant
against predators, separation from the attachment figure signals danger
(Bowlby, 1969/1983). What happens when survival is predicated on attach-
ment to a caretaker who is also a predator? When the person from whom
protection is sought is the same one against whom protection is needed?
In such situations, the child’s ability to maintain attachment will depend
on the dissociative compartmentalization of parts of the self containing
contradictory memories and affects. By containing the child’s enraged and
angry feelings, the abuser part helps the part most frequently interfacing
with the world to maintain an idealized attachment relationship with the
needed abuser. In DID, as in less-severe problems in living, this betrayal
blindness (Freyd, 1996), in which awareness of the malevolence of the care-
taker is sequestered, allows an ongoing positive, or at least safer, relation-
ship with that caretaker to be maintained.
Working With Persecutory Alters and Identification With the Aggressorâ•… 213
Even when the original environment is no longer present, as long as the

dissociative barriers are in place, this aggressor-identified part believes
punishment, and threat to the part most frequently out, is the most reli-
able means to achieve and maintain survival of the person, the system,
and the attachment to the abusive caretaker. Instead of the behavior of the
perpetrator, the child comes to identify his or her own rageful feelings and
potential behavior as the threat (Howell, 1997a). Of course, the affects of
rage and anger forbidden to the host are exactly the ones these persecutor
and abuser parts hold. In this way, they function in a way that has some
commonality with the arcane and primitive superego (Howell, 1997b).
The fact that the perpetrator self-state feels like Not-Me also reflects the
collusion of the part who is usually out. Sometimes, the memories of the
experiences are so horror filled that the part of the person usually out front
(the host) is so extremely sensitized that he or she refuses to know about
them. Thus, the host may depend on the abuser part’s parentlike function of
providing safety and protection from memories (Beahrs, 1982; Goodman
& Peters, 1995; Howell, 1996, 1997b). The attachment of the host to the
abuser self-state takes the place of the capability for trust of a real protec-
tive other person. The fact that the host often desperately does not want to
know about traumatic childhood experiences renders the host unapprecia-
tive of the intended-to-be-helpful activity of the abuser part. This, then,
perpetuates and strengthens the dissociative barriers between self-states. It
also feeds the grandiosity of the abuser part: By allying with the omnipo-
tence of the persecutor, the host does not have to feel the terror and can be
shielded from memories. Of course, this kind of internal bondage does not
work in the long run for it increases the grandiosity of the persecutor part
and does not, in the end, prevent the intrusion of terrible memories.
The persecutor part, the one who holds much of the fury for the system, often
feels omnipotent. In addition, as domination feels good, it is self-reinforcing:
For example, Sally is a patient with DID who has a grandiose dominat-
ing part called Devil. This part persecutes the helpless-host self-state
with brutal self-injury, and will at times erupt into demonic-sounding
laughter, sounding much like the original perpetrator. Devil boasts to
Sally about how powerful he is, yet when the therapist tries to engage
him and to encourage him to wield his power by defending Sally against
domineering people, Devil disappears. He does not come forward to
defend. To the contrary, the only real interpersonal defense comes from
a precocious 9-year-old part within the intrapsychic system. Devil
exerts tremendous power toward counterparts that are weak and help-
less, and it is this relational configuration that affords Devil his feeling
of power. In fact, Devil is only powerful internally. Because it appar-
ently originated from Sally’s childhood identification with the original
perpetrator, in reality, this part has only the power of a child. (Howell,
2003, pp.â•¯61–62)
How did these parts develop? Often, these abuser parts function as pro-
tector-persecutors (Howell, 1997b). Although they start out as protectors
(Spiegel, 1986), friends, or helpers in childhood, even as imaginary play-
mates (Kluft, 1985a), they often become persecutors as the person grows
older (Putnam, 1989). One reason for this is that there was more persecu-
tion than protection in the child’s environment. Moreover, the scarcity of
protection in the child’s environment means that there was little protection
for the child to model: An imitation cannot be better than what it imitates.
As such, the protector becomes a persecutor because the protection existed
primarily in fantasy.
Another important route for the development of abuser parts is by the pro-
cess that occurs via a combination of traumatization and procedural learn-
ing called identification with the aggressor. In my view, identification with
the aggressor is a two-part process. The first part is passive and automatic,
and the second is defensive. In the traumatic moment of being terrified and
abused, the child cannot assimilate the events into narrative memory. But,
the child does what people often do when they are overwhelmed by danger:
The child goes into a trancelike state in which the source of the danger, in
this case, the abuser, is focused on intently but in a depersonalized and dere-
alized way. Partly because the child is intensely attached to the abusive care-
taker (generally much more so than if there had been no abuse), the abuser’s
facial expression, posture, and words are automatically mimicked. This is an
aspect of procedural enactive learning in the attachment relationship.
Because the abusive events could not be assimilated, the experience could
not be connected with other ongoing aspects of self. Thus, it is not like a
positive identification in which a person’s identity is augmented. Instead,
it is as if the person has been “taken over from the outside” filled with the
aggressor (Coates & Moore, 1995, 1997). However, even though behav-
ioral enactments may appear to be like those of the original aggressor, and
even though this part may identify so intently as even to feel that it is the
original aggressor, it is important to remember that this part expresses its
own aggression. (I expand on this discussion of the development of identi-
fication with the aggressor at the end of this chapter.)
Importance of Accessing, Relating

to, and Empathizing With Aggressive,
Abusive, and Persecutor Self-States
It is vitally important for the therapist to do what the host has been unable
to do: connect with the abuser parts of the person. The therapist may invite
these parts into the session and talk through to them. Although they can
be dangerous and debilitating to the person as a whole, these abuser and
persecutory parts contain a great deal of the energy and vitality of the
system. Because they hold the feelings of anger, aggression, and fury, other
parts, including those most often in executive control, are often depleted
of energy. The goal is that abuser and persecutory parts ultimately become
allies in the treatment so that the affects they have exclusively held become
gradually shared across dissociative boundaries.
Persecutory and abuser parts most often erroneously believe that they are
bad. In these cases, the therapeutic action involves increasing their appre-
ciation of their own subjectivities, which almost always reveals a greater
complexity of affect and thought than they were aware of previously. A fre-
quent problem for these persecutory parts is that they have been pushed into
a corner and see themselves as only having the job of keeping the patient in
line by punishing the host. Thus, interactions with them emphasizing how
helpful they have been, how hard they have worked, and how burdensome
it may have been for them can help them to become aware of a broader
and more complex array of emotions and thoughts than they thought they
had. Often, they have not been at all happy about their pigeonholed posi-
tion but have not been able to get out of it on their own. It is often hard for
the part who is usually in executive control, who often likes to see himself
as “good,” to really “get” how rotten it feels to be considered “bad” and
to understand that he or she gets to be good only because another part is
holding the badness. Thus, it is actually unfair for the part usually out to be
critical of the parts holding the badness because these parts are in a certain
way doing the host a favor.
These parts may present themselves as scary, even calling themselves
demons and names like Satan or Devil. Despite this, they are usually angry
adolescents or even children in subjective identity. As Ross (1997) explained:
“Usually one is dealing with a school playground bully who really wants
to be contained and loved” (p.â•¯336). Once a persecutory part emerges, it is
often helpful to emphasize that there must be a good reason for the way he
or she behaves. Here, depending on the circumstances, explanation of the
development and purpose of these parts may be useful. I often say some-
thing like the following:
You have done a very important job all these years, keeping so-and-so safe. You
keep her from getting in trouble, and you may have even saved her life by keeping
all this fury to yourself. You kept her from having to know about it and from get-
ting punished because of it. You enabled her to continue to have a positive view of
the parents, despite what they did to her, and this enabled her to carry on more
safely. You should be thanked for what you have done for her and for the system.
I think it must not have been easy for you to carry such a heavy load of feelings.
In addition, inquiry into the feelings and motivation for the behavior
is helpful. For instance, why is the persecutory alter behaving in a way
that is so onerous or injurious to the body and to the one who is usually
out (e.g., arm slashing, vagina gouging, sending horrifying hallucinations,
etc.)? Often, the answer may be something like, “She deserves it; she is
such a wimp.” Acknowledgment of the abuser’s perspective, along with
the statement that such acknowledgment does not mean the host deserves
abuse, may invite more communication. Further inquiry may reveal that
the view of the host as a wimp or something similar is an aspect of the
persecutory alter’s self-aggrandizement. This self-aggrandizement may be
experienced as deserved because this persecutor part has had to be so tough
and to contain terrible memories and emotions from which the host has
been protected. At this point, observing that the host could really use some
of that energy, while the persecutory part could be less burdened, can lead
to a direct request that this strong part lend some of his or her strength.
Whereas the grandiose abuser part monitors and punishes the host’s
experience and expression of aggression, the reverse is not true. Without
the overriding constraints of concern that are developed with adequate
interpersonal guidance and empathy or that would be present with more
integration of the self, it simply feels good (and therefore is reinforcing) to a
persecutor part to be powerful and to punish other parts (Howell, 1997a).
These parts often enjoy their power over other parts. Abuse toward the
other parts can become cruel sport. When these parts emerge in the ses-
sion and engage in such behaviors as striking the patient’s face or scratch-
ing the patient’s body, it can be extremely upsetting to the therapist. Unless
or until the therapist, using words, can prevail on the abuser part to stop
harming the body, the therapist is forced to watch helplessly or to inter-
vene physically. The abuser parts must be told that this is not acceptable
behavior. And, the part who is out most of the time must be encouraged
to say “no.”
It is almost always best for the therapist to avoid power struggles with
abuser parts because you are unlikely to win (Ross, 1997). This does not
mean, however, that the therapist should not maintain appropriate bound-
aries and self-defense. In one case noted by Wagner (Chu, Baker, O’Neil, &
Wagner, 2001), a part emerged threatening to kill the therapist. The thera-
pist responded, “Then you would no longer have a therapist.” This remark
was sufficiently realistic to halt the threat. In another case (M. Hainer, per-
sonal communication, 2010), an abuser part threatened to throw coffee in
the therapist’s face and was promptly told that if she felt like that she would
have to leave immediately; she was also told that when she felt differently,
she could come back. This part immediately calmed down. Although the
clinician may encounter some abuser parts who, like psychopathic people,
are apparently nonrehabilitatable, these are in the great minority.
Often, abuser parts are able to develop and grow into more complex self-
states in the treatment. Itzkowitz (2010) presented a case in which an abuser/
aggressive part tested him in the session with minor acts of aggression, with
the result that the part learned that Itzkowitz would not retaliate as her abu-
sive stepfather had. This part would throw things on the floor with a smiling
half-smirk, as if to say, “What are you going to do about that?” She was
taking a reflective stance toward her transference, if you will, thinking about
her way of thinking about people and anticipating that it would be different
with Dr. Itzkowitz. When the host was able to reaccess these emotions, she
was learning to regulate a feeling that was hers. This is something hard for
many patients with DID. Helping these parts to learn that they can use words
rather than action to express their feelings is valuable. The acceptance of this
part’s feelings along with the setting of reasonable limits enabled the achieve-
ment of much greater integration in the system.
Janice
The following discussion regards another excerpt from a session with

Janice, who was introduced in Chapter 1. Janice is generally cheerful and
optimistic, although at times she has been extremely depressed and sui-
cidal. From her infancy until she was about 5 years old, she was sickly. In
addition, her parents were so harsh and physically abusive to her that she
felt at times that they did not want her to live. Janice soon learned to keep
her mouth shut and put on a happy face. In accordance with, or in repeti-
tion of, the way she was treated in her nuclear family, she has had many
close calls in her life and has indeed cheated death many times.
The following 75-minute session was about our 20th session. Having
become increasingly amazed at the awareness of her alters, she said that
she would like to let whoever wants to come out, come out—as it was
her stated wish to have greater communication in this way. Out came one
that expressed utter contempt and malicious hatred toward Janice, a hostile
contemptuous alter.
Hostile, Contemptuous, Persecutory Alter (HCPA):â•‡ She is such a Pollyanna—

always helping others; it is disgusting. I want to kill her, and I am always
setting traps to try to kill her, but she always slips through my fingers. I
don’t know how she escapes. She does not deserve to live. She should
not be alive.
Me: Why do you want to kill her?
HCPA: Because she is so disgusting, and she was never supposed to live. It
was always intended that she should die. [Insists that she should be dead,
and she intends to kill her, and that she is just helping things along to be the
way they should be.]
Me: Because she is so sickly?
HCPA: My job is just to carry out things as they were supposed to be. I keep
setting traps, and she keeps escaping. I don’t know how she gets away.
Me: But if you kill her, you would die, too!
HCPA: [Now identifying herself as Ereshkigal and screaming so loudly the room
shakes and the sound carries beyond the office, and I am a bit shaken, too.
The next day I received a complaint about the noise.] I don’t care! I know
that, but I don’t care! I am Ereshkigal, The Destroyer!1 I am all powerful,
and I will get her, and I don’t care if I die. She just shouldn’t be alive. She
begins slapping her face, hard and uncontrollably.
Me: [I have a moment of panic, not knowing what to do.] Please stop slapping
your face. This is not okay. Please look at me. I need to talk to you
right now.
â•… [Ereshkigal reengages with me, and the slapping stops.]
Me: Who is Ereshkigal?
Ereshkigal: The Sumerian goddess of destruction. I am all-powerful! She is such a
do-gooder. That’s ridiculous! What is that happy mood she is so often
in? Stupid! She’s stupid!
Me: [I am desperately trying to bond with this part.] Well, yes, she is a bit of
a do-gooder, and she does have a lot to learn from you. I bet you did
a pretty good job keeping her out of trouble in the family—you with
your power—you must have found ways to keep her quiet and out of
trouble with those very difficult and scary parents.
Ereshkigal: [After a while.] Well, that I did.
Me: I bet you were very much able to make her behave perfectly in that
family of hers. Janice should be very appreciative for all the help you
gave her. I think she really needed your help in the family.
Ereshkigal: Yes. I was pretty good at that. But she is still just a piece of crap and
deserved everything she got.
Me: [I emphasize her power and how Janice has a lot to learn from her.] It must
feel good to be so powerful. That must be something for you to want
to stick around for. I bet a lot of Janice’s energy actually comes from
you! I am very interested in the things you have to say and am glad to
have met you, but I am going to have to ask for Janice to come back
soon. Is there anything you especially want me to tell Janice of what
you have said—or anything you feel concerned about?
Ereshkigal: I don’t care what you tell her. No, there is nothing you need to hold
back. Tell her whatever you want.
Me: Thank
you. I am glad to have met you.
Ereshkigal: I’ll
bet you were glad to meet me! [Sarcastically; she cackles.]
â•… [Buzzer rings. Next patient is quite early.]
Me: [Iget up.] I guess I am going to have to get this rewired so I don’t have
to get up.
Ereshkigal: It’s probably good for you to get up—you need the exercise.
Me: Iwas glad to meet with you and want to talk to you again. But, I would
really like it if you would step back now and let Janice come forward.
Ereshkigal: I’m not going yet!
Me: I’m sorry. I really need to speak to Janice now.
â•… [Practically growling, she begins shaking again. And, Janice is back.]
Janice: Oh, my God. That was scary! Was I slapping my own face?
Me: Yes.
Janice: She said she wanted to kill me!
Me: Yes, but I think she also helped you when you were growing up.â•¯I think
she helped you deal with the destructiveness of your parents.
Janice: That is really weird and scary. I had no idea.
Janice is visibly quite shaken. I ask her to sign a new safety contract, and
I also ask her to call her husband and tell him what happened and when
she will be home. At first, she does not want to call him because he is busy
at work. When I insist that she call him, she does. We also talk about the
need for her to drive home safely, but she is too shaken to leave. I tell her
she can stay in the waiting room until I finish with the next session. My
next patient, also a multiple, sees how shaken Janice is, asks her if she is a
multiple, and tells her it gets better. She says she herself is so much better
now, even though she went through some rough periods. She also mentions
that she has been in therapy for 14 years.
After the following session, I return to the waiting room and invite Janice
back into the office for a few minutes. She is better and says that she is
going to get lunch and then drive home. Then, she tells me what my other
patient told her, and says, “Oh, my God. I don’t want to have to be in
therapy for 14 years! I’ve been in so long already! It’ll be almost my entire
adult life.” I ask her to call me when she gets home to let me know she is
safe. She does.
Two days later, she comes back. She is feeling much better. She reports
that she let Ereshkigal out for a bit with her husband. She became much
more assertive than she usually is, but when Ereshkigal was getting out of
hand, she took over again.
Identification With the Aggressor
As a term, identification with the aggressor is much used but frequently

confusing and difficult to understand. What are the processes by which
identification with the aggressor occurs? And, how is an explanation mean-
ingful clinically?
In my view, identification with the aggressor can be understood as a two-
stage process. The first stage is initiated by trauma, but the second stage is
agentic and defensive. While identification with the aggressor begins as an
automatic organismic process, with repeated activation and use, it becomes a
defensive process. As a dissociative defense, it has two enacted relational parts,
the part of the victim and the part of the aggressor. Here, when I use the phrase
identification with the aggressor, I emphasize its intrapersonal aspects—how
aggressor and victim self-states interrelate in the internal world.
Historically, the concept of identification with the aggressor was intro-
duced by two writers, Sándor Ferenczi (1932/1949) and Anna Freud (1966),
each with different meanings for it. Ferenczi introduced the term first in
his famous “Confusion of Tongues Between the Child and the Adult”
(1932/1949) article in which he described how the child who is being
abused becomes transfixed and “robbed of his senses,” as a result of which
the child becomes subject to automatic mimicry of the abuser. In contrast,
Anna Freud’s better-known concept of identification with the aggressor
(1966) described active identification with an authority or with the author-
ity’s aggression and power. It has a self-protective and agentic cast and can
presage superego formation. The way I understand the process owes much
more to Ferenczi’s description. Ferenczi (1932/1949) wrote:
These children feel physically and morally helplessâ•ƒ.â•ƒ.â•ƒ.â•ƒfor the overpow-

ering force and authority of the adult makes them dumb and can rob
them of their senses. The same anxiety, however, if it reaches a certain
maximum, compels them to subordinate themselves like automata to
the will of the aggressor, to divine each one of his desires and to gratify
these; completely oblivious of themselves they identify themselves with
the aggressor.â•ƒ.â•ƒ.â•ƒ.â•ƒT he weak and undeveloped personality reacts to sud-
den unpleasure not by defense, but by anxiety-ridden identification and
introjection of the menacing person or aggressor.â•ƒ.â•ƒ.â•ƒ.â•ƒOne part of their
personalities, possibly the nucleus, got stuck in its development at a
level where it was unable to use the alloplastic way of reaction but
could only react in an autoplastic way by a kind of mimicry. (p.â•¯228,
emphasis added)
I read Ferenczi as saying that as a result of being overwhelmed, the child

becomes hypnotically transfixed on the aggressor’s wishes and behavior,
automatically identifying by mimicry rather than by an agentic identification
with the aggressors role. Ferenczi was not describing an identification that
involves willful initiative or a healthy identification in which the process
augments and expands the child’s developing sense of identity—in which
the identification is linked with the rest of the self.
The word autoplastic means changing the self. The child’s sense of
agency, identity, and integrity of self are diminished in the process of iden-
tification with the aggressor. The child, having experienced him- or herself
as an object of use for the caretaker, rather than as a person of intrinsic
value, may orient around the caretaker’s needs and responses, as the center
of self. In chaotic, neglectful, or abusive familial environments, this may
involve an intent focus on the abuser’s postures, motions, facial expres-
sions, words, and feelings. In their description of the compulsive mimicry
of their mothers by some traumatized boys with gender identity disorder
(GID), Coates and Moore (1995, 1997) described this kind of experience
as one of “being taken over from the outside” (1997, p.â•¯301). This phrase
describes well the assault on the self by trauma, something that has also
been called soul murder. In his book Soul Murder (1989), Shengold revis-
ited a scene in Orwell’s 1984, in which O’Brien, the boss, torturer, and
brainwasher of Winston Smith, the hero, speaks to Winston. He said: “You
will be hollow. We will squeeze you empty, and then we shall fill you with
ourselves” (1949/2003, pp.â•¯264–265).
As Ferenczi (1932/1949) also noted, the aggressor
disappears as part of external reality and becomes intra- as opposed to

extra-psychic; the intra-psychic is then subjected, in a dream-like state
as is the traumatic trance, to the primary process.â•ƒ.â•ƒ.â•ƒ.â•ƒI n any case, the
attack as a rigid external reality ceases to exist and in the traumatic
trance the child succeeds in maintaining the previous situation of ten-
derness. (p.â•¯228)
Thus, a positive attachment relationship with the abuser, a situation of

tenderness, is preserved in consciousness, but this is illusory. In the trau-
matic trance, knowledge of malevolence that cannot be dealt with in the
“real” physical world becomes a living terror in the inner world:
Although the terror-filled relationship is dissociated, it frames the sur-

vivor’s world view as an inescapable constant background definition.
In this way, the “bad objects” never go away (Fairbairn, 1952). Many
such individuals consciously abhor violent and abusive behavior and
may have developed the lack of its expression as a personal ideal. Yet,
try as they may, this maneuver often ends up being undertaken in the
realm of illusion, for they cannot avoid being overtaken at times by the
identity of the aggressor as a result of having so many times filled this
person’s shoes. (Howell, 2002a, p.â•¯935)
With respect to this world of illusion, the problem of the child’s own
aggression is an important one in abusive circumstances. The experience
of unfettered and unpunished aggression toward a loved one has often
been absent in dissociative patients. Winnicott (1971) described how the
child’s experience and expression of aggression toward an object (the other
person) who survives and does not retaliate can enable the other to become
“real in the sense of being part of shared reality and not just a bundle of
projections” (p.â•¯88). This transformation involves an important psycho-
logical shift away from a relatively primitive form of interacting “that can
be described in terms of the subject as an isolate” (p.â•¯88) in which the
object is experienced primarily in terms of projection and identification.
The object becomes real by virtue of having been killed in fantasy, surviv-
ing, and not retaliating.
Considering this issue of “survival,” Benjamin (1990), in common
with Ferenczi, observed how unaccepted experience becomes exclusively
intrapsychic:
The flipside of Winnicott’s analysis would be that when destruction is

not countered with survival, when the other’s reality does not come into
view, a defensive process of internalization takes place.â•ƒ.â•ƒ.â•ƒ.â•ƒW hat can-
not be worked through and dissolved with the outside other is trans-
posed into a drama of internal objects. It shifts from the domain of the
intersubjective into the domain of the intrapsychic.â•ƒ.â•ƒ.â•ƒ.â•ƒW hen the other
does not survive and aggression is not dissipated, it becomes almost
exclusively intrapsychic. (p.â•¯41)
Traumatic Attachment
Like other attachments, traumatic attachments may involve mimicking of
the attachment figure. For example, Van der Hart et al. (2000) described a
soldier who had a posttraumatic twitch in his jaw that seemed to mimic the
facial movements he saw on the face of his beloved comrade who was gasping
for breath as he lay dying. The philosopher Michael Polanyi wrote of implicit
knowing in his book, The Tacit Dimension (1967), and Emch (1944) wrote
of how, in traumatized people, imitation may represent an attempt to mas-
ter essential knowledge about significant others: “If I act like that person—
become him—crawl into his skin, I shall know him and be able to predict
what he will be and not be surprised—hurt—by him” (p.â•¯14).
Current attachment theory provides ways of thinking about identifi-
cation with the aggressor that rely on processes that Lyons-Ruth (1999)
described as “enactive procedural representations of how to do things with
others” (p.â•¯385). Such unconscious enactive, procedural, relational know-
ing is the result of two-person interactions, and these procedural ways of
being with another constitute the larger portion of our lives. In contrast
to relationships of mutuality and interdependence in which there is much

validating and mirroring of the other’s experience, in traumatic procedural
learning, there is no opportunity for interchange of perspectives. Inherent
contradictions in behaviors and among implicit and explicit communica-
tions between caregiver and child cannot be examined. As a result, these
procedural models of how to be with another do not get linked.
In sum, these aggressor-identified, grandiose, and dominating abuser
self-states that often embody rage, contempt, and omnipotence may arise
as procedural, imitative, dyadic enactments.
When the child learns the roles of both abuser and victim procedurally in
conditions of traumatic attachment, the corresponding self-states are likely
to be dissociated.
Note
1. Note on Ereshkigal: According to Merlin Stone, author of Ancient Mirrors of

Womanhood (1979), Ereshkigal had been the all-powerful goddess of the dead
who was forced into submission and marriage to the god of war, pestilence,
and disease. Ereshkigal was a version of The Great Mother. An early prayer to
her had been:
I will praise the Queen of Humankind,
I will praise Ereshkigal,
Queen of Humankind,
Among all the many deities,
Ereshkigal is merciful.
Thus, it would appear that Janice’s Ereshkigal has identified with only parts
of the story—the powerful, omnipotent part (much as Freud did with the
Oedipus story; see end note to Chapter 1)—omitting the more inclusive Great
Mother identification and Ereshkigal’s subjugation.
Chapter 12
The Therapeutic Relationship

Multiple Dimensions of Coconstruction
A DID patient calls me and leaves a message that he is canceling the next
session and those in the near future because of money problems. He says
that he will call me in the future when he has the situation under better
control. I call him back to discuss this, and he answers, “What did I say?”
Another patient calls in a suicidal crisis after having precipitously quit ther-
apy. She does not remember the past 2 weeks.
What is a therapist to do? With patients with dissociative identity dis-
order (DID), the identity of the speaker may change unbeknownst to the
hearer. It is imperative that the DID therapist be aware that the identity of
the person he or she is speaking with now, may not be the same identity
present a minute ago or last week. What Bromberg (2000) called the “ever
shifting configuration of multiple real relationships in which dissociation
has a role” (p.â•¯568; emphasis in original) is especially the case with people
with DID. The patient with DID will have multiple real relationships with
the therapist and others, as well as multiple transferences. Of course, the
therapist will also have multiple real relationships and multiple transfer-
ences and countertransferences.
Traumatic Transferences
andÂ€Countertransferences
Traumatic Transferences
The most basic transference paradigm for patients with DID is the traumatic
transference (Herman, 1992; Loewenstein, 1993; Spiegel, 1986), although
this may contain some versions of the erotic transference as well. The trau-
matic transference refers to the patient’s expectation that he or she will be
abused and exploitatively used as a narcissistic extension of the therapist.
Some parts are consciously aware of this expectation. Others embody ways
of coping with life that are designed to keep the expectation of exploitation
out of awareness or to focus on other problems. Because most patients with
225
DID were traumatized in the family of origin and beginning at an early

period in their lives, their expectations of abuse can be intense.
Not only multiple transferences develop with highly dissociative patients,
but also multiple traumatic transferences. Traumatic transferences are often
hidden: The therapist may be in communication with a trusting host, while
beneath the surface are many who expect to be betrayed. Among the parts
who are highly aware that they have been exploited and who expect that
the therapist will behave in ways similar to their original abuser(s), some
are sensitive and scared, fearing that if they trust the therapist, they will
be hurt. Other parts may be easily ignited by a misplaced word or action.
Yet other parts operate in denial of the trauma. In addition, it is not only
individual parts who embody and express traumatic transferences but also
the overall configuration of the interrelationships among the parts.
There is another important matter regarding traumatic transference. In
certain important ways involving intersubjective attunement to another’s
unconscious, the suspicions and fears that some of the identities harbor
may be correct. In contrast to the therapist’s desire to be seen in a positive
and benign light:
The patient correctly perceives that within the therapist resides all those
potentials for murderous rage, sadistic thought and action, collusive
betrayal, and self-object devaluation which the patient knows too well
from the past. The therapist’s conscious or unconscious denial of these
potentials is, in my experience, the most common source of impasse
in the treatment of persons with posttraumatic disorders. (Chefetz,
1997b, p.â•¯259)
Chefetz’s observation is crucial. Therapists’ blindspots for their own

potentials for murderous rage, and so on, as Chefetz observes, may result
in unresolved enactments. Enactments in therapy do not occur on a level
playing field. Although the therapeutic dyad is coconstructed, this does not
mean that it is equally so.
Dissociative patients are more vulnerable than nondissociative ones as
a rule: They cannot always answer directly, but may disappear without
engaging if their therapist becomes harsh or hostile with them. Or, an angry
alter may appear. Although disappearance of the host or appearance of an
angry alter may transferentially repeat the patient’s early experience, such
events should also be understood in terms of the real power relationship.
Traumatic Countertransferences
The complexities of multiple dissociated identities, who all have their own
transferences, are likely to increase the therapist’s countertransferential vul-
nerabilities. Traumatic transferences yielding behaviors that are aggressively
The Therapeutic Relationshipâ•… 227
angry, aggressively needy, passively needy, passively aggressive, and so on,

especially if they are hidden, may elicit a traumatic countertransference
before the therapist is ready—or knows that it is happening. At such times
a therapist’s ability to accept and “hold” the impact of the patient’s horror-
filled memories and feelings, without tuning out or reciprocally respond-
ing, is crucial.
Patients’ posttraumatic expectations can have quite startling effects on
their therapists. Loewenstein (1993) described an occasion in which he
become momentarily
flooded with an insistent visual image and tactile hallucination of

touching the patient in an intimate manner. Although I felt intensely
disquieted and disoriented by this experience, I managed to inquire
neutrally if “something had shifted” within her at that moment. She
replied, “Yes, the sexy one is here now.â•ƒ.â•ƒ.â•ƒ.â•ƒShe’s a child.” (p.â•¯67)
Loewenstein reported that as they were able to talk about this, his visual
hallucinations disappeared.
Such experiences of intense, strange, upsetting nonverbal response to
severely traumatized patients are common. Loewenstein (1993) noted that
the patient that he described had “previously been overinvolved with sev-
eral therapists” (p.â•¯66). Kluft (1990) addressed this common countertrans-
ferential problem that far too many therapists have enacted as “the sitting
duck syndrome” for many vulnerable patients. The dissociative patient
is a sitting duck for exploitation because the dissociation of parts of the
self able to read danger cues having to do with malevolent attachment fig-
ures was in the service of survival and attachment when she was growing
up.â•¯Thus, the sexy ones may come out, enacting “a procedural way of being
with others” that is familiar but potentially dangerous to them. They are
too vulnerable to defend themselves—or sometimes even to know that they
need defending.
Two kinds of traumatic countertransferences are the pull to be abusive
and the feeling that one is being abused. In addition to the kind of pull
to be exploitative that Loewenstein (1993) identified, DID therapists may
also find themselves feeling exploited or emotionally maimed in the work
and often angry, exasperated, burned, shamed, drained, anxious, and
depressed as a result. Davies and Frawley’s (1994) outlined four matrices
of eight transference and countertransference positions that are typically
in operation in trauma therapy. The matrices that they described involve
the “uninvolved nonabusing parent and the neglected child”; the “sadistic
abuser and the helpless, impotently enraged victim”; the “omnipotent res-
cuer and the entitled child who demands to be rescued”; and the “seducer
and the seduced.” The therapist will most likely get to occupy all eight posi-
tions. (However, from Ferenczi to Davies and Frawley, I think that seduce
is usually too mild a word to describe the kind of behavior on the part of
the original perpetrator that is actually meant. Sexual exploitation would
often be more accurate.)
With highly dissociative patients, therapists may find themselves feeling
a variety of other intense emotions, such as anger, fury, horror, terror,
sleepiness, utter exhaustion, and parental-like caring, among others. The
emergence of these emotions in the therapist may be due to a variety of
factors, including processes often called “projective identification,” enact-
ment, dissociative attunement (Hopenwasser, 2008), as well as empathy
(which may lead to vicarious traumatization). Of course, all of these pro-
cesses occur in relationship, but as is also true for the patient, there will
be many times when something in the therapist’s own history, defense
structure, and other vulnerability is the major source of the therapist’s
idiosyncratic response.
By the nature of the work, as well as their own humanity, trauma thera-
pists are also vulnerable to vicarious traumatization. It can be exhausting
to empathize with so much pain and to truly take in the extent of the capac-
ity for evil of the perpetrators of some traumatized people. It is important
for therapists to have their own support systems, including consultations
and peer groups.
Erotic Transference and Countertransference

Especially with dissociative patients, erotic transferences have multiple
meanings. Chefetz (1997) highlighted how the seeming erotic transference
may express the patient’s need to be special, and how apparent hypersexu-
ality may cover all kinds of dissociated affects, including sadness, grief,
terror, loss, and longings for intimacy, that the child could not express.
A response on this level is a more accurate and helpful approach than
responding to the “erotic” transference as an adult attempt to seduce. The
erotic transference may express the traumatic transference in that a part
of the patient may feel that she must please the therapist in this way. It
may also be an attempt to preempt control of the therapeutic milieu to
avoid dealing with painful and difficult issues. Erotic transference in a
male with a female therapist may at times represent a way to claim mas-
culinity and as an aspect of defense to avoid feeling like a helpless little
boy. Chefetz (1997) sees erotic countertransference coming in part from
the same sources as erotic transference: the need to feel special and to
deny painful and “unacceptable” feelings: “The therapist unconsciously
longs for repair of his or her wounds. The therapist privately wishes to be
nurtured.â•ƒ.â•ƒ.â•ƒ.â•ƒHatred of the patient and his or her demands remains uncon-
scious” (p.â•¯258).
Projective Identification: The Interpersonal

Language of Dissociated Self-States
The vignette described by Loewenstein (1993) could be called projective

identification. In this case, a dissociative part of the patient, who was “out,”
was communicating by posture, facial expression, motion, and so on. She
was sending cues to which the therapist was responding. This example illus-
trates how work with DID clarifies understanding of the dissociative com-
munications (often also described as projective identification) of people who
do not have DID. Usually, people who are communicating dissociatively are
not able to help us to understand our unusual responses by saying something
like “the sexy one is out.” His patient’s communication helped Loewenstein
to formulate his experience (Stern, 1997). The presence of the dissociated
self-state is most often felt in the interpersonal field without the benefit of
its presence being identified. In DID, this involves the partial or temporary
appearance of a part who had not been out (who had been on the inside), in
the context of the behavior of the usual presenting self. The therapist may
find him- or herself responding in a reciprocal way but not knowing why.
In this formulation, DID is the template for understanding enactments in
work with patients who do not have a formal dissociative disorder.
Projective identification is often used to refer to a person’s attempt to
disown his or her own experience by “putting it into” another person. The
disowned affect or experience is then considered to be induced in the other
person. However, in my view, projective identification is a term rife with
multiple meanings and problems. Among the problems are the following:
• The assumption that something is “put into” Person B by Person A in

a way that allows Person B to disown any sources of the experience
(which is supposed to originate in and be disowned by A) in him- or
herself and simply blames A for whatever B is thinking or feeling. For
example, his patient was not “putting anything into” Loewenstein.
His response was his own and came from his own cognitive and sen-
sorimotor system. (This is not to say that he was not responding to the
initially unidentified presence of The Sexy One.)
• The assumption of a unified self in the original definition of projective
identification is problematic. The projector must somehow simultane-
ously know and not know about the projection. With reference to
the hypothetical unified self, if the self does not somehow know the
disavowed material, how would the person know what to expect to
interact with in the receiver? On the other hand, if the unified self
knows, the process would be conscious, and there would be no need
for the projective identification.
• The assumption that the projector is trying to control the other person.
I think it is less problematic and more accurate to think in terms of the inter-
personal language of dissociated self-states or, more simply put, enactments:
Once a dissociated self-state is expressed (in whatever way), it enters

the interpersonal field as a way of being with another. Here this way of
being with another meets another person who also has ways of being
with another. In this way of thinking, projective identification and
enactment are two sides of the same coin. (Howell, 2005, p.â•¯11)
Another way to say it might be that projective identification is one per-

son’s dissociated experience in communication with another person’s disso-
ciated experience. The language is interpersonal and coconstructed because
the recipient’s register for the experience is also comprised of dissociated
self-states. Without dissociation in the recipient, there would be no sense
of an induction of “out-of-the blue” experience, only an empathic recogni-
tion. Therefore, dissociation in both parties is required for the concept to
be meaningful. It is far simpler just to speak of enactments.
As I see it, there are two primary ways to view this interpersonal lan-
guage of dissociated self-states. One is in terms of dissociated reciprocal
role relationships, and the other involves communication from right brain
to right brain (Schore, 2003a, 2003b).
In Melanie Klein’s original meaning, projective identification was a purely
intrapsychic and unidirectional process. Laplanche and Pontalis (1973)
defined projective identification as “a mechanism revealed in fantasies in
which the subject inserts his self—in whole or in part—into the object, in
order to harm, possess, or control it” (p.â•¯356). Later, Bion, Ogden, and oth-
ers expanded the meaning of the term to include interactions in the mother–
infant dyad and in the transference–countertransference. Despite these more
positive formulations that included the interpersonal nature of the process,
articulations of this process often get repackaged in a one-person psychol-
ogy devoid of shared responsibility for the experience. Sandler (1976), also
assuming the interpersonal nature of the process, wrote that he does not
find the concepts “projective identification” or “putting parts of oneself into
the analyst” adequate to understand the dynamic interactions that “occur
in transference and countertransference. It seems that a complicated sys-
tem of unconscious cues, both given and received, is involved” (p.â•¯46). As
if in answer to Sandler, Anthony Ryle (1994, 1997a, 1997b) described how
reciprocal role procedures, involving generalized procedural memories of
dyadic interactions, are enacted. When dissociated, these dyadic reciprocal
role patterns provide templates for rigid reenactments of old experience.
Because deprivation and abuse can interfere with integrative personal-
ity organization, in traumatized patients there will be greater isolation, or
dissociation, of reciprocal role patterns and greater personality fragmenta-
tion. The internalization of self–other procedures implies the corresponding
ability and need to elicit reciprocation from others: “In enacting a role
there is always pressure on the other to relate and reciprocate in a particu-
lar way” (Ryle, 1994, p.â•¯110). As they are less consciously contextualized
within the structures of other dyadic role patterns, given dissociated role
patterns will be narrower and have a more urgent need for reciprocation
to obtain confirmation of the self. People whose reciprocal role patterns
are more isolated (dissociated) and whose repertoire is more limited tend
to interact more forcefully with others and to do so in search of a specific
response to obtain confirmation of the self. Consequently, the other person
in interaction is more likely to feel pressured. Because the demand from the
“projector” is not conscious or formulated it forces people into reciprocat-
ing implicit modes of knowing another.
In Loewenstein’s (1993) vignette, his patient’s “sexy one” was an “iso-
lated subjectivity” (Chefetz & Bromberg, 2004, p.â•¯431) in the context of
her overall self-structure. Because of her isolation, the stance and intention
of the “sexy one” were not modulated by other aspects of her self, and she
exerted a stronger pull than she might have if she had been less isolated.
However, there is another aspect of what often falls under the rubric of pro-
jective identification; and that is communication from right brain to right
brain (Schore, 2003a, 2003b).
Schore wrote of the power of intersubjective affective responsiveness
via communication from right brain to right brain. These affects are com-
municated by body rhythms, somatic states, and facial expression, all in
a right-brain-to-right-brain way. The processing of this information is so
rapid that it is not consciously perceived. Inasmuch as dissociated traumatic
memories are stored in implicit procedural memory, they are also commu-
nicated nonverbally, right brain to right brain.
Thus, in the clinical context, although it appears to be an invisible,

instantaneous, endogenous unidirectional phenomenon, the bidirec-
tional process of projective identification is actually a very rapid sequence
of reciprocal affective transactions within the intersubjective field that is
coconstructed by the patient and the therapist. (Schore, 2003b, p.â•¯73)
Whatever we call it, the interpersonal language of dissociated self-states

affects various aspects of the treatment frame. Boundary management is
often more complicated in the treatment of DID than when we are not think-
ing in a dissociative paradigm. When we are thinking of the patient as a
unitary personality, we think of the whole person’s motivations and actions.
For instance, the patient intrudes into the therapist’s life with many phone
calls or requests for the expenditure of extra time. At least in theory, this is a
simple matter of maintaining proper boundaries. For someone with DID, it is
often a particular part who is making the calls or requests, and the activity of
this part may or may not be known about by the part most frequently out.
For example, Maggie, a college student who is academically talented,

suddenly wanted help with her homework and wanted it outside the session
as well, including wanting me to read all of her papers to be turned in to the
teacher. At the same time that she was making the request for homework
help, I noticed that I was feeling as I did when nursing my own children
when they were babies. Literally, I was feeling a somatic “wish” to feed her
from my own body.
Immediately after that, Maggie informed me that her 8-year-old part
was out. This particular part longs for mothering and feels frightened and
vulnerable. (Maggie was extremely neglected by her mother and certainly
never got any help with homework from her.) The 8-year-old then began
to tell me in various ways how needy for loving life sustenance she is.
(Maggie did not put anything “into” me because the way that I responded
was already part of my experience. However, the way that I responded
remained partially unformulated until Maggie gave me some context.) My
awareness of how extremely vulnerable this part is then aided me in think-
ing about how to address the situation. Speaking to the child part, I told
her that I understood that she feels insecure about her homework and that
she longs for the feeling of having a strong, helpful, reliable relationship—
of someone being there for her, as a buttress from which to proceed in her
interactions with the outside world. I said that I would be willing to look
over a small amount of the work that she wanted me to see and see how
that feels to her, but that I could not do this routinely. Since we both know
that she is in fact smart, I suggested that we could talk about what she is
afraid of, what she wants, and what she feels she needs.
Finally, I asked if there are older, more grown-up parts who are academi-
cally more secure. There were. I then asked if they would be willing to stay
with this 8-year-old when she is frightened about so much—about needing
and about her papers. In addition to furthering integration, this approach
to helping the child part is premised on her responsibility for herself and
avoids the potentiation of an out-of-control enactment in which the treat-
ment becomes about getting mothering and bypassing the painful work of
mourning the fact that she got far too little mothering.
So far, I have been discussing the interpersonal language of dissociated
self-states in the framework of enactments. But, there is another important
aspect of dissociation that often goes unnoticed in the treatment: dissocia-
tive attunements.
Dissociative Attunements: Dancing

to the Other’s (and Hence, One’s
Own) Unrecognized Music
We are drawn into attunements with the rhythms and moods of others
often without knowing it or without knowing why. For example, therapists
working with patients with dissociative disorders often report experiencing

a fog at certain points in sessions; indeed, these experiences of the thera-
pist may be diagnostic markers for the presence of dissociative disorders
(Loewenstein, 1991). As part of being attuned to the patient, we may expe-
rience much more than simply our own cognitive and emotional reactions,
including the horror of what has happened to someone that we register in
the normal ways. When we are attuned, we are “in” it. We also experience
the rhythm and the “music” of the patient’s mood. Often, we do not know
it. This is a matter completely aside from projective identification, counter-
transference, and enactment: dissociative attunement.
I think that the concept of dissociative attunement, originally presented
by Karen Hopenwasser (2008), may well become pivotal for much rela-
tional psychoanalytic thinking of the future. Drawing on chaos theory
and the work of infant developmentalists, such as Colwyn Trevarthyn,
Hopenwasser conceptualized dissociative attunements as “systematically
self-emergent moments in which multiple self-states are shared by means
other than projection” (p.â•¯349). Further, she stated that “a mutually held
state of attunement is neither a ‘do to you’ nor a ‘do to me’ experience. It is
a synchronized, simultaneous awareness of knowing that is nonlinear and
fully bidirectional” (p.â•¯351). Dissociative attunement with respect to our
psychotherapeutic work involves empathic attunement and affective reso-
nance that are dissociated initially by both parties. What is required is that
the therapist stay with the unwelcome experience, helping the patient to do
the same. Eventually, both parties are able to mourn the pain and the loss
that were too unbearable to enter conscious experience. The therapeutic
dyad does this together. It has some similarity to Bion’s (1957, 1959) and
Ogden’s (1983, 1986) descriptions of the mother and the therapist metabo-
lizing unbearable material and then giving it back to the baby/patient, but
unlike that concept of projective identification, this is a parallel process in
which the therapist joins with the patient as they mourn and suffer together
the jointly held painful affects and ugly intentions. One could liken it to
modeling or witnessing, in that the therapist is respectively engaged in the
same process and standing by, but in contrast to “showing from above” or
“knowing from the side,” this model is completely equalitarian.
Likening dissociative attunement to a dance, in an extension of the meta-
phor of the dissociative dance used by Baker (1997) to describe projective
identification and enactments, Hopenwasser (2008) emphasized that this
is a dissociative dance in which we as therapists willingly join. In this pro-
cess, what matters most is what we and the patient do with each other. In
this frame, what we do to each other becomes more or less a distraction.
Hopenwasser described two cases, one who did not have DID and one who
did. For the patient who did not have DID, both patient and therapist expe-
rienced a “meanness” within themselves that they expressed to each other,
but that for both in the interaction felt like not-me. In describing the case, she
asked why the events would not be describable as projective identification

and answered that the patient was fully aware of her meanness. Why, then,
was this not countertransference enactment? She answered as follows:
But the repetition of these painful encounters suggested to me a shared

process beyond countertransference yet still outside of our jointly held
awareness. It felt like a jointly dissociated awareness that was actually
a function of attunement, rather than misattunement. I was not miss-
ing the mark in my comments. I was hitting a bull’s-eye over and over
again in some kind of reckless precision that stunned us both. (p.â•¯356)
Hopenwasser (2008) stated that she began to take on the quality in

interaction with this patient that the patient had most complained about
in herself: a tendency to be gratuitously mean. This was not a quality that
Hopenwasser had experienced as an aspect of her normal self. But in interac-
tion with this patient, try as she would not to be mean, “every now and then
I would open my mouth, words would spill forth with only the best inten-
tions, and wham—Marina would feel punched in the stomach” (p.â•¯356).
Hopenwasser (2008) decided to work on the problem as her own:
Over a period of many, many months I opted to work with my reiter-

ated meanness the way one would work with internal perpetrator parts.
I never blamed her for the provocation or attempted to help her under-
stand this as a coconstructed catastrophe. Instead I struggled to sit
with the urges to rid myself of shame and guilt. It became clear that an
underlying attunement would allow her to sit with me, with my shame
and guilt, with her shame and guilt, together in this whole miasma of
relationally induced shame and guilt. Simultaneously I reflected on my
own countertransference issues. (pp.â•¯356–357)
The author (Hopenwasser, 2008) stated that for over a year she and her
patient “sat in a state of dissociated internal perpetration that was finely
attuned. This attunement held us like gravity to each other. We both suf-
fered, we both struggled, but enough of the time we could both remember
that neither of us was solely malevolent” (p.â•¯357). Finally, they each learned,
with great effort, to stop being mean with each other. They each learned
better how to recover from attacks and to display caring, so that finally their
connection did not have to include this torment. Hopenwasser stated that
she believes “it was this dissociated attunement that allowed us to stay con-
nected through a mutual inner experience of perpetration” (p.â•¯357).
Hopenwasser (2008) ended by saying the following:
When we bring our own rhythmic ability into the mourning experience
we are facilitating healing in an implicit, embodied manner. When we
sit with our patients in a state of mutual grief and disappointment,

we are utilizing dissociative attunement in its most therapeutic form.
(p.â•¯362)
Our conceptual history, including concepts of projective identification as

well as transference and countertransference, has much emphasis on done
to, such as descriptions of the experience of being invaded by the patient’s
psychic contents. There have been many descriptions in our work with
traumatized and dissociative patients of the therapist being overtaken by
sleepiness—an attunement to the sleepiness that the patient is experiencing,
often as an aspect of a trance. While the therapist may assess this in the
framework of an intrusion, I do not believe that it needs to be understood
this way. The therapist has willfully joined with the patient on the path of
sharing her experience. The therapist has made a choice to enter. When one
opens new doors, what lies ahead is likely to be unexpected. We are attun-
ing to the patient’s experience, which is new to us. There is no intrusion.
We are simply entering a new world. This is truly a dyadic engagement
because both parties are there together. The model of projective identifica-
tion is a “done to” model. While in its later, post-Kleinian forms, projective
identification is a model of dyadic interaction, it involves each party with
separate experience, intruding and receiving experiences each into and
from the other. In the forms of role enactments (Ryle & Kerr, 2002) and
countertransference matrices, both the patient and the therapist are split
into experiential parts that are the reciprocal of the other. Hopenwasser’s
(2008) model builds on these earlier ones, but I think that her model of
mutually synchronizing systems is a most therapeutically promising one.
I would like to describe a case vignette that illustrates some of these
points. As opposed to Hopenwasser’s (2008) example, this is a case of DID.
The vignette illustrates attunement with multiple self-states in the patient
at any given moment.
Linda switched to a 5-year-old self-state and described her torture as she was
a captive in her home where her brothers and their friends would force her to
perform fellatio on them. Her mother would not believe her reports but would
instead beat her for suggesting such things. At times, she would go to the ceiling,
watching the “other” 5-year-old Linda who was being beaten. As the 5-year-old
part of Linda was describing this, I became aware of the distinct feeling that she
was so sweet and vulnerable as she was beaten. For a moment, I became aware
that I could hurt her. There was a feeling in me of potential sadism, potential
brutal sadism. (At that moment, I was attuned also with her internal perpetra-
tors, who were not “speaking” at that moment. These self-states understood the
experience as sadistic, although the 5-year-old Linda did not.) Once the grown-
up host had returned, I said to her, “You were treated with incredible sadism.”
Linda’s response indicated that she felt exactly understood by my comment.
In our interaction, the 5-year-old part was able to reexperience her trauma,
but with the added component that important parts of the nature of the experi-
ence had been articulated and formulated. She could also add to her experience
the fact that talking about it with me had been safe, and that nothing had hap-
pened to her. It was a corrective emotional experience. All of these were part of
the therapeutic action.
However, I would like to examine this experience from the standpoint of

dissociative attunement. I was joining with Linda in the horrible music and
brutal rhythm of a self-state of a 5-year-old abused child, who was both
suffering abuse and anticipating abuse. She was not “putting any experi-
ence” into me, and I would not describe this as a “complementary” iden-
tification with her. I had stepped into her music and had joined her in her
experience of being abused and anticipating being abused by another. She
was not doing anything to me; I was not doing anything to her. I was sit-
ting with her and experiencing with her the way she, both as parts and as a
whole, was organizing her experience.
By means of attunement, including dissociative attunement, when we pay
attention to our experience, even when we do not have the verbal means
of labeling or categorizing it, in session with the patient, we may be given
important clues about the patient’s experience—about what the patient
feels like, past and present.
States of mind shift in our patients and in ourselves. The analyst relies on
his or her acquired knowledge, past experiences of similar instances and
how they were resolved; at such times, we have little “objectivity.” What
we have is a finely honed subjectivity—our knowledge of ourselves, which
we attempt to use as a “baseline.” And, no longer is it adequate to think of
our interactions with our clients in terms of simple transference and coun-
tertransference. As humans, we influence each other in many ways that
we do not understand well beyond the fact that it happens. Nonconscious
affective communication of the sort Schore (2003b) described and likely
mirrors neurons (Gallese, 2009) as well influences our responses to others
as we empathize, identify, and imitate more than we know. But, as part of
this we also become entrained (Hopenwasser, 2008) in another person’s
way of being. This helps us to know another person, but we must be able
to exit the entrainment, to know the difference. We are like resonating
tuning forks, but our job is to let that happen without shutting down or
turning away.
Colwyn Trevarthen’s Work

As some background to Hopenwasser’s work, I would like to briefly say
something about Trevarthen’s work, which is based on some of the same
premises. Trevarthen studies babies and the interactions between babies and
their caregivers. In a way that has some similarity to Schore’s right-brain-

to-right-brain procedural communication, Trevarthen (2009) emphasized
the rhythm and the musicality of interactions: “All animal actions take the
form of rhythmic or pulsating measured sequences of movement.â•ƒ.â•ƒ.â•ƒ.â•ƒBrains
are networks or dynamic systems all obedient to the rhythms that flow in
unison” (p.â•¯76).
Trevarthen is also known for his concept of innate intersubjectivity:
The combined operation of visceral and somatic “mirror” reactions

between mother and infant gives, in ways we do not fully understand, the
infant means of expression and access to the other anticipatory “motor-
images” and “feelings” and permits direct motive-to-motive engagement
with a companion.â•ƒ.â•ƒ.â•ƒ.â•ƒThus arises the psychological phenomenon of
intersubjectivity, which couples human brains in joint affect and cogni-
tion, and mediates all cultural learning. (p.â•¯70; emphasis in original)
Trevarthen (2009) described how “protoconversations” with infants

younger than 4 months show primary intersubjectivity. These protocon-
versations are followed by musical games. Trevarthen emphasized how the
baby is constantly organizing, constantly anticipating, constantly synchro-
nizing with the tenor of his or her interpersonal environment. In an earlier
(Trevarthen, 2003) work, he described a 20-week-old blind baby conduct-
ing with her hand as her mother was singing to her—with high and low
beats in space, that is, with motoric perfect pitch and perfect rhythm. What
was most remarkable was that the baby’s beats were several seconds ahead
of the mother’s. This meant that the baby not only was following along but
also was anticipating her mother’s song. I believe that this is what people
do: We anticipate the other. And, as Trevarthyn said, we anticipate the
other to interact with the other.
Chapter 13
Dreams in DID
In analytic treatment or in dreamwork, when the therapist or dream-

worker is able to relate to each aspect of the patient’s self through its
own subjectivity, each part of the self becomes increasingly able to
coexist with the rest, and in that sense is linked to the others. It is an
experience of coherence, cohesiveness, and continuity, that comes about
through human relatedness.
Bromberg (2003, p.â•¯704)
Dreams are especially important to ask about in work with patients with
dissociative identity disorder (DID) because they can easily fall between the
cracks in the midst of the complicated and time-consuming work with the
many different parts. Dream work may often reveal important information
and feelings that were not brought forth in work with parts.
Dream work with DID patients is in many ways similar to dream work
with patients who do not have DID; in many ways, it is quite different. In
both cases, dream perceptions, thoughts, and reminiscences are often highly
condensed, overlaid, one on top of the other, like a three-dimensional col-
lage, in which the pieces blend into a structural whole. Dreams have their
own profound and special language that renders experience with vividness,
intensity, and in metaphor. Dreams telescope different times into a single
dream event, symbolically substitute one dream element for another, con-
densing disparate people, places, and meanings into one image. Dreams
may express wish fulfillment, state a message to the dreamer, or frame a
point of view. While dreams can be intricately complicated, they can also
sometimes be starkly simple and clear.
Nonetheless, often the dreams of patients with DID have characteris-
tics that more ordinary dreams do not. To begin, unlike more ordinary
dreams, posttraumatic dreams are often almost literally reenacted memo-
ries in the dreaming space. Among recurrent trauma dreams, some just
tell the same story over and over; others modify the story somewhat from
dream to dream. While some trauma dreams seem literal in the depictions,
others may include all of the symbolism, displacement, and so on that are
239
characteristic of more ordinary dreams. Even when they are symbolic,

trauma dreams may often feel literal, partly because they convey raw emo-
tion. For example, traumatized people often symbolize the decimation and
burial of parts of themselves with dream images of fallen support beams
that now trap and pin people, usually children, beneath them; of grave-
yards where children have been buried alive with horrific living memories;
or of parts of the self that have been buried alive.
Dreams may express ways that the adult as a child attempted to regulate
affect. For example, one patient who was traumatized as a child had recur-
rent dreams of rising to the ceiling, even over the trees. Yet, in the dreams
this did not feel upsetting: Her ability to accomplish such “levitation,” as
she called it in her dreams, was a matter of pride. Strangely, in her dreams
no one else ever saw her rise, and she often wished to share the joy of her
accomplishment with others but was always unsuccessful. In our analytic
work, it became apparent that these dreams probably did recall times that
she experienced herself rising to the ceiling in response to trauma. But, they
also reflected her pride in being able to dissociate as a defense, in being able
to take care of herself by being able to regulate her affect in this way. Thus,
the dream revealed not only that she had had early trauma that had sent her
rising to the ceiling, and not only how she had learned to frequently “rise”
in an anticipatory defensive way, but also how she had managed to deflect
her experience of early terror, transforming her view of this defense into
something of which she was proud.
When we move to the explicitly dissociative arena, dreams have a special
language and more particular meanings. Although the basic structure and
language are not limited to dissociative disorders, as they simply character-
ize the human mind, this language is especially important to be aware of in
the case of dissociative disorders. While we all have dissociated self-states,
dreams of people with DID illustrate with particular vividness how parts
of the self take on a character and a voice, stating their perceptions, beliefs,
fears, and desires.
Dreams may also sometimes even roughly adumbrate dissociated behav-
ior that was enacted on the outer stage of reality (Barrett, 1994, 1996;
Brenner, 2001). For example, in some of his earlier work, Fairbairn dis-
cussed personified parts of his patient’s psyche—the “mischievous boy,”
the “critic,” the “little girl,” and the “martyr”—that regularly appeared
in dreams as well as in waking life. Fairbairn (1931/1952b) stated that,
for this patient, the “personifications seem best interpreted as functioning
structural units whichâ•ƒ.â•ƒ.â•ƒ.â•ƒattained a certain independence within the total
personality, and it seems reasonable to suppose that the mental processes
which give rise to multiple personality only represent a more extreme
form” (p.â•¯219).
Dreams may express relationships and conflicts between dissociated self-
states. For example, a patient dreamt that she had a headache, and that she
Dreams in DIDâ•… 241
needed four aspirins—“two for both” of them. The same patient, a woman
for whom aggression was very much dissociated, dreamt of two women
who looked very much alike. One was trying to strangle the other. The
problems of the dissociated self are especially apparent when self-states
seek to dominate or annihilate each other, as in the dream just described.
The correspondence to action on the stage of reality is that the annihilating
parts often do not recognize that they share the same body.
The Same Dream but From a

Different Perspective
Another marked feature of the dreams of people with DID is that differ-
ent self-states may have the same dream but from different perspectives.
Different self-states may have different roles in the action of the same
dream; they may literally “see” the action of the dream differently; they
may notice different things; and aspects of the dream may be meaningful
to some parts but not to others. Sometimes, the imagery of a dream recalled
by one identity will influence the others; sometimes a dream may be specific
to one identity but not to others. The confusion about such dreams can at
times be extremely upsetting, much more so than a nightmare might be to
a “singleton.” As the therapist talks with different self-states about their
experience of the dream, information may be gleaned that provides insight
into the organization of the patient’s self-states and system defenses.
The following dream of Dennis (introduced in Chapter 1) illustrates how
different self-states may have the same dream and the importance of listen-
ing to the different things they know in the dream:
A few scientist friends were just arriving to a site in the woods. There were army
barracks and a wall of woods behind. The day was autumn-like and overcast.
The researchers wanted to study some fauna that lived only in the woods. These
animals had been bred for the purpose of weaponizing. The scientists were told
to stay on the path: “Don’t get off the path! Because if you do, they can get to
you!” There were leafless white trees that looked like they were made of bone,
all around. They had branches coming to points. They were the fauna.
There was a family behind us, a mother and a father and a 4-year-old girl. I
hear a clicky sound, like there was communication with each other from the
tops of the branches. The trees were clattering. It was very loud. The little girl
had momentarily stepped off, and three or four of the trees had skewered her
through the chest, and murdered her. One of the trees very gingerly pulled a
square film from her body—a filmy sheet that had a soft glow. The film was her
essence. It was whatever makes that person distinctly them.
As they tore it apart, I heard this other scream—raw suffering—a scream that
heralds the knowledge that you will no longer exist. Then everything was gone.
Dennis has had the same dream from the perspective of the little girl.
She momentarily steps off the path, is skewered in the chest by the same
trees, and is murdered in the same way. About this, Dennis said, “I
thought that the little girl was a facet of me that had not been examined.”
Understandably, since she is murdered, her dream is not as complexly told
as Dennis’s. She holds the terror in the dream, a terror that came through
to me as the listener quite starkly, a terror that Dennis lives with every day.
It is understandable that Dennis, whose time spent as Dennis is so often
depersonalized, from the perspective of his dream as Dennis, casts himself
as a member of a group of scientists who are studying these cruel fauna,
and he says of the little girl’s plight, “I thought the dream was a warning; I
had 60% curiosity and 40% empathy for the little girl.” It is hard for him to
fully take in, as Dennis, the horror the little girl’s plight. He has the curios-
ity of a scientist, but he does also care about her a lot. It is not surprising
that Dennis has a great many “zombie” dreams in which characters who
are dead come back to life but without the physical or emotional vulner-
abilities that they had previously had as humans.
When Dennis told me the part of the dream in which he described how
“one of the trees very gingerly pulled a square film from her body—a filmy
sheet that had a soft glow. The film was her essence. It was whatever makes
that person distinctly them,” I heard the word film as implying a visual
record, as memory. It is one thing to suffer immense pain; it is another
to have one’s memory, essence, or soul stolen. Then, remembrance is not
possible. Dennis, who is as the part, Dennis, and as a whole, a highly car-
ing person, has ambivalently told revenge fantasies. However, the bloody,
hot, bone-crunching fury is held by the part named Mnemosyne, who
is the personification and goddess of memory in Greek mythology (see
description of Dennis’s map in Chapter 10). So, he does have memory.
But, memory is mixed with rage. The dream also brings to my mind how
psychopaths often wish to deprive their victims of the very thing of which
they have been deprived—their humanity. With Dennis, they tried but did
not succeed. In addition to his attachment to his mother, his dissociation
saved him.
This dream also states in readily understandable symbolic terms how
close to death Dennis often felt—in fact, that he did die subjectively at the
hands of the human monsters who sexually and psychologically tortured
him when he was 3, and then from 8 to 10 years old. This dream is not
only about Dennis’s experience, however. It is a dream that says it all about
the nature of psychopathic human predators. In reflecting on the dream,
Dennis added that the trees were not solely evil:
They were surviving on the food they came by. The trees behaved according to
their nature. I first felt sympathy toward the parents, who knew that the little
girl’s primary essence was being devoured. It felt like a cold justness. It made me
shiver profoundly that the world had something like them in it, that the world has
something in it that is capable of that kind of destruction.
Hearing the dream also made me shiver.
The Mute Girl
Jeannie, a lovely caring woman, has symbolized herself in her dreams as

The Mute Girl. Interestingly, when Jeannie and I began our work together,
9 years ago, she was extremely disorganized in her speech, such that I
often found it difficult to follow her—which I can generally do well, even
when people go off on multiple tangents. One area where communication
was clear, however, was in her dreams. Much of the integration that has
occurred in our work together has been from her telling her dreams of her
highly dissociated multiple internal characters.
She had many, many dreams about a mute girl. Sometimes, this girl had
been buried by rubble and had to be rescued. Sometimes she was barely
alive. There was also the beautiful boy for whom she longed. These were
constant dream characters. Often, there were flocks of girls (or birds)
together, with herself as the leader; when danger emerged, she would lead
them away in flight. Sometimes, she was a bear who lives alone and keeps
people away. In other dreams, she would be viewing the world through the
eyes of another being, sometimes a cranky but loving gorilla.
The Mute Girl did not interact with anyone, but she was always part
of a unit, often a twin. Although she was closed off to the world, she was
watching and learning, and sometimes she was the dreamer. In one of the
first and clearest mute girl dreams, she lived in a self-sufficient community
of children, with a beautiful girl and beautiful boy as the leaders of several
units within the community. The beautiful girl went missing. The Mute
Girl was the only one who knew what happened to her. The Mute Girl also
had a vision of a man in a cave who had his “kills” splayed out on the walls
of his cave. It is unclear whether it was the beautiful girl who was killed,
but it was a bloody scene. In this dream, Jeannie was The Mute Girl and
heard murmurs of other voices, such as the other children’s collective frus-
trations, fear, and sadness about the lost beautiful girl and that they did not
know how to reach her, The Mute Girl, to get the information they needed
to find the beautiful girl. Her dream poignantly describes the frustrations
of parts who long for connectedness and communication, as well as the
sense of her internal beauty having been killed or lost. But, it also points
to the role of The Mute Girl as a closed-off source of information and the
importance of her eventually becoming able to speak.
Telling her dreams and discussing what they meant to her has been heal-
ing for Jeannie. I did little interpreting, mostly asking questions. Sometimes,
it has seemed to me that the Selves of her dreams were doing the talking
to me just as much as Jeannie was. For example, as we have been discuss-
ing her tendency to avoid relationships in which romantic commitment is
a possibility and how this may have something to do with early abuse, she
began to dream of a little boy who had the job in the house of monitoring
relationships. He lived in a house, in a special room where in a dedicated
way he controlled the possibilities of romantic action and commitment.
When, in the dream, he was questioned about his job, he avoided the ques-
tioning by flying deep into the basement. This little boy delighted in the
formulas he had created to ensure distrust of men. Jeannie commented:
“He could have been an enthusiastic and committed scientist were his task
and skill not so limited.”
When Jeannie began treatment with me about 9 years ago, she knew she
had dissociative problems, but she had in the past been treated mostly for
depression and suicidality rather than explicitly for dissociation. When we
began work, she was chronically disoriented; for example, she could not
remember left from right and had no regular sleep patterns. She protected
herself in an extreme fashion against being impinged on by the environ-
ment. She worked only at night in a place where she had cocreated a benign,
infantilizing environment, where a coworker called her Baby, and where
she called that coworker Mommy. A good deal of her waking hours were
spent fantasizing. She had primarily one friendship, which she described in
a way that seemed hazy to me. She was deliberately isolated, even fearing
the phone ringing. Jeannie commented:
I still get jumpy with ringing phones. And I still relate to some people in an infan-
tile manner. What’s dramatically changed is my awareness of it and my ability to
choose to be different or manage the circumstances. It looks like some of the
dysfunctional behavior that was the result of a fragmented experience remains,
but now it’s part of a greater harmony which I can create more consciously.
A careful history revealed that when she was probably about 4 or 5 years
old (she does not remember her age—like many events in her childhood),
she was sexually abused, in a nonforcible rape, by an adolescent male
babysitter. Her mother was a highly stressed and depressed hard-working
parent who had to be away from home for long hours. In addition, the
mother often dealt with her stress by beating Jeannie and her older brother,
who then also beat Jeannie. In this context, perhaps the babysitter’s atten-
tions did not seem so bad. After this, Jeannie became a highly sexualized
little girl who was often both attracted to and running away from men who
wanted her to sit on their laps. Jeannie had many large memory gaps in
her autobiographical memory. When she described graduation from junior

high school, she said she knows she was there but does not remember it
in an autobiographical way. Despite all these environmental difficulties,
she was a smart, spunky, resourceful, energetic child. When her mother
decided to take her brother and her to the river one day to drown them all,
Jeannie averted this by calling on a neighbor. This story was told without
the affect of terror. The parts of her that experienced the terror were dis-
sociated. This kind of dissociation helps to explain how, even though she
was generally exceptionally smart in school, sometimes she would suddenly
forget much of what she knew.
Jeannie’s “Happy Face”

Jeannie’s mother and relatives knew that she was clever, but they did not
value this for her. As a child, Jeanie often had to “put on a face,” not only to
cover up her misery but also to be clever for her relatives and her mother’s
friends—and at school. Her speech and her cleverness were exploited. She
was talking because she had to, not because it was meaningful. About this,
Jeannie said:
I received a lot of attention because I was an engaging child but I felt isolated and
was aware that all of me was not “seen.” Over time, my temperamental friendli-
ness became a happy face mask, and my interactions and words became meaning-
less. I was instinctively fearful people were only interested in the part of me that
was entertaining, clever, infantile, attentive, or useful. They were not interested
in any more interior part of me, so I stayed away from them, which in turn rein-
forced my isolation. The happy ways in which I related became increasingly mean-
ingless because an important part of my experience and me was hidden. I wasn’t
all there for others to value, nor for me to value. The mute girl, or whatever
wasn’t expressed, wasn’t accessible to anyone. What could have been genuinely
connective interactions as a child and an adult where people were happy to be
with me (my talents, skills, etc.) felt vacuous because there was no space for the
“mute” or other sides of me.
She added:
As I grew into a teenager, the feeling of being alone and not being seen turned
inward into sadness and despair. I was more resentful as an adult, which now
I see as a step toward growing into relationships—as an adult I had more
expectations.
Jeannie grew up in a country where there was massive, extreme, endemic

poverty. She moved to the United States when she was about 12. An intense,
clear, flashbulb-type memory from her country of origin is the visceral

reaction she had of seeing a nearly naked man walking by who had a huge
bleeding gash in his side. This was right before her dance class, which she
immediately quit afterward because she was viscerally disturbed by her
relative privilege. In the beginning of our work together, she would fre-
quently have dreams of large groups of traumatized people calling to her
for emotional and physical relief from their pain. She reported that she had
the same visceral reaction to these dreams as she did to the man with the
gash. These dreams, which represent both herself and her connection to
others’ suffering, were extremely painful for her to remember and discuss.
Today, she compares the silence about her abuse to the silence around the
trauma of inescapable poverty. She attributes it to “collective helplessness.”
About this, she says,
The friendly child developed a mute self who was stunned into silence due to
trauma. The intense feelings of powerlessness and sadness merged with the
trauma of living in a community where some suffered abject poverty, particularly
children my age (or my height) for no apparent reason. Neither experience of vio-
lence was acknowledged in the prevalent form that I experienced it. To me, the
threat of violence from men and poverty seemed to be everywhere and under-
mined the stability and meaning of the rest of life. How does a child start speaking
about this? And what is there to say when everything unspoken clearly implied
that the violence and silence is simply a feature of the world. These feelings are
alive in me still, but obviously the big change is that I can speak about them. I
can see that my mom’s death and death itself evokes a mute-girl response. I am
shocked, I avoid the feelings, I fear falling to pieces, I sob; eventually, it all passes.
The Mute Girl Learns to Speak

Finally, after many, many dreams about The Mute Girl, she learned to speak
in Jeannie’s dreams. Then, she came to life through Jeannie’s speech.
Today, Jeannie’s dreams are much more ordinary. Recently, she dreamt
that “You were sitting on a couch looking annoyed. You were working.
You weren’t listening to me. I thought you were feeling impatient about
my progress. I was worried that I was taking too long.” She has moved
from more exclusively exploring her internal relationships to exploring her
interpersonal ones, notably her therapy relationship.â•¯But, the focus on her
internal world, without my intrusion of myself into it, had to come first.
Through our work with dreams, The Mute Girl became a more inte-
grated aspect of Jeannie, and Jeannie became clearer and more articulate.
Jeannie got left and right together better. Her sleep schedule improved. Her
life became more organized as she began to work partly in the daytime. Her
social life expanded to include more real people with whom she had chal-
lenging and important relationships. She did not feel as internally confused.
In a dream that she had about 3 years ago, there were several needy children
in front of her. In the dream, she was able to acknowledge them as part of
herself, following which they all jumped inside of her. In a symbolic way,
they integrated with her and became part of her. Now, she has much more
ordinary problems—not that her dreams do not still spell out her problems
in the language of dissociated self-states, but the conversations, inside and
out, are much clearer and coherent.
The way that Jeannie had earlier structured her life exemplified a rela-
tively closed system. Bromberg (1996) has noted that people who have been
traumatized often develop an early warning system, reminding them that
there is potential danger around every corner. This assumption guided the
relatively closed structure that Jeannie had invented for herself. This rela-
tively closed system helped to give her a sense of protection from the outside
and kept her anxiety damped down.
Working with Jeannie’s dreams was not only elucidating but also safe.
It did not violate the protective structuring of her life in a way that a con-
frontational style of working with enactments in the treatment relationship
might have—eliciting anxiety and a possible retrenchment of dissociative
defenses. I was curious about her dreams—and interpretative in the sense
of Aron’s (1996) slant on the word interpretation as a personal way of
making sense of something—as one would personally interpret a work of
art. About this issue, Jeannie comments:
This is so very very true! I can assure you I would have bolted if I detected the
slightest hint of an agenda to heal me. I would have cast you as one of those
people who cannot bear my living in uncertainty, depression, or despair or the
unknown of what’s making me depressed. I needed your sustained and caring
attention to be based on trust that I, Mute Girl and all, want to be whole and
know best how to get there and at what pace. With a confrontation of any sort,
I would have been afraid you were trying to cast me into some mold of “healthy”
that’s not true to me and rush me as if I don’t have enough motivation to resolve
the conflicts. You created a safe space where not only The Mute Girl can emerge,
but also validated other happier parts of me that I assumed were in conflict with
The Mute Girl. I wonder if one way of understanding The Mute Girl’s experience
in therapy is that she came in not “breathing” or interacting in the real world, and
as you listened, you made it safe to start breathing, so she came alive. Any con-
frontation would have only made her stay very very still to the point of stopping
her—my—breath till the aggressors go away.
This approach allowed Jeannie as The Mute Girl to step out of her
dreams, in an increasingly exploratory way, onto the adjoining stage of
interpersonal reality.
Chapter 14
Suicidality in DID
There is a significant danger of suicidality in persons with dissociative

identity disorder (DID). Studies show that 1 to 2.1% of patients with
DID have completed suicide, with an incidence of 61 to 72% who have
attempted suicide (Brand, 2001). Brand, who is a prominent expert in the
field of dissociative disorders, believes this last figure is an underestimate
given that therapists who have had patients who committed suicide may be
less likely to fill out questionnaires, and that these numbers do not include
dissociative patients who have been misdiagnosed or those not in treat-
ment. Brand (2001) stressed that the rates for suicidality are comparable
with—or in some cases higher than—suicidality rates for persons with
severe depression, for which percentages are approximately 20% attempt-
ing and 3.9% completing suicide. Among persons with borderline person-
ality disorder (BPD) the percentages are 75% attempting and 5 to 10%
completing suicide; in schizophrenia, the percentages range from 30 to
40% attempting suicide and 10% completing it. In a recent study of psy-
chiatric outpatients, Foote, Smolin, and Lipshitz (2008) found that a dis-
sociative disorder diagnosis was more strongly associated with suicidality
or self-harm than any other diagnosis—surprisingly, even more strongly
than Major Depression or Borderline Personality Disorder. Furthermore,
when dissociative disorder diagnosis and Borderline Personality Disorder
diagnosis were entered simultaneously into a regression analysis, with sui-
cidality as the outcome measure, the strong association between disso-
ciative disorder diagnosis and suicidality remained, while the association
between Borderline Personality Disorder and suicidality was no longer
significant—suggesting that the dissociative disorder accounted for the
suicidality of the BPD patients, and not vice-versa.
The Meaning of Suicide
Especially in DID, suicidality can have a great many meanings. Sometimes,

it is an outgrowth of rageful fantasies and the vengeance of the powerless,
249
as is more common in dangerous depressions. At other times, persons with

DID have suicidal parts who hold the intention to put the person out of his or
her misery when things get to be too unbearable. Dissociated emotions and
thoughts are not limited to persons with DID. Even with severely depressed
patients who do not appear to be dissociative, we may increase the clinical
effectiveness of our treatment if we inquire about dissociation (e.g., about the
part of the person who wants to live versus the part who wants to die).
Take for example the case with Ereshkigal, who is a persecutor part of
Janice (Chapter 9). A persecutor part may act homicidally toward the host in
a way that from the outside looks like suicidality. Even more so (although this
was not the case with Ereshkigal), homicidal parts are often unaware that they
share the same body with the parts they wish to punish or harm and therefore
believe that they can murder another part while remaining unaffected them-
selves. When this illusion exists, one way the therapist can work to counter it is
to do things such as ask the homicidal part to look at the hands or some other
part of the body that would be recognized as belonging to another part—
maybe to the part most usually out. If the hands are recognized as belonging
to another part, how can the denying part insist that they do not share a body?
Such cognitive dissonance aids in the dissolution of trance logic.
At other times, a homicidal part may say that he (or she, as all parts may
be male or female) does not care if he also dies. At such moments, it can
be helpful to engage that part in the treatment in a profoundly emotional
way, for example, by emphasizing the valuable role that the part has played
in survival, validating the toll it must have taken, and offering empathy for
hardship they protected other parts from and endured themselves.
Often with DID, suicidality has represented a way out when life had
become utterly unbearable. It may be a secret pact that was made internally;
therefore, it is wise to ask directly about such secret pacts if one has reason
to suspect that one exists. In one case, when I asked explicitly, the patient
(a physician) revealed that he had kept a lethal supply of insulin ready for
use for over 30 years in case continuing to live became too unbearable. This
exploration resulted in his consenting to getting rid of the insulin and prom-
ising not to get more or anything else that would work as a substitute.
Often, this type of a secret way out is held by child parts who do not
understand that the pain they are experiencing now is not interminable
(although it may well have felt that way to the patient as a child). These
parts are stuck in time and think that the terror and the pain they are expe-
riencing will never end. For example, Janice, who had attempted to hang
herself from the ceiling with her mother’s stockings when she was 8 years
old, has parts named The Suicides, actually child parts whose job it was to
end life when they felt the pain was unendurable. Talking through to these
parts involved saying things like the following:
Suicidality in DIDâ•… 251
I understand it feels to you like it will never end because that is the way it was for
you and for Janice when she was young. It also felt like that was the only thing in
your power to do. And, it may well have been true then, that was the only power
you had at the time, other than to endure. But now, in this present time, Janice
has many options in her power to make things better. Even though it may feel like
it will never end, it will. Janice is a grown-up now. The horrible pain you feel will
get better because Janice today is able to make things change.
Fantasies about suicide should be explored thoroughly. As noted, the

secret way out may have been a calming salve for unbearable experience. As
Chefetz (2005a) noted, “When the therapist engages in a detailed inquiry
about these fantasies, the therapist then becomes part of the patient’s asso-
ciations ‘in’ the fantasy, and this has a stabilizing effect” (p. 664).
Safety Agreements
Safety agreements are often helpful for maintaining safety in DID treat-
ment. Such safety agreements can include a series of constructive alterna-
tives to self-harm to be taken if the patient begins to feel endangered. The
agreement may spell out a hierarchy of actions, such as reaching out to
supportive others or various forms of self-soothing (e.g., relaxing activities,
relaxation exercises, or physical exercise), all of which are to be imple-
mented before calling the therapist or going to the emergency room. Such
lists and agreements support patient self-responsibility and avoid putting
the therapist in the position of rescuer (Courtois, 1999). Safety agreements
also usually include calling the therapist or being in voice contact with the
therapist before any action is taken.
Safety agreements have several levels of utility. Not only are they con-
cretely useful, but also, because dissociative patients often have ambiva-
lence about safety, the negotiation of an agreement is likely to elucidate
hidden issues. These include unformulated (Stern, 1997) meanings of being
safe, such as ambivalence about personal safety and the meaning as well as
the responsibility to oneself and others that this entails. Because so many
patients with DID have experienced their parents as cruel, sadistic, or lethal,
discussion of safety often brings up dominant transference beliefs concern-
ing whether it is more desirable to be safe or endangered, well or sick, even
alive or dead. Helping patients to understand their ambivalence eventually
helps them to understand that they actually do have more control than they
had previously thought.
Because dissociative parts often tend to think concretely (Putnam,
1989), a written agreement tends to be experienced as binding, helpful,
and comforting. One such written agreement that is sometimes used is, “I
will not hurt myself or kill myself, or anyone else internally or externally,
accidentally or on purpose at any time” (Braun, 1986, p. 12). Here, the

wording addresses potential loopholes in a safety agreement. It addresses
dimensions of internal and external, delusions of separateness, and pur-
poseful versus accidental behavior. If all parts are asked to subscribe to the
agreement, it includes all the different “I” subjectivities. I often use some
wording similar to this, as well as stress that it is the meaning, not the
words themselves, that is important. I invite the patient to collaborate with
me in drafting an agreement that feels right. One new patient and I spent
an entire session on the safety agreement. After she had voiced many objec-
tions, she drafted her own promise (which she has subsequently kept), to
which she attached the words: “It’s the spirit of the thing that matters.”
It is also often helpful to invite the patient to set a time frame during which
the agreement applies. This gives the patient more control, and it also makes it
more concrete. However, because of the concrete thinking, it is important for
the therapist to be aware of the ending points of these time frames. Putnam
(1989) described a serious crisis that emerged when a therapist, thinking that
things were going well, became less vigilant and let a safety agreement lapse.
As a result and no longer feeling bound and contained by the agreement,
the patient became suicidal. When discussing safety agreements, I frequently
tell the patient that my ability to work depends on my feeling safe about the
therapy, and this includes my having basic security about the patient’s safety.
This works for me, and I feel that it also addresses some of the patients’
concerns. Many patients are aware of how the litigious world works and are
therefore suspicious that the agreement is only for my protection. My legiti-
mizing my own need for safety by bringing it out into the open often dispels
some such suspicion. It is important to remember that despite the benefits of
an agreement, it is not literally binding. One should not underestimate the
importance of careful exploration of the potential for suicide even if there is
a safety agreement in place. (It is also important to note that such an agree-
ment likely offers no legal protection.)
In contrast to the contract proposed by Braun (1986), I do not generally
like to explicitly forbid minor self-injury in a safety agreement, although
I make clear in discussion that self-harm is not a safe behavior regardless
of the magnitude of the self-injurious effort. My reasoning is that I do not
want the patient to break an agreement that is so stringent that even minor
initial attempts to challenge the contract would cause a crisis. Even with
an agreement in place, some suicidal behaviors may occur, as could other
“infringements” of agreements. In addition to appropriate action by the
therapist, such events speak to the need to learn more about what all parts
of the patient are feeling and fearing and what they need for the safety of
the body to be guaranteed. At such times, the spirit and the explicit content
of the contract can be enlarged with the patient as coparticipant in the
renegotiation. This is partially why I generally prefer to keep the contract
as simple as possible, directed toward the essentials of preserving life and
preventing serious injury. I make it clear that I do not want the patient to
self-injure, but I do not include explicit language about all kinds of self-
harm because this would just create a challenge for some patients to find
something that is not listed in the agreement, hurt themselves, and say that
they had abided by the agreement.
Safety agreements should be understood to apply to all dissociative parts of
the person. Although some clinicians try to get as many as possible of the parts
to sign an agreement, I more often say something like, “I am going to assume
that all of the parts inside agree with this. If not, please speak up now.”
Some patients with DID do not feel comfortable working with a written
safety agreement but will make a verbal agreement for safety. Of course, nei-
ther a written nor a verbal agreement is a guarantee of safety. It is; however,
often a great help in containment and in keeping all parties feeling safe. The
therapist should consider the agreement in the context of the patient’s life
and should not substitute reliance on it for clinical judgment (International
Society for the Study of Trauma and Dissociation, in press). The same prem-
ise that applies to the contract applies to its use: to keep the patient safe.
Therefore, if the clinical situation suggests it, more stringent measures such
as hospitalization should be explored and must sometimes be implemented.
As one negotiates and renegotiates safety agreements, it is advisable to
continuously and thoroughly address the meaning of suicide for the patient
and to keep in mind that it might not have the same meaning for all parts
of the patient.
Suicidal Behavior Is Not Always

Straightforward Suicidality
The fact that suicidality in DID is not always straightforward suicidality is

reason to be more, rather than less, alert for the danger of suicide. Different
parts may have their own motivations for destructiveness toward other
parts; and often the destructiveness is not necessarily intended to be sui-
cidal or homicidal. This may be one of the reasons for Foote et al.’s (2008)
finding that a dissociative disorder diagnosis was more strongly associated
with suicidality than any other diagnosis.
Two case vignettes follow. Both illustrate behavior that appeared to be
or was potentially suicidal but in fact had to do with a child part’s lack of
understanding about issues of lethality or death.
The Closed System

In this vignette, the problem was that a child part, though engaged in poten-
tially lethal behavior, was not aware that the behavior was indeed poten-
tially lethal. In addition, this child part was unaware of the irrevocability
of death. This child part believed that she was simply making another child
part go to sleep, but the result was what looked like an overdose as a suicide
attempt.
Rosemary is a 45-year-old, married, professional woman who has no
children. She came into treatment with me almost 8 years ago. At that time,
she was on disability and suffering from almost overwhelming depression
and anxiety on a daily basis. She was mostly nonfunctional, often losing
time, frequently switching, and struggling to perform ordinary household
chores. She had been hospitalized six or seven times in the preceding 7 years
for extreme cutting, burning, and other self-injury. As background for these
symptoms, what emerged over time was that as a child—from the age of 5
or younger and until she was about 13—Rosemary had been raped, night
after night, by her father while her mother was asleep in bed, sedated in
compliance with her doctor’s and her husband’s instructions. Rosemary’s
father had told her that if she told her mother about these events it would
kill her mother—and since she did not want her mother to die, Rosemary
did not tell. At some point, she did want to tell a teacher but had surmised,
probably correctly, that no one would believe her. Later treatment work
with me (e.g., through parts work and dream work) opened up memories
of her suffering many untreated urinary tract infections as a child. Her pain
was excruciatingly terrible and was suffered alone. (Anyone who suffered
urinary tract infections as an adult can imagine what it would be like if one
were a child with such unbearable pain that must be endured in silence,
with no one in the world to tell about it or to ask for help.)
With respect to the father’s abuse, it was only after more than 2 years
of therapy that highly explicit memories of these experiences came to the
surface, mostly through the narratives of child parts: “T,” Michael, and
Little Rosemary. At that time, Rosemary had not herself remembered most
of these incidents, but certain child parts of her did. They remembered hor-
rifying things, bloody underwear, terrible pain, and not being able to sit
down. They remembered how she would stay in the bathtub, wet her pants,
pretend to be asleep, and try all manner of strategies to deter her father’s
violations. These child parts were only able to tell of their pain bit by bit
because what they had to say would have been too destabilizing and pain-
ful to bear in large doses to the overall system, including Rosemary herself,
the adolescent parts, and other adult parts.
One of the child parts, “T, the Lifesaver, who has a hole in the middle,”
is a precocious child part who at times has taken a managerial role with
respect to younger child parts. T was originally created to perform certain
soothing and caretaking functions for younger child alters—as a life saver,
as well as to hold memories of abuse. Her name (Lifesaver) also signifies
her awareness of feeling that she has no “center,” and that she functions in
part as a transitional sugar salve. This followed from her mother’s treat-
ment of her; the mother, who was an excellent cook, would at times ply her
daughter with sweet foods but would just as often deny them altogether.
This connected sweet foods with both attachment and deprivation. Part of
T’s job was to care for Michael, her inner younger brother (Kluft’s “third
reality”), who held even more painful memories than she did. Michael was
created as male to magically deflect her father’s sexual violations.
These child parts had not finished telling about the details of their trauma
when one morning Rosemary’s husband called me to cancel her session for
the day because she was in the hospital from what appeared to be a drug
overdose. (Rosemary is still not clear about exactly what occurred or how it
occurred.) The odd thing was that Rosemary had no memory of taking any
pills and had always insisted that she was not suicidal. Later when we did
meet, and in the process of Rosemary’s and my discussion of the possible
antecedents of this event, I asked to speak to T the Lifesaver. As it turned
out, T the Lifesaver had gotten sick and tired of hearing the constant excru-
ciating crying of a younger child part, Michael. T the Lifesaver knew that
Michael was in terrible pain but did not know why he was crying so much
more than usual. All T knew was that she could not bear to hear Michael’s
crying anymore and so decided to take matters into her own hands and
to give him pills to shut him up and knock him out. As it happens, and
because of the dissociative barriers, T did not know that the reason the
younger part, Michael, was in so much grief was that Rosemary was about
to take a trip back to the town where she grew up—Michael thought that
the father (who in reality was dead) was still alive, still there, and still
capable of raping him again.
T the Lifesaver, a child part who always had to fend for herself and had
at the time needed to take too much responsibility for her young age, made
a decision—unilaterally and without consulting anyone. It was a decision
that she was too young to make but that did not seem so to a child part
accustomed to taking on too much responsibility. When we were able to
talk in session about the feelings and fears of Michael and T the Lifesaver,
Michael was able to share why he was frightened and crying, and T the
Lifesaver talked about hating to hear his crying. Following these interac-
tions, T the Lifesaver knew why Michael was crying and understood that
she was too young to give anyone pills. She has agreed, if ever in severe
distress again, to call me rather than undertake any unilateral action.
Rosemary also became aware of this intrapersonal conflict and knows how
to get help to deal better with conflict (at least when she is able to recog-
nize that a conflict is occurring). Work with Rosemary is still very much
in progress.
If looked at only from the outside, the event appeared as a suicide
attempt. However, not only did this make no sense to Rosemary (since she
was aware of no suicidal ideation), but also the idea of suicidality did not
make sense to T or to Michael. To put Rosemary’s action as a whole into
intelligible context, I needed to take her dissociation into account. In her
case, I needed to be in contact with T the Lifesaver as well as with Michael,

and when these parts were consulted, the emergent understanding of what
was taking place was able to unfold: The action was more about attempt-
ing to silence another’s unbearable crying and trying to deal with terrifying
problems and events of long ago (via current action enacted by child parts)
than about suicidality or homicidality. For the dissociative nature of this
event in Rosemary’s life to be understood and begin to be healed, I had to
know T the Lifesaver and Michael, and I needed to be made aware of their
own fears and desires. Rosemary also had to learn to know what I knew.
While there is more healing work for Rosemary to do, this understanding
was an important event in her history.
Promise Me You Won’t Go to the Ocean

In this second vignette, the suicidal danger is specific to the way that this
patient’s dissociative structure adapted to and interpreted her life history.
Anna had been separated from her beloved mother at age 9. She desperately
desired to be reunited, and a child part wanted to find a way to go home
to her beloved mother. The trance logic of this child part’s thinking posed
dangerous consequences that had the potential to result in a (dissociatively
accidental) suicide.
Anna is a 43-year-old woman, married with four children, who has
been in therapy with me for 7 years. Anna is highly intelligent and well
spoken in spite of having had only minimal formal education and gram-
mar that sometimes is poor in spots. After she escaped her sister’s house-
hold when she was 15, on the basis of her intelligence, personability, and
ability to work hard she managed to work her way up in the work world,
eventually becoming a well-paid and well-respected midlevel execu-
tive. However, since her breakdown (which occurred when her oldest
child reached the age that her own abuse began), she has been unable to
work because of the constant posttraumatic intrusions and trance states
that she experiences. She is a competent mother, certainly a caring one,
and the usually presenting part is caring and responsible as a person.
Although Anna spends most of her days in a zone of lost time, she comes
to when it is time for her to go get the children at school and is an atten-
tive, nurturing, caring, and vigilant mother. She supervises her children’s
homework and makes sure that they have top (A+) grades. She listens to
her children’s problems, has great empathy and concern for them, gives
them advice, and is a strong disciplinarian. She defends her children at
school and befriends and stands up to the teachers as appropriate.
Anna’s plight began when, due to political instability in her country
of origin, Anna’s parents put her on a plane to go live with her sister in
Chicago to help take care of her sister’s children. She was 9 years old at the
time. Unbeknownst to Anna’s parents, she was made into a household slave
by her sister and a sex slave by her brother-in-law. In terms of nutrition, she
was forbidden to eat anything except peanut butter and bread. She slept
in her jeans. She went to school only sporadically, and by the eighth grade
even this ceased. She was forbidden to use the phone or leave the house and
was threatened by her brother-in-law that he would tell her mother that she
was a bad girl if she tried to leave. Anna imagined that this was the way it
was supposed to be since everything was so completely different in this part
of the world. For instance, snow was at first incomprehensible to her—she
had never seen anything like it and had no idea what it was when she first
saw it. On some vague level, Anna thought that everything that was hap-
pening must have been okay with her mother, and the last thing she wanted
to do was displease her mother. So, she endured. Nevertheless, she accumu-
lated a stash of lethal household cleaning agents that she planned to use if
things got to be more than she could stand.
In many ways, Anna is currently low functioning: She spends most of the
day in trance, often hallucinating, and is up many nights for much or all of
the time, also in trance, doing such things as setting the table for unknown
guests. There were times when she has needed my support to understand
that her hallucinations are not real (e.g., she might see her living room filled
with people, her different self-states, and feel that she literally cannot move
in there because there is no room).
Anna has multiple physical problems that come and go. Sometimes, her
feet swell (I have seen them). She reports that they want to “take off,” both
in a run and to the ceiling. At these times, she feels that she cannot keep
herself on the ground but rises to the ceiling. She has been diagnosed with
complex regional pain syndrome (CRPS), a condition in which she cannot
move her right hand and in which the pain and paralysis also move to her
shoulder. Her hand is swollen, and the skin has a different appearance on
the right arm than on the left.1 While CRPS is a medical diagnosis, it does
tend to be cyclical and respond to weather changes, stress, cold/heat, and
so on, with the result that symptoms can wax and wane in some patients.
Like other of Anna’s physical symptoms that would have been diagnosed
as “hysterical” a century ago, it is hard to know the extent to which her
CRPS symptoms may be somatoform, parts dependent, or entirely based in
a medical disorder, which can be exacerbated by stress.
For a good part of the therapeutic relationship, Anna has been compul-
sively self-injurious to her vagina and her rectum, to the extent that she has
had infections and much pain and might have done some damage to her
vaginal wall. Interestingly, Anna reported that her hand “had to do it”;
this self-harm did not feel like it was under her volition. In part due to the
bleeding, but also because she experienced “sticky stuff” all over her, Anna
reportedly felt that she had to shower four or more times a day. With the
work in therapy, the somatic flashbacks, self-injury, and the constant show-
ers have ceased in the last 3 years.
And yet, suicidal ideation has continued. From the beginning of our work
and during many of our sessions until approximately the last 3 years, she would
tell me that she wanted to kill herself. Generally, I could get her to promise to
be safe until we met the next time, often by using slightly coercive psycho-
education about how terrible it is for children whose parents have committed
suicide and how it increases their own chances of suicide. Her complaints of
suicidal impulses have greatly decreased over time but have not disappeared. It
is most often terrible flashbacks about the abuse she suffered while in Chicago,
as well as memories about that time, that have made her feel suicidal.
In the session excerpt that follows, Anna describes how a self-state modeled
on her sister took her to get her hair cut. Then the memories of the abuse suf-
fered in Chicago contributed to the emergence of a child part who desperately
wanted to go home to her mother and thought she could get back to her mother
by going over the ocean.
Me: You cut your hair. It looks nice.

Anna: I got my hair cut in preparation for going to the ocean. My sister [meaning
the sister inside] took me because I was too weak to go myself. There was
a very little girl in the chair. [She is describing her perception of herself in the
hairdresser’s chair.] My sister walked me back. Then, I looked in the mirror
at home. My face was all green. After that was when I saw the priest in the
grocery store, who said I looked terrible and asked if I wanted to see him.
Me: You got your hair cut in preparation for going to the ocean? What about
going to the ocean?
Anna: I was going to the ocean because everything was so bad. That is the only
way I could think of to get home. I would go to the ocean, lie on my back
on the waves, and have the ocean take me home. I knew I came over the
ocean, even though I came by plane.
Me: Yes, that is a little girl’s imagining of a way of how to get home. She must
have been desperate to get out and with desperate longing to go home.
Anna: That is why I have been going to the ocean and sitting on the bench and
wanting to go in. It is hard to keep myself from going there at night.
She and I discuss how she experiences a replay in her mind of events
when she was in Chicago: getting her hair cut by her sister and getting her
hair cut now, trying to figure out a way to escape from the home of her
sister and brother-in-law and now from her own home. We explored why
is this happening now.
Me: So,how long after you arrived in Chicago did your sister take you to get
your hair cut?
Anna: My sister took me and had my hair chopped off soon after I got there.
Me: That must have been a horrifying shock.

Anna: My hair was down to my knees. That is the way girls wore their hair where
I grew up. No one cut their hair.
Me: Why did your sister want your hair chopped off?
Anna: She hated my hair. It’s like what happened with a friend of my daughter’s.
My daughter has beautiful long hair, all the way down her back. This other
little girl in her school was so mean to her all the time, until finally she
grew her hair long, like my daughter’s and now she is very nice to my
daughter, and they are friends. It’s like she couldn’t stand my daughter hav-
ing what she did not have.
Me: Yes, she was envious. She did not want your daughter to have what she
couldn’t just as your sister couldn’t stand to see your beautiful long hair. So
your sister—and also the sister inside—was upset with your beautiful hair.
I would like to hear more about this.
She then remembers suddenly that her sister had told her that she had just
eaten White Face. (White Face was her cow and pet when she was a little
girl. White Face would come and stick her face in her bedroom window in
the evening, and Anna would pet her face. She loved White Face and was
comforted by her presence.)
Me: Your sister told you that you had just eaten White Face? [She was not
allowed to eat anything but peanut butter and bread, even though she cooked
regular meals for her sister and brother-in-law.]
Anna: Yes; one day about a month after I had been there, my sister and brother-
in-law said they were going to give me a treat. They gave me a hamburger,
but I did not know what it was. I liked it. They were both watching me with
interest and were gleeful. Then, my sister said after I finished it, “Did you
like it?” I said “Yes.” Then my sister and brother-in-law began laughing, and
she said, “You just ate White Face!”
Me: How horrible! What a mean trick! You must have been devastated! And
were you at the time observant of your upbringing dietary laws against eat-
ing beef?
Anna: Yes. I would not eat beef. Cattle were sacred. We ate meat very rarely.
Once or twice a year we would eat chicken or lamb. Of course, we ate fish
all the time. All we had to do was go out and catch it.
As I try to explore how she felt about the incident, it is hard for her to
stay with it, and she comes more into the present adult and says that her
shoulder hurts. She holds her shoulder and says that she has not slept well,
in great part because she is so preoccupied about going to the ocean and
trying to prevent herself from going to the ocean. It seems that the memo-
ries of her sister’s sadistic cruelty—both the haircut and the hamburger—
while not something she could continue to think about, had been in part
motivating the child part’s desperate desire to go home to her mother via
the ocean.
Me: I
am going to talk to that little girl now. Her suffering must be awful! That
is so horrible, that trick about eating the hamburger, a terrible, terrible
assault on your identity and beliefs. So sadistic. And, especially when you
were hungry and so deprived of food.
â•… [Talking to the little girl part.] You have been through unimaginable hor-
rible things. Of course, you wanted to find a way to get home. That was
very active thinking—to be wanting to get out. But you know, of course,
that you can’t really get home that way. And you know that your mother is
dead. Your mother isn’t there anymore. The ocean can’t take you to your
mother because she isn’t there. It is proactive to be thinking of how to get
out, though. You have been through so much, and you are thinking so hard.
But we can’t solve that problem in Chicago now. We will work on it. Right
now, you need to take a rest. Is that okay?
At this point, Anna is clearly becoming emotional. Talking to the little

girl inside, even though she is not able to respond back to me in words, is
bringing up a great deal of emotion.
Anna: I am so angry with myself!

Me: For what?
Anna: I should have figured out a way to get home.
Me: You were 9 years old. 2 The first thing that happened to you when you got
there was that you were raped, you were deprived of food, deprived of
sleep, your clothes were taken away, your sense of self and beliefs was sys-
tematically assaulted, and then your sister took you and had your beautiful
long hair chopped off. You were in a state of shock. You couldn’t get back
by plane. You couldn’t even get out of the apartment on your own. You
didn’t know the right elevator button to push. You were forbidden to use
the phone, and you believed that somehow your mother thought this was
best for you, and you did not want to disappoint your mother, whose health
was so frail.
She seems satisfied, or at least does not continue saying she is angry with
herself.
Me: I’msorry that we are going to have to stop soon. [Talking to the little girl.]
You need to get some rest. Go inside and get some rest. Going to the
ocean is proactive thinking given your situation, but it won’t get you to
your mother. We will come back to and talk about this awful situation more
later. [The little girl part goes inside.]
We spend time in the session talking about how she, also, as an adult,
needs to get some rest. She describes how she talked to the monsignor about
her difficulties and how he was supportive. She also remembers how the
nuns, whom she knows in the context of her children’s religious training,
had always been nice to her and how, when she was functional she would
always bring cookies for them at Christmas because she had observed that
people forget the nuns and only think of the priests. Then, she said that the
nuns had offered that she could come stay with them.
She talks more of suicidality and of wanting to go to the ocean, say-
ing as she has in the past that she would just like to get it all over with by
sitting on a bench by the ocean in a bad neighborhood and hoping to get
murdered. This is yet another (more present time) aspect of the wish to go
to the ocean, which is in addition to the previously discussed child part’s
thought that she could go home to her mother by walking into the ocean.
We explore other possible reasons for the reemergence of suicidal ideation
now. In retrospect, I probably asked the little girl to go inside too soon or
with inadequate reassurance that I wanted to hear more about her feelings.
Perhaps some feeling of inadequate recognition was behind her response.
Me: Do you think you should be hospitalized? That is an option. The number
one priority is to keep you safe.
Anna: No. It would upset my children. They would be too upset and not be able
to manage.
Me: If you are not safe, then the most important thing is to protect you. Your
kids would manage if you went to the hospital. If you think it would upset
them for you to go to the hospital, remember that that upset would be min-
iscule compared to the effect on them if you died. It would be unbearably
difficult for them if you died. It would be just horrible for them! Remember
that children whose parents have suicided are much more likely to commit
suicide themselves.
Anna: I will be all right. I just need to be by myself.
Me: What about the nuns; they said you could stay with them if you needed.
Anna: I can’t leave my kids.
Me: So you don’t want to go to the hospital or to the nuns? Can you, and can
all your parts, promise that you will be safe, at least until our next meeting,
and that you won’t go to the ocean?
Anna: I promise.
Notes
1. On the hunch that this may be somatic dissociation of parts of the body, I have
asked her to twist her arms together and look at her hands and feel her arms
against each other. This appears to have helped. (See also Feliu & Edwards,
2010.)
2. Age 9 is considered a late age for the onset of DID. However, the torture that
she endured cannot be called anything else, and it was severe. Although she
seems to have had a secure and loving attachment to her mother (which is the
basis for her strong mothering and good relationships with her own children),
there were some early separations from her mother on account of her mother’s
health that might have contributed to a disorganized attachment or perhaps to
more severe fragmenting, and this might have provided a structural dissocia-
tive underpinning for the later dissociative solutions that may have saved her
from suicide at that time or from psychosis.
Chapter 15
Comorbidity and
Seeming Comorbidity
Problematic Outcomes of
Severe and Rigid Dissociative
Structuring of the Mind
This chapter addresses questions of comorbidity and seeming comorbid-

ity. How do we understand and work with dissociation and dissociative
disorders in the context of other categories of emotional difficulty and the
diagnostic constructs of these? I discuss how symptoms of psychosis, per-
sonality disorder, and neurosis are manifest in dissociative disorders and
how the underlying phenomenon of dissociation exists for many problems
in living.
The Trauma/Dissociation Model
The trauma/dissociation model is edging its way into psychoanalytic and

psychotherapy discourse as a good way of explaining many aspects of what
is thought of as psychosis, personality disorder, and neurosis. We have
a nosological system (the Diagnostic and Statistical Manual of Mental
Disorders [DSM]) in which there are many overlapping categories that
describe various problems in living. Our DSM is based on a medical model
of disease, in which there is often a specific cause, such as a bacterium, that
causes certain specifiable symptoms and that may or not be ameliorated by
certain medicines and treatments that specifically target the cause. Because
the DSM system does not exactly address problems in living, people who
come to see us often have multiple diagnoses, such as anxiety disorder,
depressive disorders, posttraumatic stress disorder (PTSD), sleep disorders,
dissociative disorders, psychotic disorders, and so on. Does this mean that
the anxiety, the depression, the sleep problems, the posttraumatic stress,
the DID, and the psychotic symptoms all have different sources? It could,
but on the other hand, at least some of them could be related to a common
source. Often, a common source of these problems is relational trauma and
consequent dissociation.
Sometimes, the issue of comorbidity is a complicated one to assess. For
example, is it that someone has psychosis and PTSD, or that, unknown
to the assessing clinician, the psychotic-seeming symptoms are actually
263
intrusions of past trauma? In this case, the psychotic-seeming symptoms

do not represent a loss of contact with reality because they are appropri-
ate and understandable responses to a past situation that was real. The
problem is that the clinician does not know about and understand their
origin, and the patient may be automatically classified as psychotic. I am
not suggesting that schizophrenia and certain other psychotic disorders
are not separable from trauma/dissociation-based problems and may not
often need a specific course of treatment. However, I am suggesting that
the important process of diagnosis should include careful assessment of
the source of the symptoms.
Similarly, personality disorders may well be trauma and dissociation
based (Bromberg, 1998; Howell, 2002a). The correlations between border-
line personality disorder (BPD) and dissociative disorders are high (Dell,
1998; Sar et al., 2003, 2006), they both have high histories of trauma (Dell,
1998; Putnam, 1997), and there are commonalities in assumed psychic
structure (Howell, 2002a, 2003, 2008; Howell & Blizard, 2009). Sar et
al. found in two studies (2003, 2006) that 64 and 72%, respectively, of the
participants in the study who had BPD also had a dissociative disorder.
Finally, while the term neurosis is no longer in the DSM and is now
infrequently used, the term is meaningful in psychodynamic diagnosis
(McWilliams, 1994; PDM Task Force, 2006). Neurotic symptoms have
been understood to be the result of psychic conflict between wish and
defense, in which repression was the central defense. Hand in hand with
neurosis was a punitive superego, which is understood both as the source of
psychopathology and as a moral agency. Clinicians often work intuitively
with superego as if it were a dissociated internal persecutory presence or
self-state rather than as theoretically described in terms of the structural
model and the Oedipus construct. Indeed, multiple personality disorder,
now termed DID, was categorized as neurosis through the early 1900s.
A harsh, punitive agency characterizes both severe superego and DID
(Howell, 1997a). Thus, many people with DID have problems that could
be explained by the superego construct; likewise, many people who might
be called “normal” and “neurotic” can be understood to be suffering from
problems of dissociated self-states.
I proceed first with a case illustrating manifestations of psychosis in a
person with a dissociative disorder, followed by an examination of person-
ality disorders (in particular BPD) in terms of dissociative processes, and
finally present a case vignette demonstrating superego-type problems in a
person with DID.
A Case of “Psychosis”
The following vignette describes how “psychotic” symptoms were resolved
by addressing dissociative gaps in the person’s experience, and how as a
Comorbidity and Seeming Comorbidityâ•… 265
result of the work, the person felt she now “had a story.” Margaret is a
35-year-old woman with DID who was introduced in Chapter 1. She is
married with two children and is employed as a university literature profes-
sor. She is well groomed, attractive, and well put together.
Margaret came into my office and told me that she had again been feel-
ing that she smelled; that is, she smelled a smell on her body with olfactory
conviction. What she smelled was putrid, like a rotting dead person. She was
awakened by the smell on Friday night, and since Saturday morning when
she awoke, 3 days ago, she has been trying to scrub the smell away in the
shower to no avail. Her husband has told her that she does not smell, but that
has not been sufficient to keep her from trying repeatedly to shower it away.
About a year ago, Margaret presented with similar, but much more
severe, symptoms. At that time, she stated her conviction that she was dead,
and that others around her just did not seem to understand this. She had
wondered how long she had been dead, and that they did not know. She
could smell her body rotting as well. As in this more recent instance, the
onset had been sudden. When it occurred last year, the appearance of psy-
chosis, along with suicidality, necessitated hospitalization. Fortunately, on
this more recent occasion, the conviction of being dead was not entrenched.
It was still something we could talk about as a troubling set of thoughts
and sensations.
I could have written this off as an emerging psychosis, arranged for a
consult for antipsychotic medications, and begun inquiry into possible
hospitalization. But, knowing that this person is highly dissociative and
knowing that a crisis had not yet occurred, I worked from a different set
of premises.
As one would normally, I first inquired about recent events. What might
be the context that initiated this incident? In general, she had been thinking
about her ex-husband and how he had both rescued her from her parents
and had abandoned her. But, she was trying to make sense of some piece
of this, some set of memories and beliefs and meanings. And in our session
of the previous week, she had reported a dream in which he was walking
around in her head. While she had had an intense headache following that
dream, she did not feel dead or smell herself as dead. Although she was
enveloped in the feeling of his earlier abandonment of her, along with the
awareness of his great importance to her in the story of her life, she had
e-mailed him to express her appreciation of the ways he had helped her
earlier in their lives together. He did not respond. Other than these events,
there was nothing notable about the context for these emerging olfactory
symptoms.
Knowing that time was short, I asked if she would be willing to go into
trance to further explore these symptoms. After deepening the trance, I
described a pathway filled with her favorite flowers and leading to a library.
I suggested that she would find a book with her name on it, and that I did
not know where she would open it or whether she would see an image or
print, that she would learn only as much as was safe for her to know, and
that she could return the book to its place when she was done. I also sug-
gested that the information could go to her mind without being conveyed
to me at that time or that she could convey it to me, but that either way, she
would only remember as much as felt safe.
While in the library and looking at her book, she began to tear up, and
then she said, “I opened the book to page 28, and all there is on the page
is blood. There is something about my hysterectomy and my mother’s
hysterectomy.”
I asked her to tell me more about these hysterectomies. She said that she
was 28 when she had her hysterectomy, and that she had been hemorrhag-
ing profusely for months before, ever since her daughter was born. Then,
she described her mother’s hysterectomy, which occurred when her mother
was 29 and had been occasioned by endometriosis. While in the hospital,
her mother had complained that someone in the hospital had broken glass
inside her uterus. When she returned home, she was screaming and crying
and telling her children all how much she hated them, that they were nothing
but trouble, and that she wished they had never been born. Understanding
vaguely that her mother was psychotic and that this was ratcheting up her
more normal hatefulness, Margaret had tried to comfort her.
I asked Margaret to tell me more about her own hysterectomy. She began
to describe months of terrifying uncontrolled bleeding following a botched
childbirth delivery. Her uterus had been so damaged that it did not return
to its normal size following the birth but stayed huge, soft, and bleeding.
For many months prior to the hysterectomy, she could not go places because
of the profuse bleeding and her weakness. Because she was so weak, she
stayed in bed with her baby. The blood had an intense, putrid, acrid smell,
like something rotting. The smell was unremitting. No matter how many
times she showered, it was always there. She could not get rid of it. She was
alone. No family members could be called on or were willing to help her,
and her husband had abandoned her prior to the childbirth. She felt lost
and completely alone. Her baby was failing to thrive because, unbeknownst
to Margaret, her baby was allergic to cow’s milk. Margaret feared that
her child was dying, and she feared that she would die. In fact, she was so
certain that death was a real possibility that she filled her refrigerator and
freezer with food just before her hysterectomy so that her other child would
not starve if she died.
When I asked if that mental state of feeling near death, and being so
helpless and alone, brought to mind any other time in her life, she reported
that it did remind her of times in her early childhood when she had been
left alone, tied up after being raped by her father. Referring to these times
and to the months of hemorrhaging, she said, “I often wondered if anyone
would notice if I were dead.”
After we discussed all of this new material, Margaret said that she felt
much better. One aspect of her feeling so relieved was that, “It’s a story. I
now have a story about it.” Piecing these memories together had given nar-
rative coherence to a certain set of overwhelmingly frightening and painful
memories of her life. Now, they fit together, and she could situate herself
in time. She did reexperience some of the pain as she talked about these
times, but she was also in the present, feeling her sympathy for herself and
my sympathy. In part because she was in two places at once, the telling was
integrative rather overwhelming. She called me later in the day to tell me
that she had no more symptoms of bad smells or of feeling dead, that she
continued to feel relieved and was okay.
What Margaret was experiencing was the intrusion of olfactory flash-
backs, originating from the time of the massive blood loss that resulted
from the botched delivery of her child. The associated, but unformulated,
memories, along with the threads of associations to these, concerned the
anticipation that she was about to die—and perhaps the unformulated
sense that she did die. What looked like psychosis was an intrusive flash-
back, probably evoked in this case initially by memories and feelings about
her ex-husband and how she had been trying to pull together a narrative
about that time in her life. But, an important part of that narrative was that
her ex-husband had abandoned her in a situation in which she was help-
less and alone, fearing death. This memory was associatively connected to
earlier childhood memories in which her father had abused her and then
left her tied up, helpless and alone. Because the flashback had no context
in conscious memory, it could not be resolved on its own but expanded to
the feeling that she was dying or dead. (As the trance was deepening, she
heard me describe potted plants as “dead bodies.”) The flashbacks of a
putrid, rotting smell on her body that she could not rid herself of and the
anticipation of her own death represented dissociated memories that were
too overwhelming to be catalogued in narrative memory. As a result, they
could not be placed in context with the present issues that were evoking
them. As she said, following this work, she then had a story.
Personality Disorders/Borderline
Personality Disorder
Philip Bromberg’s (1995) “speculation” that personality disorders are dis-

sociation based is one that I agree with wholeheartedly. He says:
I have speculatedâ•ƒ.â•ƒ.â•ƒ.â•ƒthat the concept of personality “disorder” might

usefully be defined as the characterological outcome of the inordinate
use of dissociation, and that, independent of type (narcissistic, schiz-
oid, borderline, paranoid, etc.), it constitutes a personality structure
organized as a proactive, defensive response to the potential repeti-

tion of childhood trauma.â•ƒ.â•ƒ.â•ƒ.â•ƒI am suggesting, in other words, that
personality disorder represents ego-syntonic dissociation no matter
what personality style it embodies.â•ƒ.â•ƒ.â•ƒ.â•ƒA dissociative disorder proper
(Dissociative Identity Disorder, Dissociative Amnesia, Dissociative
Fugue, or Depersonalization Disorder) is from this vantage point a
touchstone for understanding all other personality disorders even
though, paradoxically, it is defined by symptomatology rather than by
personality style. (pp.â•¯200–202)
Bromberg’s (1995) speculation was given partial support by Dell’s (1998)

findings that among DID outpatients, 53% were borderline, 68% self-
defeating, 76% avoidant, and 45% passive-aggressive. In addition, many
qualified for two or more personality disorders (Dell, 1998). As noted, Sar
et al.’s studies (2003, 2006) found that 64–72% of those who had BPD also
had a dissociative disorder.
I concentrate here on BPD because it is often the most problematic—as
well as most frequently discussed—personality disorder. An estimated 2%
of the general population, 10% of persons in outpatient clinics, and about
20% of admitted psychiatric inpatients are diagnosed as having BPD (APA,
2000, p. 708). As do people with DID, people with BPD frequently also
have problems with anxiety, depression, substance abuse, eating disorders,
and other manifestations of affect regulation. Because only five of the nine
criteria are required to make the diagnosis of BPD, different combinations
of these nine criteria yield strikingly different symptom and personality
profiles.
Before the advent of the borderline category, the primary division in psy-
chopathology had been that between neurosis (understood as manifesta-
tions of superego problems) and psychosis (loss of contact with reality).
By the late 1800s, some patients were categorized as in a “borderland”
between the two (Rosse, 1890, cited in McWilliams, 1994). By the mid-
1900s the term borderline was introduced to demarcate this new domain
of psychopathology (Stern, 1938).
Initially, borderline was understood in the context of schizophrenia. This
categorization was supported by the tendency of this group of patients to
have psychotic-like symptoms in situations of stress, intimacy, or projective
testing. Following in this way of thinking, other diagnostic classifications
that had been considered related to schizophrenia, such as “pseudoneurotic
schizophrenia” (Hoch & Palatin, 1949), “psychotic character” (Frosch,
1964), ambulatory schizophrenia, and schizotypal personality, were recat-
egorized as borderline (Kriesman & Straus, 1989). However, borderline
became increasingly differentiated from schizophrenia as it was observed
that borderline patients showed little evidence of thought disorder, that
those psychotic symptoms seen in BPD were not typically schizophrenic
(Tarnopolosky, 1992), and that it almost never evolved into schizophrenia

(Stone, 1992).
This view of borderline schizophrenia was supplanted by the view that
borderline personality organization (BPO), which includes BPD, is a cate-
gory of developmental diagnosis that is separate from psychosis or neurosis
(Kernberg, 1975). Kernberg emphasized the problem of excess aggression
and the defense of splitting, including five related defenses that character-
ized BPO (and BPD): projective identification, denial, primitive idealiza-
tion, omnipotence, and devaluation.
High correlations between BPD and a history of trauma and neglect have
been increasingly noted (Courtois & Ford, 2009; Golier, Yehuda, Bierer,
et al., 2003; Gunderson & Chu, 1993; Gunderson & Sabo, 1993a, 1993b;
Herman, 1992; Herman & Van der Kolk, 1987; Kroll, 1993; Perry &
Herman, 1993; Putnam, 1997; Ryle, 1997a, 1997b; Yen, Shea, Battle, et
al., 2002; Zanarini, 1997). Such high correlations have also been found for
DID. Childhood abuse occurs in 50 to 81% of patients with BPD and 85 to
100% of patients with DID (Putnam, 1997).
At the same time, clinical literature was emerging that was in conso-
nance with these studies. Judith Herman’s landmark book, Trauma and
Recovery (1992), with its focus on the traumatic sources of dysfunction,
was informative and relieving to many people, both patients and thera-
pists. Similarly, Christine Courtois’s Healing the Incest Wound (1997) and
her Recollections of Sexual Abuse: Treatment Principles and Guidelines
(1999) have helped clinicians to formulate the trauma psychodynamics in
their borderline patients.
Soon BPD, along with DID and DDNOS, was understood to be a form
of “complex trauma” disorder, also described in the proposed diagnosis
(Van der Kolk, 1996b) of disorders of extreme stress not otherwise specified
(DESNOS). Howell and Blizard (2009) have also proposed the term rela-
tional trauma disorder. Difficulty with affect regulation, so characteristic of
DID and PTSD, is an essential component of complex trauma and DESNOS,
as well as relational trauma disorder. As Schore (2003b) stated: “It is well
established that the loss of the ability to regulate the intensity of affect is the
most far-reaching effect of early traumatic abuse and neglect” (p.â•¯267).
Fonagy et al. (2002) noted that the abusive environment leads to deficits
in reflective thinking, the capacity to think about mental states, processes,
feelings, beliefs, and intentions of self and others. One of the reasons sug-
gested by these authors is that maltreated children avoid thinking about the
hateful intentions of their abusive caregivers toward them because under-
standing the implications of their maltreatment would make them more
aware of the parents’ malevolent views of them. In effect, they must disso-
ciate knowledge of the parents’ malevolence. This severely limits the devel-
opment of reflective functioning (RF). Poor RF, then, inhibits the child’s,
and later the adult’s, capacity to regulate affect. This in turn predisposes to
dissociation and splitting.
What I would like to highlight is the particular dissociative organization
that I think characterizes BPD and places it on the dissociative spectrum.
As I see it, borderline splitting is similar to state switches in DID (Howell,
1999, 2002a, 2005). Splitting, in the sense of opposites, generally involves
a dramatic switch or shift in affect state, including experiences of the self
and expectations of the other. One difference between DID and BPD is
that with BPD there is continuity of memory and acknowledgment of a
dramatic shift in behavior and affect. To manage the experience, its mean-
ing is disavowed. Since there is no amnesia for the switch in BPD, it is a
partial, not a full, dissociation. Another difference is that personification of
parts does not characterize BPD. Finally, in BPD there is the characteristic
alternation between primarily two self-states (splitting).
With respect to splitting, it might be closer to experience and more spe-
cific to consider the alternating views of the other and the self in terms
of victim and aggressor self-states. Splitting in this sense seems to involve
a particular organization of alternating dissociated submissive/victim and
rageful/aggressor self-states that reflect the impact of relational trauma on
defense and psychophysiological processes (Howell, 2002a, 2005, 2008).
These alternations reenact and embody the relational positions of the victim
and aggressor. In the process that is often termed “identification with the
aggressor” (e.g., Ferenczi, 1932/1949), these self-states become partially or
entirely dissociated. (See Chapter 11 for more description of identification
with the aggressor.) In the victim-identified position, the child may be pas-
sive, submissive, numbed out, helpless, robotic, and experience the self as
attached to and dependent on the aggressor/caregiver. But, the child knows
the abuser role well as a result of procedural identification.
Thus, the victimized child learns both roles: victim and abuser.
Interestingly, some of the borderline defenses that Kernberg (1975) related
to splitting can be understood specifically in terms of dissociated victim and
aggressor states. For instance, primitive idealization is felt from, and only
from, the victim state. Omnipotence and devaluation relate to the abuser’s
experience in relation to, and treatment of, the victim. This is evident in the
aggressor state and may help to explain the isolated rage, contempt, and
omnipotence often termed identification with the aggressor.
How, then, does this dissociative organization work in BPD?
As long as the person oscillates between a hyper-attached self-state

and an aggressive self-state in which attachment has been deactivated,
terror is kept out of consciousness. Thus, splitting, like dissociative
defenses in general, avoids the traumatic memories and impedes their
assimilation and is thereby self-reinforcing and self-perpetuating. While
both of these states of mind avoid the terror-filled traumatic memo-

ries, the oscillation in tandem is even more rigidly avoidant, producing
the “stable instability” of BPD.â•ƒ.â•ƒ.â•ƒ.
This oscillation occurs because the rageful self-state can only be
maintained briefly before fear of abandonment or annihilation triggers
the idealizing self-state which, in turn, can only be maintained for a
short while before fear of vulnerability triggers the rageful self-state
(Howell, 1999). Perhaps it is the ability to switch to an alternating self-
state, the splitting, that (like the dissociation in DID) affords some sta-
bility and organization that avoids full psychosis. In DID traumatized
states and emotional parts of the personality are more fully encapsu-
lated. This often allows more of what Fairbairn called central ego and
the consistent ability to think reflectively. Because of the tendency of
borderline persons to switch from victim to bully and back again, this
domain of living is preoccupying, providing some sense of organiza-
tion, purpose, and identity. (Howell, 2008, p. 111, italics added)
With the intent of showing how personality disorders can be understood

as dissociation based, I have taken us through a brief diagnostic history—
an etiology of an etiology, perhaps. What I want to emphasize is the specific
way that I think this dissociative organization works in the prototypical
personality disorder, BPD. I have accounted for the characteristic stable
instability as an outcome of a procedural identification with the aggressor
and oscillation of victim and aggressor self-states.
Superego-like Manifestations in DID
The predominant defense in neurosis has been understood to be repression.

For example, repression has been understood to be central in severe super-
ego problems, hysteria, depression, and obsessions. However, it may be fit-
ting to view the kinds of problems in living earlier understood as neuroses,
as trauma and dissociation based. Clinicians often implicitly conceptualize
and work with certain kinds of “superego problems” as one would concep-
tualize and work with dissociated, persecutory self-states. The following
vignette is an example of superego-like problems in DID.
Archaic, Harsh Superego and DID

Shirley, an adult long in the workforce but returning to school, called to
say that she had dissociated right before an exam. As a consequence, she
had arrived 45 minutes late for a 3-hour exam. This was despite stringent,
fail-safe measures that she had instituted to keep her focused and less vul-
nerable to dissociative intrusions, withdrawals, or overt switching. Because
the exam was an hour earlier than regular class time, she had reoriented
her internal time clock, setting the alarm an hour earlier every day for the
entire previous week. She had set a timetable for last-minute studying and
organizing the material in her mind in the morning before the exam. She
had studied well and was prepared.
But, this well-prepared-for morning became disastrous when she decided
that she had prepared so well that she had time to read her e-mail. She
opened an e-mail (the possibility of danger from this source was one contin-
gency for which she was unprepared) from a sister who had been physically
abusive to her when she was a child. In the e-mail, the sister demanded that
she call her and visit her mother, who lives in a distant city, for Christmas,
and she chided her for not having done so. Her mother, who had already
disowned her, had been highly unsupportive of her academic aspirations.
In addition, intensely envious of Shirley’s academic ability, her mother had
actively undermined her academic pursuits on those rare occasions when
she tried.
Despite her mother’s extreme hostility and rampant neglect toward her,
Shirley has some child alters who are intensely attached to her mother and
who long for her mother’s love. (As we know, in a way that seems contra-
dictory, neglect and abuse often have the effect of intensifying attachment
longings. In accordance with Bowlby’s evolutionary theory about attach-
ment, danger increases attachment to the caregiver in a young child in a
way that is hardwired. Thus, even when the caregiver is the source of the
danger, the child seeks the attachment bond all the more intensely because
the danger is greater.)
Our work in session revealed that one of Shirley’s child parts who denied
her mother’s abuse and who just wanted to be close to her had been trig-
gered in a covert switch. This part only wanted to please and propitiate
her mother. All this part knew was that it was up to her to ameliorate the
situation—by messing up her exam. This part was out for about an hour.
However, because this part was unfamiliar with all of the fail-safe mea-
sures that Shirley had instituted and had not been part of that decision,
she did not know that the exam was an hour earlier. Just as she was going
into class, Shirley switched again to the part of her who attends classes and
realized that she was 45 minutes late. She was mystified about how this had
happened.
This sort of psychodynamically motivated self-destructiveness is some-
thing we see all the time in so-called neurotic patients. The patient is
bonded to the unsupportive or abusive parent and fails as a way to please
the real parent and the parent introject. This particular example, how-
ever, illuminates the possibility that the dissociative process is universal
and just as much a part of the human neurobiology as is attachment need.
Furthermore, it suggests that the more familiar and usual way we have
of conceptualizing psychodynamically motivated failures is not specific
enough. In particular, there is a problem with conceptualizing these kinds

of failures as behaviors of the whole person. This kind of behavior is a sign
of lack of integration. If the motivation had been that of the whole, much
more integrated person, in Shirley’s case, the behavior most likely would
not have occurred, for positions countervailing to the desire to please and
propitiate mother would have been in mind along with that desire, and the
overriding decision would have been something like, “I know this makes
me anxious, but it is more important for Me to do well on this exam, even
if Mother does not want me to.”
More likely than motivation of this sort residing in the whole person,
or even in “superego,” the motivation is located in an isolated, dissociated
self-state. The information about it is not available to other self-states. The
traumatic bond, which for me (see Chapter 2) is by definition dissociative,
is an operative motivational force. What this means is that “normal” psy-
chodynamically motivated failures stem from the dissociated self-states
that hold feelings that are not integrated with the rest of the personality.
In my view, many of the kinds of problems in living earlier understood
as neuroses are highly trauma and dissociation based. Neurotic symptoms
were understood to be the result of psychic conflict between wish and
defense. Repression was considered central, and a unified self was assumed.
Hand in hand with neurosis was a punitive superego, which is understood
both as the source of psychopathology and as a moral agency. Superego
was understood to arise from the threat of castration, eventually leading to
the internalization of the parents’ superegos. However, castration threat,
which Freud (1925) felt made the boy’s superego superior to the girl’s, is
potentially traumatic. Taken literally, castration threat as the threat of dis-
memberment and deprivation of masculinity can be understood as more
potentiating of dissociation than of mature morality. Kohut (1984), view-
ing castration anxiety a pathological symptom of a disorder of the self,
stated, “A boy who is exposed to the responses of psychologically healthy
parents does not experience a significant degree of castration anxiety dur-
ing the oedipal phase” (p. 14).
A crucial distinction may hinge on whether the structure called “super-

ego” arises from the child’s need to control uncivilized impulses, which
would be moral; or from the child’s attempt to deal with traumatic
impingement from an uncivilized world.â•ƒ.â•ƒ.â•ƒ.â•ƒHarsh superego, aris-
ing from the threat of castration linked to the oedipal conflict, may
better describe how the child becomes self-punishing than how the
child achieves mature morality. Uncivilized wishes can be forgotten
(repressed) in an overall sense of the continuity of personal history
(Ogden, 1986; Bromberg, 1996) whereas overwhelming terror seems
more likely to lead to a segmentation of self-experience (dissociation).
[Howell, 1997a, p. 234]
Clinicians often work intuitively with superego as if it were a dissoci-

ated internal persecutory presence or self-state, rather than as theoretically
described in terms of the structural model and the Oedipus construct. The
superego is, of course, dissociated from the ego (Cameron & Rychlak,
1985). However, I believe that the psychodynamics involved are largely dis-
sociation based, in addition to repression-based.
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Index
A manager parts, 64
mapping organization of, 201–204
Abreaction, 177–179 mother figure, 61
Adolescent Dissociative Experiences
negotiating with, 196–197
Scale (A-DES), 156–157
Not-Me, 213
Adult Attachment Interview, 98
overview, 133–134
Aggressor, identification with, 138–
persecutor identity. see Persecutory
139, 214. See also Persecutory
alters
alters
protector, 61
attachment issues related to, 221
psychotic parts, 64
description of, 220
process of, 220 rescuer identity, 61, 139–140
role of, 220–221, 222 soother identity, 61
Ainsworth, Mary, 93 trauma, link between, 134, 135
Alters. See also specific case examples trust development with, in
abuser parts, 62–63 therapeutic alliance, 175
aggressor, identification with. see victim identity, 136
Aggressor, identification with Amnesia, 119, 148
animal identities, 64–66 Animal defense states, 122–124
asking host to ask inside, 191–193 Anna O., 44
asking inside to aid memory, Anorexia, 165
194–196 Antibonding parts, 67
attributes, embodiments of, 61–62 Aron, Lewis, 30, 50
body parts, connecting with, Assessment interviews
199–201 appearance changes, 153–154
child parts. see Child parts diagnostic indicators, 151–152
common types, 58 face-to-face, 151–152
coping strategies offered by, 134 inquiry topics, 152–154
creation of, 133–134 overview, 151
dead parts, 64 Attachment, 28–29
description of, 58 Adult Attachment Interview. see
encouraging them to have empathy Adult Attachment Interview
for each other, 193–194 avoidant, 95
gender, different, 63 contradictory, 33
integration of. see Integration of deactivation of, 95
alters disorganized. see Disorganized
intercontextualization of, 142 attachment
interpersonal language of, 229–232 infant, 93–94
301
302â•… Index
intergenerational transmission of, Janice. see Janice, case of

97–99 Margaret. see Margaret, case of
relational attachment theory. see Catharsis, 178
Relational attachment theory Charco, Jean Martin, 41–42
secure, 94 Child parts, 60–61, 199–200, 202
traumatic, 222–223 Children with DID, 65
Attunements, dissociative, 232–236 Closed system organization of DID,
Autoplastic, 221 70–71, 253–256
Coconsciousness. See also Alters
B active, 187–188
asking host to ask inside, 191–193
Battle fatigue, 51, 78 body parts, connecting with,
Benjamin, Jessica, 30 199–201
Betrayal blindness, 87 defining, 187
Bipolar disorder, 147, 164–165 EMDR as a tool for, 206–207,
Bleuler, Eugen, 44, 48 208–209
Borderline personality disorder, 41, hypnosis as a tool for, 206–207
162–163, 249, 267–271 journals as a tool for, 206
Bowlby, John, 89, 91 visualization as a tool for, 204–206
Brain Comorbidity and DID. See also specific
amygdala, 129 disorders
brain stem, 129 archaic, harsh superegos, 271–274
deactivated areas in trauma victims, overview, 263–264
120 Conceptualization, 105
fMRI studies of PTSD, 116, 117 Contextualization, 8, 141–144
hypothalamic-pituitary-adrenal Cortisol, 112
axis, 112 Countertransferences, 67, 236
hypothalamus, 129 erotic, 228
limbic system. see Limbic system traumatic. see Traumatic
memory consolidation by. see countertransferences
Memory
One Brain, Two Selves study, D
119–120
orbitofrontal cortex, 128–129 Davies, Jody, 30
PET scan studies of PTSD, 116–117, Dennis, case of
119 abuse, childhood, 22
psychotherapy and brain adult-onset trauma, 22–23
integration, 128–129 alter, 21, 23
right-brain processes, 126, 127–128 amnesia, 203
social design of, 137–138 childhood, 21, 22, 23
trauma processing by, 111–113 death, fear of, 22
triune, 121 Denny, 202, 203
Breuer, Josef, 44, 45, 46, 47 disability of mother, 23
Bromberg, Philip, 30 dreams of, 241–243
Bulimia, 165 hospitalizations, 23
hysterical blindness, 22
C Little Denny, 141–142
Little Sophia, 202, 203
Caretaking-controlling strategy, map of alters, 203f
107–108 Mnemosyne, 203
Case examples, 15 Onyx House, 202, 204
Dennis. see Dennis, case of overview/background, 21
Indexâ•… 303
Sheila, 204 dissociated self-states. see Alters

shooting of father, 22, 23 Dissociationism 1, 47–48
Depersonalization, 114, 116, 117, 152 Dissociationism 2, 48
Depression, major, 249 Dissociationism 3, 48
Diagnosis of DID, 1. See also specific Dissociationism 4, 48
screening instruments function of, for abused child, 86–87
assessment interviews. see inconsistencies in professional field,
Assessment interviews in diagnosis, 82–83
comorbidity, 163–164 maladaptive, 77–78
criteria for, 4–5, 6–7 multiplicity, relationship between,
differential diagnosis, 160.see also 32
specific other disorders) origins of concept, 42–43
hidden, 2 persistent, 77–78
misdiagnosis, 2, 5–6, 151, 163–164 repression, contrast between, 36–37
switching. see Switching repression, relationship between,
techniques, 147 37–38
voices, hearing, 154 trauma, relationship between, 42,
Diagnostic and Statistical Manual of 76–77
Mental Disorders Dissociative Disorder Interview
dissociative disorder not otherwise Schedule, 159–160
specified (DDNOS), 148 Dissociative disorder not otherwise
dissociative identity disorder, 3, 6, specified (DDNOS), 147
148 diagnosis of, 148, 149–150
Discrete behavioral states, 88 switching and, 150
Discrete Behavioral States (DBS) Dissociative Experiences Scale (DES),
model, 52 155–156
Disorders of extreme stress not Dissociative Experiences Scale-Taxon
otherwise specified (DES-T), 156
(DESNOS), 79–80 Dissociative flashback episodes, 82–83
Disorganized attachment Dissociative identity disorder (DID)
caretaking-controlling strategy in alters. see Alters
response to, 107–108 causes, xvii–xviii
causes of, 97 diagnosis. see Diagnosis of DID
contradictory affects, 96 disorganized attachment,
description of, 96–97 relationship between. see
disorders caused by, 103–104 Disorganized attachment
dissociative disorders, impact on dissociated self-states. see Alters
development of, 101–102 dreams. see Dreams with DID
dissociative process, as, 100 factitious/malingered, 159–160
hypnoid states in babies, 100–101 intercommunication of dissociated
pattern of, 97 identity states, 34
predicting, 97 personality organization. see
predictor of later dissociation, 85 Personality organization
prevalence, 96 prevalence, 1, xvii, xviii
sequelae of in later life, 104–105 professional resistance to, xvi–xvii
symptoms of, 96 psychodynamics of, 33
trauma, poorly equipped to handle, relief when first revealed, xvi
106–107 shame of, xv
Dissociated self-states. See Alters symptoms, 106–107, 150–151
Dissociation, 28, 29 trauma as cause. see Trauma
capacity for, 38 trauma model, 86–87
defining, 35–36 Dissociative process, 36
304â•… Index
Dissociative trance. See Trance, H

dissociative
Harris, Adrienne, 30
Double consciousness, 41
Herman, Judith, 30, 31
Double personality, 41
Higher-order consciousness, 102
Drama triangle, Karpman, 56, 66–67,
Horney, Karen, 30
102–103, 135–136
Hull, Clark, 50
Dreams with DID
Hyperarousal, 109, 113, 114, 122, 139
alters views’ of, 241–243
infant response to stress, as
characteristics of, 239–240
126
expressions in, 240–241
overemphasis in literature on PTSD,
Happy Face dream, 245–246
116
importance, 239 Hypermnestic, 69
language of, 240 Hypnoid states, 44, 45–46, 100–101
Mute Girl, 243–245, 246–247 Hypnosis, 39–40
symbolism, 239–240 history of, 40–41
trauma depictions in, 239–240 hysteria, relationship to, 40–41
Dybbuk, 39 memory retrieval, use for, 208
tool for coconsciousness, as,
E 206–208
Hypoarousal, 113, 114
Eating disorders, 164, 165, 197 Hysteria, 41, 42
Emotional brain, 116 Anna O. case, 44
Empedocles, grid of, 45 battle fatigue. see Battle fatigue
Enlightenment, the, 39 causes of, 46
Erotic countertransferences, 228 defense hysteria, 45
Erotic transferences, 228 history of, 44–45
Executive control, 58–60 shell shock. see Shell shock
Eye Movement Desensitization splitting, link to, 45
Reprocessing (EMDR), 116,
133, 189, 208–209
I
F Infants
anticipatory behavior, 236–237
Factitious/malingered dissociative hyperarousal, 126
identity disorder, 159–160 imitative behavior or, 138
Field, Sally, 2 Integration of alters. See also Alters;
Fight or flight, 113, 121, 122, 123 Contextualization
Fixed ideas, 42 complexity of, 142–143
Flashbacks, 70 defining, 142
Fleiss, Robert, 47 fear of, on part of people with DID,
FMRI studies, 116, 117 143
Frawley-O’Dea, Mary-Gail, 30, 67 interdependence, 141–142
Freeze response, 123 redefining, 143–144
Freud, Sigmund, 27, 29–30, 31, 44, 45, Internal family systems model, 67
46, 47 Internal working models, 91–93, 95,
Fright without a solution, 99–100 98, 100
Full dissociation. See Switching discordant, 105
G J
Ganser’s syndrome, 150 James, William, 41, 43
Indexâ•… 305
Janet, Pierre, 29, 41, 42, 43, 45, 109, M

167
Magnetism, 40. See also Hypnosis
Janice, case of
Margaret, case of
abuse, childhood, 17, 18, 181
abortion, 25
awareness of parts, 16–17
abuse, childhood, 24
birth of, 20 father, 24, 25
birth of own children, 19–20 Good Girl, 197–199
caretaking-controlling strategy, mother, 24–25
107–108 near-death experience, 24
depression, 19–20 overview/background, 24–26
dissociative barriers, 188 psychosis, 264–267
Ereshkigal, 219 rape, 24, 25
father, 17–18, 20 sexual abuse, 25
goddess of destruction alter, 62–63 suicide attempts, 26
hospitalization, 15–16 Masochism, 170
Hostile, Contemptuous, Persecutory Memory
Alter (HCPA), 217–219 consolidation by brain, 111
Inner Violet, 108 dissociated, 110
Little Girl in the Torn Dirty Slip, explicit, 110
181–182, 192–193 implicit, 110, 111–112
mother, 17–18, 19 traumatic, working through,
multiplicity, development of, 16 176–177
overview/background, 15, 17–19, Mesmer, Anton, 40
217 Miller, Jean Baker, 30
parentage, 20 Minnesota Multiphasic Personality
parts, 16 Inventory 2 (MMPI-2), 159
prostitution, 20 Mirror neurons, 137
punishment, childhood, 17 Mitchell, Steve, 30, 52–53
rape, 19 Multidimensional Inventory of
secondary dissociative PTSD, 114, Dissociation, 151
Multiple personality disorder (MID),
115
xvi. See also Dissociative
sexual abuse, 19–20
identity disorder (DID)
sexuality, 19, 20
early history of term, 49
therapist’s description, 17 Multiplicity, 28, 29
torture, 18, 192–193 capacity for, 32
trauma program, 15–16 Mute Girl dream, 243–245, 246–247
treatment, seeking, 15–16
Jung, Carl, 43
N
K Neutral personality state, 119
Noninterference theory, 50
Karpman drama triangle, 56, 66–67, Nonverbal communication, 126
102–103, 135–136 Norepinephrine, 112
Kluft, Richard, 52 Numbing, 126
Kohut, Heinz, 30
O
L
Obsessive-compulsive spectrum
Lewis, C. S., 133 disorders, 165
Limbic system, 116–117, 127 Oedipus complex, 44, 47
306â•… Index
P Phase I, 163, 169–171

phases, overview, 168–169
Partial dissociation, 5–6
stages of recovery, 168
Perry, Bruce, 110
Piaget, Jean, 43
Persecutory alters, 137. See also
Polyfragmented multiples, 57
Aggressor, identification with
attachment issues related to, 212 Polyvagal theory, 121–122
complexity of, 217 Possession, 39, 40
importance of addressing in Posttraumatic stress disorder (PTSD),
therapy, 214–217 7, 41, 43, 69
integration of, 217 complex, 78
omnipotent feelings of, 213–214 cultural acceptance of term, 78
prevalence of in cases of DID, diagnosis, Diagnostic and
211–212 Statistical Manual of Mental
protective-persecutors, 214 Disorders, 74
role of, 211, 212, 213 dissociative nature of, 81–82
Personality organization hyperarousal. see Hyperarousal
abuser parts, 62–63 hypothalamic-pituitary-adrenal
alters. see Alters response to, 112
animal identities, 64–66 patterns, neurophysiologic, 112,
child parts, 60–61 113, 114
closed system organization of DID, polyvagal theory. see Polyvagal
70–71 theory
dead parts, 64 post-Vietnam War usage of term,
differentiated parts, 56 51, 167
dissociated parts, physical images secondary dissociative PTSD, 114,
of, 57 115, 118–119, 139
drama triangle, Karpman. see symptoms of, 82, 83, 154
Drama triangle, Karpman victim identity, 136
executive control. see Executive Prepsychoanalytic period, 45
control Primal scream therapy, 178
experience of personalities as
Prince, Morton, 43
different people, 55
Projective identification, 229–232
female organization, 55–56
Protoconversation, 138
gender, different, 63
Pseudodelusions, 86
internal family systems model. see
Internal family systems model Psychoanalysis
internal world of persons with DID, origins of, 31
56 rise of, 50
manager parts, 64 Psychophysiologic reenactment, 111
protector, 61 Psychosis, 161, 264–267
psychotic parts, 64
rescuer, 61 R
soother, 61
we, use of term, 55 Rape, 30
Personality, whole, 88–89 Relational attachment theory, 89–91
Phase-oriented treatment model Relational theory
abreaction, 177–179 bridge between intrapsychic and
central conflict of, 180–182 interpersonal, 28–29
overview, 167 description, 28
Phase 2, 175–177 Relationality, 27–28
Phase 3, 182–184 psychoanalysis, impact on, 31–32
Indexâ•… 307
Repression, 34–35, 271 Structural theory of dissociation,

dissociation, contrast between, 118–119
36–37 Submission, total, 122, 123–124
dissociation, relationship between, Substance abuse disorders, 164, 165
37–38 Suicide and DID, 170
Resiliency, 75 alters, case studies of, 253–256,
Reynolds, Mary, 40 256–261
Ross, Colin, 83 attempted, 249
completed, 249
S danger of, 249
fantasies about, 251
Safety agreements, 173, 190, 251–253 meaning of, 249–251
Schizophrenia, 147, 151, 160–162 safety agreements. see Safety
diagnosis, 49 agreements
introduction of the term, 44, 48–49 Sultan, Harry Stack, 30
Schore, Allan, 126, 127, 128, 129 Superego problems in DID, 271–274
Schwartz, Richard, 67 Switching, 88, 149, 150
Seduction theory, 46, 47 amnesia, 4
Self-care system, 140 description of, 4
Self-destruction, 1, 170, 272–273 partial dissociation. see Partial
Self-hypnosis, 137 dissociation
Self-states, multiple, 7–8
talking through, 190–191
Sexual abuse, childhood, 30
Sybil, 2
cultural change in acknowledgment
Sympathetic nervous system, 121, 125
of, 78–79
Symptoms of DID, 2–3
DID in patients who were abused,
xvii
early history of discussion of topic, T
49–50
Terror, chronic, 170
Freud’s views on, 46, 47
gender (boys abused versus girls), Tertiary structural dissociation, 69
xviii Therapist training for DID, 8–9
prevalence, xvii Third reality, 57, 140
psychological trauma from, 78–79 Thirds, rule of, 206
somatoform dissociation. see Thompson, Clara, 30
Somatoform dissociation Tonic immobility, 124–126
Shame, 170 Trance logic, 11, 57, 177
Shell shock, 51, 78 Trance, dissociative, 38–39
Somatic reenactments, 70 Trance, possession, 39, 40
Somatization, 83 Transferences, 67, 236
Somatoform dissociation, 110, 112, erotic, 228
123 traumatic. see Traumatic
Sonambulistic states, 44–45 transferences
Soul murder, 221 Trauma, 28
Stern, Donnel, 30 definition, 74
Stolorow, Robert, 30 description of, 74
Stone Center, 30 dissociation, link to, 73
Structural Clinical Interview for memory and, 75
DSM-IV Dissociative piecemeal processing of, by brain,
Disorders-Revised, 159 109–114
Structural dissociation of the prevalence in DID cases, 73
personality, 68–70 psychological, 74
308â•… Index
relationality, relationship between, safety agreements, 173, 190,

30–31 251–253
theories on, 32 treatment alliance, 171–173
Trauma/dissociation model, 263–264 Trevarthen, Colwyn, 236–237
Traumatic bonding, 87
Traumatic countertransferences, 225, U
226–228
Traumatic personality state, 119 Unconscious, 28
Traumatic transferences, 225–226 overview, 34
repression. see Repression
Treatment of DID, 1–2
alters, communicating with. see
Alters V
asking host to ask inside, 191–193 Van Derbur, Marilyn, 87
body connections, facilitating, Vietnam War, 30
199–201
engaging with alters, on part of the
therapist, 189–190 W
phase-oriented model. see Phase- Warning system, early, 212
oriented treatment model Whiplash syndrome, 123
psychoeducation, 174–175 Women’s movement, 30

Elizabeth F. Howell - Understanding and Treating

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Understanding and Treating

Relational PeRsPectives Book seRies

New York London

This edition published in the Taylor & Francis e-Library, 2011.

International Standard Book Number: 978-0-415-99496-5 (Hardback) 978-0-415-99497-2 (Paperback)

Library of Congress Cataloging‑in‑Publication Data

Howell, Elizabeth F., 1946-

Visit the Taylor & Francis Web site at

ISBN 0-203-88826-X Master e-book ISBN

A Personal Note xiii

1 The Lives and Psychotherapy of Three People With DID 15

2 The Dynamic Unconscious and the Dissociative Structure

3 “The We of Me”: Personality Organization in DID 55

4 DID Is a Trauma Disorder 73

5 Dissociated Self-States, Trauma, and Disorganized

6 Some Neurobiological Correlates of the Structure and

7 Dissociated Self-States: Creation and Contextualization 133

8 Assessment and Diagnosis of DID 147

9 Phase-Oriented Treatment 167

10 Facilitating Coconsciousness and Coparticipation in the

11 Working With Persecutory Alters and Identification

12 The Therapeutic Relationship: Multiple Dimensions

13 Dreams in DID 239

14 Suicidality in DID 249

15 Comorbidity and Seeming Comorbidity: Problematic

If this book were a piece of music, the hauntingly beautiful, melancholy,

more fully in Chapter 5) may result from overwhelming experiences in the

of the human mind. From this perspective, none of us is a singular unit,

I am immensely grateful for the help and contributions to this book of

Despite the significant prevalence of dissociative disorders—rates rang-

DID Is Frequently Misdiagnosed

DID Is Often Hidden

Although it is not rare, DID is often hidden. In contrast to the flamboyant

unaware of their behavior and therefore be unable to explain it to others;

The phenomenon generally considered most characteristic of DID is switch-

D. The disturbance is not due to the direct physiological effects of

There Is Not Only Full Dissociation

schizophrenia. Kluft reported that patients with DID endorse 8 of the 11

DID Is Confusing to Everyone

Multiple Self-States and

When we speak of partial dissociation as an important aspect of DID, it

contextually interrelated and part of what comprises the sum of who we

As humans, we adapt to the varying contexts of our lives. However, we

Therapist Training for DID

facilitating psychic health derive from an understanding of the psychic

Organization of This Book

explains different conceptual schemes for understanding the organization of

The Lives and Psychotherapy

Janice is a 43-year-old woman, recently remarried, who has two teenage

suffer immeasurably. (See Chapter 14 for more discussion of suicidality.)

Dennis, who has DID, is a personable, extremely intelligent, 32-year-old

Margaret is a 35-year-old woman, married with two children, who is

The Dynamic Unconscious

Today, but only just recently in historical time, dissociation, relationality,

we understand the mind. Together with awareness of multiplicity, trauma,

Relational psychoanalysis is now a central piece of the psychoanalytic

continued to write about how real relationships affect psychodynamics,

relationality, as joined ideas, became a natural outflow of the confluence of

Relationality, Trauma, and Dissociation

And, partly as a consequence of this omission, trauma theories have relied