Forging a Deeper Understanding of Flashbacks: Part I

I believe that experienced trauma therapists (Think: PTSD specialists) possess an approximate, rather cognitive understanding of flashbacks. On the other hand, I am certain that dissociative disorders therapists (Think: DID specialists) have a much richer grasp of flashbacks, but I don’t think that their richer grasp adds up to a truly rigorous understanding. Not yet, anyway. I guess what I’m saying is that we all probably know less about flashbacks than we think we do. And much of what we do know consists of the hard-won clinical insights of individual therapists — insights that are seldom written down (and thereby made available for general discussion)..

Let’s try to forge a better understanding of flashbacks. This is obviously a very difficult task or it would already have been accomplished. By the way, I, too, find this task to be very difficult.

The Stress of Major Life Events

When I was a graduate student in the early 70s, the Holmes and Rahe Stress Scale was quite popular (Holmes & Rahe, 1967). The scale consists of 43 life events, each with an assigned stress value. The most stressful event is Death of a Spouse (with a stress value of 100). Strikingly, even positive events are stressful (e.g., raises in salary, outstanding personal achievements, vacations). Holmes and Rahe reported that increased stress was associated with an increased incidence of illness.

At about the same time, Mardi Horowitz was studying the intrusive thoughts that follow major life event. Horowitz found that major life events, whether positive or negative, were always followed by intrusive thoughts (about the event). According to Horowitz’ model, these thoughts keep intruding into conscious awareness until the person has cognitively assimilated the event and, ideally, fully accomodated to the event’s personal implications.

Sound familiar? But remember, we’re not talking trauma here. Just major life events. These intrusive thoughts are not flashbacks. They are simply automatic, unbidden thoughts about a big change in your life. Think about: Winning the Lotto. Guaranteed to produce intrusive thoughts for quite a while!

Intrusive thoughts after a major life event are absolutely normal. Major life events always have implications for oneself, one’s future, and one’s place in the world. Consequently, each of these understandings about self and world (and, sometimes, a whole lot more) needs to be recalibrated. Horowitz called this process of recalibration the completion principle. The essential idea here is that intrusive thoughts continue to recur until the person finishes accomodating to the major life event.

Note: The Janet scholars in our midst will note a distinct affinity between Horowitz’ ideas and Janet’s ideas about realization and personification.

In any case, many clinicians have applied Horowitz’ model to flashbacks. Interestingly, many clinicians come to this idea on their own — without having read Horowitz. After all, Horowitz’ model is a very sensible and appealing idea. But, I’m not sure how well the model applies to flashbacks. Maybe yes, maybe no. I’m still on the fence about this one.

The Difference Between Intrusive Thoughts and Flashbacks

Let’s get one thing out of the way. The kinds of intrusive thoughts that follow a major life event are absolutely normal. In fact, I think evolution has shaped the functioning of our neocortex such that Horowitz’ completion principle is built into us. But — there are, indeed, many kinds of abnormal intrusive thoughts.

Good places to find people suffering from abnormal intrusive thoughts? People with obsessive-compulsive disorder. Schizophrenics. People with anorexia nervosa.

In this section of my blog post, however, I am not talking about OCDs, schizophrenics, or anorexics. I am talking about you and me and our normal reaction to major life events — automatic, unbidden, intrusive thoughts about that event until we come to terms with it.

OK. How are flashbacks different from these normal intrusive thoughts? First of all, flashbacks are not thoughts. They are perceptual (imagistic, sensory, and emotional). Thoughts involve both language and awareness-of-the-self-that-is-thinking. Both of these may be lost during flashbacks.

With normal intrusive thoughts, there is always a clear connection between self and the intrusive thought. We own that thought and accept it as mine. The ‘work’ that needs to be done with intrusive thoughts is to fit that major life event — and its personal implications — into our understanding of ourselves and our world. Said differently, we need to accommodate our existing narrative (i.e., our understanding) of self and world to this new information. As we sometimes say about a new idea, “I need some time to wrap my mind around this.”

Flashbacks Exist Outside Language

As humans, we have language and a human consciousness. We live in a narrative world. Our very human existence is inseparable from language. Humans live a narrative existence. That is what it is to be human. We live within language. Flashbacks lie outside language. They are perceptual — imagistic, sensory, and emotional.

Psychologists and philosophers occasionally talk about “raw, sensory data.” But the notion of raw, sensory data is largely a fiction. We don’t perceive raw sensations. What we perceive is already, preconsciously, sorted/arranged into some familiar object or category. We perceive objects and categories — not raw sensations.

I apologize for getting all philosophical on you, but I think this particular point is crucial for understanding flashbacks. Intrusive thoughts come to us already formed into language. Flashbacks don’t. Flashbacks are fragmented images, sensations, and affects. In order for a flashback to finally stop, we must bring those fragments into language. We must develop a narrative of what happened.

OK, this is a good stopping point. What do you think about flashbacks existing outside language?

Posted in dissociation, evolution, first-person accounts, flashbacks, PTSD, trauma | Tagged , , , , , , , | 40 Comments

What Are Flashbacks and Why Do They Happen?

Experienced trauma therapists know that persistent flashbacks are incredibly toxic; they frequently cause counter-productive coping, escalating depression, suicidality, clinical emergencies, and hospitalizations. Today’s question is not how to manage flashbacks, but something much more fundamental: “What the heck are they?” We know what they look like. We know their clinical impact. We have a fair idea how to help our patients with them. But what are flashbacks, really? Why do they happen? What is their function? Do they even have one?

When Is Dissociation Not a Defense?

My previous post challenged the concept of dissociation-as-a-defense by asking, “Are flashbacks dissociative?” Our discussion of this question produced an unanticipated (at least by me) outcome.

Therapists (including me) repeatedly insisted that some flashbacks (i.e., those characterized by a complete loss of contact with the here-and-now) are unquestionably dissociative. On the other hand, therapists had almost nothing to say about the fact that flashbacks are not a defense. Their comments suggest that, for them, the most salient feature of flashbacks is the patient’s complete loss of contact with present-day reality.

In contrast to therapists, dissociative individuals had a very different point of view. These ‘insiders’ insisted that flashbacks are not dissociative. In fact, they pronounced flashbacks to be “the opposite of dissociation.” I take this to mean that they are highly aware of the defensive, protective function of dissociation. And why not? After all, they have a personal stake in the matter. Flashbacks have all the subtlety of being blindsided by an 18-wheeler. They know damned well that flashbacks represent a failure or collapse of their dissociative defenses.

Neuroimaging Studies of Flashbacks and Dissociative Symptoms

Functional magnetic resonance imaging (fMRI) studies of PTSD patients have repeatedly shown startlingly different patterns of brain activity during flashbacks versus during acute incidents of dissociation. In these studies, PTSD patients and trauma-exposed persons without PTSD listened to scripts of their worst trauma and visualized the trauma while being scanned in an fMRI machine.

This procedure triggered flashbacks and hyperarousal in about 70% of the PTSD patients, and an episode of acute dissociative distancing in the remaining 30%. In the lead article of the July issue of the American Journal of Psychiatry, Ruth Lanius and colleagues reviewed this body of literature and analyzed its implications (Lanius, Vermetten, Loewenstein, Brand, Schmahl, Bremner & Spiegel, 2010).

The flashback/hyperarousal PTSD patients exhibited a pattern of brain activity which indicated a failure of corticolimbic inhibition. Specifically, the flashback/hyperarousal PTSD patients exhibited (1) an abnormally low activation in the ventromedial prefrontal cortex and the rostral anterior cingulate, and (2) increased activation of the limbic system, especially the amygdala and the right anterior insula.

Translation: The brain regions associated with modulation of arousal and regulation of emotions were largely shut down, while the brain regions associated with emotion, fight/flight responses, and the experience of these reactions were highly activated.

The PTSD patients with dissociative distancing exhibited a pattern of brain activity which indicated excessive corticolimbic suppression. That is, they exhibited (1) an abnormally high activation the dorsal anterior cingulate and the medial prefrontal cortex, and (2) decreased activity in the amygdala and right anterior insula.

Translation: The brain regions associated with modulation of arousal and regulation of emotion were abnormally activated, while the brain regions associated with emotion and its experience were substantially inactivated.

A Dissociative Subtype of PTSD

Lanius and colleagues concluded that there is a dissociative subtype of PTSD which is quite different from the more common re-experiencing/hyperarousal type of PTSD that is so well described by the DSM-IV criteria for PTSD. Both types of PTSD undergo flashbacks, but only the dissociative subtype frequently experiences a spontaneous dissociative distancing of the memory of the trauma. Moreover, as one ‘insider’ member of our community of dissociation aficionados has noted, and as Lanius et al. also reported, a person who has the dissociative subtype of PTSD may simultaneously experience a flashback and a dissociative distancing from that flashback.

Finally, as that same aficionado wryly asked, if we are going to call flashbacks a form of dissociation, does dissociative distancing from a flashback = “dissociating from the dissociation”? Flashbacks and dissociative distancing really are very different. And it is very confusing to call both of these things “dissociation.”

Finally, it may be worthwhile to know that Lanius and colleagues define dissociation as “detachment from the overwhelming emotional content of the [traumatic] experience” (p. 640). This is certainly a reasonable description of dissociative distancing (but a very poor description of a flashback).

Final Comment: Well, we have covered a fair amount of material about the relationship between flashbacks and dissociation, but we still don’t know exactly what a flashback is. And we certainly don’t know why they occur.

PS. I know they are triggered by a reminder of the trauma. The important question is,“Why does the reminder of trauma trigger a flashback (instead of just a memory)?”

Posted in alterations of consciousness, defense, dissociation, dissociative subtype, DSM-IV, evolution, evolution-prepared dissociation, first-person accounts, flashbacks, neurobiology, PTSD, published/presented research, repression, trauma | Tagged , , , , , , , , , , , , , | 27 Comments

Are Flashbacks a Dissociative Symptom?

Dissociation is generally considered to be a defense mechanism because it distances us from painful or unacceptable realities (e.g., depersonalization, derealization) or it makes a painful reality disappear entirely (i.e., dissociative amnesia). Today’s thought question is: “Are flashbacks dissociative?” Do flashbacks protect us from a painful or unacceptable reality?

Hmmm. This is definitely an interesting question. PTSD patients seldom celebrate the ‘comforting’ or ‘protective’ nature of their flashbacks. 🙂

The Current Draft of DSM5 Insists That Flashbacks Are Dissociative

In contrast to DSM-IV, DSM5 may claim that  flashbacks are a dissociative reaction. In the current working draft of DSM5, the list of intrusive symptoms for PTSD includes flashbacks — described as follows:

Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)…” (www.dsm5.org, emphasis added)

Many dissociation experts have long argued that flashbacks are a dissociative symptom. These experts consider DSM5’s understanding of flashbacks to be a significant advance from DSM-IV. But is it? Is it an advance? Is it even correct?

Four Other Models of Dissociation

1. DSM-IV

If dissociation protects a person from something painful or unacceptable, then flashbacks certainly cannot be an example of dissociation. On the other hand, according to several other descriptions or models of dissociation, flashbacks are definitely dissociative. For example, DSM-IV states that:

“The essential feature of the Dissociative Disorders is a disruption in the usually integrated functions of consciousness, memory, identity, or perception.” (DSM-IV-TR, p. 519, emphasis added)

Yup, flashbacks are definitely disruptions of the usually integrated functions of consciousness, memory, and perception.

2. ICD-10

Clinicians in the United States are guided by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Clinicians everywhere else are guided by the World Health Organization’s International Classification of Diseases (ICD-10). According to ICD-10:

“the common theme shared by dissociative (or conversion) disorders is a partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements.” (World Health Organization, 1992, p. 151, emphasis added)

By this definition, flashbacks are unmistakably dissociative; they are a partial or complete disruption of normal integration.

3. Dell and O’Neil (2009)

OK. That’s what the two ‘Bibles’ say, How do other sources define dissociation? In 2009, John O’Neil and I published a large edited volume whose purpose was to bring clarity to dissociation and the dissociative disorders. In the book’s preface, we offered a three-paragraph definition of dissociation. That definition begins with this sentence:

The essential manifestation of pathological dissociation is a partial or complete disruption of the normal integration of a person’s psychological functioning. (Dell & O’Neil, 2009, p. xxi, emphasis added)

After reading what DSM-IV and ICD-10 had to say on this matter (above), the Dell and O’Neil definition has to feel distinctly familiar. And again, according to this definition, flashbacks must be classified as dissociative.

4. Dell (2006)

Finally, bear with me as I present one final definition of dissociation — my own definition from 2006:

“the phenomena of pathological dissociation are recurrent, jarring intrusions into executive functioning or sense of self by self-states or alter personalities.” (Dell, 2006, p. 8, emphasis added)

Note that this definition of dissociation has two parts. According to the first part, flashbacks are certainly dissociative because they are recurrent jarring intrusions into executive functioning. On the other hand, according to the second part of the definition, flashbacks are dissociative only if they are caused by self-states or alter personalities.

The difference between my 2006 definition of dissociation and the three preceding definitions is that my 2006 definition goes beyond description and phenomenology. Namely, it defines dissociation in terms of a specific mechanism — a self-state or alter personality that intrudes into conscious functioning.

This is where an annoying narrator would say: “The discerning reader will have noticed …”  I’ll try to avoid being that annoying, but there is an important point to be made here.

The point is this: In 2006, when I added that mechanism to my definition of dissociation, I added a structural model of dissociation to the DSM-IV and ICD-10 accounts of dissociation.

Translation: Disruptions of normal integrated functioning are dissociative if, and only if, they are caused by a self-state or alter personality (i.e., caused by a dissociative structure of the personality).

Aha! Now the fun really begins. We have a new question: Are flashbacks caused by dissociated structures?If they are — and Van der Hart, Nijenhuis, and Steele insist that they are — then:

(1) the flagship symptom of PTSD (i.e., flashbacks) is a dissociative symptom, and

(2) PTSD itself is a dissociative disorder.

The proponents of structural dissociation firmly insist upon both of these points: flashbacks are dissociative and PTSD is a dissociative disorder. But.. The Powers That Be in DSM5-land do not think that PTSD is a dissociative disorder — and I agree with them.

Worse, I think that both the structuralists and the DSM5 Powers That Be are wrong about flashbacks. Although some flashbacks seem to be distinctly dissociative, I think it is a big mistake to classify all flashbacks as dissociative.

Posted in defense, depersonalization, derealization, dissociation, dissociative disorders, DSM-IV, DSM5, first-person accounts, flashbacks, ICD-10, PTSD, repression, structural dissociation | Tagged , , , , , , , , , , , , | 59 Comments

Persisting Peritraumatic Dissociation Is Different From Evolution-Prepared Dissociation

Evolution-prepared dissociation provides a hyper-clear picture of the dangerous circumstances that evoked it. In contrast, non-evolution-prepared peritraumatic dissociation does precisely the opposite — it distances, obscures, pushes away, avoids, hides, and blocks a clear picture of the dangerous circumstances that evoked it. Researchers’ failure to distinguish between these opposite kinds of dissociation has prevented us from obtaining a clear empirical picture of (1) these two kinds of dissociation, and (2) their respective relationships to posttraumatic psychopathology (i.e., acute stress disorder [ASD], PTSD, and the dissociative disorders).

Evolution-Prepared Dissociation

As noted in UnderstandingDissociation.com’s last post (and in comments from several of you), evolution-prepared dissociation involves accelerated mental processing, a hyper-focus on the details of the dangerous situation, a subjective slowing of time, and a dissociative suppression of fear, pain, and other disruptive emotions. This ‘package’ of responses is a ‘gift’ that natural selection has given us. It is highly adaptive and it maximizes our ability to take effective action and, thereby, survive an imminently lethal situation.

Peritraumatic Dissociation

Note: “peritraumatic” literally means ‘near or around the time of the trauma.’  Contrast evolution-prepared evolution with DSM-IV’s description of peritraumatic dissociation:

“a subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of his or her surroundings; derealization; depersonalization; or dissociative amnesia…” (American Psychiatric Association, 2000, p. 469)

This view of peritraumatic dissociation is inseparable from the idea that dissociation is a defense mechanism. For example:

“Dissociation leads to inner distancing and is thus to be regarded as a fundamental withdrawal mode enabling the person in question to phase out the unbearable reality for the moment and pretend that it has never happened.” (Breh & Seidler, 2007, p. 54)

Research on Peritraumatic Dissociation

Neither the researchers of peritraumatic dissociation, nor the instruments that they use to measure it, have drawn a clear distinction between defensive peritraumatic dissociation (which seeks to avoid reality) and adaptive evolution-prepared dissociation (which shines a bright spotlight on reality)! No wonder the research on dissociation that occurs near or around the time of the trauma (i.e., both kinds of dissociation) has produced modest and inconsistent results. Specifically, instruments that indiscriminately mix defensive peritraumatic dissociation with adaptive peritraumatic dissociation produce scores that are only modestly related to subsequent PTSD symptoms (Effect size = .34-.36). This effect size is significant, but not especially impressive.

On the other hand, researchers who have distinguished between immediate peritraumatic dissociation and peritraumatic dissociative symptoms that persist for weeks have found a very different result. Their multivariate statistical analyses show that immediate peritraumatic dissociation is unrelated to subsequent PTSD, whereas persisting peritraumatic dissociative symptoms are highly related to subsequent PTSD (Briere, Scott & Weathers, 2005). Similar results have been reported by other researchers (Halligan, Michael, Clark & Ehlers, 2003; Murray, Ehlers & Mayou, 2002; Panasetis & Bryant, 2003) .

It is important to note, however, that peritraumatic dissociation (whether immediate or persistent) is not the whole story when it comes to developing PTSD. That is, the same studies that revealed the importance of persisting peritraumatic dissociative symptoms also showed that

(1)many persons with no peritraumatic dissociation go on to develop PTSD, and

(2) many persons experience peritraumatic dissociation, but do not develop PTSD.

The Next Question About Dissociation

The next big question about dissociation at this point in our discussion is: “How and why does peritraumatic dissociation persist in some people? And perhaps become chronic? And why and how does peritraumatic dissociation persist a bit for some individuals, but then ultimately subside without any psychopathological after-effects?

What do you think?

Posted in Acute Stress Disorder, defense, depersonalization, derealization, dissociation, dissociative disorders, evolution, evolution-prepared dissociation, measures of dissociation, peritraumatic dissociation, PTSD, published/presented research, trauma | Tagged , , , , , , , , , , | 12 Comments

The Evolutionary Link Between Trauma and Dissociation

As a clinician who wants to understand dissociation, I keep bumping into two fundamental questions:

1. What is the relationship between trauma and dissociation?

2. What is the relationship between dissociation and PTSD?

I ended my last post with a question about dissociation and PTSD (i.e., “Do all persons with PTSD have structural dissociation?” — as the proponents of structural dissociation contend). Let’s defer consideration of that question for now. Instead, let’s address the most basic issue of all– the relationship between trauma and dissociation.

Trauma-Dissociation Skeptics and Deniers

If you do not read the academic literature on trauma and dissociation, you may not know that there is a contingent of skeptics in academia who insist that there is no causal connection between trauma and dissociation. These skeptics often seem to ‘cherry pick’ scientific findings in order to support their preconceptions. These ‘guys’ remind me of the people who insist that there is no global warming or who reject Darwin and evolutionary theory. In any case, I will not talk about these skeptics today. I just wanted to make sure that you know these skeptics exist.

Evolution-Prepared Dissociation

Evolution produced the original link between trauma and dissociation. Natural selection, however, is never really about trauma or dealing with trauma. Natural selection is about survival (and reproduction).

So, the original link between trauma and dissociation was actually a link between (a) imminent threat of death (i.e., survival) and (b) a sudden alteration of information processing that involves dissociation. The threat of immediate death triggers a shift to an altered (and accelerated) form of information processing: rapid thinking, very high mental acuity, a slowed sense of time, and an automatic dissociative silencing of pain, fear, and other emotions that could interfere with survival-related thought and action. These survival-related shifts maximize the person’s ability to act decisively and effectively.

Survival-related dissociation is not a recent evolutionary development. Its origins do not lie in the human neocortex, but in the paleomammalian brain — the midbrain (e.g., periacqueductal gray) and parts of the limbic system. I emphasize the subcortical location of this evolution-prepared dissociation because it is probably very different from the dissociation of persons with a major dissociative disorder (which, I think, is largely located in the neocortex).

What Does Evolution-Prepared Dissociation Look Like?

The first, and still one of the best, accounts of evolution-prepared dissociation (although not labeled as such) was published in 1892 by Albert Heim in a Swiss mountain climbing journal. Heim interviewed dozens of mountain climbers who had survived potentially lethal falls. Ninety-five percent of them described some version of the following experience:

[N]o grief was felt, nor was there paralyzing fright of the sort that can happen in instances of lesser danger (e.g., outbreak of fire). 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 hundred-fold velocity or intensity. The relationships of events and their probable outcomes were overviewed with objective clarity. No confusion entered at all. Time became greatly expanded. The individual acted with lightning quickness in accord with accurate judgment of his situation… Men who had fallen from great heights were unaware that their limbs had been broken until they attempted to stand. (Heim, 1892/1980, pp. 130-131)

The next contribution to our understanding of evolution-prepared dissociation did not occur for another 80 years. In the late 1970s, Russell Noyes, a near-death researcher, interviewed many people who had near-death experiences (e.g., falls, accidents, near-drownings, etc.). Here is one such account (of a person who was driving at 60 miles per hour when the steering on his car failed):

My mind speeded up. Time seemed drawn out. It seemed like five minutes before the car came to a stop when, in reality, it was only a matter of seconds. I remember that my sense of touch and hearing became more acute…. My mind was working rapidly and reviewed information from driver’s education that might bear on what I should do to save myself…. While all this was taking place I felt calm, even detached. (Noyes, Kletti & Kupperman, 1977, p. 376)

The Essential Features of Evolution-Prepared Dissociation

It is crucial to appreciate that evolution-prepared dissociation is utterly biological. It is ‘hard-wired,’ and not psychological. It is not a defense. It has been built into all of us by natural selection.

Evolution-prepared dissociation has six characteristics:

1. It is about danger, threat to life, and survival.

2. It is automatic and near-instantaneous.

3. It is just one component of an organized response to an immediate threat to survival.

4. It is a brief, time-limited phenomenon (which ceases as soon as the danger is over).

5. It is a subcortical response (i.e., from phylogenetically old areas of the brain).

6. It is completely normal. There is nothing whatsoever that is pathological about evolution-prepared dissociation.

How Does Evolution-Prepared Dissociation Relate To Chronic Dissociative Symptoms?

I believe that evolution-prepared dissociation is the original root of human dissociation. But — and this is a big but — I also believe that evolution-prepared dissociation is not the chronic dissociation of persons with posttraumatic and dissociative disorders. Chronic dissociation seems to be a phenomenon of the human neocortex. Still, there may (or may not be) important links between chronic dissociative symptoms and the mid-brain structures of evolution-prepared dissociation.

Peritraumatic Dissociation

The closest approximation to evolution-prepared dissociation in the literature is the concept of peritraumatic dissociation. I will explain in a future post my thoughts about the relationship between evolution-prepared dissociation and peritraumatic dissociation.

OK. I hope that this post has given you a lot to ‘chew on.’ What do you think? Don’t hold back. Let yourself really think about these ideas — and share your thoughts with our little community of dissociation aficionados. By the way, personal reports of your own experience with evolution-prepared dissociation are welcomed.

Posted in defense, dissociation, evolution, evolution-prepared dissociation, first-person accounts, peritraumatic dissociation, PTSD, research ideas, skepticism, structural dissociation, trauma | Tagged , , , , , , , , , , | 38 Comments

It Takes a Community To Understand Dissociation

Understanding Dissociation.com launched one week ago. Since then, it has logged 500+ Hits, 41 Comments (albeit nearly half of them mine as I respond to your Comments), and 19 subscriptions by email. A good start, I think.

Because I am convinced that it takes a community to understand dissociation, I believe that the true riches of UnderstandingDissociation.com reside among and between its Comments. The Comments show the effects of my posts on your thinking about dissociation. And, because, my Comments address the core ideas in your Comments, the real ‘action’ lies in that give-and-take between the Comments.

Read the Comments to the previous post and allow them to enrich your own thinking! Go ahead. Click on “Are You Aware of the Disagreements About Dissociation?” (below) and read the responses that were submitted by our nascent community.

Participate in all of the fun and take in all of value that is on offer. Our community of dissociation aficionados grows and matures the more that you learn and the more often that you share your thoughts with the rest of us. Remember: UnderstandingDissociation.com is a community!

Is Dissociation a Many-Splendored Thing?

I need to make a brief statement about the theory of structural dissociation. I have focused my blog posts on this model not because I disagree with it (I actually agree with about 80-85% of it), but because the structural model of dissociation is, by far, the most clearly stated position in the field.

Experience has shown me that even more clarity arises when a very clearly stated position is closely examined or challenged. Clearly stated positions always seem to repay the effort that you put into thinking about them — even if you wind up disagreeing with them in the end.

Perhaps the clearest statement of the structuralists’ view of dissociation is “Dissociation versus alterations of consciousness: Related but different concepts” (Steele, Dorahy, van der Hart & Nijenhuis, 2009). This is an excellent account which I highly recommend. In that chapter, Kathy Steele, Martin Dorahy, Onno van der Hart, and Ellert Nijenhuis make several essential points:

  • There is serious conceptual confusion about dissociation.
  • If an alteration of consciousness is not caused by a dissociated structure of the personality, then that alteration of consciousness is not dissociative.
  • It is very difficult to distinguish structural vs. nonstructural alterations of consciousness. In fact, our measures of dissociation (e.g., DES) indiscriminately mix the two together in their test scores.
  • The continuum model of dissociation (wherein normal forms of ‘dissociation’ lie at one end and pathological forms lie at the other end) is incorrect.
  • Persons with structural dissociation routinely experience nonstructural alterations of consciousness as well.
  • All trauma-related disorders (Think: especially PTSD) are rooted in structural dissociation.

Of the six points listed above, I can heartily sign on for five of them. But I don’t think that empirical evidence supports the structuralists’ last contention.

My bottom line: I think that some persons with PTSD have structural dissociation, but I think that other persons with PTSD do not.

So, your turn. What do you think?

Posted in alterations of consciousness, dissociation, measures of dissociation, PTSD, structural dissociation | Tagged , , , | 6 Comments

Are You Aware of the Disagreements About Dissociation?

We are in the midst of a largely unacknowledged disagreement about what dissociation is. A few parties to this disagreement are quite explicit about their difference of opinion (e.g., Steele, Dorahy, Van der Hart, & Nijenhuis, 2009). Most of us, however, have little to say about different views of dissociation. In fact, many of us do not seem to notice that there is any disagreement. But there is.

How Can So Few of Us Be Aware of These Disagreements About Dissociation?

Easily. And for at least two excellent reasons:

(1)   Most people who deal with dissociation are front-line clinicians (and their patients). They tend to be basically pragmatic. They just deal with what comes up and they don’t think a lot about the nature of dissociation.

(2)   The deep reason that we are not aware of disagreements is that present-day clinicians and researchers ‘grew up with’ a bastardized concept of dissociation.

So, let’s try to dismantle our colloquial understanding of dissociation. I think you will find this excursion to be more than just educational. It should actually be a bit revealing.

Pierre Janet

Janet is the originator of the concept of dissociation, but his model of dissociation has remarkably little to do with today’s colloquial understanding of dissociation.

Janet described dissociation as a structural phenomenon. What does that mean? According to Janet, separate parts of the personality are dissociated. Separate parts = separate structures. Thus, the essence of Janetian dissociation is the existence of separate parts of the personality (each of which can autonomously assume executive control, or intrude into, the functioning of the person).

How or why did these separate parts of the personality come into being? Here is where our colloquial understanding of dissociation starts to enter the picture. Janet said that dissociation was caused by a lack of ego strength (actually, he described it as a low level of mental functioning). According to Janet, a debilitating deficit of ego strength can undermine a person’s capacity to psychologically ‘take in’ a stressful event. When this occurs, these stressful events ‘fall to the side,’ thereby creating a separate part (separate compartment, separate structure) that now ‘holds’ those events.

Did you feel it? Did you feel the challenge to the notion of dissociation that you ‘grew up with?’ Note: Janet did not say that something traumatic or aversive was ‘pushed away,’ or ‘split off,’ or ‘repressed.’ Our colloquial notion of dissociation, however, is completely centered around this idea – i.e., the idea that dissociation takes something unacceptable and pushes it away, splits it off, denies its existence, rejects its reality, disowns it, etc. The problem is that Janet never said that.

For Janet, dissociation was a ‘falling apart’ due to mental weakness. To make this easy to grasp, I will reduce Janet’s model to two points:

(1) The nature of dissociation: separate structures/parts of the personality.

(2) The cause of dissociation: a deficit of mental strength that undermines a person’s capacity to ‘take in’ a distressing event or an unpleasant reality.

Our colloquial understanding of dissociation decisively (but unknowingly) rejects Janet’s cause of dissociation.

OK, let’s finish dismantling our colloquial understanding of dissociation so that we can see what it is – and where it came from. Time for Freud.

Sigmund Freud

After a very brief flirtation with Janetian dissociation in 1893 (Breuer & Freud, 1893), Freud explicitly rejected Janet’s concept of structural dissociation. He also explicitly rejected Janet’s cause of dissociation (i.e., mental weakness). By the way, in doing so, Freud became an early rejecter of the concept of multiple personality. In fact, Freud so thoroughly rejected dissociation and multiple personality that he made it difficult for subsequent Freudians or psychoanalysts to pay any attention whatsoever to either multiple personality or dissociation.

Freud’s big contribution to our colloquial understanding of dissociation is his concept of repression. Repression is very different from Janetian dissociation – for two important reasons:

(1) Repression does not create any dissociated structures. Repressed material is simply no longer conscious; it does not create some new compartment to hold it.

(2)   The cause of repression is not a ‘falling apart’ due to mental weakness, but instead, an active, motivated (albeit usually unconscious) mental rejection or disowning of some aspect of reality (pertaining to others or the self). Bottom lineRepression is a psychological defense.

Freud essentially invented the concept of psychological defense. Janet and Freud had an ongoing disagreement about this. For Freud, everything was defense. For Janet, defense was largely irrelevant.

Today, our 21st century understanding of human nature has so totally assimilated Freud’s ideas about psychological defense that we find it hard to imagine a human psychology that does not include defenses.

Although largely unrecognized, Freud’s notion of repression lies at the heart of our colloquial understanding of dissociation. That is why we think of dissociation as a pushing away or splitting off of something aversive. In Janet’s hands, dissociation was a consequence of mental weakness, not a defensive maneuver of the mind. Nevertheless, today’s colloquial understanding of dissociation is that dissociation is a defense.

To summarize, our colloquial understanding of dissociation:

(1) Has lost its Janetian cause (i.e., a mental weakness that causes a ‘falling apart’ of the personality)

(2) Has adopted the Freudian cause of repression (i.e., a motivated pushing away or suppression)

(3) Often seems to reject Janet’s structural model (i.e., that what is dissociated are separate parts or structures of the personality)

(4) And seems most comfortable with a repression-like model of dissociation (where something distressing is unconsciously suppressed, but does not create a new compartment or dissociated structure to ‘hold’ it.

This post is already much too long. I will close by noting that the most vocal challengers of our colloquial understanding of dissociation are modern-day Janetians – namely, the proponents of structural dissociation. They insist that dissociative phenomena must be driven by dissociated structures. And yet, as we will see in future posts, most colloquial and contemporary understandings of dissociation make no mention of any dissociated structures.

More to come in future posts.

So, what do you think about all this? Is dissociation a defense? If you dissociate, do you experience it as a defensive response or reaction? Must dissociation involve dissociated structures? [To comment, or to read the comments of others, click on Comments (in gray immediately below)]

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