September

The International Society for the Study of

Dissociation

NEWS

Volume22, Number 5

September/October 2004

Inside: New DSM V Task Force . . . . . . . . . . . . . . . 3 Forensic: Who’s in Jail? . . . . . . . . . . . . . . . 6 Dissociation in Literature . . . . . . . . . . . . . . 8

Y O U R S O U R C E F O R U P - T O - D AT E I N F O R M AT I O N O N C O M P L E X T R A U M A A N D D I S S O C I AT I O N

From the President

Steven Gold, Ph.D.

Mainstream Recognition of Dissociation: Quixotic Folly or Central Mission of ISSD? “Everyone is much more simply human than otherwise” – Harry Stack Sullivan

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n his account of the founding of ISSD, Rick Kluft (2003) writes that most of the pioneers who helped form the society came to “share a realization already all too plain to Connie Wilbur – that regardless of the quality of one’s contribution, whoever works with MPD will be regarded as outside the mainstream of the mental health sciences” (p. 10). The word mainstream leapt out at me recently as I read this passage… The theme of this year’s ISSD International Fall Conference is “Moving Dissociation into the Mainstream.” The disparity between this annual conference theme and Dr. Kluft’s caveat gave me a new appreciation for why he chose to open his account of the history of ISSD with a reference to Don Quixote. Are those of us with an interest in dissociation merely tilting at windmills? Is it folly to believe that dissociation will ever be a topic that the mainstream will recognize as legitimate, relevant, and worthy of serious study? Dr. Kluft’s point about the marginalized status of DID in the realm of mental health science is indisputable. There are few diagnoses in the DSM whose very existence is questioned as widely. The level of skepticism is especially disheartening given that it seems to persist regardless of an impressive body of empirical evidence in support of the validity of DID (Gleaves, May & Cardeña, 2001). There are some who conclude that interest in dissociation will always be limited, and that we therefore simply

must resign ourselves to the fact that ISSD is fated to existence as a “niche” organization. Although this type of thinking is understandable, to accept this type outlook would be tragic. It would almost certainly be a self-fulfilling prophesy, and would ultimately lead to abdication of our responsibility – indeed, of our mission – as an organization. Many of us are painfully aware that there exists a vast collection of people seeking treatment for dissociative problems unsuccessfully because so few professionals receive training in dissociation that demand far outstrips supply. We also know from empirical research that many more spend years in inappropriate and ineffective treatment because their dissociative difficulties go undetected. In the final analysis, our charge as an organization is to change this state of affairs, an objective that will never be attained if we adhere to restricted aspirations. So, how do we bring awareness of dissociation to the mainstream despite the enduring skepticism? Here are a few suggestions. 1) We need to clarify the construct of dissociation rather than relying on defining it in terms of its specific manifestations. There is a sense in which, as Dr. Kluft asserts, the study of DID may always lie outside the mainstream. This is true simply in the sense that DID is a specialized topic most likely to be of interest to a relatively small sector of mental health professionals with expertise in its assessment and treatment. However, this is vastly dif1

ferent from concluding that the study of dissociation in general, as opposed to DID in particular, will and can never garner mainstream interest and acceptance. The challenge here is that it is hard enough to arrive at a consensually validated definition of DID, but infinitely more difficult to identify and articulate the more general and abstract construct of dissociation. This objective requires identification of phenomena that are agreed to be manifestations of dissociation, and then identifying the features that these disparate manifestations had in common. Work in this area has long been in existence. Conceptual systems such as the BASK (behavior-affect-sensation-knowledge) model of dissociation (Braun, 1988) and the dimensions of dissociation that form the conceptual scaffold upon which the SCID-D (Steinberg, 1994) is built (amnesia, depersonalization, derealization, identify confusion and identity fragmentation) are examples of these efforts. We need however to continue to develop models such as these, explicating, for example, what amnesia, derealization and identify fragmentation have in common that marks them all as forms of dissociation. 2) To effectively educate those outside the organization, we need to approach them not from our point of view, but from theirs. One of the pitfalls of membership in a specialty organization is that it is easy to forget that other people do not know what we know. Since we share a common perspective, knowledge base, and language, we lose sight of the fact that they are not shared by others. We are so used to talking to each other that we sometimes slip into the assumption that what we consider obvious is also evident to professionals outside our organization and to the general public. I am amazed how often I have heard members of ISSD say “but everybody knows that” about continued on page 2

President continued from page 1

established principles in trauma and dissociation that are common knowledge within ISSD but far from widely known elsewhere. A vivid example of this phenomenon occurred just recently in a discussion in an ISSD task force formed to review and update the Guidelines for Treating Dissociative Identity Disorder (Multiple Personality Disorder) in Adults. One of the task force members suggested that we remove the following sentence from a draft of the guidelines: “The patient is not a collection of separate people sharing the same body.” The argument for deleting this sentence was, “but everybody knows that.” Coincidently, within 24 hours of this discussion, the previous (July/August 2004) issue of the ISSD News was posted on the ISSD web site. In the “Publications of Interest” column, an article titled “Delusion, Dissociation and Identity” was summarized. The synopsis indicated that the authors of this article criticize “the metaphysically extravagant ‘multiple persons’ view” of DID. Here, apparently, was an entire article in an academic journal devoted to disputing a misconception about DID that several members of the task force had assumed need not even be mentioned in the guidelines because “everybody knows that.” Some members of the task force were astounded. Much of what keeps dissociation outside the mainstream is misconceptions such as that placing credence in the validity of dissociation entails believing that alters in a DID system are separate people. If we are to be effective in our educational mission it is critical that we make the effort to take on the perspective of those we are trying to reach and address them from that vantage point. On the day that “everybody knows” what we know, there will be no need to discuss how to bring dissociation into the mainstream; it will already be there. 3) We need to “think outside the box” of what we already know to discover connections between dissociation and other areas of study. A momentous advance in the field of

dissociation occurred with the publication of Peter Barach’s (1991) article, “Multiple personality disorder as an attachment disorder.” This article took the well established literature on a fundamental process in psychological development, attachment, and proposed how it related to DID. A quick search on the keywords “dissociation” and “attachment” in PsychINFO yields over 90 citations of works that have subsequently furthered exploration of this relationship by authors such as Ruth Blizard, Elizabeth Howell, Bessel van der Kolk, Daniel Siegel, Giovanni Liotti, Allan Shore, Philip Bromberg, Pamela Alexander and Karlen Lyons-Ruth. In parallel fashion, others have explored the relationship between the field of neuropsychology and dissociation. However, we will only come to recognize the connection of dissociation and basic knowledge in other fields (and consequently deepen our understanding of dissociation) if we move outside the areas of dissociation and trauma with which we are so comfortable and familiar, and delve into other domains. Imagine, for instance, the untapped resources in social psychology, systems theory, sensation and perception and cognitive psychology for clarifying the nature of dissociation, and how integration with those areas can help render dissociation more relevant to mainstream concerns and studies. 4) We need to be open to recognizing manifestations of dissociation in mainstream, everyday life. A marvelous series of examples of dissociation in everyday life can be found in the just published special issue of the Journal of Trauma & Dissociation (volume 5, issue 2) on “Dissociation in Culture.” An interchange between a couple in counseling dramatically illustrates how dissociation can operate in everyday life. I want to emphasize that neither member of this couple meet criteria for a diagnosis any more severe than an Adjustment Disorder. The wife is addressing the counselor: “He doesn’t care! He doesn’t listen! [To her husband, beginning to tear up:] You don’t listen!” “How was I to know there was regular 2

coffee in the house?” the husband replies, his voice tinged with a vague mixture of desperation and resignation. “We never keep regular coffee in the house. Caffeine gives you migraine headaches.” “Have you looked in the pantry lately? We have bags, cans and jars of regular coffee! I keep it in the house for guests. My God! What house do you live in? How do you manage not to see what’s in front of your nose every day?” The situation she is referring to began with an interchange with two overnight houseguests the evening before. She and her husband were sitting in their living room with their guests the previous evening. ”I told them clearly,” she admonishes her husband. “I made a point of it. ‘We don’t drink regular coffee. I bought the red can of regular coffee for you so you can make it for yourselves when you wake up in the morning. It’s in the refrigerator.’ You were sitting less than two feet from me! How could you not have heard me? Do you know what could have happened to me if I had drank that cup of coffee you made from the red can? I would have been laid up all day with a migraine! You don’t listen! You just don’t care!” “I didn’t know you were talking to me! I thought you were talking to them…” He trails off, looking, if this is possible, even more desperate and resigned than he was a moment ago. “You were sitting less than two feet from me!” she repeats. “Do I mean that little to you? How is it humanly possible not to have heard what I was saying when you were sitting right next to me!” This interchange could be lifted directly out of the extremely successful bestseller Men Are From Mars, Women Are From Venus (Gray, 1992). It typifies what Gray describes as men’s tendency to retreat into their “cave.” There is no doubt that observations such as these hit a mainstream chord; this is precisely why the book sold millions of copies. Dissociation is already in the mainstream. We just have to open our eyes to see it. Then we have to convey to the mainstream – from its vantage point rather than ours – what it is that we see. For references see page 10

ISSD Creates New DSM V Task Force

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he ISSD Executive Committee (EC) recently passed the following motion: “That the Executive Committee of the ISSD commit the Society to a 7-year initiative to participate in the DSM-V process and to influence the content of DSM-V.” As part of this initiative, the EC voted to create an ISSD DSM-V Task Force. The co-chairs of the task force are Paul F. Dell, Ph.D. and Daphne Simeon, MD. DSM-V will probably be published in 2012; the writing of the new DSM is scheduled to begin in 2007. Prior to the development of DSM-V, the American Psychiatric Association will also publish another revision of DSM-IV-TR in 2007. This interim version of the DSM is necessitated by the fact that the United States will switch from using the International Classification of Diseases-9 (ICD-9) to using ICD-10. The interim version of DSM-IV-TR will contain the alphanumeric coding for ICD-10. This interim version of DSM-IV-TR may also contain revised text (but not revised diagnostic criteria, etc.). The ISSD DSM-V Task Force will undertake a variety of activities. Most importantly, the task force will convene a Dissociative Disorders Research Planning Conference. The Research Planning Conference has four major purposes: (1) for dissociative disorders researchers to achieve some consensus about what should happen in DSM-V; (2) to summarize the data in support of each of the dissociative disorders, especially as those data bear upon diagnostic criteria, phenomenology, the validity of the dissociative disorders, and researchers’ ideas about DSM-V; (3) to identify unsettled research issues, lacunae in the literature, and empirical weaknesses of the dissociative disorders literature that bear upon researchers’ and ISSD’s emerging goals for the DSM-V; and (4) to identify and design the crucial studies that need to be conducted in support of those goals for DSM-V. The American Psychiatric Association (APA) is currently engaged in pre-DSM-V planning. In particular, the APA is spon-

soring 11 DSM-V research planning conferences—a Research Planning Methods Conference that was held at NIMH in February and ten topical research planning conferences: (1) Personality Disorders (2) Substance Use/Reward Dependence Disorders (3) Deconstructing Psychosis (4) Comorbidity of Depression and Anxiety (5) Stress and Fear Circuitry Disorders (6) Dementia and other Cognitive Disorders (7) Externalizing Disorders of Childhood (ADHD, Conduct Disorder, ODD) (8) Obsessive-Compulsive Spectrum Disorders (9) Somatic Presentations (10) Public Health Issues The DSM-V Steering Committee has encouraged researchers to conduct additional research planning conferences that cover additional topics or areas. The ISSD-sponsored Dissociative Disorders Research Planning Conference will be one of those additional conferences. In keeping with the other 10 research planning conferences, the Dissociative Disorders Research Planning Conference will be co-chaired by an American research psychiatrist (Daphne Simeon) and an international research psychiatrist (Vedat Sar from Turkey). ISSD’s DSM-V Task Force will sponsor a DSM-V-related plenary session at the 2005-2010 ISSD fall conferences. In addition, ISSD members are encouraged to contribute their ideas about the dissociative disorders and DSM-V to the task force. Ideas should be sent to: [email protected]. Ideas that are submitted will be discussed in future issues of the ISSD News.

There was not a creature in the world to whom she spoke with such unreserve…not anyone, to whom she related with such conviction of being listened to and understood, of being always interesting and always intelligible…all those little matters on which the happiness of private life depends… Jane Austen 3

DDPTP Registration Open

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he Dissociative Disorders Psychotherapy Training Program (DDPTP) continues to enjoy wide acceptance among members and non-members alike. The course is given at 17 locations throughout the USA, Canada, England, Germany and the Middle East: Boston, Chapel Hill, Chicago, Cincinnati, Duisburg, Leeds, Haifa, Houston, Los Angeles, London, Montreal, New York, Philadelphia, San Francisco, Tucson, Toronto, and Washington DC. This year we are piloting an advanced course in Cincinnati and San Francisco. The former location will also have the standard course. Additionally, our Online course remains popular. We already have 13 registrants, so make your move now, if you are interested. Classes for most sections begin in late September. A full description of course offerings is available at www.issd.org under ‘Training and Conferences’. Please recommend this course to your colleagues, or take it yourself, if you always wished you had more time to tune yourself to the literature on the dissociative disorders. The co-directors, Liz Bowman, Rich Chefetz, and Steve Frankel, invite your participation!

Welcome New Component Group

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t is with great pleasure that we announce the addition of a new ISSD Component Group – the Rocky Mountain Trauma Society. ISSD Component Group status has been conferred upon the Rocky Mountain Trauma Society effective August 5, 2004. The group is located in Denver, Colorado, and consists of 56 members, four of whom are also ISSD members. For additional information about the group, contact ISSD member Peter A. Maves, PhD, at: [email protected]. ISSD would like to welcome this group to our roster of Component Groups and extend our best wishes for a successful experience.

Love is what you’ve been through together. Thurber

International Column The Italian contribution to the understanding of dissociation

Prof. Eli Somer Ph.D. University of Haifa, Israel email: [email protected]

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he sensitive responsiveness of the parent to a child is traditionally regarded as the most important determinant of attachment security in the infant (Isabella, 1993). Such close affectional bonds is conceived as a universal human need (Bowlby, 1980). Fonagy suggested that secure attachment is the basis of the acquisition of metacognitive or mentalizing capacity, and that attachment formed in abusive families can cause a variety of psychological impairments (Fonagy et al., 1996). Important research and writing on disruptions in normal attachment processes and on the development of dissociative pathology are currently underway in Italy. One of the prominent contributors to this field is Giuseppe Miti, MD. Dr. Miti translated the DES into Italian and authored the book “Personalità Multiple,” among many other publications. He is on the faculty of the Italian Society of Cognitive-Behavioral Therapy (SITCC), the founder of the Italian Association for Research on the Psychopathology of Attachment, and a member of ISSD. His report follows.

Attachment and dissociation Giussepe Miti, MD Forlanini Hospital, Rome, Italy [email protected]

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ince mid 80s, dissociation has become a focus of interest among Italian scholars, particularly in relation to Bowlby’s attachment theory. The growing body of studies around Mary Ainsworth’s Strange Situation model and Mary Main’s Adult Attachment Interview (AAI) suggests that disorganization of early attachment represents a risk factor for the development of psychiatric disorders involving dissociation or a propensity towards dissociative experiences. The behavior of thousands of children around the world in the Strange Situation reflects three principal patterns of attachment: A (avoidant), B (secure), and C (anxious-resistant). In all the samples examined, one group of children, representing approximately 8%, does not fit into any of these categories and has been defined as attachment pattern D. Children in this group tend to show contradictory behaviors toward their mothers expressed as incomplete and pointless movements. During the standard experimental sequences of brief separations from and reunions with the caregiver,

these infants display disorganized attachment patterns by showing both approach and avoidance behaviors toward the caregiver. Disorganized attachment may also present as disoriented attitudes of the infant toward the caregiver (e.g., trancelike states during interactions with the caregiver). On the other hand, in various countries where studies have been conducted using the AAI, results demonstrate a link between unresolved parental trauma (a mental state classified as U, Unresolved) and their children’s disorganized attachment pattern. These studies have led to hypothesized risk factors for the development of dissociative disorders (DD). It is not only abusive caregivers’ behavior (linked to the child’s early traumatic experiences), but also simply frightened and/or distressed parental behaviors that can be harmful to a child. Parental abuse of children mediated by attachment disorganization is a widely recognized risk factor for DD, though it may be overstressed in North America as the main contributor to the development of DD. Child abuse alone does not explain the existence of comparatively rare cases of dissociative disorders where no history of childhood trauma can be reconstructed, 4

nor of cases of severe childhood trauma associated with other disorders (anxiety disorders, borderline personality disorder, mood disorders and even schizophrenia). Italian researchers tried to test whether unresolved loss or trauma in non abusive mothers’ lives was linked to dissociative disorders in their adult children. The assumed links were as follows: frightening/frightened mothers (suffering from an unresolved major loss or trauma) would induce a disorganized/disoriented attachment pattern in their infants that, independent of overt trauma, would predispose these children to the development of a dissociative disorder in adulthood. A few cogent controlled studies conducted in Italy corroborrated the hypothesis that early disorganized attachment is linked, throughout development, to a propensity toward dissociation (Pasquini, Liotti, 2000; Liotti, Pasquini, 2002; Miti, Chiaia, 2003). These studies not only contribute to a fuller understanding of the etiology of the Dissociative Disorders; they also provide further understanding on what impact attachment disorganization has on the complex and often dramatic therapeutic relationships these patients tend to establish with their therapists. Some observations on the therapeutic implications of this attachment style can be found in Liotti, Mollon & Miti (in press). Essentially, although the restoration of the integrative functions of memory, consciousness and identity requires the working through of trauma, our research data help us focus the treatment on developmental, relational and self-regulation processes. Developmental psychopathology research suggests that an important curative vehicle for the treatment of dissociative psychopathology lies in the therapeutic relationship and should be guided by knowledge on disorganized attachment. For references see page 10

Component Group Bylaws Change

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n response to a proposal submitted by the ISSD Component Group Committee, the Executive Council, at its June 27, 2004, meeting, voted to eliminate the requirement that all officers of Component Group boards be ISSD members. While working on the online ISSD Component Society/Study Groups Guide and reviewing the organizational structures of current ISSD Component Groups, it had become obvious that there was a wide variety of Component Groups. Some are big, some are small, some are very formal and highly organized, others are very informal and not organized. Some meet in person, some only meet via electronic media. Since it was not a requirement that Component Groups even have a Board or elected officers, the Executive Council decided that the requirement was prohibitive for the development of new Component Groups and inhibitive for maintaining Component Group status, since groups change and members come and go. If a non-ISSD member wishes to volunteer or accept the responsibility of a Board or elected position, it was decided that person should be allowed to do so and encouraged to join ISSD – not be required by mandate. It was therefore decided that the Bylaws be changed and that each Component Group be required to have a designated ISSD Contact Person that: is a current member of ISSD; will function as a liaison between the Component Group and ISSD; will be responsible for maintaining ISSD standards, goals, and adherence to the ISSD mission statement; will be responsible for submitting the annual Component Group report. It was believed that eliminating the current requirement would allow groups to form, develop, expand, meet ISSD mission goals, and encourage members to join ISSD through witnessing and/or experiencing the collaborative efforts of the Component Group and ISSD – what seems to me to be a more natural progression towards ultimately increasing ISSD membership.

For further information on this change, please contact the Component Group Committee Chair, Dennis S. Pilon, ACSW, BCD, at: [email protected]. For more information on how to establish a Component Group in your area, visit the ISSD website’s Online Component Society/Study Group Guide at: http://www.issd.org/Component/ studygroupguide.htm.

Building Our Future and Making a Difference, Together!

Development Campaign 2004 Nears Completion

You have several choices to complete your contribution: •Send a check to ISSD now; •Go to our website and make your donation online (www.issd.org); •Add your contribution to your annual Membership Renewal fee when it arrives in the mail; and •Contact Headquarters to discuss special payment arrangements. We know you already are passionate about this cause or YOU would not be a member of ISSD.

Let’s Take it to the Next Level! Tom Tudor, Ph.D. Chair, Development Committee Rich Chefetz, M.D. Co-Chair, Development Committee

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he first year of our five-year Development Campaign to raise $250,000 will be complete at year’s end. Many of you have given generously, some extraordinarily so, to create the financial base we need to bring our exciting goals to fruition. These goals include the continuation and expansion of our programs to educate mental health professionals and students about dissociation and chronic traumatization, the education of community gatekeepers, and the creation of The Center for the Study of Chronic Traumatization, our new research component. For those of you who have not yet given, NOW IS THE TIME TO ACT. If you were to donate, each month, the average cost of one psychotherapy session, ISSD would be in a powerful position to meaningfully and effectively pursue our goals. What would it be worth to you to end the marginalization of our field? A half-session per month? Anything at all that you give will help us level the playing field. Not only will these funds allow ISSD to pursue our goals, it will put us in a better position to solicit much larger amounts of money from foundations and granting agencies. We know that these additional funding sources consider the breadth of support of membership a significant factor. When you make a contribution, you make a statement of your commitment that others take as a serious vote of confidence in achieving our goals.

ISSD NEWS 60 Revere Drive, Suite 500 Northbrook, IL 60062 847-480-0899/fax:847-480-9282 E-mail: [email protected] http://www.issd.org Editor Don Fridley, Ph.D. Founding Editor Bennett G. Braun, M.D.

Executive Director Richard Koepke, MSW Administrator Charlotte L. Rich

ISSD EXECUTIVE COUNCIL 2003-2004 President Steven Gold, Ph.D. Past President Richard A. Chefetz, M.D. President-Elect Fran S. Waters, MSW, DCSW, LMFT Secretary/Treasurer Su Baker, M.Ed. Directors Ruth Blizard, Ph.D. Paul F. Dell, Ph.D. Catherine Classen, Ph.D Ellert R.S. Nijenhuis, Ph.D. Clare Pain, M.D. Gary Peterson, M.D. Eli Somer, Ph.D Subscription Rates: If you are interested in subscribing to ISSD News, contact ISSD headquarters at 847-480-0899 for membership information. Subscriptions are available only as a benefit of ISSD membership.

Opinions expressed in articles contained herein are those of the authors, not necessarily of the International Society for the Study of Dissociation (ISSD) or of its individual members. ISSD encourages contributions representing a diversity of viewpoints and disclaims any responsibility for making a substantive review or assessment of the accuracy or validity of the contents thereof. ©2004 International Society for the Study of Dissociation Printing courtesy of Sheppard Pratt Health Systems

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Forensic Forum: Who’s in jail? A. Steven Frankel, Ph.D., J.D. Philip J. Kinsler, Ph.D., Co-editors

Philip J. Kinsler, Ph.D.

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he incarceration rate in the United States has more than tripled since 1980. In 1998, 283,800 people with mental illness were incarcerated in U.S. prisons and jails. This is four times the number of people in state mental hospitals throughout the country.1 Approximately 16% of male prison inmates and 57% of female inmates are reported to have suffered physical or sexual abuse or both in childhood.2 More than 114,000 state prison inmates were on psychotropic medications as of June 30, 2000. There are almost 19,000 prisoners in 24-hour mental health facilities within prisons. 179,200 state prison inmates and 547,800 probationers have reported a mental illness. About 44% of men and 87% of women with abuse histories, who later were incarcerated, spent time in foster care. Thirty percent of male and 70% of female prisoners grew up with a serious substance abuser in the home. Seventy percent of State and 57% of Federal prisoners report prior regular substance abuse.3 As I do my forensic work, I am often struck that the persons I examine for court purposes have the same life histories as those I see in my trauma practice. They have led horrible lives of multiple abuse and neglect… and often turned to alcohol and other substances early in life to obtain a kind of ‘substance facilitated dissociation.’ I want to provide a few vignettes of some of the people I see within the criminal justice system, and then describe some opportunities-challenges-responsibilities for those of us working with severe abuse survivors.

The Case of R.R: The Combination of Substance Abuse, Family Dysfunction, Mental Disorder, and Intellectual Limits Many would dismiss RR as merely an alcoholic and a professional thief. He came from a family that was ‘legendary’ in the community; one could always find

a brother or uncle in the local jail for alcohol, domestic violence, and theft related actions. Mr. R came to the attention of the author through his public defender. The attorney called in the author because Mr. R was simply refusing to speak to her. He was mute, appeared sad and lonely and was sometimes in tears. He had been arrested for a home intrusion—he entered an occupied home and tried to steal electronics to sell in exchange for alcohol. The occupants heard him, and the male member of the couple confronted Mr. R and a physical fight ensued. In this fight, handfuls of Mr. R’s hair were pulled out of his scalp. About a third of his head was a raw red bald spot. He had received special permission from the prison to wear a bandanna over it so that he would not be mercilessly teased by the other inmates, leading to fighting. Physically, he was a skinny, narrow-faced man perhaps five feet three and one hundred thirty pounds… a perfect target. His attorney reported to Dr. Kinsler that a guard said that R was ‘crying over a stuffed animal.’ It was unclear whether the presenting issues were depression, regressed behavior, inability to cope intellectually, or simple refusal to cooperate, with attempts to malinger mental illness or cognitive disability. An evaluation was conducted at the regional jail, as Mr. R was considered too dangerous to be out on bail. The examination was replete with poignant moments. When Dr. Kinsler met him initially, he asked what R liked to be called. Mr. R replied he didn’t care. Dr. Kinsler insisted that every person had a right to decide this. Mr. R lifted his head, previously hanging down without eye contact, and said ‘Mr. R…….’ He had always previously been called ‘Little R,’ a diminutive and somewhat insulting name for a 33-year-old. He sat up a bit straighter and made a bit of eye contact. He told Dr. Kinsler that he was refusing to talk to his attorney because he couldn’t. He was ‘too upset.’ It turned out he was upset about the fact that not one single individual from his family had 6

remembered his birthday while he was ‘in the joint.’ So, he was sitting on his bunk cuddling with the first stuffed animal he had ever owned, a Christmas gift from jail volunteers. A guard took it away from him as contraband. He sunk into sadness and withdrawal and easily becoming emotionally upset, varying from rages to tears to elective mutism. The Case of Ms. C.G.: The Sequelae of Trauma in the Life of the Developmentally Delayed In a symbolic turnabout, the state women’s prison in Vermont is actually located on the grounds of the old State Hospital. Ms. G was incarcerated there on charges of burglary, forgery, and marijuana possession. She was living in a motel with a man more than double her age—a man with a long criminal history of ‘uttering forged instruments.’ Ms. G reported that this man would ‘take her SSI checks’ and ‘always complain about money.’ She insisted that it was her idea to steal and cash checks from a neighbor…but once she did so she was ‘handing D… hundred dollar bills.’ She told the examiner that ‘it was her responsibility to give him money… my mother always supported all my fathers.’ The author was brought in to assess Ms. G’s need for a cognitive facilitator, courtroom and probation accommodations, and to make treatment planning recommendations that were sensitive to the interface between her cognitive issues and the ‘fallout’ from her life history. She provided me with the following account of her family background, which was largely confirmed through documentary records: Ms. G reported that she grew up in a chaotic and multiply abusive family; her mother had a chronic problem with alcohol and drug abuse and with ‘going to the bars,’ in Ms. G’s words. She became involved with men from the same lifestyle. As a child Ms. G was exposed to intense and repeated family violence throughout her childhood. She reported seeing her mother ‘punched, slapped, kicked’ on a ‘daily basis.’ She said she saw her mother ‘smashed in the face with bottles.’ She learned to ‘pretend it was a nightmare; pretend it was a bad dream.’ The children often did not go to school

because ‘because my mom was too embarrassed by all the bruises and black eyes to take us.’ As if this was not an abusive and neglectful enough beginning, when Ms. G was eight years old, she was repetitively sexually abused over a two-year period by a neighbor and friend of her stepfather. This man also abused other neighborhood children. The police became involved, and came to Ms. G’s home, informing the mother what had happened to her. Ms. G felt that her mother became enraged at her. Her life was so horrid that she ‘set fire to a highchair for one of her dolls and put it under her bed, hoping to burn to death.’ She was nine or ten years old. To Ms. G’s great credit, she and one other neighbor child were able to stand up to the grueling court process. Though the ‘case went on for years,’ eventually the ‘man went to jail for twenty years.’ Not surprisingly, Ms. G has a long history of psychological struggles. In addition to chronic suicidality, she has suffered with flashbacks, nightmares, extreme agitation, and with literally clawing herself, clawing her face at night during flashbacks. She has a history of choosing older, highly exploitive men, and being used by them. And, she has always had multiple cognitive issues. She was evaluated in another state in 1997, and found to have a Verbal IQ of 73, a Performance IQ of 72, and a Full Scale IQ of 72 on the WAIS-R, all in the 2nd to 3rd percentile. She was also diagnosed with a developmental reading disorder. She had very significant adaptive behavior deficits—she was unable to manage her own money, Ms. G’s mother would have to pick out what she needed when they went shopping, and the mother also had to do her laundry. Ms. G has not been able to hold a steady job, and has felt overwhelmed when she has tried such roles as working at Burger King or in a sheltered workshop. The evaluation Dr. Kinsler performed assessed both cognitive and traumabased symptoms. The TSI™ [Trauma Symptom Inventory™]4 indicated that Ms. CG suffered with severe trauma symptoms; her highest peak was on the dissociation scale. The cognitive testing occurred after

what was a grueling day for Ms. G: she had an upset with other inmates; her cell was moved triggering feelings of not being safe; and she had just recited the extremely upsetting family history summarized above. She appeared childlike and regressed through the cognitive testing and highly self-critical. She would say ‘I must be stupid’ when she did not get an answer. She was accompanied to the testing by a support person; this person spontaneously asked ‘Was she in a child state while she was taking those tests?’ Her behavior was seen as quite suggestive of dissociative processes, with these behaviors dramatically affecting her intellectual results. What do these statistics and vignettes mean to those of us who treat dissociative patients? Here are some basic thoughts about opportunities, challenges, and responsibilities: 1. There is a seriously underserved population within our prison systems who are not receiving services for their trauma based symptoms and behaviors. The author has had a conversation with a state director of prisoner mental health who denied the need for or efficacy of trauma therapy, and stated they were afraid of ‘opening up’ prisoners—as if their trauma based problems were not already splashed all over the facilities. There are opportunities to serve particularly traumatized men within these settings; to design programs that combine trauma and substance abuse treatments; and potentially to reduce domestic violence, recidivism, and enormous financial and social costs—by getting involved in the treatment of prisoners. There are jobs to be had, programs to be designed, and research to be conducted within these traditionally ignored settings. Many behavior change programs within Corrections departments are delivered by corrections officers with little training, not mental health professionals. So, don’t ignore those Department of Corrections ads, and perhaps expand your vision of where you can deliver effective trauma treatment. 2. Prison settings are highly judgmental—no surprise—and it is challenging but worth it to get corrections officers, defense attorneys, and prosecutors to look at trauma based symptomatology, 7

not just ‘bad behavior.’ In the RR case above, we actually were able to convince the judge and prosecutor that what Mr. R really needed was DBT. He was transferred to the State Hospital where he went through two sequences of DBT treatment and is now, to the best of our knowledge, successfully completing an intense substance abuse treatment program. 3. There may well be differences in how trauma and dissociation work for people who wind up in the prison system. In evaluations of several hundred prisoners within the last five years, the author has seen only 1-2 cases of apparent DID—but hundreds of cases of derealization, de-personalization, and ‘substance aided dissociation.’ There is a research agenda here for those with these interests. In a recent project within the State of Vermont, we tracked all the admissions into the Public Defender system within three counties over an 18 month period. A remarkable 67% were multiple abuse survivors, most often survivors of physical abuse, witnessing family violence, and parental alcoholism. They were not screened for dissociation. Probably the last thing readers of the ISSD News need is another population that needs their help—and yet, our prisons are becoming the mental health facilities of last resort, and it is our responsibility to try to be helpful here, also. References 1 Ditton, P., Bureau of Justice Statistics, Special Report, Mental Health and Treatment of Inmates and Probationers, July, 1999, NCJ 174463 2 Harlow, C., Prior Abuse Reported by Inmates and Probationers, Bureau of Justice Statistics Selected Findings, April 1999, NCJ 172879. 3Kinsler, P., Saxman, A., & Fishman, D., The Vermont Defendant Accommodation Project, Psychology, Public Policy, and Law, V. 10, Number 1-2, Marsh/June 2004, 134-161; see Table 1, pp. 136-137. 4 Briere, J., Trauma Symptom Inventory, Psychological Assessment Resources, Odessa FL., 1995

“Now that we have seen each other,” said the unicorn, “if you’ll believe in me, I’ll believe in you.” Lewis Carroll

Critical Issues: Trauma, Dissociation and Modernism We are fortunate to have Dr. Michael Cotsell Ph.D. providing us with a different perspective on dissociation. Dr. Cotsell is a professor in the English Department at the University of Delaware. He has been interested in the phenomenon of dissociation as it has been portrayed in literature. He provides us with an excellent view of how dissociation is seen by other than professional therapists. I hope you enjoy the article as much as I have. You may contact Dr. Cotsell at [email protected] Donald Fridley Ph.D., ISSD Editor

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t is important to understand the context of Pierre Janet’s first great work L’Automatisme Psychologique (1889) (Psychological Automatism, but still not translated into English).Eugène Azam’s (1822-99) studies from 1858-93 of a famous case of multiple personality, Félida X, had provoked both the utilitarian Hippolyte Taine and Janet’s scientific mentor, Théodule-Armand Ribot, to argue that “the various states in which direct intuition of the self …[were] lost” by Félida demonstrated that the mind was essentially an automatism. In contrast, Janet’s uncle, the philosopher Paul Janet, read such evidence as a case of “an extension of dreams or somnambulism” which affect “the fundamental self.” As Jacqueline Carroy and Regine Plas have pointed out, Janet’s L’Automatisme was a response to the controversy over Azam’s work. Proceeding with the scientific methodology recommended by his mentor Ribot, the view of “automatism” developed by Janet in L’Automatisme yet defended his uncle’s philosophical perspective on mind. Thus the case of Félida occasioned, Carroy and Plas declare, “a turning point for French psychology.”1 I will go further than that and say that Janet’s groundbreaking work provided a defining point for modern western culture. Janet drew on his research with twenty-seven patients at Le Havre between 1882 and 1888, some of which he had discussed in a series of articles in the 1880s. His considerable descriptive and analytic powers make his case histories enormously interesting. He was able to discern consciousness even in extreme cases of catalepsy. He also described a

number of cases of successive (i.e. alternate) personalities, and the different types of “désagrégation psychologique” (i.e. dissociation). Here, for instance, is a description of the emergence, under hypnotism, of an alter of the patient Lucie that so impressed William James that he included it in his Principles of Psychology (1890): “Do you hear?” he asked. “No,” was the unconsciously written reply. “But to answer you must hear.” “Yes, quite so.” “Then how do we manage?” “I don’t know.” “There must be someone who hears me.” “Yes.” “Who?” “Someone other than Lucie.” “Ah! Another person. Shall we give her a name? “No.” “Yes, it will be more convenient.” “Well, Adrienne then.” 2 L’Automatisme is crucial text for a number of reasons. First of all, Janet used the evidence of the subconscious to establish the modern recognition of the reality, complexity and multiplicity of the mind, including the persistence of the past in the present. Second, Janet made the crucial break between mind and somatic determinism as well as what William James would call “the succession of things perceived” (associationism). Third, Janet provided the basis for understanding and treating trauma (past injury) and dissociative disorders (including hysteria). His superb case histories and analysis in this and later works underlie all subsequent work in dissociative studies. America’s greatest philosopher, William James, had made similar cases against automatism and deterministic association in essays published in the early 1880s, which he subsequently included in his enormously influential Principles of 8

Michael Cotsell Ph.D.

Psychology (1890). 3 James worked on his masterpiece for nearly a decade, so it is a striking fact that he extensively revised and reinforced his text in the light of Janet’s L’Automatisme and articles by Alfred Binet published less than a year before his own work. What James took from Janet can be briefly suggested by his subheading: “Thought turns to Personal Form.” 4 He also included numerous accounts of multiple personality in his work. It is thus the attack on biodeterminism and mechanical associationism along with the analysis of pathological disassociation that makes the term “dissociationism” doubly appropriate for the perspective of Janet, James and their colleagues. With James’s own famous ninth chapter, “The Stream of Thought,” in mind, we might almost say, that Janet and James stand at the modern discovery of “life”. The consequences of the work of Janet and James and their associates for European and American culture leading up and into Modernism were enormous. The Decadents of the fin de siècle, of course, delighted in wicked doubles (Jekyll and Hyde) and evil hypnotists (Svengali). Doubles are, however, also to be found in serious modernist drama, including in Ibsen and Eugene O’Neill. Then, as Modernism proceeded, the double was typically supplemented and replaced by more complex portrayals of multiplicity, as in Joyce’s Ulysses (1922) or with the self-contradictory characters of O’Neill’s Long Day’s Journey into Night (written 1939-41). Ribot realized that Janet’s evidence of the intensity of traumatic memory contradicted his own law of memory (that memories uniformly fade with time) and revised his work accordingly. His Illnesses of the Memory and Illnesses of the Will, both influenced by Janet, were published in Russia in 1900. From them the great modernist actor and director Konstantin Stanislavski in part derived his idea of “affective memory” or “emotional memory,” the guiding idea for actor training of

the twentieth century. So as well, the philosopher Henri Bergson (1859-1941), who attended high-school with Janet, was similarly prompted by Janet’s revelations to propose his distinction between internal duration and external time (Time and Free Will, 1889, etc.), an argument that had a profound influence on Marcel Proust’s exploration of the heuristic character of intense memory in À la recherche du temps perdu (Remembrance of Things Past) (1913-27). The work of the intense Swedish dramatist August Strindberg (1849-1912) lies behind all of subsequent modernist drama. Thus, in relation to trauma, it is worth quoting the familiar words from his well-known preface to A Dream Play (1901): The personalities split, take on a duality, multiply, vanish, intensify, diffuse and disperse, and are brought into focus. There is, however, one single-minded consciousness that exercises a dominance over the characters: the dreamer’s. Strindberg wrote to a friend quoting a passage from the case history of Ansel Bourne in James’s Principles. The phenomena of multiple personality, Strindberg remarked, might explain, “the strangeness of our existence, our double life, obsessions, our nocturnal life, our bad conscience, our groundless fear, our persecution mania, which is perhaps not a mania but we are persecuted.” 5 Following from Strindberg, the German expressionist play (which so strongly influenced O’Neill and his American contemporaries) is typically written from the internal perspective of the protagonist (the Ich, the I, the soul). The expressionist play was thus a return to allegory (a language of part-selves), but a modern nightmare allegory unsupported by a stable, shared world-view or rational order. The central figure often appears in an agony or ecstasy of protest or alienation or rebellion and his or her most characteristic expression is the famous schrei or cry (familiar from Edvard Munch’s famous painting “The Scream” of 1893). Another influential movement for Modernism was Symbolism. Arthur Symons (1865-1945) in The Symbolist

Movement in Literature (1899), following

the French poet Jules Laforgue (186087), wrote of dédoublement (the splitting of the self) as a characteristic of Symbolism. Rémy de Gourmont (18581915), another poet advocate of Symbolism, headed an essay “The Dissociation of Ideas”. T. S. Eliot, one of the very greatest figures of Modernism, read Symons, and hence Laforgue, on whom he based his early style. Eliot was also an undergraduate at Harvard in 1906 when Janet delivered the lectures which became The Major Symptoms of Hysteria (1907). He went on to read Janet, James and Morton Prince, and to attend the classes of Bergson and perhaps Ribot and Janet in Paris. Thus his great poem, The Waste Land (1922) may well be called an epic of trauma and dissociation. Consider the lines describing the aftermath of a seduction: On Margate Sands, I can connect Nothing with nothing. The broken fingernails of dirty hands. (Part 3, ll.300-3) The great themes of the dissociationists were both the subconscious and consciousness. James’s chapter “The Stream of Thought” is famous for its suggestiveness of heightened awareness of both the internal and external worlds (which James would argue could not be conceived apart). For Janet the goal of therapy was consciousness, defined as a combination of “mental force” and “mental vitality”: “presentification” he called it. 6 The intertwined themes of subconsciousness and consciousness run throughout the modernist novel from Henry James (who uses the term consciousness 85 times in The Wings of the Dove (1902) and whose late stories such as “The Turn of the Screw” (1898) explore unconscious states, through the German Thomas Mann, another author influenced by Bergson, to Gertrude Stein (James’s pupil at Harvard), James Joyce, Virginia Woolf, Faulkner and others. It is not hard now to see the connections between interior monologue or stream of consciousness and trauma in Woolf or Faulkner. 7 We may also note that Joyce’s first great work, Dubliners (1914) was, as he said, based on the theme of “paraly9

sis”. Janet was not alone in connecting paralysis with hysteria, but his chapter “Paralysis” in the Major Symptoms of Hysteria is a major statement on the subject. Again, is not Franz Kafka (18831924) the great novelist and story-teller of trauma and dissociation? Similarly, in all of the great innovations in art of the time, there is evidence of the influence of the philosophical and psychological arguments of the age of Janet. Futurism (consider Umberto Boccioni’s “States of Mind” series (1911-13) in MOMA), Expressionism (of course) and Cubism all speak of both a freedom from realism (that had been underpinned by the psychology of association) and trauma and traumatic dissociation. Guernica (1937) is alone evidence of Cubism’s capacity for representing trauma. What tipped the dissociationist culture of the late turn of the century into the modernist culture of trauma was undoubtedly World War I. It may be said that until then, the stresses and opportunities of industrial and urban uprootedness, the city, the experience of mass society, the starker experience individualism, secularization, mechanization, imperialism, and the obsessive insistences on restrictive morality and religion that sought to defend against these pressures had been bearable. But the War declared it all unbearable, unredeemable by what Ezra Pound referred to as “two gross of broken statues,/ … a few thousand battered books” (“Hugh Selwyn Mauberley, 1920, ll.94-5). Both “shell shock” and the horror of the war itself therefore gave trauma a new appalling relevance. If internal conditions after the conflict were also violent and shattering, as, in different degrees they were in Germany, the former Austro-Hungarian Empire, Italy, or the US, the relevance was still greater. In America, recall, this was the age of the “Red Scare” and the Klu Klux Klan. The War underlined what Boris Sidis had always seen: the traumatizing capacity of social conditions. Of one patient he noted, “Born in New York, of parents belonging to the lowest social strata, he was treated with severity and even brutality.” Of an immigrant from Poland, Sidis wrote: “He dreams of being capcontinued on page 10

Critical Issues continued from page 9

tured by robbers and is in danger of being killed or even being skinned alive. Occasionally he dreams of his parents captured and assaulted by brutal, terrible looking men.”8 In his Philistine and Genius (1911), he presented modern civilization as an almost wholly traumatizing environment: “Our civilization is a mere gloss,” he declares. “Look at our sweatshops; the poverty of the masses; the vast numbers incarcerated; child labor”: “We are stock blind to our own barbarities.”9 But what, you may ask, of Freud? You certainly should, for in departments of literature and cultural studies throughout the country there are only two figures in the history of dynamic psychiatry: Freud and Lacan (though to be fair to my colleagues, what university psychology department teaches Janet?) Freud did not initiate sexual liberation, though (as the seventies showed us) sexual liberation is likely to lead to the recognition of sexual trauma. What Freud did do was reveal sexual disfunction in the family. It remains true, however, that almost every modernist resists Freud’s subsequent “suppression of trauma” in two important ways: one, by insisting on the reality of incest, and, two, by emphasizing the formative influence of the mother over the rivalry with the father. Modernists, and particularly women modernists, uniformly rewrote Freud. They did so with the aid of the vocabulary of dissociationism. When, with the ascendancy of the Freudians, that vocabulary ceased to be available, Modernism ended. Neither it, nor the possibilities for the appreciation of the psychological self, nor the recognition of environmental psychological impingements including trauma, nor the social and political responsibilities they demand, returned until our own time. Despite all we have learned in recent years, however, it seems there remains much to do. Consider that another of the great dissociationist psychologists was James’s pupil, W. E. B. Du Bois (18681963), who made the first great analysis of race, trauma and dissociation. Why does the ISSD not give a prize in his name? It always dismays me when I read and teach Judith Herman’s wonderful Trauma and Recovery (1992) that it contains no discussion of the Civil Rights

Movement. After all, what white novelists and dramatists in recent years can match African-Americans for the candor and depth of their explorations of both the trauma of race and of incest? As well, dissociative studies remain threatened by varieties of somatism and certain postmodernisms. Our psychological practice lacks the supporting philosophic structure of the age of Janet, though if we observe that in a key figure like William James dissociationism— thanks to his colleague, Charles Sanders Pierce (1839-1914)— goes along with the emergence of pragmatism and semiotics, we may have the basis of an alternative. There remains much to develop, much to urge on a public which has consumerism and the industries of trance, both liberally greased with libido, to distract it; much to defend against the health insurance industry. Trauma is a “constant variable.” Half the world goes on in states of trauma and degrees of dissociation. There is much to suggest that societies themselves (now in global relations) can be analyzed as systems of the production and regulation of trauma and dissociation. More than ever, we need the clinical vision and culture of dissociationism. More than ever we need that consciousness Janet recommends.

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References 1 Jacqueline Carroy and Regine Plas, “How Pierre Janet used Pathological Psychology to Save the Philosophical Self”, Journal of the History of Behavioral Sciences 36:3 (2000), 231-40. 2 Principles of Psychology (Chicago and London: Encyclopedia Britannica and the University of Chicago, 1952), 148. 3 James, “Are We Automata,” Mind 4 (1872), 1-22; “On Some Omissions of Introspective Psychology,” Mind 9 (1884), 1-26. 4 Principles, 147. 5 Michael Meyer, Strindberg (New York: Random House, 1985), 348. 6 The best study of late Janet in English is Björn Sjövaal, Psychology of Tension: An Analysis of Pierre Janet’s Concept of “Tension Psychologique” (Upsala: Scandanavian University Books, 1967 7 Louise De Salvo, Virginia Wolf: The Impact of Sexual Abuse on her Life and Work (Boston: Beacon Press, 1989). 8 Boris Sidis, “Studies in Psychology,” Boston Medical and Surgical Journal 156 (1907), 9 Sidis, Philistine and Genius (New York: Moffart and Yard, 1911), 13, 22, 36.

President continued from page 2

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References Bowlby J. (1980). Attachment and loss. Vol. 3: Loss: Sadness and depression. London: Hogarth Press (Italian translation: Attaccamento e perdita. Vol. 3: La perdita della madre. Torino: Boringhieri, 1983). Fonagy P., Leigh T., Steele M., Steele H., Kennedy R., Mattoon G., Target M. & Gerber A. (1996). The relation of attachment status, psychiatric classification, and response to psychotherapy. Journal of Consulting and Clinical Psychology, 64, 22-31. Isabella R.A. (1993). Origins of attachment: Maternal interactive behaviour across the first year. Child Development, 64, 605-621. Liotti, G., Mollon F., & Miti, G. (in press). A chapter in G. Gabbard, J. Beck & J. Holmes, eds., The concise Oxford textbook of psychotherapy, Oxford University Press. Liotti, G., Pasquini, P. & The Italian Group for the Study of Dissociation (2000). Predictive factors for borderline personality disorder: Patients’ early traumatic experiences and losses suffered by the attachment figure. Acta Psychiatrica Scandinavica, 102, 282-289. Miti, G., Chiaia, E. (2003). Patterns of attachment and the etiology of dissociative disorders and borderline personality disorders. Journal of Trauma Practice, 2, 19-35. Pasquini, P., Liotti, G. & The Italian Group for the Study of Dissociation (2002). Risk factors in the early family life of patients suffering from dissociative disorders. Acta Psychiatrica Scandinavica, 105, 110-116.

References Barach, P.M. (1991). Multiple personality disorder as an attachment disorder. Dissociation, 4(3), 117-123. Braun, B.G. The BASK model of dissociation. Dissociation, 1(1), 4-23. Gleaves, D.H., May, M.C., & Cardeña, E. (2001). An examination of the diagnostic validity of dissociative identity disorder. Clinical Psychology Review, 21 (4), 577-608. Gray, J. (1992). Men Are From Mars, Women Are From Venus. New York: HarperCollins. Steinberg, M. (1994). Interviewer’s Guide to the Structured Clinical Interview for DSM-IV Dissociative Disorders. (Revised). Washington, DC: American Psychiatric Association.

However much we describe and explain love, when we fall in love we are ashamed of our words. Explanation by the tongue makes most things clear, but love unexplained is Rumi clearer.

ISSD’s 21st Conference News Philip J. Kinsler, Ph.D. Christine A. Courtois, Ph.D. Conference Co-chairs

Su Baker, M.Ed. Conference Manager

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lready it is fall, the time of the ISSD Annual Conference in New Orleans. Mark your calendars. This conference, as always, promises to be broad-ranging and innovative. The program addresses theory, research, and clinical application and includes an international array of presenters from many countries including Australia, Austria, Belgium, Canada, Germany, Greece, Israel, Italy, the Netherlands, New Zealand, Northern Ireland, Norway, Russia, South Africa, Spain, Sweden, Turkey, the UK and the USA. This year’s contributors are also diverse in terms of experience level and areas of interest, providing a mixture of senior and more novice researchers and clinicians, including graduate students. They hold the promise of making this a conference that advances the scope of understanding of dissociative process and disorder, all directed at moving it into the mainstream of professional and public awareness. As in the past 5 years, we will have a one and a half hour Town Hall meeting. This year, we are leaving the agenda and discussion up to you – our ISSD members and conference attendees (members or not). We encourage everyone to contribute their comments and questions at the Town Hall. Once again, John O’Neil, MD, FRCPC will be the moderator and we expect that there will be lively discussion and new initiatives coming out of the meeting. If you are going to be a first-time conference attendee, you will find that the Town Hall meeting is a real highlight of the conference. Immediately after the Town Hall and just before the President’s Reception, for the first time in many years, we will have a poster session. Please pay a visit to it and feel free to discuss the posters with the presenters, some from as far away as Russia, Australia and Norway. We are

excited to see that our conference has grown into a poster session after many years without. Our venue for the 21st conference is equally exciting. We are returning to New Orleans, one of the favorites of conference attendees. After a day’s intellectual stimulation (and this year we have some evening programs and activities as well), “laissez les bon temps roulez”, as they say in the Big Easy. We are happy to see, at the time of this writing (early August), that registration has already started and the hotel has been making reservations for rooms. Please remember that the deadline for guaranteed rates at the JW Marriott is

Moving Dissociation into the Mainstream JW Marriott Hotel Nov. 18-20, 2004 New Orleans, LA Oct. 31. However, since we have only a certain number of rooms, please reserve early – the last time that we were at the hotel, we ran out of available rooms, and even though we have increased our number of rooms set aside, it is possible that we will overbook again this year. You can make your reservations by calling the New Orleans JW Marriott registration desk at 1-504-525-6500. You must mention that you are with the ISSD conference, not only to receive the low conference rate, but also to count toward the “room block” which we must fill. (So if you have some other cheaper access to rooms at the hotel, please still ask to be part of the ISSD room block.) If you wish to share a room and don’t have a roommate, we can help you out. Contact Ellen (Rusti) Klein for roommate matching service at [email protected]. Please remember that this is only for those staying at the JW Marriott. Also remember that the deadline for

early registration is Oct. 16, after which the price does go up, so register early to avoid extra costs. Some of you may be attending for the first-time and feel a little intimidated, even though the feedback that we get every year is that the conference attendees are warm, welcoming and very approachable. In order to help new attendees, a “conference guide” service is available. A “conference guide” is someone who has attended ISSD conferences in the past and will be a friendly face to help you “find your way” around the conference offerings and networking and social occasions. You and your “guide” can meet by e-mail before the conference to get to know each other a bit and define what the expectations are – it is open and up to the new attendee and guide to decide how much time they will spend together. And while on the topic of guides, we need people who have attended at least one or two ISSD conferences in the past and who can help out a new attendee. The commitment of time is decided on by the two of you – so please consider being a “conference guide”. For more information on being a guide or finding a guide, please contact Ellen (Rusti) Klein at [email protected]. We also need volunteers to help out with a variety of tasks, such as working at the registration or CME/CEU desk, collecting tickets at the luncheon or President’s reception, turning off and on tape recorders during presentations of patient videos, etc. In exchange for halfprice registration, volunteers are expected to be available about half the time of the conference, but often not at times of presentations (though there will be some need for volunteers during times of presentations). If you are interested in volunteering, contact Su Baker at [email protected] or [email protected] for more information. This is a first-come, first-serve selection with a limited number of positions available, so don’t delay!

Hope to see you in New Orleans!!! 11

Publications of Interest: Recent Books and Articles Kathy Steele, M.N., C.S. Stephanie Dallam, R.N., M.S.F.N.P. Co-editors Bowins, B. (2004). Psychological defense mechanisms: A new perspective. American Journal of Psychoanalysis, 64(1), 1-26. Approaching psychological defense mechanisms from the perspective of an evolved strategy, it is proposed that most of the classical defense mechanisms described in the psychoanalytic literature represent a form of cognitive distortion with some also containing strong elements of dissociation. Frequently conceived of as pathological, these psychological phenomena actually constitute overlapping spectrums with milder manifestations being common and highly functional, and more severe variants less common and typically dysfunctional. For instance, dissociation provides the capacity to adaptively detach from disturbing emotional states, and cognitive distortions place a positive ego-enhancing spin on experience. Reprints: B. Bowins Email: [email protected] Brosky, B. A., & Lally, S. J. (2004). Prevalence of trauma, PTSD, and dissociation in court-referred adolescents. Journal of Interpersonal Violence, 19, 801-14. This study examines the prevalence of trauma, PTSD, and dissociative symptoms in adolescents. The sample consisted of 76 females and 76 males, between the ages of 12 and 18, referred to the Child Guidance Clinic of the Superior Court of the District of Columbia for a psychological evaluation. Results of the study suggest a high prevalence of trauma in both genders; however, females had significantly higher rates than those reported in males. Similarly, female adolescents demonstrated significantly higher prevalence rates of PTSD symptoms. There was a low prevalence of dissociative symptoms across both genders. Reprints: B. A. Brosky, Woodburn Center for Community Mental Health, Annandale, VA 22209 Email: [email protected]

Dalenberg, C. J., & Palesh, O. G. (2004). Relationship between child abuse history, trauma, and dissociation in Russian college students. Child Abuse & Neglect, 28, 461-74. This study examined the relationship between violent trauma, child abuse history, and dissociative symptoms in 301 Russian undergraduate students from Moscow State Linguistics University. Scores on dissociation and its subfactors were significantly higher in the Russian sample compared to the normative US group. The best predictors for dissociation were experiencing a violent trauma, child abuse history, and/or the experience of a fearful event. Those participants with a prior child abuse history were more symptomatic after adult trauma than those with no such history. The authors conclude that the relationship between trauma/abuse and dissociation is unlikely to be a result of suggestion by therapists or media exposure, since the correlation appears in a Russian population who are relatively unexposed to these suggestive sources. Reprints: C. J. Dalenberg, Psychology Department, Trauma Research Institute, Alliant International University, 10455 Pomerado Road, San Diego, CA 92131 Email: [email protected] DePrince, A. P., & Freyd, J. J. (2004). Forgetting trauma stimuli. Psychological Science, 15, 488-92. Previous work reported in this journal suggested that the cognitive capacities of high dissociators are impaired under conditions of focused (selective) attention, but not under conditions of divided attention, compared with the cognitive capacities of low dissociators. Using a directed-forgetting paradigm, the current study demonstrated that under dividedattention demands, high dissociators have impaired memory for words associated with trauma (e.g., incest) but not for neutral words, as compared with low dissociators. In addition, high dissociators reported significantly more trauma history and significantly more betrayal trauma (abuse by a caregiver) than low dissociators. These results are consistent with the 12

proposal that dissociation may aid individuals with histories of betrayal traumas to keep threatening information out of awareness. Reprints: Anne Deprince, Department of Psychology, Room 340, Frontier Hall, 2155 S. Race St. Denver, CO 80208 Email: [email protected] Erdinc, I. B., Sengul, C. B., Dilbaz, N., & Bozkurt, S. (2004). [A case of incest with dissociative amnesia and post traumatic stress disorder]. Turk Psikiyatri Dergisi [Turkish Journal of Psychiatry], 15, 161-5. The authors present a case study of an adolescent who was found wandering around aimlessly. She could not remember anything about her identity or personal history. No sign of intoxication or infection was detected and her physical, laboratory, and neurological examinations were normal. EEG and CT were also normal. After the family was found and revealed a history of sexual and physical abuse, the patient was diagnosed with dissociative amnesia. Psychometric evaluations supported this diagnosis. As the dissociative symptoms began resolve, PTSD symptoms became more apparent. After she described her traumatic memories, PTSD symptoms began to recede. This case presentation demonstrates the relationship between childhood physical and sexual abuse and dissociative disorders. Reprints: No information provided Garcia-Valdecasas Campos, J., Herreros Rodriguez, O., Vispe Astola, A., & Gracia Marco, R. (2004). [Based on one case of dissociative disorder: A conceptual review]. Actas espanolas de psiquiatria, 32(2), 123-6. The authors describe a clinical case of a patient diagnosed with dissociative disorder and provide a review of the diagnosis of dissociative disorder and its polemics. The authors discuss concepts such as dissociation and hysteria, their historic evolution and their relationships. Some modern cognitive theories on dissociative disorders and their relationship or opposition to psychodynamic theories are presented. The authors conclude that at the

present time important questions must be solved in the area of dissociative disorders in order to progress in the psychiatric knowledge of dissociative processes. Reprints: J. Garcia-Valdecasas Campos, Hospital Universitario de Canarias, Tenerife, Canary Islands Email: [email protected] Glisky, E. L., Ryan, L., Reminger, S., Hardt, O., Hayes, S. M., & Hupbach, A. (2004). A case of psychogenic fugue: I understand, aber ich verstehe nichts. Neuropsychologia, 42(8), 1132-47. This paper reports a case of psychogenic fugue in which the individual lost access not only to his autobiographical memories but also to his native German language. Neuropsychological, behavioral, electrophysiological and functional neuroimaging tests converged on the conclusion that this individual suffered an episode of psychogenic fugue, during which he lost explicit knowledge of his personal past and his native language. At the same time, he appeared to retain implicit knowledge of autobiographical facts and of the semantic or associative structure of the German language. The patient’s poor performance on tests of executive control and reduced activation of frontal compared to parietal brain regions during lexical decision were suggestive of reduced frontal function, consistent with models of psychogenic fugue proposed by Kopelman and Markovitsch. Reprints: E. L. Glisky, Department of Psychology, University of Arizona, P.O. Box 210068, Tucson, AZ 85721 Email: [email protected] Goldstein, L. H., Deale, A. C., Mitchell-O’Malley, S. J., Toone, B. K., & Mellers, J. D. (2004). An evaluation of cognitive behavioral therapy as a treatment for dissociative seizures: A pilot study. Cognitive and Behavioral Neurology, 17(1), 41-9. The authors conducted an open prospective trial on the effectiveness of cognitive behavioral therapy as a treatment of adults with dissociative seizures (i.e., “pseudoseizures”). Twenty patients diagnosed with dissociative seizures were offered treatment comprising 12 sessions of cognitive behavioral therapy. Principal outcome measures were dissociative

seizure frequency and psychosocial functioning, including improvement in employment status and mood. Measures were administered before treatment, at the end of treatment, and at a 6-month follow-up. Cognitive behavioral therapy was associated with a highly significant reduction in seizure frequency and an improvement in self-rated psychosocial functioning. These improvements were maintained at the 6-month follow-up. There was also a tendency for patients to have improved their employment status between the start of treatment and the 6month follow-up period. Reprints: L. H. Goldstein, Department of Psychology, Institute of Psychiatry, De Crespigny Park, London Email: [email protected] Grant, J. E. (2004). Dissociative symptoms in kleptomania. Psychological Reports, 94(1), 77-82. Many patients with kleptomania report an altered state of consciousness during acts of theft. The purpose of this investigation was to clarify a possible link between kleptomania and dissociation. Twenty-six treatment seeking adult outpatients who met DSM-IV criteria for kleptomania were administered the Dissociative Experiences Scale and compared to 22 normal controls. The patients with kleptomania had scores that differed significantly from those reported by normal controls. Reprints: J. E. Grant, Department of Psychiatry and Human Behavior, Butler Hospital/Brown Medical School, 345 Blackstone Blvd., Providence, RI 02906 Email: [email protected] Haugaard, J. J. (2004). Recognizing and treating uncommon behavioral and emotional disorders in children and adolescents who have been severely maltreated: Dissociative disorders. Child Maltreatment, 9, 146-53. Somatoform disorders are likely to occur more frequently in children and adolescents who have been severely maltreated than in others. The symptoms of somatoform disorders in children are reviewed, strategies for distinguishing somatoform disorders from other disorders are examined, and treatment strategies are explored.

Reprints: Jeffery J, Haugaard, Van Rensselaer Hall, Department of Human Development, Cornell University, Ithaca, NY, 14853 Email: [email protected] Keck Seeley, S. M., Perosa, S. L., & Perosa, L. M. (2004). A validation study of the Adolescent Dissociative Experiences Scale. Child Abuse & Neglect, 28, 755-69. The purpose of this study was to further the validation process of the Adolescent Dissociative Experiences Scale (A-DES). The A-DES discriminated between the sexually abused and nonabused adolescents. However, in post hoc analyses, the A-DES did not discriminate between PTSD adolescents and those with other psychiatric diagnoses. The authors concluded that the A-DES items are internally consistent, and the A-DES shows promise for screening adolescents for pathological dissociation. Reprints: Susan M. Keck Seeley, Marion City Schools, 163 E. Center St., Marion, Ohio 43302 Kremers, I. P., Spinhoven, P., & Van der Does, A. J. (2004). Autobiographical memory in depressed and non-depressed patients with borderline personality disorder. The British Journal of Clinical Psychology, 43(Pt 1). 17-29. This study investigated the specificity of autobiographical memories among depressed and non-depressed patients with Borderline Personality Disorder (BPD) (n = 83), compared with depressed patients (n = 26) and controls (n = 30). The influence of childhood trauma, intrusions of traumatic events, avoidance of intrusions, dissociation and depression on memory specificity was also studied. The results showed that of the borderline patients only the subgroup with a co-morbid diagnosis of depression had trouble remembering specific events from the past. Trauma, intrusions, avoidance of intrusions and dissociation seem to be unrelated to the specificity of autobiographical memories in BPD. Reprints: I. P. Kremers, Department of Psychology, Leiden University, The Netherlands Email: [email protected] continued on page 14

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Publications of Interest Continued from page 13

Koopman, C., Carrion, V., Butler, L. D., Sudhakar, S., Palmer, L. & Steiner, H. (2004). Relationships of dissociation and childhood abuse and neglect with heart rate in delinquent adolescents. Journal of Traumatic Stress, 17, 47-54. This study examined the relationship of dissociative symptoms, abuse and neglect, and gender to mean heart rate (HR) in 25 female and 16 male delinquent adolescents. Dissociative symptoms and abuse and neglect were assessed by structured interviews. Participants were randomized to one of two conditions, to describe either their most stressful life experience or their free association thoughts. Greater dissociative symptoms were associated with lower mean HR, whereas abuse and neglect, being a girl, and participating in the free association task were associated with higher mean HR. The finding that high levels of dissociative symptoms may be related to a suppression of autonomic physiological responses to stress support Bremner’s conceptualization (J. D. Bremner, 1999) that dissociative symptoms comprise one of two subtypes of the acute stress response, differing physiologically as well as subjectively from a predominantly hyperarousal or intrusive symptom response. Reprints: C. Koopman, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California 94305-5718 Email:. [email protected] Maaranen, P., Tanskanen, A., Haatainen, K., Koivumaa-Honkanen, H., Hintikka, J., & Viinamaki, H. (2004). Somatoform dissociation and adverse childhood experiences in the general population. Journal of Nervous & Mental Disease, 192, 337-42. This study examined the relationship between childhood trauma and somatoform dissociation in the Finnish general population (N = 1739). The prevalence of high somatoform dissociation (Somatoform Dissociation Questionnaire ≥ 30) was 9.4%. The results revealed a strong, graded relationship between an

increasing number of adverse childhood experiences and high somatoform dissociation. Unemployment, a reduced working ability, and a poor financial situation were also associated with high somatoform dissociation. Reprints: P. Maaranen, Department of Psychiatry, University of Kuopio, P O Box 1777, Kuopio 70211, Finland Matsumoto, T., Azekawa, T., Yamaguchi, A., Asami, T., & Iseki, E. (2004). Habitual self-mutilation in Japan. Psychiatry & Clinical Neurosciences, 58, 191-8. The purpose of the present study was to clarify the relationship between bulimic behavior, dissociative phenomenon and sexual/physical abuse histories in Japanese subjects with habitual self-mutilation. Subjects consisted of 34 female outpatients who had cut their wrists or arms on more than 10 occasions. Two age-matched groups, which consisted of 31 general psychiatric outpatients and 26 non-clinical volunteers, served as controls. The habitual self-mutilation group had significantly higher scores on the Beck Depression Inventory-II, Bulimia Investigatory Test of Edinburgh, and Adolescent Dissociative Experience Scale than either of the two control groups (P < 0.001). Furthermore, the habitual selfmutilation group more frequently had a history of illicit psychoactive drug use (P = 0.001), shoplifting (P < 0.001), suicide attempts (P < 0.001), overdosing with medicine (P < 0.001), sexual abuse (P = 0.011), and childhood physical abuse (P = 0.001) than the general psychiatric controls. These results are consistent with those in Western studies and support an association between habitual self-mutilation and sexual and/or childhood physical abuse in Japan. Reprints: T. Matsumoto, Department of Psychiatry, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan Email: [email protected] McNally, R. J. (2004). Is traumatic amnesia nothing but psychiatric folklore? Cognitive Behaviour Therapy, 33(2), 97-101. Some psychotherapists believe that certain experiences are so overwhelmingly traumatic that some victims become incapable of remembering their worst trauma 14

except under special circumstances (e.g., therapy) many years later. Unfortunately, clinicians who endorse this concept of traumatic amnesia often misinterpret the very studies they adduce in support of it. More specifically, they misinterpret other, unrelated memory phenomena as evidence for traumatic amnesia, such as ordinary forgetfulness, psychogenic amnesia, organic amnesia, incomplete encoding of traumatic experiences, nondisclosure of remembered trauma, and simply not thinking about something for a long time. The purpose of this article is to dispel confusions rampant in this literature. Reprints: R. J. McNally, Department of Psychology, Harvard University, Cambridge, Massachusetts 02138 Email: [email protected] Merckelbach, H., & Jelicic, M. (2004). Dissociative symptoms are related to endorsement of vague trauma items. Comprehensive Psychiatry, 45, 70-5. Current psychiatric literature suggests that dissociative symptoms originate from aversive childhood events. However, this view is largely based on cross-sectional studies that do not rule out a scenario in which dissociative tendencies contribute to self-reports of childhood trauma. In two studies, the authors tested one particular implication of this scenario, namely, that dissociative symptoms are related to endorsement of vague rather than specific items about childhood trauma. In study 1 (N = 43) and study 2 (N = 127), nonclinical participants completed standard measures of dissociation, childhood trauma, and fantasy proneness. Correlational and regression analyses were performed on the data. Fantasy proneness and responses to broad trauma items, but not responses to factual trauma items predicted dissociation levels. This pattern of findings shows that the link between trauma and dissociation is considerably more complex than is often assumed. As well, it suggests that at least in nonclinical samples, dissociative symptoms may breed endorsement of vague trauma items. Reprints: H. Merckelbach, Department of Experimental Psychology, University of Maastricht, The Netherlands [email protected]

Sawa, T., Oae, H., Abiru, T., Ogawa, T., & Takahashi, T. (2004). Role of imaginary companion in promoting the psychotherapeutic process. Psychiatry & Clinical Neurosciences, 58(2), 145-51. An imaginary companion (IC) has been considered to be a transitory phenomenon sometimes seen in the normal developmental process of children. In recent years, however, it has been observed that ICs are related to various disorders, and their clinical significance is again attracting notice. Although an IC may in certain ways aggravate the patient’s symptoms and regression, an IC may also serve to advance the therapy, for example by indicating the location of the patient’s troubles, or acting as an intermediary between the therapist and patient. In cases of dissociative (conversion) disorders, it is generally difficult for patients to verbalize their troubles, but the present patients gained insight into themselves by closely examining their ICs. It is concluded that by incorporating ICs into the therapeutic strategy as a presence supporting the patient’s growth, it is possible that the psychotherapy may proceed more smoothly. Reprints: T. Sawa, Department of Psychopathology and Psychotherapy, Postgraduate School of Medicine, Research Center of Health, Physical Fitness and Sports, Nagoya University, Nagoya, Aichi, Japan Email: [email protected]

Manuscripts Wanted

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he Journal of Trauma and Dissociation is currently soliciting articles for submission. At the present time, we are particularly encouraging submission of clinicallyoriented manuscripts (e.g., case studies, clinical review papers, treatment approach discussions). Mentoring for first time authors is available. Information for authors interested in submitting to JTD can be found at the following website: http://www.issd.org/indexpage/jtdauthorsinfo.html. Manuscripts and inquiries can be sent to James Chu, MD, Editor, at [email protected]. The Journal of Trauma and Dissociation is dedicated to publishing peer-reviewed, scientific articles in the areas of psychological trauma and its sequelae, including dissociation and posttraumatic stress disorder.

ISSD Professional Seminar Project

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s a result of the very successful 2004 Spring Seminars in Los Angeles and New York City, the ISSD Executive Council has decided to further expand this project and looks forward to offering similar events at four potential sites in 2005. At the June 27, 2004 Executive Council meeting, a proposal submitted by the ISSD Professional Seminar Project Committee was adopted to develop a “four tier” plan, based on requests and feedback from the Executive Council, interested ISSD members, and 2004 Seminar attendees. Each of the four approaches are designed to include one or more of the following goals: • introducing the concept of dissociation • educating professionals about the effects of chronic traumatization; spreading knowledge about ISSD • facilitating increased ISSD membership • increasing attendance at the ISSD Annual Conferences; assisting in the development and/or revitalization of Component Groups. The “Four Tier” Plan Tier 1 This approach will offer one-day Professional Seminars in cities prior to the ISSD Annual Conferences (i.e. 2005 – Toronto; 2006 – Los Angeles; 2007 – Baltimore; etc). Tier 2 This plan combines “encore” presentations of Professional Seminars in places that have previously hosted an event (i.e. 2005 – Los Angeles & New York City), along with other big cities (i.e. Chicago, Boston, Washington DC, Atlanta, Miami, St. Louis, New Orleans, etc.) depending on how many seminars are approved by the Executive Council each year. Tier 3 This approach offers Professional Seminars in smaller locations (i.e. Minnesota, Indiana, Kentucky/Ohio, S. Carolina, etc) where it is determined there is a need for professional education and increased awareness of ISSD. Tier 4 This plan attempts to respond to requests from interested parties (i.e. Puerto Rico, Brazil, Europe, small cities in the USA, etc) that have resources and manpower to assist in the seminar management in those locations. In keeping with this approved “four tier” plan, we are pleased to announce the tentative schedule for the 2005 Professional Seminars: February 11, 2005, Torrance, California Allan Schore, PhD, & Richard Chefetz, MD, presenting on “Integrating Neuroscience and Clinical Practice: Mind and Body in the Treatment of Psychological Trauma”. March 18, 2005, Atlanta, Georgia Christine A. Courtois, PhD, & Joyanna Silberg, PhD, presenting on: “Trauma, Dissociation, and Clinical Practice: Childhood and Adult Manifestations of Psychological Trauma”. April 2005, Toronto, Ontario, Canada details to be announced. May 2005, New York City, NY details to be announced. San Juan, Puerto Rico details to be announced. Watch your ISSD News and the ISSD website for future developments. If you or your Component Group/organization would like to see an ISSD Professional Seminar in your area, and you have suggestions for facilities and/or speakers, please submit your ideas to the committee. Further information can be obtained from the ISSD Professional Seminar Project Committee by contacting Dennis S. Pilon, ACSW, BCD at: [email protected]. 15

Marginalia What is therapy? Below is our standard answer.

It is the story of their becoming human together. Gilgamesh (H. Mason, translator)

But what is therapy really? Does it do anything fundamental or transcendent? Do even therapists believe that it really and truly works? And if we sort of believe that it sort of works sometimes, how does that happen? The answer, among the many possible, that we have been thinking of recently has to do with relationship, connection, love if we can allow such an explosive word into our deliberations. The Kohutians tell us that if we can find a way to function in a person’s psychic universe as a selfobject then every psychic activity will be stabilized. Once attached to a reliable self-object, the individual’s decision-making becomes firmer and clearer, the energy and capacity to act increases, and the capacity to act effectively and to experience oneself as having succeeded bolsters self-esteem which has already been enhanced by having a self-object and so forth. This is an elegant explanation, which lends itself to spiral diagrams replete with numerous lovely arrows, but surely there is more to it than that. What does it take to become a workable self-object? As a bare minimum the requisites include utter goodwill, unwavering respect and scrupulous fairness and honesty. We go back to the poets for the rest of the story.

Jean Goodwin Reina Attias In this matter it would be well to trust rather to friendship than to great wisdom. J.R.R. Tolkien

In our work it can be truly said that in our best moments of dispassionate and objective analyzing we love our object, the patient, more than at any other time and are compassionate with his whole Hans Loewald being. Love is the highest form of understanding. When we truly love we understand with an insight that nothing can transcend and nothing can equal. Frank Lloyd Wright

Ignorance and bungling with love are better than wisdom and skill without. Thoreau I suppose the story of my life is a search for love. But more than that, I have been looking for a way to repair the damages I suffered early on and to define my obligation, if I had any, to myself and my Marlon Brando species. Send your ideas about what it is about therapy that helps people get better to jmgoodwin@ aol.com.

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