治療論 英訳 推敲の推敲 5

 Trauma and the origin of aggression

Issue of the actuality of trauma is closely related to another important problem: where aggression of the patients comes from? What Freud had in his mind was that the repression of sexual and aggressive drives would cause neurotic symptoms and these drives naturally derive from within. However, if we acknowledge the actuality of trauma, we need to consider the origin of the aggression somewhat differently.

One of the early papers that deal with the origin of aggression was Ferenczi’s seminal paper “Confusion of Tongues” (1936). He discussed the issue of the “identification with the aggressor”. However, what Ferenczi discussed was not exactly the way the victim turns to be another aggressor. He rather described the process of the victim’s identification with the aggressor’s wishes and desires in a masochistic way. He states that the most destructive is the “victim’s introjection of the guilt feelings of the adult” (p.162) and the resultant masochism of the victim (Frankel, 2002). Ferenczi stressed rather the way that the victim hurt him/herself instead of aggressing others.

Frankl explains this nature of Ferenczi’s description of the “identification with the aggressor” as follows. While discussing this topic, Ferenczi mainly talks about “concordant identification” with the aggressor based on Heinrich Racker’s classification of the two types of identification process (Racker, 1968). However, there should be another type of identification: “complementary identification” where the victim identifies with his aggressive nature and becomes the one. In this context, Okano (2018) also discussed this process in his discussion of “shadowy personality”. It is of interest to mention the notion of the “identification with aggressor” proposed by Anna Freud (1936). This notion describes more closely to the way this complementary identification with the aggressor, but in a quite different context.
   Let us look at the way modern analysts conceive the issue of aggression in DID. Dissociative personalities with aggressive nature have been described generally as “the internal persecutor” or “persecutory personality” by various authorities (Kluft, Putnam, Ross, Howell, van der Hart, etc.). Putnam suggests that some persecutor personalities can be recognized as introjects of the original abuser (1989, p.108).Van der Hart et al（2006）states that the persecutory part of the personality is at least one type of EPs (emotional part of personalities) and that has some protective role, and recommends clinicians that they pay respect to them (2006). Howell (2011) also stresses defensive purposes when one of these “persecutory personalities” are formed and states: “having persecutory and abuser identity states is like having an internal Al Qaeda or Taliban that punishes you for the slightest infraction of bizarre and arcane rules. It involves being emotionally attached to inner and perhaps outer persecutors, even though you were tortured by them” (2011, p.211). Howell further states that the “system depends for its safety, on the inhibition of expression or the exclusion from consciousness of powerful overwhelming affects, such as terror and rage.” (Howell, 2016, p.211).

According to these experts, DID’s aggression is generally understood as a result of internalizing what was initially external, i.e., the aggressors, that is expressed by the victims in a self-destructive and masochistic way. Here again, we are facing the dual nature of the aggression that DID patients experience. Ferenczi and experts of DID talk mainly the influence of the aggressors when children went thorough trauma. Recognition of the actuality of trauma underscores externality of the aggression. However, by discussing the process of identification and internalization they describe how the aggression becomes a part of the victim’s internal psyche. Perhaps what is not stressed is the way that originally external aggression gets merged with what has been originally inside, which is referred to as the aggressive drive. 

治療論 英訳 推敲の推敲 4

 2.      The actuality of trauma during infancy and early childhood.

This second point that Itzkowitz raises might also invite another kind of “turn” in our conceptualization of the mind in psychoanalysis. In Freud’s drive model, the goal for psychoanalysis was to make unconscious conscious with an assumption that repressed sexual and aggressive drives in the child need to be dealt with. Freud established this theory after he rejected the actuality of the sexual trauma that a child experiences in 1897. If we accept and acknowledge the actuality of trauma, the whole basis of Freud’s theory might need to be looked at from a different angle. Howell & Itzkowitz states (2016a), “Even Freud’s most influential theories- for example, the Oedipus complex - can readily and easily be deconstructed in terms of the underlying motifs of the most heinous type of child abuse; infanticide, murder”. (Ross, 1982, 2016a, p8)

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治療論 英語 推敲の推敲 3

 Stern and Bromberg 

 In recent psychoanalytic literature, there are two major figures in the theories of dissociation and dissociative phenomena: Donnel Stern and Phillip Bromberg, and their works are relevant to be discussed in this context. The current notion of dissociation proposed by them is characterized by their unique understanding of what is not conscious. Stern states: Freud accepted without reservation the idea that the mind―and, therefore, the unconscious―is composed of fully formed contents. (Stern, 2009, p.655.) Stern discusses that in traditional psychoanalysis the repression model assumes that there is one truth in the unconscious that corresponds to one objective reality. He calls this notion “correspondence theory” and proposes a different mechanism of the mind at play in dissociation.

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治療論 英語 推敲の推敲 ２

 Fairbairn, Winnicott, and Sullivan.

Before moving on to discussing modern psychoanalysts’ argument on this topic, I would like to briefly summarize the stance taken by three major figures in the early part of the history of psychoanalysis: R. Fairbairn, D. Winnicott, and HS. Sullivan.

Fairbairn’s theory of a schizoid mechanism is closely linked with splitting and dissociation discussed by Janet, Morton Prince, etc. As Fairbairn goes (1952),

… So far as the manifestations of dual and multiple personality are concerned, their essentially schizoid nature may be inferred from a discreet study of the numerous cases described by Janet, William James, and Morton Prince … The personality of the hysteric invariably contains a schizoid factor in greater or lesser degree, however deeply this may be buried. (p. 5.)

 Thus, Fairbairn’s notion of dissociation was not quite specific and was discussed interchangeably with "schizoid," and "splitting” (van der Hart, et al., 2009), lacking a focus on its unique nature of division in psychic organization. Although schizoid problems became one of the main focuses of the British object relations theory, it developed apart from the concept of dissociation originally described by Breuer in his notion of “hypnoid” phenomena and double consciousness.

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治療論 英訳 推敲の推敲 １

“Dissociative Turn”and its Implications in Psychoanalysis

Historically, dissociation is a topic that Sigmund Freud did not welcome in his psychoanalytic theories. This was against the background of his conflict with Joseph Breuer, Pierre Janet and Sándor Ferenczi. Since then, as Glover (1943) expressed, the term dissociation has a “chequered hisoty”(p.12) in psychoanalysis. However, since Steven Marmer (1980) took “a first step in posing a psychodynamic formulation for multiple personality (p.455), there seems to be a “growing chorus of American thinkers” “who hopes to rescue dissociation from obscurity” in the theory of psychoanalysis (Goldman, 2012. p. 338). The topic of dissociation has been discussed in an increasing number in the psychoanalytic literature. A psychoanalytic research engine (Pepweb) indicates that its number doubles in each decade for the past 40 years (405 between1980~1989, 935 between 1990~1999, 1629 between 2000~2009, and 2461 between 2010~2019). This movement can potentially invite some major reorganization in the psychoanalytic literature, that Sheldon Itzkowitz (2015) referred to as the “dissociative turn.” So, what is it about his “turn”? In his compacted paper with the same title, Itzkowitz (2015) mentions as follows.

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治療論 英訳 推敲 7

 Discussion

In this paper I discussed what Izkowich refers to as “the dissociative turn” and considered what might be its theoretical and clinical implications. I indicated that this issue was related to the way psychoanalysis started in the end of the 19^th century. Freud encountered clinical cases where splitting of consciousness was indicated by Breuer and Janet, and chose to go along monopsychism. He might have felt that he needs to choose either monopsychism or polypsychism and practically picked the former. His choice must have been correct in that it resulted in this prosperity of the psychoanalytic movement that we all are familiar with. However, some analysts should have encountered dissociative cases and felt they need to take a second look at their theoretical approach to them, such as J. Rampl-de Groot (1981). She stated in her “Notes on Multiple Personality”(1981) that “the purpose of this paper is to draw attention to my experience that both ‘splitting’ and ‘multiple personality’ are originally present in all normal humans.”(p.615.)

It is remarkable that her “turn” was so drastic that she concluded that multiplicity, polypsychism, not monopsychism, is the natural state of mind.

It is worth remembering that Freud himself did not hide that he could have been a similar situation somewhat close to that of Rampl-de Groot. In a later stage of his analytic career, Freud stated as follows.

 Depersonalization leads us on to the extraordinary condition of “double conscience”, which is more correctly described as “split personality.”But all of this is so obscure and has been so little mastered scientifically that I must refrain from talking about it anymore to you. (Freud, 1936, p.245)

Freud’s candid acknowledgement about his lack of scientific knowledge and experience about “split personality” is impressive. It is unknown if, with more time and curiosity, Freud might have developed a new view about dissociative phenomenon and make his own “turn”. It is very fortunate that current analysts might not need to make an exclusive choice that Freud faced: which of monopsychism or polypsychism reflects the truth of human mind.

Here I reiterate beautiful statement of Bromberg.

A noticeable shift has been taking place with regard to psychoanalytic understanding of the human mind and the nature of unconscious mental process- away from the idea of a conscious/preconscious/unconscious distinction per se toward a view of the self as decentered, and the mind as a configuration of shifting, nonlinear ,discontinuous states of consciousnesss in an ongoing dialectic, with the healthy illusion of unitary selfhood.（Bromberg, 1998. p. 270.）

Lampl-de-Groot, J (1981) Notes on Multiple personality. Psychoanalytic Quarterly, 50;614-624

Bromberg, P (1998) Standing in the Spaces. Psychology Press, New York, London.

An inevitable question might arise. Can we really take both of these two stances in a clinically useful way? If I conjure up an image of a clinical case who demonstrates several different personalities, I still think that she is a single person, perhaps that I would refer to as “they”. However, I think I have different way of having relationship with each of them as well. Usually a patient of DID has some sense of “we-ness” with a recognition that they share the same body, and perhaps the same identity. As much as they have this sense, a therapist develops some type of “generic” transference as well as that with each personality. Clinically I cannot determine whether I am dealing with one person or many. Instead of either or attitude, modern clinicians should opt flexibility and latitude in choosing their view about dissociative patients, depending on the clinical context they are in. I hope that I discussed some of the points clinicians can bear in mind in choosing their ways.

治療論 英訳 推敲 6

 3. Establishing communication and understanding between the dissociated self-states as the Therapeutic goal

There are many discussions as regard to the purpose of the treatment of dissociative disorders. In days when dissociative disorder began gathering attention from clinicians in 1970s ~ 80s, getting parts of personality together to achieve a whole personality tended to be considered as a goal for the treatment of those with DID. Richard Kluft asserted that to establish“integration”and“fusion”is the final goal of the treatment. He states as follows.

It usually becomes essential to replace dividedness with unity, at least for the purpose and motivation, for any treatment to succeed. Work toward this goal and possible integration of all personalities distinguishes the treatment of MPD (1984, p.11)
  In his study Kluft reported that among 171 DID patients during his study, 83 of them reached fusion (Kluft, 1984). Following his clinical report and suggestions, many analysts consider that the integration of personalities as the long-term outcome of DID. However, fusion or integration were not altogether promoted blindly. Although it is supposed to be the goal, Kluft himself admonished the “premature overemphasis on pursuit of fusion”which can cause its failure.(p.11). Van der Hart (2006) noted that “there is the persistent myth that merely integrating experiences is sufficient for overcoming　traumatization”　(Howell,182~183), implying that there is more than just integration.

The idea that fusion and integration as a goal can relatively smoothly merge with traditional analytic thinking. Although psychoanalysis “analyzes” human mind, Freud acknowledged that the integration that he calls “psycho-synthesis” is thus achieved in analytic treatment as the final result.
 As we analyze...the great unity which we call his ego fits into itself all the instinctual impulses which before had been split off and held apart from it. The psycho-synthesis is thus achieved in analytic treatment without our intervention, automatically and inevitably. (Freud, 1918, 161).

  However, recently more diverse ideas have been proposed in the analytic community. Itzkowitz indicated as follows:
 The goal of the working through process is not necessarily the consolidation of self-states into a single, integrated individual … [But to help] the person understand and negotiate meaningful forms of relatedness with these heretofore unknown parts of herself.（p.152）”.

He thus indicates that both integration and relatedness among parts can be a therapeutic goal. In the guideline for the treatment of DID issued by the International Society for the Study of Trauma and Dissociation (ISSTD) has a much less stress on the fusion/integration as a treatment goal:
 A desirable treatment outcome is a workable form of integration or harmony among alternate identities. (ISSTD, 2011, p.133).
 Thus, although the term integration is still used as a treatment outcome, its nuance is changed and is now paraphrased as a harmony among identities. The term integration itself gained its duality and ambiguousness.

International Society for the Study of Trauma and Dissociation (2011) Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision. Journal of Trauma & Dissociation, 12:115–187.
Kluft, R (1984) Treatment of Multiple Personality Disorder. A Study of 33 Cases. Psychiatric Clinic of North America p.9~30.

The current therapeutic approach for the dissociative disorder tends not to discuss whether integration is the goal or not, but to take a phase-oriented approach where the therapist responds to the patient's condition in a contextual way. They are often described as follows　(Howell, 2011, p.168).

・Establishing safety
・ remembrance and mourning
・reconnection with ordinary life

It is noteworthy that there is no particular remarks about fusion or integration. Howell discusses coconsciousness and co-participation where she stresses the importance of dissociative parts cooperating and helping each other to run their life in a peaceful way. She states that the purpose of the treatment is that “more information essential to healing and enhanced functioning is shared among dissociative parts” so that “dissociative barriers are lessened.” Howell states that integration is a “one-person concept” (p.143).” She promotes the notion of contextual interdependence which avoids the problem in the often implied opposition between dissociation versus unity.”　
  Modern analyst Bromberg speaks in a very similar tone. He promotes respect for the uniqueness of each personality and the attitude of “finding and directly engaging the patient's dissociated voices as discontinuous but individually authentic expressions of selfhood” instead of resorting to the promotion of premature integration (Bromberg, 1998, p.199).
  To summarize, what Itzkowitz stated as a goal for the treatment suggests us as a “turn” to an even handed approach beyond “opposition between dissociation versus unity” (Howell, as above). Again it is not “either or” but somewhere between, or both, depending on the clinical context.

 Freud, S. (1918). "Lines of Advance in Psycho-Analytic Therapy" SE. XVII. p.161