BookREVIEW: The Dissociative Mind in Psychoanalysis: Understanding and Working with Trauma
Elizabeth F. Howell and Sheldon Itzkowitz (eds.)
Reviewer Brad McLean
The ubiquity of trauma is a distressing reality that fills our therapy rooms with the horrors, both major and minor, that reverberate through our clients’ lives with cruel and pervasive effects. Trauma, it seems, is all around us and, as the authors of this book point out, we live in an age where natural disasters, crimes against humanity, smaller scale ‘domestic disasters’, and abuses in institutional ‘care’ settings, form a barrage of transgressions, overwhelmingly dominating news headlines. Edited by Elizabeth F. Howell and Sheldon Itzkowitz, leaders in the field of traumatology and psychoanalysis, this 294-page volume is a collection of contributions from 19 distinguished experts in their respective specialties, who offer a rich foray into the world of trauma and dissociative disorders, and the complex positioning of these concepts in the history and present day world of psychoanalysis.
The process of the psychoanalytic excommunication of trauma and dissociation was set in motion in 1897, when Freud turned away from linking hysteria to trauma generated by explicit and real life experiences, such as childhood sexual abuse, because the ideas were not easily embraced by the Victorian medical world. In response, Freud began to ‘privilege repression and the drive-defence-fantasy’ (p.7), which positioned symptoms as arising from fantasy-based conflict as a result of the battle between the drives and defences. Reality, and the events of reality, began to move out of focus, with the result that, “for the traumatised and dissociative patient then, her reality is likely to be overlooked, misunderstood, misinterpreted as fantasy, or wishes, and/or not to be considered as valid data for analytic inquiry … thus, the denial of exogamous trauma becomes itself a real source of exogamous trauma” (p.8). It is difficult not to feel moved by the realisation that many analysands, over a century of analytic theory and practice, have undoubtedly had the reality of their experiences ignored and, worse, reconfigured as having origins in the realm of childhood fantasy, rather than reality.
Anyone in the analytic world who disagreed was also excommunicated, along with their ideas that might recognise the role of real trauma. I refer here to Sandor Ferenczi, who was labelled as mad because he a) believed sexual trauma in childhood was a primary cause of psychopathology and b) because he worked with the ‘worst cases’ using a relational method of real engagement. The Ferenczi chapter in the book, written by Margaret Hainer, is an excellent exploration of his disenfranchisement from the psychoanalytic world for his theory and practice, which has now reached prominence today. I find thinking about these issues of the casting out of reality to be disturbing truths; actions that ironically reside in the realm of dissociation itself.
Fortunately, major sections of the analytic world have come full circle which is a key reason why The Dissociative Mind in Psychoanalysis: Understanding and Working with Trauma is such an important and brilliant book. It sets out to show that despite this difficult history, psychoanalysis has moved to embrace the truth: that trauma occurs in reality, and that dissociation and dissociative identities (and many other responses) can be a product of that reality. The relational turn in psychoanalysis, as it is sometimes called, has ushered in an era in which trauma, and the notion of multiple self-states – including dissociation – are conceptualised as interpersonal-relational events, which induce a wide range of responses and intersubjective effects.
The book is divided into four sections. The first dissects the conflicted history of analytic theory, and the casting out of dissociation and trauma in the analytic world, before its subsequent reintegration. The second section, very accessibly written, offers some personal explorations of how the different analytic orientations conceptualise and work with aspects of complex trauma, dissociation and dissociative disorders. Freudian, Jungian, Winnicottian, Kleinian and the intersubjective/relational orientations are featured in this section. The third section is devoted to specific aspects of treatment such as working with dreams, dissociative processes and self-states, as well as dilemmas of diagnosis. This section also includes an interesting – and somewhat disturbing – chapter on children and trauma by Valerie Sinason. The author explores factors that contribute to the inadequate diagnosis and treatment of children with dissociative disorders, and speaks of the continued neglect and under-diagnosis of children with such disorders. Meanwhile the fourth section of the book looks at current research trends, including an overview of the diagnostic validity, assessment, and treatment of DID, all of which continue to be questioned in some therapeutic circles, despite strong evidence of DID being a valid diagnosis.
Within section 4, I was particularly struck by the posthumously published essay by Abbey Stein, an expert in criminal psychopathology, child mistreatment, victimisation and states of consciousness during the perpetration of violence, on the under diagnosis and treatment of dissociative disorders among forensic populations. This chapter reflects the sense of the denial of the link between crime, trauma, and dissociation. Stein has written about a reluctance to acknowledge and support trauma interventions directed at prison populations, or to accept the role of dissociation in the performance of criminal and violent acts. The chapter is a disturbing insight into how far we have failed to come in understanding, accepting and intervening with trauma, in places where it is most rawly re-experienced.
Coming towards the end of the book I was moved and distressed by the reflection of a recurring pattern about our relationship to trauma and dissociation, from Freud onwards: we seem to want to deny its existence and reframe its impacts, or ignore them altogether. While the increasing prominence and recognition of trauma-informed models of care, and the greater recognition of the role of trauma in the DSM-5, are positive signs, some clinicians, the community, the courts, social services, and law enforcement providers, contribute to a process of denial and obfuscation of trauma; another shame very skilfully highlighted by this powerful book.
In my view, The Dissociative Mind in Psychoanalysis: Understanding and Working with Trauma carries with it an important sense of the parallel process of trauma in itself. You get a sense that, not only in the past but also in the present we, as a society and as a group of mental health professionals, continue to struggle with accepting trauma, dissociation and its effects. My overall assessment might sound gloomy, but the book is not. It is an accessible academic volume of cutting-edge thinking on theory, practice and the application of psychoanalysis in the field of trauma and dissociation, and an invaluable resource for counsellors, psychology students, and both psychodynamic and other clinicians. I highly recommend the book.