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Introduction

Over the last few years we in the therapeutic community have been hearing more and more about the extreme abuse from which young children have survived. Many times these memories are surfacing with the advent of middle age. Dissociation, a state of unconsciousness and self-preservation, has been called a tool of great creative survival. The community of therapists worldwide has been pulling their resources together, in an attempt to help these people in the most efficient manner. For many, there have been many years of misdiagnosis and inappropriate approaches.

This paper proposes the use of the transpersonal psychological therapy called Psychosynthesis, and suggests that, in looking at its makeup, efficiency, and connection to other therapies, that psychosynthesis is a viable, extremely useful tool for working with the Dissociative community.

A definition of Dissociation

The idea that extreme abuse could produce something as complicated as multiple personalities was something very novel only a short 20 years ago. From then, until now, much has been learnt about this very complex survival mechanism we now call Dissociative Identity Disorder. The American Psychiatric Association has taken the time to elucidate and categorize, placing symptoms into recognizable slots. Dissociative Amnesia refers to the state of disturbances where there are episodes of inability to recall important personal information, usually of a traumatic or stressful nature. These symptoms must cause significant distress or impairment and not be due to direct physiological or substance effects. Dissociative Fugue happens when one travels from home with the inability to recall their past. There is identity confusion, with the possibility of assuming a new identity. Dissociative Identity disorder requires the presence of two or more distinct identities or personality states which take control over the person's behaviour. There is an inability to recall personal information that can't be explained by forgetfulness. Depersonalization disorder involves a persistent or recurrent experience of detachment from self, as if becoming an observer of one's mental processes or body. There is also a classification called Dissociative Disorder Not Otherwise Specified in which there are Dissociative symptoms but the specific criteria aren't met. This may include people who have encountered brainwashing or other forms of coercive persuasion or indoctrination.

DID is a method of coping with and surviving overwhelming traumatic severe, chronic childhood sexual and/or physical abuse, neglect, loss or changes of caretakers. Child autohypnosis creates alter personalities to contain the pain, anger, and memories. Persons with DID are courageous, intelligent, creative, socially skilled, talented people whose dissociative abilities allowed them to survive traumatic abuse. Some of the symptoms of DID include lack of appropriate emotional response, memory loss, lost time, not knowing what has been said or done, feeling dream-like, a sense of watching oneself speak or act, dizziness, headaches, numbness in body parts, feeling disjointed, spontaneous trance states, not remembering childhood or major life events, hearing voices or thoughts that don't seem to belong to the person, unexplained items in possession, drastic and rapid changes in mood and behaviours, addictions, eating disorders and disruptive sleep patterns, suicide attempts and self destructive behaviours, displays of hypervigilence and denial of behaviour observed by others.

A historical perspective

Cornelia Wilbur is the originator of the term Multiple Personality Disorder, which is now called Dissociative Identity Disorder, and was the first to describe the complexity of the alter system in patients. She saw it as a developmental disorder related to childhood abuse and trauma and was the first to formulate the modern view of Dissociative defenses and multiple transference reactions. In 1980 DID had only about 200 cases reported in the world. Since then publications have accumulated as well as many research groups forming centered around DID studies. Since then it seems like there has been an explosion of cases, when, in fact, the diagnosis of Dissociative Disorders is really a result of the recognition of patients who have always been with us but simply were not 'seen' before.

Why people with dissociation would seek professional help

Help is usually sought out of sheer desperation. There are feelings of complete mental and physical exhaustion coupled with an inability to sleep. There are usually problems with drug or alcohol abuse as well as suicidal thoughts or actions. Many fear for their lives and seek safety and protection. They need help dealing with the crises caused by their memories. Headaches are common, as well as other physiological complaints. Many have been given false diagnosis by other professionals, and have been falsely criticized, ridiculed, or have not been believed.

How therapists have dealt with Dissociation

DID is a treatable, albeit difficult, disorder with tools that are eclectic, psychodynamically oriented, as well as containing some cognitive principles. Since the patient presents with a conflicted internal family of selves, it is easy to think in systemic terms. With a cognitive focus we would look towards rules, boundaries, power, and roles. It is not uncommon for patients to get caught in childhood double binds such as: I am responsible for the abuse and not responsible for my own behaviour, I deserve punishment, and why is this happening to me. Many patients are guilt-ridden, blame themselves for the abuse and punish themselves. The core beliefs can take the form of erroneous syllogisms or logical propositions with the quality of automatic thoughts. There are usually moral injunctions, all-or-nothing thinking, personalization and overgeneralizations. Psychodynamic analysis would speak in terms of regression, projection, and psychotic transference. There are infinite permutations in their assumptions and cognitions. Believing that the different parts of the self have different bodies allows for self abuse, denial, and inability to take responsibility. The primary personality usually can't handle the memories so there is amnesia of the abuse and idealization of the abusers. Cognitions must be dismantled gradually through a negotiated process of memory recovery. Acting out and dangerous behaviour requires definement/refinement. Many times the cognitions occur in overlapping sets. Non-cognitive techniques would include abreactions, adjunctive hypnosis, negotiation and internal dialogues between alters.

The International Society for the Study of Dissociation has suggested guidelines for treatment for adults with DID, especially given the fact that most patients, given the complexity of the disorder, have been frequently misdiagnosed. With an accurate diagnostic procedure, early screening, and appropriate treatment there is more hope for a positive outcome. It is suggested that primary treatment be outpatient psychotherapy with sessions reflecting the patient's functional status and stability. While a once or twice a week meeting may be sufficient, marathon sessions (longer than 90 minutes) should be scheduled, structured, and have a specific focus. Cognitive therapy protocols can be used for depression and anxiety with psychodynamically aware psychotherapy often eclectically incorporated with other techniques. In patient treatment should be used for specific therapeutic goals and objectives. It should occur in the context of a goal-oriented strategy, designed to restore stable levels of functioning. Emphasis should be on building strengths and skills to cope with the destabilizing factors. Group therapy is not considered to be a viable primary treatment and electroconvulsive therapy has been shown to be ineffective and inappropriate. There is no evidence to support psychosurgery and pharmacotherapy may or may not be effective for anxiety and stress symptoms but is still experimental. Physical contact is not recommended. Restraint, while indicated for violent acting out, needs to be used cautiously. Hypnotherapy can be used as crisis management for flashbacks as well as ego strength and stability during painful somatic and traumatic material retrieval. Abreactions, while not a therapy in itself, may be useful for retrieving information, for planning, exploration, and titration strategies and to help develop a sense of control over the emerging material. Art therapy, occupational therapy, sand tray therapy, movement therapy, play and recreational therapy can be helpful toward achieving treatment goals. The timing and integration into the overall treatment plan is important. Boundary management must be monitored with treatment taking place at predictable times with a predetermined session length. Relevant legal and ethical codes with respect to gift exchanges, dual relationships, and informed consent for treatment must be taken into consideration and abided by. Couples, family, or sibling sessions may be indicated for DID patients that are parents.

A brief history and introduction to psychosynthesis

Roberto Assagioli formulated the idea of Psychosynthesis in 1910.For most of his life he was unrecognized except for a small group of people in Europe. He was an Italian psychiatrist who was a student of Freud, a member of the Zurich Freud society, and Italy's first psychoanalyst. Along with those who are considered humanistic psychologists such as Fromm, Rogers, Jung, Maslow, Bugental and Frankl, Assagioli believed that there are facets of the human being that are just as powerful as instinctual drives, and that a standard of emotional health must include the aspects of altruism, creativity, love, and a sense of purpose in life. Assagioli believed that, in order to fully express such qualities, the individual must integrate his personality to the degree that he is free to fully express his potential, similar to what Maslow refers to as self-actualization. Assagioli states that the individual should be freed to explore more fully his spiritual nature and that the spiritual is a vital aspect of the human being. His attention to and writings in this area have had some bearing on the emergence of the field currently called transpersonal psychology. It is currently practiced in Italy, Switzerland, Germany, France, England, Holland, Australia and Japan as well as in North America.

Specific Psychosynthesis Techniques

Assagioli suggested specific techniques for personality integration which were later further developed and refined. Such techniques are intended to help the patient make sense of inner chaos and to strengthen the ego/self and cognitive awareness so that the patient has more charge over and more choice about his inner nature.

Subpersonality work involves exploring the nature of inner conflict through clarifying the conflictual patterns in the person's current life, defining the personality aspects involved and gradually resolving the conflicts through helping the patient assume an objective 'observer' stance that enables more insight, responsibility and choice. Subpersonalities are similar to Jung's persona and Roger's false self, and to the concepts developed later, in the sixties, by Perls (Gestalt), Berne (Transactional Analysis) and, more recently, Stone and Winkelman (Voice Dialogue) and Watkins (Ego State Therapy). Getting a sense of the patient's subpersonalities can aid the therapist in assessing ego strength and in hypothesis factors such as patient safety issues, boundaries, and speed and pacing of the work.

Disidentification is a core tool and process used in sessions, along with journaling and reflective work. This involves taking an objective stance in relation to, for example, subpersonalities as well as to other personality contents and material that may be emerging from the unconscious. This objective observer is similar to James's "I". In essence, it strengthens and enlarges the ego/self, empowering the patient with more options and the ability to make choices more clearly. This disidentification technique is so key that Assagioli recommended formal practices to support disidentifying from personality contents and identifying with the central self.

Imagery work is a third major area considered at length by Assagioli. He states that the imagination is a key function of the self (the others being thought, intuition, emotion-feeling, impulse-desire, sensation, and, the function most intimate with the central self, the will). The imagination itself, he observed, is of a somewhat integrative nature, combining as it does thinking, feeling, and sensation. He stressed the power of the image, for good or for ill; the effect of images on the will; and the importance of training patients in the right use of the imagination. To aid the patient in strengthening higher qualities of his nature, Assagioli recommended the use of positive images as a focus for meditation. Imagery work is often also used to help explore subpersonalities, or material emerging from the lower or from the higher unconscious.

Psychosynthesis posits the existence of three levels of consciousness: the lower so -called Freudian unconscious containing instinctual drives, conflicts arising from childhood themes, and anything from the personal past that lies outside the patient's awareness, including emotional, cognitive, or meaning aspects of partially remembered material. The middle unconscious contains material that is easily accessible to us, such as remembering a name or phone number. At the center is the point of awareness, that which one is conscious of at any given moment. The third level of consciousness is the superconscious or higher unconscious. It is in this domain that the qualities which are the most evolved, such as love, will, joy, compassion, exist. The higher unconscious is also the source of intuitive insights, creative ideas, illumination, and the drive toward meaning and purpose. By providing access to this domain experientially, we have found that a patient can be helped to see themselves in a less critical and self-demeaning light and that the healing process is expedited.

Assagioli distinguishes two levels of self, the personal self or "I" and the transpersonal of Higher Self. In a Subpersonality map the ego is played out through major identification. The "I" or self is the first transcendence of the ego/personality level of being or development, where we experience ourselves more centered in the core of our being in contrast to being caught up in our personality. The central, or functional "I" is the most centered place a person can 'get to' at a given point in time before reaching the stage of pure self-awareness. The discovery of the "I" can be a profoundly healing experience and is invariably accompanied by an increased freedom and clarity of will. Every disidentification from a limited identification and recognition of what one was identified with brings more freedom and choice.

Assagioli's view is that selfhood, once attained on a personal level, has the capacity to open to the spiritual or transpersonal Self. These 'peek' experiences are considered to be normal and he suggest that people from all walks of life have moments where they move beyond their personal ego concerns. The psychosynthesis worldview is that each person is unique, evolving, capable of reaching towards a personal self or "I", and is a spiritual being. Psychosynthesis refers to the "ongoing synthesis of the psyche, a process which transcend specific models and methods" (Brown, 1983,P.ix), and it was Assagioli's observation that this process goes on naturally in life. The beginning is where the person is in his/her current life and works to help the patient disidentify enough to see patterns and resolve intrapsychic conflicts that may be impacting interpersonal and work relations. Patients leave with a stronger ego, an experience of the personal self or "I" and may connect deeply to their spiritual nature.

A comparative study with other therapies

Psychosynthesis utilizes interpretation, the evoking of insights from the client, which are common psychodynamic and ego-building techniques, and is open to exploring any emerging theories of psychology and integrating them into its practice. Developmental and ego psychology, cognitive psychology and behavioural psychology are all being used by practitioners of psychosynthesis, as well as using the transference and counter-transference tools of psychodynamics.

Erikson defines the ego as a central principle of organization in…experience and action" (Erikson, 1963, P.415). Rogers description of 'person' (Rogers, 1961, P.124) also resonates with the psychosynthesis conception of the personal self or "I".

Chart 1 gives a comparative description of the various levels of therapy, the theorists, and the methods used.

Using Psychosynthesis with Dissociative clients

Psychosynthesis holds as its primary premise, the fact that we are wholeness bringing together our parts, much like the actual therapeutic techniques used for Dissociative clients. As a transpersonal psychotherapy that holds, as its primary belief, the fact that humans have an innate instinct to wholeness and health, it is called a psychology with a soul. Psychosynthesis draws from many former, active psychotherapeutic techniques while it solely maintains the multi-polar model of the human psyche, the central position of the self, the importance of the will, the existence of the transpersonal realm, the pathology of the sublime, the use of imagery for the exploration of the unconscious, the transformation of neurotic patterns, and the expansion of awareness, the concept of a natural tendency towards synthesis and syntropy, and the move towards the spontaneous organization of meaningful and coherent fields within the psyche.

Because Psychosynthesis draws on the other therapies, as well as expanding, not only on other techniques, but also on itself, it is known as a therapy in growth.

For very depressed or trauma-survivor patient this can mean a connection to something larger, simple hope, or simply the sense that 'I'm OK'.

Conclusion

Dissociation is a condition whereby a person, as a defense mechanism to extreme abuse in childhood, creates two or more distinct identities or personality states which take control over the person's behaviour. Dissociative Identity Disorder, previously called Multiple Personality Disorder, is a method of coping with and surviving overwhelming traumatic severe, chronic childhood sexual and/or physical abuse, neglect, loss or changes of caretakers. This disorder was first described by Cornelia Wilbur and is presently being researched at many different levels, the International Association for the Study of Dissociation being one of those professional organizations. People with DID usually seek help when they have reached a state of sheer desperation, complete mental and physical exhaustion, problems with drug or alcohol abuse as well as suicidal thoughts or action. Many fear for their lives and seek safety and protection. Physiological complaints are common and many have been falsely criticized, ridiculed, or have be given false diagnosis and treatment by professionals. DID is treatable with tools that are eclectic, as well as psychodynamically and cognitively oriented. Rules, boundaries, power, and roles are important aspects of the healing process and regression, projection, and psychotic transference are part of psychodynamic analysis. There is usually amnesia of the abuse and idealization of the abusers. Cognitions must be dismantled gradually through a negotiated process of memory recovery. Abreactions, adjunctive hypnosis, negotiation and internal dialogues are some non-cognitive techniques.

The International society for the Study of Dissociation (ISSD) suggest outpatient psychotherapy with once or twice a week session, not longer than 90 minutes, reflecting the patient's functional status and stability. Group therapy, electroconvulsive therapy, psychosurgery, pharmacotherapy and physical contact and restraint are not effective. Hypnotherapy can be used for crisis management. Art therapy, occupational therapy, sand tray therapy, movement therapy, play and recreational therapy can be helpful.

Psychosynthesis, formulated by Roberto Assagioli, uses specific techniques such as Subpersonality work, disidentification and imagery work for personality integration. With its three levels of consciousness and two levels of self, psychosynthesis holds the capacity for the central or functional "I", the most centered place of existence, to reach the peek experience of the spiritual or transpersonal Self. Because psychosynthesis holds the fact that humans have an innate instinct to wholeness through a bringing together of its parts, and because it draws from many other psychotherapeutic techniques as well as solely maintaining the multi-polar model of the human psyche, the central position of the self, the importance of the will, the existence of the transpersonal realm, the pathology of the sublime, the use of imagery for the exploration of the unconscious, the transformation of neurotic patterns, and the expansion of awareness, psychosynthesis may be considered the most complete therapeutic tool for working with people in the Dissociative state.

Copyright Shamai Currim 2003

References:

Assagioli, R (1965) Psychosynthesis, NY, Penguin Books

Assagioli, R (1973) The Act of Will, NY, Viking

Brown, Molly Young (1983) the Unfolding Self: Psychosynthesis and Counselling. Los Angeles, Psychosynthesis Press

Erikson, E (1963) Childhood and Society, NY, W.W. Norton

Kluft, Richard P. (1985) Clinical Perspectives on Multiple personality Disorder, Washington, American Psychiatric Press

Rogers, C.R. ((1961) On Becoming a Person, Boston, Houghton Mifflin

Ross, Colin A, Gahan, Pam (1984) Cognitive Analysis of Multiple Personality Disorder, American Journal of Psychotherapy, Vol.XLII, No.2, April 1984

Diagnostic and Statistical Manual of Mental Disorders-DSM IV. American Psychiatric Association.

Integration: A Pamphlet of the Multiple Personality & Dissociation Society of Kingston. March, 1994

Guidelines for Treatment, The International Society for the Study of Dissociation, http://www.issd.org/isdguide.htm, September 14, 2000