“If you have a single, undivided mind, it must be difficult to fathom how people could walk around with splits in their mind; how one part of the mind could take over and all the other parts would know nothing of it.”
These are the words of Wendy Hoffman, a survivor of the most profoundly terrifying ritual abuse, in her memoir The Enslaved Queen. It is an attempt to draw us into understanding why people with shattered personalities seem, so often, inexplicable. And it gets directly to the reason we need Living With the Reality of Dissociative Identity Disorder (Karnac), a newly published collection of deeply affecting writings by people telling how the extensive and unbearable child sexual abuse they endured, caused their personalities to fragment as a defense against the unspeakable torment of what they were forced to go through, and to form sometimes many different “alters” who live inside them.
This fractured state of being is known, clinically, as Dissociative Identity Disorder, and Hoffman is right it is mighty hard for many of us to fathom what it means to live with a cast of characters one of whom may, without your will or permission, suddenly take over . But Oriel Winslow in her vivid contribution describes her experience being known as an A grade Student at university but who would suddenly be overtaken by one of her alters, and at the time, she was unaware of the later diagnosis of DID that would come. Nor did she know anything of her being a host to the different people within her who would suddenly make themselves known. The four-year-old suddenly screaming in the middle of a seminar presentation; an alter dealing with the fear of being raped for failing an exam by not turning up for the exam, a starving four-year-old trying to get fed by stealing other students’ food , self-harming every night. “Our entire undergraduate years were spent as a battle for the body”.
Oriel’s healing began when she got a DID diagnosis and began to make sense of her confusing and frightening behaviour and she is one of many with DID who have and have had their reality and experiences denied as too bizarre. Yet as Orit Bådouk Epstein, a therapist who has spent many years working with such victims and has written the final chapter of the book says: “In order for them to survive, the roots of the painful memories had to be stored and concealed in hidden pockets of existence.” She has seen over and over how, when the outside world denies the victims’ reality it denies them the opportunity to find help and move on with their lives.
It is a thought taken further by Lady Xenia Bowlby, co-editor with Deborah Briggs of this book: ”Government, law enforcement, the justice system and all of us who make up “society” need to recognise that terrible abuse happens, and that it is often organised and always hidden. The perpetrators are always powerful - privately or publicly “.
Pat Frankish, consultant clinical psychologist, past President of the BPS and first chair of the Paracelsus Trust talks about the role of the media publicly rubbishing what clients say as deranged. She acknowledges that it is hard to believe people will harm their own children the way they do with the sadism, psychological torment and pleasure people from parents and other family members to those in influential positions in society described so often in this book. “But this is not sufficient reason to fail to believe them. Of course it is the core identity that is attacked in ritual abuse, as this ensures that the person on the receiving end can often be discredited as an unreliable witness.’
Nicky Robertson is 57 now and married to a vicar, and has three grown up children. It was just five years ago that she was diagnosed with severe DID along with PTSD and depression which she now knows is the legacy of satanist abuse perpetrated by her parents and in the process of torture and mind control “played havoc” with a spiritual belief in good that she tried to cling to, so urgently.
“By the time I was a teenager deep depression had set in. I had little or no sense of self-worth “. Age 17 she considered taking her own life. As an adult she had a breakdown and ‘the many people parts “ started to unravel but that led to years of ‘misdiagnosis and inappropriate treatment’ before a DID diagnosis.
Nicky has come to understand, too, how profoundly this overwhelming abuse makes the secure attachment infants need from a care giver impossible and leaves instead chaotic attachment patterns to develop. For her the Church has become solace and succour but with a struggle to find her own way of believing in the good in humanity as healing. And she feels now:’ the spiritual aspect of all that has been survived is vital in any journey of healing from trauma and abuse.’
I have selected these contributions because to give a flavour of what is covered in this hugely valuable and accessible collection of intimate stories of survival, but that necessarily means missing out others that have much of value to tell and should be read. The contribution of Carolyn Bramhall and Deborah Briggs on the role of friends in recovery is important because, at a time when current revelations suggest there will be many more ritually abused “children” needing help, and far too few specialized therapists , they discuss how good friends may be able to offer much needed support, help and vital love.
For all the chilling tragedy in Living With The Reality of DID there is a formidable display of strength, determination, joy at finding a new way of being and indeed some humor. However many clinical books there may be on DID this one should be read as the very personal, compelling voices of those who have lived the condition if those of us fortunate enough not to be victims, are to understand and offer the compassion we should.
Angela Neustatter is a British freelance journalist and author of many books who writes extensively about family matters and mental health.
Attachment Theory in Adult Mental Health : A Guide to Clinical Practice
Edited by Adam N Danquah and Katherine Berry
Book reviewed by Hazel Leventhal
This book explores how Attachment Theory relates to every aspect of mental health and impacts on all the issues that practitioners meet during their working life. Each chapter is written by a different author or authors on their own speciality and includes the most recent theories and practice in this field.
The book is divided into four parts, the first one being “Attachment theory and practice – the basics”, which consists of an introduction by the two editors and David Wallin, giving a comprehensive account of the basic concepts of attachment theory, followed by a chapter by Jeremy Holmes. He gives an account of how attachment styles play out in a therapeutic setting and says: “…the basic interpersonal architecture of therapy is (a) a person in distress seeking a safe haven, in search of a secure base; (b) a care-giver with the capacity to offer security, soothing and exploratory companionship; and (c) the resulting relationship, with its own unique qualities.” This sets the tone for the rest of the book and under the heading of “Emotional connectedness” he asks “When does a therapist move from being a helpful professional to the role of an indispensable attachment figure?” Section two of the book, “Clinical problems and presentations”, has eight chapters covering most mental health disorders.
Paul Gilbert’s chapter on compassion focused therapy for depression discusses SAHP (social attention holding potential) and explains how this “is first experienced positively in the loving gaze and embrace of an affectionate parent” where “we have the emotional experience of existing positively in the mind of another.” However when SAHP is negative there are issues of shame and stigma and how useful it is for therapists to “understand the evolutionary roots of dynamics of shame”. He goes on to talk about the neurophysiology of attachment and affiliation and how “attachment and affiliative relationships down-regulate the threat system” which can go on to “creating a sense of safeness from which exploration can occur.” He says how “a good deal of the work for depression in CFT focuses on building compassionate capacity”. He explains how some patients are “reluctant to engage with the source of their suffering, such as early trauma or the implications of the need to change lifestyle” so CFT “seeks to build motivation and these abilities, skills and competencies to address suffering and the causes of suffering in compassionate, containing ways.”
Gail Myhr’s chapter on attachment-related interventions in cognitive behavioural therapy of anxiety disorders provides useful insights and uses some relevant case study examples to highlight how recognising anxious attachment styles can help the therapist offer their client attachment-related interventions.
The chapter on attachment theory and psychosis by Matthias Schwanneur and Andrew Gumley explains how early difficulties in attachment relationships can adversely affect the development of an internal secure base and therefore “result in a ‘sealing over’ recovery style in response to psychosis.” They continue by saying that “Secure relationships are based on collaborative and carefully attuned communication” and that “the therapeutic relationship is central to therapy in people with psychosis.” There is a clinical example showing how a patient was helped to formulate the ‘secure base’ treatment goal which led to greater understanding of her own experiences and those of others. They state that “working with people with a diagnosis of psychosis also requires a co-ordinated multi-disciplinary response to clients’ needs” and that “a key function of multi-disciplinary teams is to facilitate a ‘secure base’ through providing continuity and consistency of care, providing sensitive and appropriate responses to affective distress, and providing emotional containment during times of crisis.”
Kathy Steele and Onno van der Hart’s chapter on understanding attachment, trauma and dissociation in complex developmental trauma disorders starts by saying “The heart of psychotherapy is in understanding and changing the ways in which individuals experience, develop and maintain human relationships” and explains how “No-one is more in need of help with attachment and regulation than those who have been chronically abused and neglected in childhood.” This chapter clearly demonstrates how chronic childhood traumatisation results in an unstable foundation for future healthy development and adaptation putting such people at risk for ongoing psychological, physiological and relationship problems. They describe dissociation and dissociative attachment in an easily understood way and explain how “a dissociative person’s ways of being are not co-ordinated, they become activated at the wrong time or in the wrong situations and are even actively in conflict with each other” illustrating how an individual can have “more than one sense of self within a single personality”. Using case study examples and explanations of the ANP and EPs they show how to work with perpetrator-imitating parts, how to overcome phobia of traumatic memory and eventually personality integration and rehabilitation.
Giovanni Liotti’s sensitive chapter on disorganised attachment and BPD provides great insight into the risk factors of infant disorganised attachment and future dissociative mental processes and the early relational trauma that causes dissociation and a disorganised IWM. He provides useful research data and shows the benefits of an attachment-based model of working psychotherapeutically with such vulnerable people and cogently explains how working with two therapists can allow for repair.
The chapter on eating disorders by Rudi Dallos highlights how these can be some of the most dangerous and difficult problems to treat and shows “a multi-level perspective, including a focus on attachment patterns, family relationships and the cultural contexts underlying eating disorders.” There are some valuable case study examples of using attachment narrative therapy and the benefit of using genograms to identify trans-generational patterns.
An attachment perspective on understanding and managing medically unexplained symptoms by Robert G Maunder and Jonathan J Hunter also uses clinical vignettes to demonstrate how “physical symptoms that are never adequately explained by organic disease are one of the most common and challenging phenomena in medicine” and how attachment styles can be used to help identify and understand underlying problems.
Section three of the book concentrates on specific populations and begins with a chapter by Susie Orbach on a gendered perspective to attachment theory and shows with her usual clarity the transmission of attachment styles and gender transmission.
One of the most moving chapters is on Attachment in African Caribbean Families by Lennox Thomas in which he writes that “Separation is a big part of Caribbean history and this became something to which the people of the region were desensitised. The harshness of attitude to separation and loss came to be seen as strength because to really experience such loss would destroy the soul.” He explains how the devastating legacy of slavery has permeated families right up to today and says “Separation and broken attachments are an unmentionable truth in the history of African-descended people and its ubiquity is such that it has gone unrecognised for many years.” He adds “Understanding attachment behaviour is not only important for understanding its role in the patient’s life cycle but also for understanding affective responses to loss.” He describes how grandparents, parents and children were separated by migration and the difficulties when children were reunited with parents they may not have seen for years and illustrates this by a detailed case study.
The third chapter in this section is about meeting the mental health needs of older people using the attachment perspective and talks about attachment across the lifespan and how our attachment needs continue throughout our lives and reinforces the therapeutic relationship as a foundation of treatment using clinical examples including dementia care.
The fourth section brings things round to the therapist’s own attachment style and the impact this has on treatment outcomes. The first chapter by Gwen Adshead and Anne Aiyegbusi on “Four pillars of security” about forensic mental health care focuses on violent patients and the relevance of attachment insecurity to the risk of violence. This highlights the relationships within a hospital setting and the prevailing hierarchy which is often counter-productive to healing and shows how things could be recalibrated to take account of ambivalent feelings towards relationships and managing fear, sexualised attachments and professional and personal boundaries.
Martin Seager’s chapter on using attachment theory to inform psychologically minded care services, systems and environments continues this theme and expands on it as he talks about early attachment in human mental well-being and how this is not taken into account in most mental health settings at the moment. Personally I think this particular chapter should be required reading by everyone connected with mental health services.
David Wallin’s final chapter “We are the tools of our trade” explores the therapist’s attachment history and shows how identifying and working with the therapist’s attachment patterns can “help patients both to deconstruct the attachment patterns of the past and to construct fresh ones in the present”. He describes the therapist’s differing states of mind and how these can affect the relationship with their patient as long as they are aware of what is happening for them as well as for their patient.
I found this book to be of immense value and would recommend it to anyone working with traumatised people from whatever perspective they are coming from. It covers all aspects of mental distress and sheds light on almost any conceivable problem a practitioner is likely to face but also shows how attachment theory underpins our lives in every way.
Cognitive Behavioural Approaches to the understanding and treatment of Dissociation
By Kennedy, F., Kennerley, H. and Pearson, D
2013. Routledge: London.
Book reviewed by Angela Kennedy
The remit of this book is clear from the title. It aims to show the usefulness of Cognitive Behavioural Therapy for dissociation and to raise awareness within CBT therapists that dissociation is not just an issue for dissociative disorders. As an edited text, it collects the ideas of 23 authors in 18 chapters. The majority of authors were from the NHS in the UK, which has not been particularly embracing of dissociation as a concept (a state of affairs acknowledged by the editors, who suggest this book is an attempt to redress this). They cover a range of clinical presentations and discuss a variety of models that encompass ‘Cognitive Behavioural Therapy’. The editors are well known within the UK for working with dissociation.
The book has a distinctive pragmatic flavour. There was no debate about the nature of dissociation but there was a decent overview of diagnostic inconsistencies in the first chapter. Most of the chapters use a continuum model of dissociation, with some conceptualising it as defensive process and some as integrative failure. Kennerley (one of the editors) has long emphasised the role of emotional learning in triggering certain detached states of mind with avoidance being a key reinforcer of compartmentalization. Many of the chapters distinguish between dissociative detachment and dissociative compartmentalization. Kennedy and Kennerley (chapter one, page 13) make a helpful distinction between the differing goals of therapy for each of these types of dissociation. CBT for detachment requires identifying triggers and ‘grounding’ strategies. CBT for compartmentalization aims instead to reintegrate aspects of experience.
Chapter two begins with a neat description of the two kinds of dissociation that is the basis for a complicated model describing how dissociation may lead to mental health problems. It then outlines Fiona Kennedy’s own cognitive model of dissociation that is based on Beck’s model of the personality. The chapter makes an important point that therapists’ awareness of dissociation is important in helping clients move towards recovery, understanding the reaction to therapy, and managing crises as progress moves towards integration. The chapter ends discussing the Wessex Dissociation Scale that is based on the model but is limited in assessing Dissociative Identity Disorder.
The important role of attachment and neglect is covered by Pearson in chapter three. Chapters four and five are both written by Kennerley and Kischka. Chapter four gives an overview of the basics of memory for therapists. There follows a chapter on the brain and dissociation, which explains how flashbacks precede panic and are dissociative in nature by being unintegrated aspects of experience. The importance of parasympathetic over-activity on limbic system inhibition and hence emotional detachment is also reported. The therapeutic implications are that a period of stabilisation is indicated before trauma work begins. Stopa then discusses the role of imagery in dissociation and the creation of false memories. The role of imagery in organising both memories and self representations of different self states is clearly an under researched area. Another chapter on memory by Huntjens, Dorahy and van Wees-Cieraad presents research evidence that dissociation enhances memory for perception and inhibits meaning. It is interesting that dissociative memory perceptions appear to be linked to subjective experiences of memory fragmentation but not objective measures of fragmentation. One explanation suggested is that subjective measures are essentially assessing meta-cognitive processes. They suggest fruitful avenues of further research based on a potential model. The therapeutic implications for CBT were discussed.
Chapter eight begins the move into more disorder specific territory with the discussion of Eating Disorder research. Mountford reports that dissociative detachment and compartmentalisation are more of an issue for people with bulimia, with a suggestion that not all of this is trauma related. Therapy needs to address the intolerance of negative self awareness, which prompts the dissociation, before the Eating Disorder can be addressed. Mountford also includes some key questions for the novice therapist to identify dissociation. There followed an important plea by Newman-Taylor and Sambrook in chapter nine to include dissociation in assessment of psychosis. A simple and clear model for somatising is presented in chapter ten that I suspect could be followed by clinicians quite easily, in spite of the illustrations for the case studies being in the wrong order. Of note is that Brown suggested avoiding any mention of trauma in the formulation of one of the cases. Evidence for cognitive problems being related to dissociation in Borderline Personality Disorder is discussed by Haaland and Landro. Although cause and effect is unclear, such issues may make therapy more difficult. Hunter gives a good description of Depersonalisation Disorder next and a clear model to follow. The chapter illustrates the role of cognitions in maintaining the problem using a case example. The case is very normalising but the chapter does not discuss much trauma related DPD.
The case study by Cowdrill in chapter thirteen was one of the highlights of the book. It was a very clear chapter which makes good suggestions for the novice therapist. Gilbert then presents a model of dissociative splitting based on evolutionary preparedness. This chapter stood out as being more integrative in nature by discussing the vitally important concepts of mentalising, attachment, conflicts and the role of positive affect in building resilience. The Van der Hart and Steele chapter followed well from that. Interestingly, they gave the best summary in the book of the range of stabilising interventions that can be useful for therapists. The book finished with chapters on Perceptual Control Theory (Mansell and Carey) and Acceptance- Commitment Therapy (Neziroglu and Donnelly), which help clients challenge the notion that beliefs define them and then use mindfulness to address avoidance.
This book was a step towards Cognitive Theorists considering a vital issue in the ‘self’ (noted in p13). Therapists who already work with dissociation may find this book lacked depth in this respect. What was missing from many chapters was discussion of the influence of interpersonal learning on the internal representations of the self and other and the resulting reciprocity of both internal and external roles that result. Not all the chapters presented work specific to dissociation and not many suggested ways of addressing emotional processing in therapy. However, some CBT therapists new to dissociation may feel it addresses an unmet need for them. The foreword by Arnoud Arntz noted the disconnection of the dissociation literature from mainstream practice. Major steps forward could come from more dialogue between therapists of differing persuasions and more integrative approaches. It would have been interesting to see how more of the contributors could have interpreted literature on the dissociated self that was outside of CBT. That would have taken the book further. However, it is good to see mainstream CBT and the UK embracing dissociation at last.
On her 11th birthday, young Angelike steps out of her bedroom wearing a satin white dress and a plastic smile. Looking like a toy ballerina, we see her stiffly waltzing with her grandfather to Leonard Cohen’s Auschwitz tribute ‘Dance to the end of love’. While her grandma slices the pale, pink iced birthday cake, Angelike resolutely walks to the balcony, climbs out and leaps to her death. In this intimate domestic horror drama, we are slowly introduced to the middle class family of an accountant from Athens who lives with his wife, 2 daughters and 3 younger children. The family insists that Angelike’s death was an accident while they continue to live their lives within a rigid routine of numbness and detachment; although there is a hint of terror shown in the frozen eyes and fragile smile of the eldest daughter, Eleni’s face. They are in grief, but not for long, as conditions prove to be impossible for any normality to take place; hence dissociation is now in charge, and we are gradually exposed to a chilling account of insidious childhood sexual abuse. As we left the cinema I overheard a man behind me whispering to his partner ‘I feel dirty, never before have I felt so degraded by watching a film’. Similarly, having to adjust myself back to the bustling streets of London, my body too, felt shell shocked, my mirror neurons were firing wildly.
Slowly, inch by inch, the camera takes the viewer and the narrative to more disturbing and dark places. The family’s apparent orderly behaviour (AOB), verging on pristine perfection, is the outcome of a grandfather who runs the house like a tyrant and controls everything down to the last gram of cornflakes eaten. The increasing eeriness of the film takes the viewer into a realm which is meant to be hidden from the world of the outsider. ‘It almost seems like nothing has happened’ says the baffled social worker who comes to visit the family home after their tragedy. ‘Thank you’ replies the grandfather ‘we’ve worked very hard to make it that way’
Like the film ‘Dog tooth’ (reviewed in issue no. 1) which was also set in Greece, this film is one of the darkest yet most accurate accounts of hidden child sexual abuse in what seems like an ordinary family life. Unlike ‘Dogtooth’, the film lacks any irony and absurdity. Some critics claimed that the film also lacks any imagination. However, as no documentary can ever expose the atrocities committed against children in this type of close-knit family behind closed doors, in my view, the strength of this well-structured drama lies in its concrete realism and lack of metaphor. In a recent interview the director, who studied art in Berlin said that the film is based on a true story that happened in Germany and that he saw it as a universal case of depravity against children: ‘There is something uncomfortably utilitarian about the way sexual abuse serves the larger ideas here’ (Avranas to Paul Risker, 19.06.2014).
The film also attempts to be an allegory about moral and economic decline in Greek society today and shows the grandfather manipulating the system in a time of recession in Athens where men and morals are both bankrupt and ravished by corruption. Yet, we know that child sexual abuse and trafficking exists regardless of any economic and financial conditions. Austerity times or not, perpetrators and paedophiles such as the notorious Austrian abuser Joseph Fritzl, are hardly ever influenced by economic currents. If anything, in times of prosperity, they might increase their income from child trafficking.
With deep unease, the viewer is forced to suffer the most graphic and violent scenes starting with the uncomfortable and leading to the most unwatchable scenes of sadistic abuse. Thanks to digital media and directors such as Avarnas and Lanthimos (Dogtooth), the reality of such cases is now more believable than ever before. Without going too much into the dynamics of power and who has the most power the perpetrator or the one who feels the pain, for us who work in the field of trauma and abuse, we know that in the face of such dynamics, helplessness can be understood only through a powerful mechanism called dissociation. Avarnas and his cameraman mostly filmed within four walls, palpably capture the agoraphobic feelings and facial expressions; from pain to total detachment and the numbness shown on the victims of rape in this film.
This Greek tragedy could have happened in any place in the world. It is not a film for the feint-hearted and is hard to stomach. I would not have chosen to review it had I not thought that for us professionals who work with survivors of sexual and violent abuse, this is a candid account of the insidious crimes that some of our clients report to us, brutal as it may be. These crimes are often masked by a placid surface of the most mundane, revealing to us the knowledge that unspeakable things are happening off screen and behind closed doors. This is where our deeper knowledge and understanding of attachment theory and dissociative phenomena can come in handy.
Paris 1870, it is Tuesday at the Salpêtrière hospital and Dr. Jean Martin Charcot, a prominent neurologist, is demonstrating to his fellow male colleagues the treatment he has been giving to young women who display symptoms of hysteria.
We then see Augustine, a 19 year old kitchen maid (played by the French singer Soko), who abruptly crashes to the floor while serving dinner, and begins to have a seizure. Suffering from paralysis to the right side of her body, she is rushed off to the Salpêtrière. where she joins a ward full of women whose myriad symptoms are all considered to be of a hysterical nature. In today’s diagnostic terms this would be identified as complex PTSD and somatoform and psychoform dissociative disorders. Dr Charcot, known as the “Napoleon of Neurosis”, chooses Augustine as one of his special case studies. He believes that he is on the brink of a crucial insight into finding the psychological and neurological roots of hysteria. We see Augustine being brought up in front of the voyeuristic male audience and while under hypnosis she re-enacts some form of orgasmic delirium, although to those of us who work in the field of trauma this might be some form of sexual enactment of early abuse, possibly rape. Her half naked body is prodded, poked and drawn upon as she is used as a guinea pig. In one particularly uncomfortable scene Charcot applies something called an “ovarian compressor” to Augustine’s lower abdomen as she compliantly whimpers in pain. In today’s society this would not only be considered as a retraumatising experience for any patient but also a form of sexual abuse.
Eager to impress the medical establishment, the humourless and somewhat morose Charcot (acted by Vincent Linden) adopts Augustine as his special patient. He provides her with her own room in the hospital, feeds her soup and takes her to his home where he introduces her to his pet monkey. Their relationship, which began as clinical, increasingly becomes erotically charged and later reaches a point of climax. Told that she must pray to Charcot and not to God, the illiterate Augustine soon learns to know what is required of her, she then uses her sexuality as a freedom ticket from her male oppressed environment, and eventually finds a way to escape from the hospital.
This dark period drama, with its distinct gothic atmosphere is, to some degree, a crossover between ‘Jane Eyre’ and ‘Dangerous Method’ had the potential to introduce the viewer to the abhorrent mental health conditions of patients in the 19th Century, in particular, the power dynamics between patient and doctor, as well as the objectification, the abuse and exploitation of women at that time.
Alice Winocour, the director, attempts to create a drama that is half-horror and half love story, but is not bothered too much by the historical accuracy, and more importantly fails to fill in Augustine’s back story. Instead she chooses to provide a modern interpretation. Her political message attempts to make the film into a feminist parable of gender power where a woman’s body is a public object exhibited like in a pornographic peepshow for the Parisian high society. It is also about the treatment of mental illness that actually involves the torture and abuse of those institutionalised women. All of which would have made a powerful case, if only the film’s narrative was not so inaccurate.
In Winocour’s screenplay, Augustine is transformed from object of study to object of desire and sexual misconduct. However, looking at the history on which this story is based, the true facts about this case are evidently misrepresented.
In real life Louise Augustine Gleyes was a 14 year old housemaid who escaped severe abuse and trauma. She was raised in a cruel and harsh nunnery, and was later raped by her mother’s lover. Also as a child, her older brother offered her to his friends for further sexual exploitation.
The Salpêtrière was originally an asylum for homeless and unwanted women. Hysteria was the official blanket term, covering a wide range of neurological and psychological conditions. Charcot, who in 1862 became the director of the Salpêtrière, continued the tradition of the brutality and punishment used against these women. He was the first doctor to recognise that Hysteria was rooted in traumatic experiences. He noticed that some of his female patients suffering from hysteria were, during their “hysterical attacks” re-enacting sexual abuse experiences. According to Van der Hart ‘Although these attacks in his female patients often involved re-experience of sexual abuse, he ignored the etiological role of early traumatisation in the development of the disorder’. As a neurologist he was much more interested in describing and classifying the various positive and negatives symptoms of hysteria. However, he did acknowledge the contribution of traumatic experience in victims of work related accidents and rail disasters. To prove his theory, Charcot used hypnosis, took many photographs and made detailed illustrations. He diagnosed Augustine with ovarian hysteria. The Tuesday lectures appeared at times to be theatrical performances. Students from all over the globe flocked to view the famous neurologist amongst them were Janet, Freud, Young and Jacob Putman.
Charcot’s methods of practice were indeed cruel and abusive and deserve great criticism. He exploited and abused Augustine as his medical muse and treated her as the object of study and of display. Charcot used hypnotism to help him prove that these patients’ symptoms had links between the attacks and the kind of violence often sexual, hence some critics saw the performances as a fantastical drama (the French writer Guy de Maupassant was one of them). But there is nothing in the literature that points towards any sexual liaison between the doctor and his patient. Equally there is nothing that mentions that Augustine seduced Charcot.
It was Charcot’s assistant Dr. D.M Bourneville who was responsible for Augustine’s care. He documented every photograph, illustration and prepared the medical notes about her. It is said, in the literature that Augustine told her doctor that there was an intern by the name of Camille whom she was in love with, but who most notably had disappointed her by refusing to have sex with her and who at one point helped her escape the hospital. It is unknown who Camille was and whether they ended their life together remains a mystery to this day.
By trading historical details for the sensual and for an atmospheric cinematic impact, the director fails to do justice to Augustine’s sad life. This does raise issues about the ethics of art and its moral limitations. But more so, the film does explore the issues that could have been raised by acknowledging Augustine’s traumatic childhood, in which she was abused by many men in ways far more horrific than Winocour suggests. Perhaps the film would have been more effective had the director focused her attention on the brutalization, sexual abuse and sheer desperation that these female patients had to put up with under dehumanised conditions of that era.
Encyclopaedia of Psychological trauma, Van der Hart O. (2008
“Medical Muses: Hysteria in Nineteenth Century Paris”, Asti Hastvedt, Norton, 2011.
“Invention of Hysteria: Charcot and the Photographic Iconography of the Salpêtrière”, Georges Didi-Huberman, Cambridge Press, 2003.
Global perspectives on dissociative disorders : Individual and Societal Oppression
By Şar, Vedat; Middleton, Warwick; Dorahy, Martin
(2014) London & New York: Routledge
Book reviewed by Joseph Schwartz
Psychotherapists have an occupational hazard which this collection does much to correct. We tend to work individually without the benefit of daily collegial contacts and, when we are trauma specialists, our practice tends to be intense, challenging and consuming. We rarely are able to lift our heads over the parapet to see just how prevalent abuse is world-wide and even more rarely are able to understand the epidemiology and causes of abuse world-wide.
Şar, Middleton and Dorahy in their powerful introduction to this collection of articles from the Journal of Trauma and Dissociation, the journal of the International Society for the Study of Trauma and Dissociation (now in its 30th year) ask us to look at the global pattern of abuse and its cause. Şar, MIddleton and Dorahy are distinguished clinicians and researchers in the field of trauma and dissociation. Şar is past president of the ISSTD and current president of the European Society for Traumatic Stress Studies. Middleton and Dorahy are on the Board of the ISSTD. Their detailed description of the prevalence of abuse world-wide concludes:
The chapters in this book demonstrate through a variety of examples that oppression is part of the human condition in democratic and undemocratic societies. And where oppression resides, dissociation is by necessity a constant companion.
And in the first paragraph of their introduction they say:
Even within established democracies there are frequently groups or organizations that have power structures worthy of the most totalitarian state, and, although such entries may include orphanages, churches, cults and organized criminals, globally the most commonly encountered abusive totalitarian structure is based on the family.
In between the first and last paragraphs come the facts of the case.
In the scandal of the Catholic Church in the US, 6100 priests were accused to have sexually abused 16,000 victims. Four hundred priests were convicted and jailed. In 2012 the Church paid $3 billion to settle out of court. Internationally 60 Catholic bishops from 20 countries have been convicted or forced to resign because of sexual offences. Other organisations have similar records including the scouts, orphanages, old age homes and special schools.
Şar, MIddleton and Dorahy go on to build their case that because the powerful are in a position to abuse the vunerable they do go on to do so. Their view corresponds to the long-standing feminist analysis of rape succinctly expressed by Andrea Dworkin: “Why do men rape women? Because they can.”
Mental health is not immune from this power dynamic. In 1986, in the case of Jules H. Masserman, a past president of the American Psychiatric Association and the author of 20 books and 400 articles, Masserman settled out of court with four women who testified that he had drugged and sexually molested them. The APA Appeals Board suspended him for five years but did not expel him - a global pattern of leniency, avoidance and bystanding by the responsible authorities. I was forcefully reminded of the exposure of TV star Jimmy Savile in the UK where everyone stood by and let Savile abuse over 450 youngsters over a period of 30 years with the response: “Oh that’s JImmy”.
Although we all know from our practices that the connivance of the authorities with the abusers is the rule rather than the exception, we are reminded by Şar, MIddleton and Dorahy about the Holocaust where at the infamous Evian Conference in 1938, 32 countries wrung their hands at the plight of the Jews in Germany and Austria while simultaneously slamming their doors shut. And we are further reminded that genocide has become a fact of international life as in Rwanda and Srebenica.
We get up-close to what we see in our consulting rooms in the presentation of organised abuse. But I certainly had no idea of the global extent of organised abuse and its invariable cover-up when well connected people are involved - Belgium; Portugal; North Wales; London; Pennsylvania; Argentina; Wollongong, Australia; Jersey; Omaha, Nebraska. In March 2011, 184 suspects of being members of an international child pornography ring were arrested by police in 40 countries linked to an internet address where police found 71,000 IP addresses in 109 countries. As Şar, MIddleton and Dorahy are at pains to emphasise, abuse is not an exception it is a global fact of life.
Warfare is an additional factor leading to dissociation. “...the populace is not only oppressed in their daily behavior by the threat of unforseen mass violence, but also by governments and agencies designed to protect them”.
The appalling phenomenon of child soldiers receives attention including examples from the Western democracies. The youngest British soldier killed in WW1 was John Condon age 14. In WW2 the youngest was Reginald Earnshaw also age 14. The Russians and Germans are well known for their desperate use of youngsters in the fighting on the Eastern Front. In our period, up to 95,000 child soldiers were killed in the Iran-Iraq war.
In limning the world in which we inhabit as one where oppression is the norm rather than the exception, Şar, MIddleton and Dorahy offer a different and thought provoking way to view dissociation, a different paradigm from the one most of us use in our treatment of traumatised patients:
An alternative paradigm with which to view dissociative disorders is to characterize them as a chronic human rights abuse syndrome of childhood. Here various forms of oppression operate, including oppression of the child by the abusive and potentially colluding non-abusive caretaker, and the multiple ways in which their lived experience is ignored or invalidated by social, political and medical systems. Research from every continent increasingly demonstrates the ubiquity of dissociative defences and the universality of the sorts of traumas that engender them. (Emphasis added)
Şar, MIddleton and Dorahy call for an ending of the silencing that can surround the perpetration of abuse whether in families or institutions. But the task of ending the oppression that lies at the root of abuse seems enormous. In my practice I am always struck by how poorly we defend our children, how far we are from the African ideal: “It takes a whole village to raise a single child.” But it seems it is more than we don’t protect our children and the vulnerable in our society. We tolerate or support power structures that make abuse inevitable. What role can clinicians play in the political process to help limit the exploitation of the power differences that lead to the ubiquity of dissociation? It is an epidemiological challenge perhaps only equalled by the ubiquity of cancer causing agents in our global environment. One small thing might be for the ESTD to fund a press office that can attempt to encourage the media to consult us as clinicians whenever a story of abuse emerges. It was painfully obvious to see that in the Jimmy Savile case no mention was made of the difficulty of healing the children, now adults, damaged by Savile’s crimes. Action does seem urgent.
Morad, a 17 year old boy from an Arab village in the north of Israel, sent an innocent text message to a girl in his class who was already betrothed to someone else. The girl’s older brother read the message and, with his friends, kidnapped Morad and savagely beat him up, leaving him badly injured and unconscious. It took 11 days for him to regain consciousness.
The film begins with a scene showing Morad in hospital, in a state of catatonic shock. After two months he was still mute and not responding to any conventional treatment for PTSD. Dr. Ilan Kutz an unusual psychiatrist, whose sensitivity and ability to think outside the box, surpassed any professional expertise, decided to introduce him to Dolphin therapy in Eilat in Southern Israel.
Like horses and dogs, dolphins have an enhanced sensory capacity which enables them to tune in on a non-verbal level to the human need for affection. Dolphin therapy has been widely recognised since the 1970s and helps alleviate symptoms of children with autism, cerebral palsy, shell-shock, cancer and other traumas. Although research has not yet determined what it is that actually helps relieve these symptoms, we know that swimming with dolphins changes hormone levels and increases endorphins in the brain.
Morad’s father’s love and dedication for his son is palpably moving. He quits his job; sells his properties and the two move to Eilat where Morad is introduced to the dolphin reef and the welcoming staff. When Morad finally dives into the blue water of the Red Sea, a connection is instantly made and a bond is created that feels deeper than any ocean. After five months of swimming with dolphins, he begins to smile and starts to speak but he has no memory of his past. When asked where he was born: he shrugs: “Here in Eilat”. His bond with the dolphins continues to intensify to the point where he mirrors and mimics their behaviour. He learns to dive to a depth of 30 metres and releases air bubbles through his eyes in the style of a bottlenose dolphin. A part-self, featured as dolphin boy is now in charge. What’s more, he refuses to reconnect with his mother and return to his village. Instead he adapts to a new Israeli environment where he loses all trace of his Arab accent and even falls in love with a Jewish Israeli girl. As well as having a dolphin boy part, he now has an Israeli young male part. Nevertheless, his PTSD symptoms remain acute; he continues to have nightmares, sudden rage outbursts and is incapable of crying.
For 4 years, while away from his village, the camera followed Morad’s recovery process. The camera also works as a therapeutic tool providing Morad with a new narrative that is empowering and validating his experiences. We witness the unwavering devotion of his father; his intense bond with the dolphins; his intimate relationship to the Jewish Israeli female; the dedication and creativity of treatment given by Dr. Kutz and the supportive team at the reef. Eventually at the age of 21 he is finally ready to return to his village. Morad’s phobic part that couldn’t cry is overcome and in a cathartic moment, when he departs from Eilat and says goodbye to the dolphins, we see tears rolling down his face. He also reunites with his mother. This is a transformative and most humbling documentary, a remarkable story that demonstrates the healing capacity of mammals to overcome human cruelty.
My review could end here. Yet, as an attachment based psychotherapist, I am left feeling slightly curious: why did Morad so adamantly refuse to see his mother and why did it take him so long to recover, for someone who didn’t seem to have a history of vulnerability with respect to his attachment style?
The film is a humanitarian one and its emphasis is on the power of human and animal love. In an interview the director was reluctant to give the film any political message that this was about an Arab boy who erases his Arab identity in Israeli society. Yonatan Nir said: ‘regardless of one’s culture, we perceive this as a person who escaped trauma and his change of identity is part of the escape. This can happen to a rape victim from a kibbutz or a child that was sexually abused in an orthodox community (2011)’.
We know dissociative amnesia is all too helpful for such an escape. In his conceptualisation of the self, John Bowlby saw the impact of external events on relationships as crucially important to our understanding of our own sense of self-worth: ‘During the earliest years of our lives, indeed, emotional expression and it’s reception are the only means of communications we have, so that the foundations of our working models of self and attachment figure are perforce laid using information from that source alone.’(Bowlby, p.157) We don’t know much about Morad’s early life or his relationship with his mother. We see her mainly in the background, a religious woman looking sad and excluded from the dominant male bonds in her family. We don’t know much about the family’s status in the village and their blood relations. We are told that his attack did not involve any sexual trauma.
The cultural context and recognition of some important cultural and political issues seemed glossed over. As someone who grew up in the Middle East, I think the importance of issues around shame has been greatly overlooked. ‘Shame can be defined as the feeling we have when we evaluate our actions, feelings or behaviour and conclude that we have done wrong. It encompasses the whole of ourselves; it generates a wish to hide, to disappear or even to die’ (Lewis, 1992, p.2). ‘One of the causes of shame is the recognition of the self’s failure to conform to social norms and expectations.’ (M. Dorahy, 2013). Shame and honour are usually associated with something greater than the individual. Honour shaming is almost always placed on a group. This can be the immediate family, the extended tribe or in some cases, it can be as large as an entire nation. The fear of shame in Arab culture is so powerful because the identification between the individual and the group is far greater than in the west. The importance of the group weighs heavier than the importance of any individual. If an individual is in a position of shame, he then loses his influence and power; similarly his entire group will suffer.
Wilson et al (2006) argue that ‘States of post traumatic shame and guilt form the pathological nucleus of simple and complex PTSD’, p.124. Could it be that Morad’s deeply rooted fear of honour shaming his family might have played a major role in his dissociative amnesia? - Recovery was possible only where the spacious desert and the deep sea could facilitate the distance he needed from his village and where dolphins could reach and touch him without any prejudice or prior judgement to him.
To find out more, please join me, Dr. Ilan Kutz and Andrew Moskowitz for a screening of “Dolphin Boy” followed by a discussion at the ESTD bi-annual conference in Copenhagen 2014.
Bowlby J., A Secure Base, Routledge,1998
De Hooge I.E, Zeelenberg M.B., Reugelmans S.M.2010 Dorahy M. (2013)
Lewis M. (1992) Shame: The exposed self. NY, Free Press.
Wilson J.P., Drozdek.B., Turkovic,S.2006. Post traumatic Shame & guilt. Trauma, violence & abuse, 7.122-141.