Book and film reviews - 2016

 

Emilia 
By Na’ama Yehuda, 2016

First Edition USA

 

Book reviewed by Valerie Sinason

From ESTD Newsletter Volume 5, Number 4, December 2016

Na’ama Yehuda is an internationally known speech language pathologist with a deep understanding of dissociative disorders. As well as lecturing and writing within the professional field (Communicating trauma: clinical presentations and interventions with traumatised children ,Routledge 2016) Na’ama also writes for children and adults.

It is complex task for a professional who has mastered the subtleties of narrative in one domain to try and translate it to a literary one. A poem, play or novel can influence and move more people than many peer-reviewed papers. Thomas Hood’s “The Song of the Shirt” and Charles Kingsley’s “Water babies” are just two examples from the UK that helped change conditions for seamstresses and child chimney sweeps respectively. However, such attempts can also fail through having too strong an educational aim. Soap operas receive negative reviews when an obvious burning social issue becomes too obviously flagged up.

Na’ama has achieved a truly substantial and moving success in that her book is both a gripping page-turner of a thriller and a detective story on the literary level , whilst showing in parallel the complex detective story of how trauma impacts on mind and body and how to heal it. We are educated through our involvement with the story.

A small child Emilia, who has lost her family through illhealth, is seized by a predator Mr C. KayAnne, her new tutor finds her in danger and runs away with her to a literal and symbolic lighthouse where the elderly wise custodian, Marion and other good men and women provide healing for both of them. KayAnne is a wounded healer and Na’ama subtly shows us how inevitable this is. The tiny child, with good native intelligence and who was once loved, is aided by a horse, a dog, a wounded bird and a doll as well as good honourable men and women. It takes a village to destroy a child and a village to offer the chance for healing.

There is no idealised concept of recovery. Emilia has faced death and has physical and mental scars. There is a long way to go. KayAnne is still injured and is not equipped to provide sole care of Emilia. The Light house Keeper has all the understanding but is very old, 85, and aware of mortality. However, in not underestimating how much it takes of a total environment to provide help Na’ama shows us what is needed for the child who receives none of this. With a light but serious touch we are shown only too clearly how easy it would be for police, lawyers and doctors to unintentionally cause more damage.

There is nothing gratuitous here. The fact that the shock sight of Emilia in her actual moment of trauma that was witnessed by KayAnne is just a few lines long makes the narrative even more painful. The wince or wariness of a child described so clearly allows the reader to understand in their own way the cruelties she was subjected to. Emilia does not burst into happy songs and cuddles. She is silent, withdrawn, wary, and it is animals and birds that awaken in her flashes of a capacity to nurture them and through them her own hurt self. The fact that KayAnne cannot attune in the way Marion does allows us to see how delicate the task of attunement is. On the other hand we see a successful couple where a former victim aided by Marion is now an adult with a loving husband.

Marion is the wise crone in whose loving and sharp company we journey through this book. Like an experienced therapist and supervisor she aids all of us to recognise the nature of the pain in Emilia, how it shows itself, how to respond to it and the depths of it. Reading her words is a supervision made all the more moving for the fact that this is a novel.

Na’ama understands how to express something in words children can understand and I look forward to reading her new work.

 

Instrumental
James Rhodes Canongate Books, 2015

 

Book reviewed by Julia Bueno

From ESTD Newsletter Volume 5, Number 4, December 2016

‘I was used, fucked, broken, toyed with and violated from the age of six. Over and over for years and years. And here’s how it happened.’

So begins an autobiography, a love story about music and a son, and a polemic about the classical music industry. It’s so viscerally, and at times, brutally honest in confronting abhorrent facts, that I struggled to read parts of it, even though I’ve read and heard many painful stories of abuse. James Rhodes’ Instrumental nearly didn’t make it to our shelves, as his ex-wife sought to protect their son from it’s raw details with an injunction. It doesn’t surprise me that he successfully overturned the Court of Appeal though – he has an indomitable life force best experienced on hearing his awesome piano playing. However, the paradox remains that he has spent years coping with his anguish with various forms of self-annihilation. ‘Sadly I’m only ever two bad weeks away from a locked ward.’

Rhodes throws us in the deep and very dark end. His story begins with him aged five, beautiful and shy, at a prep school in a well-heeled area of North London. He becomes a favourite of Mr Lee, the gym teacher, who grooms him and repeatedly rapes him until he leaves that school aged ten, a shadow of his former carefree self. ‘You want to know how to rip all the child out of a child? Fuck him’. Rhodes is unsparing in his language throughout, and at no point does it feel unnecessary to use the words that he does. Seemingly only one other teacher suspects something when she finds tiny Rhodes in tears with blood running down his legs (or at least is the only one who has gone on the record since), but her alarm is dismissed by colleagues. And appallingly, years later, no alarm is raised by medical staff when Rhodes has the first of three operations on his spine - shattered by the rapes.

Rhodes copes in the best way humans can - becoming the ‘automaton version’ of himself, riddled with shame (‘Shame is the legacy of all abuse. It is the one thing guaranteed to keep us in the dark, and it is the one thing vital to understand if you want to get why abuse victims are so fucked up’), tics and behavioural rituals, auditory and visual hallucinations, promiscuity, and at least a year of drink and drugs. He doesn’t dwell much on these, clearly desperate to focus on his path to far better health, and to avoid being defined by his suffering. Denial it may be, but the book is set out to be far more than one about his lived-experience of suffering. The author’s self-awareness is acute throughout, perhaps as a result of all the psychological work he has done and obvious intelligence, but it allows for excruciating insight into the psychic realms he has been to, and can go to. This is particularly so when later on in adulthood, with few details spared, he turns to the temporary high of self-harm. We get to learn, very close up, how he needs to feel, although clearly terrified at this stage, to approach what really needs to be felt. Another saviour is his all-encompassing love for his son Jack, whose very presence in his mind pulls Rhodes away from suicide more than once. Unsurprisingly though, Jack approaching five years old triggers another period of disintegration and hospitalisation.

Rhodes refers to early experiences of dissociation, but doesn’t dwell. These began as a tiny child in the gym: ‘So I leave my body, floating out of it and up to the ceiling where I watch myself until it becomes too much even from there, and then I fly out the room, straight through the closed doors and off to safety. It was an inexplicably brilliant feeling’. He alludes to continuing lapses in concentration and ‘loss of time’ states (although never when having to learn thousands of notes for his piano recitals), but again, he doesn’t linger on these much and partly copes via others’ understanding of these lapses.

There is a mention of a number of diagnoses he’s received throughout the years – including PTSD, autism, ADHD and …dissociative identity disorder, where I have a number (thirteen if you are curious) of ‘alters’ who, depending on the situation, take turns to run the show… all share one common goal – to survive no matter what. We don’t hear more about how it is to live with these alters – I quote the only reference in the book that I found – nor indeed much detail about his therapeutic care and treatments, apart from a miserable episode on medications following his first breakdown, and a brilliant psychiatrist he meets in later years. Their warm and trusting relationship clearly contributes to healing.

We repeatedly experience a see-sawing between explicit descriptions of despair and anguish, and a steely will to become the best person he can be, which always seems to involve self-recrimination. He powerfully conveys the tormenting nature of his mind that can dismantle and scramble good things said and done to him, leaving him powerless to trust in another, yet simultaneously he kicks himself for self-indulgence and selfishness and for wrecking his first marriage, and other relationships. He always returns to music, which held his hand tightly throughout the years of hell, and organises his mind in a way other relationships can struggle to. People can always let him down, but Bach won’t. Rhodes’ stated ways of coping show us how brilliantly resourceful human beings can be, even if we may interpret them as defences.

It’s at a recovery centre in Phoenix that recovery begins in earnest. There, reluctantly at first, Rhodes begins to confront his past and turn toward some terrifying feelings. He struggles with being vulnerable and this leaks out in his slightly dismissive (yet also respectful) explanation of some therapeutic exercises he eventually engages in. Later on, he describes the next leap in his recovery when his manager and dear friend gives him two books – Waking the Tiger and Homecoming. Openly embarrassed at being helped by these books (viewing self-help books as toe-curling), he is also honest in describing how much they help him to make further sense of his past, and to integrate it in his present. He learns how his body stores trauma, which in itself, needs attending to: ‘The most helpful thing I learned was to experience painful, shameful feelings but to drop any kind of storyline attached to them… I would just see where in the body they were gathered (invariably in the heart or stomach), watch them, experience the pain, sit with it. And I promise you when you do that, all starts to heal.’

Ultimately, Rhodes is keener to emphasise the healing power of music above any other intervention he’s had, along with the loyalty and love of certain people. A talented pianist as a child, he picked it up again properly in his mid-20s after a brief money-making career in the City and a decade away from a piano. Music has saved him more than once and I’d urge you to hear him play to understand how. He describes in fascinating detail how certain composers grabbed him and took him to pleasure over pain - the Bach-Busoni Chaconne as a very young child and, much later, the Bach-Marcello Adagio, which is smuggled in to him on a locked ward by a very wise friend. Other powerful pieces accompany the book as a playlist that Rhodes put on Spotify for us – including Bach’s Goldberg Variations, Shostakovich Piano Concerto No. 2, Chopin’s Fantasie in F minor, Op 49.

Each piece links to a chapter, making the writing even more impactful, if that were at all possible. Rhodes also gives us a potted biography of each great composer – he clearly empathises with their difficult lives and ruptured relationships and wants us to contextualise their creations. In the same way, I think he wants us to focus more on his piano playing with an awareness of his past – rather than focusing on him as a survivor of abuse who is a talented pianist… ’if living life is the equivalent of running a marathon, then sexual abuse in childhood has the net effect of removing one of your legs and adding a backpack of bricks on the starting line.’

 

The Trinity of Trauma: Ignorance, Fragility, and Control. The Evolving Concept of Trauma /The Concept and Facts of Dissociation in Trauma.

By Nijenhuis, E. (2015)

 

Book reviewed by Adah Sachs

From ESTD Newsletter Volume 5, Number 4, December 2016

This book is, arguably, the most comprehensively argued book on trauma and dissociation currently in existence. It consists of two parts; volume 2, which includes part 3, will appear in December 2016.

It is not an ordinary volume: to start with, it is 635 pages long, which requires a serious commitment from the reader. It is also somewhat daunting in its frequent use of long words, long sentences, slightly confusing expressions and unfamiliar acronyms. But it did not take me long to overcome these hurdles, and settle into an extremely interesting read.

The book is almost encyclopaedic in the number of angles from which trauma and dissociation are considered, and the depth with which each of these angles is explored. With the breadth of a real ‘renaissance man’ and the rigour of an expert, Nijenhuis deconstructs the concepts and definitions of dissociation, trauma, identity, personality and self. He examines them through their historical context; as philosophical concepts; in their various linguistic meanings; regarding their scientific substantiation and their clinical usefulness. Stating that the trauma is biopsychosocial (one of the aforementioned long words), Nijenhuis examines these concepts not only from a psychological perspective, but also for their sociological significance, and the role that the body (including the brain) has in our sense of self, personality, identity, trauma and dissociation.

But the encyclopaedic breadth of the book does not make it an encyclopaedia of trauma and dissociation. An encyclopaedia is impersonal and offers no point of view. This book is entirely personal, and offers us Nijenhuis’s definitive thoughts and views on, it seems, every single question that he has been grappling with in this field. The deliberations are presented in full details, the definitions are made meticulously and are well argued (including the ones I disagree with), and the conclusions are most certainly relevant to clinical observations and practice. As well as a comprehensive analysis of the field to date, Nijenhuis also offers a fresh formulation of dissociation of the personality, which highlights the relationships between the ANP,(who is ignorant of trauma, in at least some important aspects), a group of fragile (victim) EPs and a group of controlling (aggressive, dismissive) EPs. This relationship, we are shown, can be found internally (in the structure of DID); but it also exists outside of the patient. It can be seen in ANperpetrator(s), who have perfectly ordinary aspects of their lives and personality, which are dissociatively separated from their controlling (abusive) or fragile (hurt) parts. This dynamic is further seen in the social structure of abusive groups (including families), and in society as a whole. This formulation is particularly interesting, because it encompasses the internal (psychological) and the external (societal) realities, as they meet in the physical (bodily) reality of the abused person.

Although I found some sections of this massive volume rather impenetrable, the book as a whole makes for a very satisfying, thought-provoking and inspiring read. An important addition to any trauma-thinker’s bookshelf.

 

White witch in a black robe : a true story about criminal mind control

By Wendy Hoffman 

 

Book reviewed by Sandra Buck

From ESTD Newsletter Volume 5, Number 3, September 2016

I read Wendy’s first memoir, The Enslaved Queen before reading this. I felt I needed to know about her life before she came to write the second memoir. I am in awe of the strength it took to write this account of her life, dominated by such deeply seated mind control. This is not comfortable reading, but those of us who have survived this far in the field of trauma should be able to handle it, and learn a lot.

 

As Neil Brick wrote in his endorsement on the cover, “Most people don’t reach this level of recovery.” This continuation of Wendy’s story has the same authenticity as her first memoir, highlighting what life is really like for children and adults undergoing this lifelong torture. I still carry with me the portrait of an older boy who looked out for Wendy, and showed her love and care for as long as she knew him. He didn’t survive, and he knew his time was limited. Nobody else ever treated her kindly. He had a significant impact on her life.

Wendy’s story reminded me of when I was a volunteer on a helpline for parents under stress, 30 years ago. I could not understand the mother who told me she had to leave her baby/toddler in his cot all day and not go to him when he cried. Now, in addition to the other things this woman told me, it makes it very likely that her family was involved in this criminal mind control.

Many families in Wendy’s community were involved and the mind-controlling abuse was multi-generational. In the first memoir I was horrified to learn that Mengele visited regularly, to continue the kind of experimentation that he had begun in Germany before and during the war. I was shocked by so much. The regular ‘mind control’ sessions were a part of Wendy’s weekly routine, like homework or piano lessons. The horrific intensity of deliberately planned mind control programming comes over very strongly. Some survivors in this country will have been controlled in the same way as Wendy. She was trained to the level where she was considered a prophet with psychic skills, and she was required to travel to different countries, to secret meetings, including the UK. This involved connecting with well-known people, those who had power and influence.

Wendy exposes the barbarity and cold-hearted way her entire life, up till the age of seventy, was callously controlled and manipulated by others. I also see her strong sense of purpose and outrage,

 

which reaches back to the start of her life. She was 43 years old when she started getting her first flashbacks, but it wasn’t until she met her last therapist, Alison Miller, that she was able to discover that she was still being influenced by the mind control. Wendy writes in a way that makes you feel you are almost ‘watching’ parts of her therapy sessions. Alison asks questions that Wendy has never considered before. It is wonderfully encouraging to see the way in which her journey of enlightenment culminated in her mosaic part-selves all finding their places back home with her, giving hope to other survivors.

The book is divided into 4 parts.

Part 1

Streams of consciousness: This details the development of the mind control over the years. It travels through many mind control events. There is ‘act and don’t remember’ and ‘don’t get noticed’. Wendy describes the abusers deliberately provoking anger in her as a child, in order to channel it in another direction. The use of ‘close down’ programming, ensures that none of the training is remembered. All of the mind control programming involved lies, drugs, torture, and electric shock. Even when Wendy was an adult, the power of these methods lay in the age of the child parts brought out for further training, who developmentally responded as young children.

Part 2

White Witch in a black robe: This section is about the last set of memories to return to Wendy, about how she was trained as a prophet to be used in different countries. The methods used to close down her memories of these trips and conscious knowledge are hard to read about, as are the contacts with powerful people.

Part 3

The final sorrow: This covers Wendy’s contact with her son and his family, and her realization that a part of her had been in contact with her ‘minders’ until 2013. There was ten months of therapy with Alison before this all came out.

Part 4

Co-consciousness and integration: It is amazing when the fragments of memories begin linking together. This starts from Alison’s questions, but the work is actually done by Wendy, because she is willing to face what she needs to. For co-consciousness to occur, she needed to return to a memory of when she was three years old.

I recommend this book on two levels. Firstly it is a lived account of what is like to be a child, then an adult, with this level of mind control. But it is also a window into a therapist’s ability to enter and understand the internal landscape of mind controlled child parts, so that co-consciousness becomes possible. It gives hope, and we all need that to be involved in this field of work.

 

Intensive psychotherapy for persistant dissociative processes : the fear of feeling real

By Chefetz, R.A. 2015

New York: Norton

 

Book reviewed by Kate Forbes-Pitt

From ESTD Newsletter Volume 5, Number 3, September 2016

Richard Chefetz has written an accessible book that conveys a considerable array of knowledge. Whether laying out verbatim vignettes, neuroscience, or positioning his work within the plains of psychoanalytic theory, his style is engaging and it is a pleasure to read. He sees this book as about hope: “I’m hopeful that reading this book will generate resilient hope for people who have minds too governed by persistent dissociative processes … that hobble the growth of a child and distort the metamorphosis into conscious adulthood.” (viii) This quote highlights two important facets of the book. First, that it is written for both clients and clinicians, which is important to understand when reading it, and second, Chefetz’s basic theoretical commitment about the origins, importance and results of dissociative processes.

The book can be very roughly divided into three parts; not a strong delineation, but present as an underlying narrative. Initially, Chefetz ‘sets out his stall’, locating his contribution and reviewing theories of dissociation against those historically dominant in psychoanalysis. This is not a literature review; he prefers to bring forward underlying theory as he needs it. Unsurprisingly, the body of theory underlying Chefetz’s contentions is consistent with other major books on dissociation.

Occasionally US/European cultural differences are apparent. Boundary issues over writing prescriptions, for example, will be less prevalent in the less medicalised European practice model and Chefetz’s own history as a medical practitioner will not be as common this side of ‘the pond’.

Chapter 2—Life as Performance Art, which looks at enactment and neuroscience—introduces the powerful thread of coherence. As the book weaves theoretical and clinical together, we meet Alice, William/Will, Samantha, Robert, John, Anya, Rachel and Marla. Their stories are not confined to small vignettes, but are put to work throughout the book, illustrating the subjective processes on which Chefetz focuses. Theory is supported by these cases and also works to unpack them; these two aspects are inseparable in the writing, affirming his dynamic approach. This style may appeal to some and not others, but it stands robustly alongside Chefetz’s call to authentic—not counterfeit—coherence.

Having situated both theories of dissociation and his own thoughts, Chefetz goes on to offer practical advice, first in the recognition of self-states and then in opening treatment. Here you might expect a caveat that in initial treatment self-states may not be visible. Chefetz, however, sees self-states in everyone—including clinicians—and the issue as one of their integration or otherwise, so the caveat does not apply. “Self states”, writes Chefetz, “are ubiquitous and normal.” (81)

Chapter 3—‘Recognizing Dissociative Experience and Self-States’—orients the reader towards practice. The kind of intense observation in session called for will not be unfamiliar to readers from a more transference-focused modality, but it is different and yields different results. Chefetz is clear that such observation cannot be accomplished sitting behind a couch. He asserts that both PTSD and ADHD are dissociative at root, providing statistics that strengthen this anecdotal clinical experience.

Chefetz doesn’t shy away from theory, reviewing competing ideas of the formation of self-states, from multiple-blow models of dissociative outcome (Kluft) to Putnam’s normative and naturalistic evolution of discrete behavioural states which, he says, uses the ‘cognitive behavioural aspect’ of attachment theory. Preferring to think of ‘splitting’ as ‘unintegrated experience’, he cites Main and Hesse, among others, in an extensive review of Type D attachment and its consequences. Mentioning Lyons-Ruth—“The best predictor of adult dissociation is emotionally unresponsive parenting.” (91)—he leaves little doubt as to his own perspective.

Chapter 4—‘Opening a Treatment for Persistent Dissociative Processes’—is less of a ‘how to’ than the title implies. Chefetz doesn’t want the dissociative client sent away to a ‘specialist’, but the clinician to recognise dissociative processes and attune to the patient’s subjective experiences. Samantha introduces the numbing of intra-subjective experience and highlights depersonalisation and discontinuity. She also provides examples of dissociative experience: how it is described, what people say it feels like, and how people write about it.

It is in this chapter that Chefetz highlights an undercurrent of the book: “… it is most important to appreciate a focus on dissociative process rather than dissociative disorders.” (129) This aligns with his consistent focus on experience and process rather than self and identity. This is not explicit, but he does focus on dynamic process ‘in-the-moment’ with clients and the experience of experience. While keeping mind central, he does not emphasize either self/selves or identity/identities arising from it. In other words, his focus is metaphysical rather than ontological; he does not seek taxonomy—to name ‘things’ or define ‘structures’ for dissociation—he seeks to identify and attune to individual, subjective experience of dissociative processes. He sees dynamic epistemological subjective experience rather than ontological states. Something that is also apparent in the definitions he offers for affect, emotion and feeling in Chapter 5.

Returning to the book’s loose sections, from Chapter 6—Fear and Depersonalization—there is more focus on manifestation and what might be seen as causes of dissociative processes. Appropriately, Chefetz returns to attachment. In a reversal of more traditional thinking, fear is primary to aggression in attachment (Slade, 2008). Chapter 7 concerns the relationship between incest, sexual addiction and dissociation, perhaps a link of cause and manifestation. Anya’s words bring to life difficulties of incest, and Chefetz unpicks these using the sensual-sexual axis. Once again he rigorously applies terms to lived, felt experience rather than as taxonomy. In keeping with his focus, Anya has the final say in this chapter: “… there is so much sadness inside of me. So much.” (256)

Following the republication of the well-known paper ‘Waking the Dead Therapist’ (Chefetz, 2009) as chapter 8, chapter 9 turns to negative experiences in and of therapy. “The capacity to oppose”, says Chefetz, “is a sign of growing agency” (281) adding that “[b]ecoming an agent of destruction is better than having no agency at all.” (286). He discusses negativity in a dissociative context, fleshing out the agent of destruction in relation to early reactions to the perpetrator(s) of abuse under the subtitle ‘attackment relationship’ (287). This chapter contains much about countertransference and he honestly outlines his own countertransferential difficulties with Rachel resulting from his abandonment. It is perhaps such honesty, and humility, that represents some of the most helpful literature for clinicians, especially when beginning or approaching something new.

Chapter 10 discusses his coercive relationship with Alice. Once again we come across hypnosis, which Chefetz uses in his practice. Dissociative clients are susceptible to hypnosis, as he highlights, and readers will have their own ‘take’ on its utility; its use and results are honestly reflected in this book.

Enactment is chapter 11’s focus, which highlights objective and subjective countertransference, the latter bringing “… to life in the clinician what is idiosyncratic in their own psychology.” (350) The book has subtly and gradually moved from discussing dynamic process and experience within the client, of which the clinician can be subjectively and inter-subjectively aware, to discussing dynamic processes within the clinician in response to, and in transference with, the subjective self-states within the patient’s system. It is a gradual move, carrying the reader on easy prose to more difficult places.

It is a long time since I read a book cover-to-cover rather than dipping into the section I want or need before returning it to the shelf. I applaud the attempt to create a book accessible to all, but wonder what the jargon of psychoanalysis would mean to me if I hadn’t already known psychoanalytic theory. I would have liked a more rounded conclusion that draws together the many threads that Chefetz elegantly weaves, but leaves hanging. Perhaps, however, it is appropriate to leave the reader with uncertainty, holding the unknown, and with an incomplete experience.

I enjoyed reading this book, it made me think and it fed directly, immediately and effectively into my practice. For these reasons I highly recommend it.

 

In pursuit of the truth : a life in the met

By Detective Chief Inspector Clive Driscoll

Published by Ebury Press, 2015

 

Book reviewed by Nancy Borret

From ESTD Newsletter Volume 5, Number 2, June 2016

At first glance, the autobiographical memoir of a former Detective Chief Inspector of Police may seem an unlikely choice for an ESTD journal book review. This is, however, a hugely important book for survivors of organised abuse and their supporters. Among other things, Clive Driscoll writes openly and courageously about his personal experience of working in the London Borough of Lambeth in the 1990s, investigating events which have come to form part of the UK’s current high-profile child sexual abuse enquiry.

Most famous for securing convictions in London’s notorious Stephen Lawrence murder, nineteen years after it happened, Driscoll is renowned for persevering with the kinds of crimes that have defeated his colleagues and seemed impossible to solve. Organised abuse fits neatly into this category, alongside so-called ‘honour killings’, an example of which also features in the book. Each of these involve extreme violence and terror, complex relationships, loyalties (either familial, belief-based, or both), and perpetrators seemingly protected by powerful networks.

Driscoll embodies the qualities we all hope and long for in a policeman; an open mind, the courage to value the truth above his career progression or personal need for approval and, most of all, bags of compassion and empathy.

His book combines a degree of personal disclosure with a forthright portrayal of life within the London Metropolitan Police force. The theme of trauma weaves in and out of the narrative in various ways, both personal and professional. Driscoll’s own father – a traumatised war veteran –- left the family home shortly after his birth. With his maternal grandfather and 1960s benevolent TV police character ‘Dixon of Dock Green’ as male role models, Driscoll treads a path of unassuming integrity and courage, identifying strongly with the most honourable of traditionally paternal qualities.

With an interest in finding creative ways of connecting with all kinds of people, Driscoll describes spending his limited spare time playing piano for groups of learning disabled youngsters, as well as arranging football matches between inner city youths and teams from the Met as part of the Community Engagement Programme. He still runs a team called ‘The Metropolitan Police’, made up of young Londoners “from communities where the Met aren’t exactly regarded as friends”, and has spent a lifetime championing many of the most vulnerable groups of people in British society.

Driscoll’s work in Lambeth, and later as police liaison for the Clinic for Dissociative Studies in London, have brought him directly in contact with some of the challenges of working with dissociation and multiplicity , just as issues of serious crime so shockingly confront therapists and others working with survivors of organised abuse.

When hearing extraordinary and deeply disturbing allegations, like a good trauma worker, Driscoll does not leap to assumptions, but rather retains a respectful and neutral stance, and holds the maintenance of trust, listening, and a close working relationship at the centre of all he does. He seems able to sit with ‘not knowing’, as we all strive to do. Crucially, he does not dismiss things as impossible simply because they seem emotionally overwhelming or unimaginable.

Driscoll describes how a combination of disbelief and seeming corruption in some investigations led to a dismissal of survivors’ testimonies:

“....it was easier to dismiss (her) claims as madness, rather than investigate such a taboo subject.”.

Though this kind of response to hearing about extreme abuse will not come as a surprise to most of us, I personally found it validating, though at times hugely frustrating, to hear some of the challenges from a police perspective. Driscoll’s warmth and honesty shine throughout. He offers hope too:

“...the truth is out there – and getting nearer. If and when it does come out, it could cause the greatest shake-up of our country since Cromwell.”.

Perhaps surprisingly and despite sometimes feeling deeply disillusioned and betrayed by members of his own force, Driscoll has been able to hold on to a strong faith in the core principles of police work. He is, however, open about the personal impact of such relentless and gruelling service, and his own secondary traumatisation, describing ongoing symptoms of PTSD as a result of trauma witnessed and experienced over the course of his career.

This book is a stark reminder of the highly traumatic nature of so much of the work of the uniformed services, as they grapple with the darkest facets of society, in order that the rest of us can remain oblivious, ANP- style.

This is a gripping page-turner of a book with a straightforward and conversational writing style. Down- to- earth and full of affect-regulatory humour, it describes some dark and disturbing experiences in a refreshingly readable way.

This book is a heartening read and also an accessible way of sharing information about some of the UK’s most disturbing, yet least understood crimes.

Driscoll’s ongoing private investigative work is shared amongst his three favourite charities, one of which is the Paracelsus Trust, supporting traumatised survivors of extreme and organised abuse.

 

The dissociative mind in psychoanalysis : understanding and working with trauma.

By Elizabeth Howell & Sheldon Itzkowitz (Eds).

London, Routledge

 

Book reviewed by Nelleke Nicolai

From ESTD Newsletter Volume 5, Number 2, June 2016

It is no secret that between psycho-analysis and trauma theory, a big rift exists. This rift makes it difficult to treat trauma patients in psychoanalysis. Concepts such as repression do not work with patients whose inner world is a turmoil of anxiety and unbearable affects.

In my own training during the eighties as a psychoanalyst, I learnt that a real trauma was a contraindication for psychoanalysis. Psychoanalysis was for the treatment of neuroses and their concomitant unconscious fantasies, and not for the consequences of real events, be it from exposure to war, sexual violence, or for the second generation survivors of the Holocaust. Still, psychoanalytic theory has a lot to offer us; in working with traumatised patients, in the form of concepts such as transference, countertransference, and techniques to understand and contain unconscious affects such as unbearable anxiety, shame, and guilt.

This rift was in part due to Freud’s abandonment of his trauma/affect theory in favour of the role of sexual phases, fantasies, and the concept of repression. It is also due – at least according to this wonderful book – to the dissociation in the psychoanalytic world of the incidence and prevalence of real trauma.

When dissociative disorders became known in the Netherlands, at the end of the eighties, we were at a loss in mainstream psychoanalysis. Personally, I can remember that my teachers were very much against the concept of dissociation. They called it a deviation –even a defection – from the “real” theory. They claimed they had never come across a patient with multiple personalities. And so I kept my mouth shut about my own dissociative patients who did not seem to exist in my teachers’ eyes.

Luckily, in those days, a new intersubjective and relational way of thinking gained importance in psychoanalysis, thanks to the work of Ira Brenner, Donnel Stern, Jessica Benjamin, Elizabeth Howell, and Philip Bromberg, among others. They treated patients with dissociative disorders; they wrote about them and even tried to theorise about them within the confines of psychoanalytic theory. They

 

used the theories of Ferenzci and Fairbairn on splitting of self-states. They were influenced by new empirical investigations of the mind by Allan Schore and other developmental research. Attachment theory, for example, has done much to open our eyes to the devastating influence of developmental trauma on attachment status. Bromberg, for example, has substituted the psychoanalytic idea of psychic structures such as the Ego, Id, and Superego by a concept of multiple self-states. He was not the first to use that concept: it inherits its use from the interpersonal theories of Harry Stack Sullivan, but he is one of the first to use it to describe dissociative states in psychoanalytic practice. According to him, we have all have multiple self-states. The mind is a divided unity par excellence. Our Self is an illusion, although our memory enables us to sense ourselves as a whole, coherent in time and space. The difference with dissociative patients is that they cannot integrate these different self-states into a coherent autobiographical narrative, because of amnesia and phobia of emotions.

The dissociative mind in psychoanalysis is a landmark in the growing synthesis between psychoanalysis and trauma theory. Elizabeth Howell (who wrote several important and much awarded books about the dissociative mind) and Sheldon Itzkowitz, composed a wonderful volume, brimming with interesting yet contradictory information.

The book consists of four parts. In the first part, the authors treat the history of complex trauma and dissociative problems in daily life In this part, most chapters are written by Howell and Itzkozwitz, who provide a thorough review of the history of psychoanalysis. The main theme is expressed by the questions: Can one treat a traumatised person with psychoanalysis? What are psychoanalytic “facts”? Is it possible to treat somebody’s external experiences with methods derived from a restriction to an internal world of unconscious fantasies and drive derivatives? And to add to these questions: do we unknowingly contribute to an iatrogenic disavowal of the consequences of trauma, if we stay on that track?

The history of psychoanalysis is described in Chapter two. Trauma is defined in the next chapter, followed by a very informative chapter about Janet’s lesser-known work by Onno van der Hart, an internationally renowned expert on Janet and dissociative disorders.

At first, Breuer and Freud understood dissociation as an underlying cause of hysteria. They wrote about “double conscience” and hypnoid states. Howell and Itzkowitz call this phase in psychoanalysis, conforming to the use in mainstream psychoanalysis, the “pre-analytic phase”. I have always understood it as the “trauma/affect” phase, partly relinquished, but every decade discovered anew, as practitioners had to deal with exogamous traumatic realities of war, persecution, rape, incest, and abuse. So even if officially, trauma played no part in mainstream theory, in clinical practice, psychoanalysts have always treated patients with traumatic histories. The trauma/affect model emerged again, notably after the Second World War. Even at the height of the drive model, Sidney Furst, Anna Freud, and Phyllis Greenacre wrote about incest and abuse. In the nineties, Bennet Simon and Rachel Blass wrote their beautiful series of articles about the errors made in psychoanalysis and, doing so, paved the way to a reform in psychoanalysis.

Chapter five by Margaret Hainer is a very interesting discussion of the way the work of Sandor Ferenczi was disavowed and repressed in psychoanalysis. The author states that Ferenzci, bases on his experience with traumatised adults, puts the concept of dissociation anew to the fore in his idea of “a quasi-hallucinatory form... a trance state... We might say that analysis is not legitimate, to suggest or hypnotize things into the patient, but is not only right, but advisably, to suggest them out.” (p. 134) Already in 1931, he described the splitting of “the self in a suffering, brutally destroyed part and a part that knows everything, but feels nothing. .... [This] is the genesis of the narcissistic split of the self...under the stress of imminent danger part of the self splits off and becomes a psychic instance self-observing and desiring to help the self, and that possibly this happens in early − even in earliest childhood”. (In Child Analysis in the Analysis of Adults, 1931, p.135-136.) As we know, his most famous article is: The confusion of tongues between Adults and Child: the language of tenderness and passion, already presented and written in 1932, but translated and published only in 1949. He read his notes to Freud, who strongly objected to his paper and tried to convince Ferenczi to withhold it. Some authors wonder if Freud objected to Ferenczi’s theory or to his practice of mutual analysis and active techniques, or rather to Ferenczi’s criticism of the Death instinct, a concept that Freud insisted on very much at the time. Ferenczi presented this paper at the International Psychoanalytic Congress in Wiesbaden and was met by a stony silence. However, his contributions have been reconsidered since then and today, “The confusion of tongues” belongs to the most cited and valued papers in psychoanalysis: an indispensable part of the psychoanalytical training nowadays.

The second party of the book is devoted to the discussion of the concepts of dissociation and trauma from the perspective of the major schools of psychoanalytic thought. These are respectively Jungian, Kleinian, Self-psychology, Winnicottian, and Interpersonal-relational (Bromberg). And last but not least, a cross-cultural perspective on the syndrome of Latah. Latah is a Malaysian/Indonesian syndrome consisting of the startle reaction and concomitant behaviour of shouting of obscene words, undressing, and showing obscene behaviour, common in elderly women of lower social status.

Part two is interesting because it becomes clear that many psychoanalytic ideas do not fit with what we call dissociative phenomena. The languages diverge. The author of the chapter on Klein for example, Joseph Newirth, describes the dual nature of Kleinian theory. First the interpersonal dimension as driven by power and aggression, and the structure of relationships, and then the cognitive dimension: from concrete thoughts to symbolic thinking. Traumatized patients are often stuck in concrete thinking, not being able to reflect on their own thoughts and feelings. So part of Kleinian theory is usable and seems to describe phenomena we can apply in our understanding. However, Kleinian theory is not engaged with external events, but with the role of internal unconscious phantasies, projected on the other and reintrojected as persecutory by the infant, due to innate aggression and anxiety. There is not much room in the theory for external events. Moreover, Newirth’s use of the concept of dissociation does not correspond to the use of dissociation in the first chapters by Howell and Itzkowitz.

It seems that every school has its own idea of what is dissociated (or split off or non-thinkable, unformulated experience, or Beta elements), but no agreements exists regarding what dissociation and the dissociative mind really are, except in the chapters by writers who self-evidently have experience in treating adults with dissociative disorders. Split-off feelings are not the same as being haunted by amnesia, fugue-like states or indescribable feelings of terror.

This is also the case in a chapter on Self psychology and Jungian Analysis. According to Jung dissociated parts of personal experience have a universal tendency to image themselves in dreams and other fantasies as coherent animate presences he called complexes. I doubt if complexes as described as such, really are understandable as forms of dissociative entities as we define it now in structural dissociation theoretical terms.

An interesting chapter from Dodi Goldman describes the finding of unpublished notes on dissociation among Winncott’s papers, discovered by Jan Abram in 2012. Winnicott planned to present these thoughts to an International Psychoanalysis (IPA) conference in 1971, but he died before the event took place. Winnicott had proposed a revolution in psychoanalysis. He understood dissociation as being different from repressed or split-off parts as we can see in this quote: ‘It may be that in dealing with the repressed unconscious, we are colluding with the patient and the established defences. What is needed of us, because the patient cannot do the work of analysis by self-analysis; someone must see and witness the parts that go to make the whole, a whole that does not exist except as viewed from outside. In time we may have to come to the common failure of many excellent analyses has to do with the patients’ dissociation hidden in material that is clearly related to repression taking place as a defence in a seemingly whole person”. (Quoted in Abram, 2012, pp. 312-313.)

Part Three is devoted to aspects of psychoanalytic treatment of complex trauma and dissociation. In a very dense and compact chapter, Kluft explores dissociative patients’ dreams. Dreams are not a royal road to the unconscious for DID/DDNOS patients, but a royal road to understanding the interpersonal and therapeutic dynamics. Firstly, Kluft avoids any drive of wish interpretation. Secondly, he explores the dream with the personality part that presents it, but also the contribution of the other parts. Thirdly, he identifies Nathanson’s four shame scripts, which are always at the core of the affective self-experience of dissociative patients: withdrawal, denial, attack self, or attack other.

Petrucelli writes an excellent chapter on eating disorders and dissociation. Hoppenwasser makes a fascinating foray in the neurobiology of attunement and the lack of what she calls entrainment in the therapeutic relation with dissociative patients. Entrainment is the unconscious synchronisation between brains in an intersubjective alignment. Extreme stress, terror, and pain interfere with the developmental integration of the neuronal networks that connect intersubjectively. By this, “information is not temporally integrated”. This leads to “renegade memories: memories out of sequence, out of context, off the arrow of time”.

Wilma Bucci writes about her multicode theory: symbolic, sub-symbolic verbal and nonverbal (bodily) processing of information, and about emotion schema that form the affective core of our self. Emotion schema are a type of memory schema, incorporating sensory, bodily, and motoric processes, going on in our bodies and minds, mostly in an unconscious way. In this view, dissociation is the disconnecting between symbolic and sub-symbolic components within emotion schema and disconnection between the various emotions schemas in our relation to others that each person develops during life. She emphasises how dissociative patients cannot use their bodily processing: they do not feel their bodies, and so are cut off from the daily information of what they feel and of who they are.

Brenner describes beautifully a multiphase model of treatment of dissociative disorder patients. Valerie Sinason posits the important question: “Where are the child therapists who diagnose and treat dissociative children?” Part four consists of diverse chapters, not immediately connected to psychoanalysis. The late Abby Stein worried about the absence of any professional interest in dissociative problems in forensic populations. Dissociative disorders are entwined with violence: as perpetrator or as a victim. Many violent men were traumatised as children.

Bethany Brand and Daniel Brown write about the validity of the diagnosis in reaction to the accusations of various Dutch researchers such as Harald Merkelbach, among others, that DID is an iatrogenic syndrome and that dissociation is a consequence of fantasy-proneness. They elegantly undermine the fantasy-proneness theory, by their meta-analysis. The last chapter from Brain Koehler is a bit disappointing, because he does not adress the overlap and difference between psychosis and dissociative disorders, but mainly describes DeBellis’and Teicher’s research findings in developmental neurobiology.

This a wonderful book, a “must-read” for anyone interested in the bonus of psychoanalytic thinking in the field of trauma and dissociation, but also a must-read for every psychoanalyst working with survivors of trauma and dissociative patients. However, I have some points of critique. Some psychoanalysts use the “safer” concepts of self-states. It appears that they think of dissociative states or parts as ego states. The feeling of dissociative parts is essentially “not--me” or”alien”, due to amnesia or denial. That is different from the feeling of ego states as, for example, “the child within yourself” that is felt as “me”. The question of what dissociation is does not receive a clear answer. Everybody seems to have their own definition, depending on their original school of thinking. Object and Self representations, as described, for example, by Fairbairn’s “the Internal saboteur”, are not the same as perpetrator part-personalities; they are, however, entwined, because, as has been stated before, self-states are experienced as “me” and dissociative parts as “not me”.

Dissociation is also not a defence in the same league as denial and repression. Denial and repression suppose an internal conflict, thus the presence of a Self. Dissociation, on the other hand, is the only way out of terror and inescapable shock. It precludes a coherent Self and secondarily it undermines the formation of a coherent Self. And lastly, even if we are all able to use dissociative defences, it is not the same as having a dissociative mind structure.

To conclude: The dissociative mind in psychoanalysis is a highly readable book with excellent chapters by Howell, Itzkowitz, Brenner, Bromberg, Kluft, Hoppenwasser, Bucci, Van der Hart, Hainer, and Sinason: more than enough to make this more than a very worthwhile and important book.

 

The disintegrating self : psychotherapy of adult adhd, autistic spectrum, and somatopsychic disorders

By Phil Mollon

April 2015, London : Karnac

 

Book reviewed by Julia Boeno

From ESTD Newsletter Volume 5, Number 1, March 2016

Phil Mollon wrote The Disintegrating Self as a response to his growing realisation that many clients he and others have worked with, have been, and continue to be, misunderstood by mental health professionals. Like colleagues, he “may have placed too much faith in the dynamics of the psyche alone – as opposed to the psyche in relation to the brain and body.” This is perhaps unsurprising for a psychoanalyst who has tirelessly expanded his psychoanalytic theorising with an integration of body-led fields of inquiry. Indeed, most recently he has pioneered the development of Psychoanalytic Energy Psychotherapy which focuses on the subtle and nuanced energy systems of our bodies that many of us know little about (or may even feel sceptical about). His work, and this book, impressively integrates neurobiological, cognitive, and energy thinking into his Freudian and Kohutian frame.

Mollon recognises that many clients with ADHD and autistic spectrum disorders often present in therapy practices as they may struggle terribly with their internal worlds. Yet sadly, many have not been helped, or at worst, misdiagnosed –ADHD is often, he thinks, a hidden core within the clinical picture seen as borderline personality disorder, or indeed seen to be the result of extreme early trauma. Dissociative defences of autistic spectrum states may be misunderstood as a result of sustained trauma or abuse. Mental health professionals therefore need to better understand the interplay of both neurobiological and psychological perspectives – each informs the other and neither are understood well enough. This book aims to help us here, and is structured in discrete chapters that can be read alone and out of sequence – there is some overlap and repetition, particularly in the early chapters on ADHD, although each has a particular theme.

Typical ADHD traits are explored in great detail, more than those of the autistic spectrum. These traits tend to include those that may also cluster in a borderline or antisocial personality disorder presentation such as hyperactivity, impulsivity, a propensity to rage, a narcissistic vulnerability, rigid thinking, and a low self-esteem combined with grandiosity. With potentially tragic consequences, when a child suspected with ADHD is seen in a family context, Mollon has seen a “misguided tendency” to view his or her problematic behaviours and feeling states as a result of inadequate boundary setting and structure – i.e., family dynamics rather than anything else. This can, of course, be a shaming experience for those families who have struggled hard to cope with inevitable disruption brought by a child in distress.

Given that all mental health states and processes have a neurobiological basis, and we work psychologically with these to alter them, it follows that we can work psychologically with these “non-neurotypical” clients too. Mollon urges us to deepen our understanding of these brain states, and apply much of what we know therapeutically already. Pharmacotherapy – often used in the US and UK - is therefore not the only feasible option, although Mollon concedes that psychotherapy with these clients can be slow and difficult. I imagine I’m not the only one wondering how the NHS provision of psychotherapy can work effectively with such clients when short-term interventions are the norm.

Mollon’s thesis is that ADHD and related autistic spectrum conditions are to do with an impaired self-regulation and an associated enhanced need for others to help regulate an emotional world. Kohut’s thinking is particularly helpful here for him here (as it has for much of Mollon’s thinking over the years), as others are experienced as “self-objects” – i.e., the other person forms a part of the regulatory system of the self. To defend against such an overwhelming and continual fear of disintegration, these clients particularly rely upon the organising, stimulating, and regulating empathic responsiveness of other people – therapists included of course. Their mental world is a fragile one that readily falls apart, compromising thinking, planning, and focus.

Without these helpful responses from others, which may be very difficult to elicit from someone who can’t understand what’s really going on in the other’s mind - rage, shame, and a search for stimulation may result (along with other tricky behaviours). If autistic traits are present too, this may also result in a withdrawal from other people and a desire to seek comfort in repetitive activities or with inanimate objects.

Like someone with ADHD, someone with autistic spectrum traits may not have been able to use the responsiveness of caregivers adequately to regulate his or her emotional and physiological state. Mollon doesn’t deny that carers may well have been deficient, but he makes the case that the neurobiology of these brain states make self-object responsiveness extremely difficult. Furthermore, with someone on the autistic spectrum, the experiencing of others is complicated further by a processing flaw. Normal means of communication – such as eye contact, words, and body language – are often mistrusted. This means that ordinary life can feel deeply overwhelming - “a bombardment of particules of experience”, making an autistic person flee to an escape through various forms of dissociative defences, such as a complex alternative inner world. While we accept now that sustained trauma and abuse is a cause of dissociative disorders – the other less commonly recognised one is autistic spectrum sensitivity.

The important point to reiterate is that these conditions that Mollon explores aren’t always a result of any “environmental deficiency” from early caregivers or traumatic experiences, but they may well have a neurobiological underpinning that creates unusual and particular needs for “environmental ego support” – these are “self-object disorders” in Kohutian terms. Not only is this de-shaming for some families, but for those who suffer too, and Mollon writes movingly of the relief of some clients when they understand their struggles are not their “fault”. He also writes about the positive aspects of ADHD and the successes of those who are able to harness their unusual minds and energies in fulfilling ways and with self-worth.

The early chapters explore in great depth the features, experiencing, and neurobiology of ADHD, before moving on to principles of psychotherapy with this client group – here’s where Mollon’s vast authority on psychoanalytic and more recent neurobiology applies itself best. He offers detailed clinical examples too, which bring some of the denser material to light. As with much of his work, Mollon pays deference to Freudian thinking, looking at drive theory and the predominance of aggression, the functioning of the ego and its need for support, the dominance of the pleasure principle over the reality principle, and superego deficits. Honing in of aspects of the therapy relationship and process that support development of these deficits forms the interesting part for clinicians – in particular, interventions that facilitate ego functioning.

CBT has a “passing glance”, while energy psychologies get more of a look than a glance. A handful of exercises Mollon finds particularly useful are found in some detail in an appendix, but it may be that readers who have some experience, understanding, and even training in energy psychology approaches (TFT, EFT, AIT, TAT, and PEP included) will find these interventions more appealing than those who haven’t. Although Mollon has great faith in their worth, he accepts that many still regard these as “experimental” stage. For those that do, the chapter on “subtle energetic aspects of ADHD: reversed and scrambled energy fields and yin-yang imbalance” may find the territory too unfamiliar – acupressure meridians and chakras are a given here. Mollon uses the idea that the agitated emotional state of a person with ADHD will have a disturbed subtle energetic field (or “reversed” in Mollon’s view), which will also be experienced negatively by others. Simple exercises may be very fruitful to re-balance the brain and energetic states, along with suggestions for commercial brain-training programmes.

I found the chapter on “somato-psychic fragility syndromes” particularly interesting, with its focus on Ehlers-Danlos syndrome (EDS) – a condition I have met in my own consulting room a few times. The various manifestations of EDS result from the absence of sufficient collagen in the body – it has, traditionally, been difficult to diagnose. This means the connective tissues of the body aren’t held together well - ligaments and joints become loose and liable to dislocation. As muscles have to work hard to compensate, chronic exhaustion, pain, and associated low mood can result. Symptoms may mimic those of bipolar or ADHD disorders. Mollon sees that a sufferer – like those with ADHD and autism may feel a danger of physical and psychological disintegration too.

Again, the point he urges upon his readers is to take on board that the workings of a mind with these less usual brain states may well be determined in part by the substrate of a compromised brain or body. This is a valuable and robustly supported shift in thinking that all clinicians should make..er their area of practice.

 

Gas light

Director: George Cukor (1944)

 

Film reviewed by Orit Badouk Epstein

From ESTD Newsletter Volume 5, Number 2, June 2016

“Knowing what you are not supposed to know and feeling what you are not supposed to feel” (John Bowlby, 1988).

During the past few months here in the UK, Radio 4 listeners have been transfixed by the popular radio show, The Archers. This middle class drama normally features the eventless life of a farming community in rural England, except instead of discussing the price of hay, the plot has taken a turn to the troubled side of domestic life. Things got heated when one of the characters, Rob Titchener was controlling and emotionally abusing his passive and compliant wife, Helen, in insidious and manipulative ways, whilst to the outsiders in the community, all seemed to be perfectly loving and acceptable. The drama eventually reached a climactic episode when Helen finally lost the plot and stabbed her husband with a kitchen knife. This has not only caused an uproar amongst the loyal listeners of the programme but has also sparked a wider public debate about domestic abuse and women as its main target. What seem to be relevant to this film review, however, is the use and the return of the term “Gas-lighting” and its modern interpretation that I find can be helpful in the clinical setting.

Originally written as a play, this film noir was set in Edwardian times in England and tells the story of Paula (Ingrid Bergman) who finds the body of her murdered wealthy aunt, by whom she was adopted as an infant, in the house where they lived together (9 Thornton Square). The police fail to find the murderer. Looking fragile and confused, the bereft and traumatised Paula is then sent to Italy to study music while being told that she must forget all that had happened. In Italy she gets courted by her piano teacher, Gregory Anton. The vulnerable Paula falls in love with him, they get married and the couple eventually return to her aunt’s abandoned house in Thornton Square. Once settled in, Paula then finds a letter, she shows it to Gregory, who clearly looks agitated by its contents, since he has a lot to hide. He then slowly begins to torment Paula psychologically in various subtle ways such as dimming the gas lights in her bedroom; hiding objects; and then returning them to their place, whilst telling her continuously that she is not looking well and should lie in bed. Having clearly been left vulnerable by her traumatic early life, the confused Paula begins to doubt her own reality and her health gradually deteriorates. The rest of the film is a bit of a clunky thriller with a happy ending, such as when the tables are turned, and Paula says to Anton “It isn’t here, you must have put it there. Are you suggesting that this is a knife I hold in my hand? Have you gone mad, my husband?”. Despite this it’s a classic and its strength lies in it being psychologically accurate storytelling way ahead of its time.

Since then, there has been a revival of the use of the term “gas-lighting”, which is used to describe emotional abuse as a way of controlling and denying the victim’s sense of reality to the point that it becomes distorted. Gas-lighting happens not only domestically but culturally and interpersonally, we can see this in politics and the media. For example, at the Wellcome Collection museum in London, there is currently an exhibition on the unconscious (States Of Mind; Tracing The Edges of Consciousness, showing until the 16th October). As well as some very powerful and informative exhibits, the exhibition’s main message concerns the question: “is memory always a reliable tool though? We can so sometimes be fooled by ‘false memories’, as our brains fill in gaps using information and experience of the world, or are deceived by suggestive images. AR Hopwood explores our surprising vulnerability to this in his False Memory Archive”. “This form of distortive propaganda is meant to control the masses’ notion about the credibility of memory and we are all familiar with what follows that.” (quoted from the exhibition brochure)

Traditionally one might also equate the term gaslighting with men who try to possess and control women. Mental health has improved greatly, yet we still hear of cases where the power dynamics between men and women remain corrupted. Unlike the happy ending of the film, some severely gaslit women do end up being sectioned in mental institutions after their husbands successfully convinced the authorities that their wives were crazy. The association between women’s behaviour and being labelled crazy has a long and infamous history in many cultures. The word hysteria, defined as behaviour exhibiting excessive or uncontrollable emotions of fear and panic, has been regularly associated with women. Until the early 20th century – when the medical field was mostly ruled by men - female hysteria was the official medical diagnosis for a truly massive array of symptoms in women (including, but not limited to, the loss of appetite, nervousness, irritability, fluid retention, emotional excitability, outburst of negativity, excessive sexual desire and a tendency to cause trouble). It is so pernicious, even as we creep towards equality, that many women don’t even recognise that they are powerless victims. Calling hysteria a medical issue meant that men didn’t have to respond to behaviour that challenged male belief structures. Instead labelling women as hysterical made it easier to diminish women’s concerns and maintain men’s control.

Still, the gas-lighting phenomena is not exclusive to men. Fundamentally it is one’s belief that it is okay to possess and own another and by doing so overwrite their reality to the point of the annihilation of another person’s selfhood. One of my clients, who was born into a family of organised ritual abuse, has experienced gas-lighting by her mother for most of her life and has clear memories where her mother day after day, repeatedly told her: “Darling, you were always quite dramatic,” “you never had much stamina” and constant comments about having tonsillitis, constipation, too many antibiotics, glandular fever, and then when she collapsed at 24 with ME, her mother would visit her in hospital and assert that it was the Lariam (antimalarial tablets) that caused it. For this client, recognising the term “gas-lighting” has not only helped her get closer to her EPS (emotional parts) but has also enabled her lift to the veil of secrecy around her mother’s involvement in the abuse and to come to terms with that loss.

My appreciation for this film is not only with its advanced psychological thinking, but more so with its contributions to the English lexicon, its cognitive resonance and psychoeducation property. Emotional literacy is a way of being, not just knowing or doing, that helps individuals differentiate and enables people better to reach their feeling self. When we finally find a word that accurately matches our experiences, whether internally or externally, something inside us shifts since we feel we are being understood, and by way of doing so, we not only expand our awareness but better understand our rights as humans.

 

Medical muses : hysteria in 19th-century Paris

By Asti Hustvedt (2011)

New York: W. W. Norton & Co.

(Paperback edition: Bloomsbury Publishing, London, 2012)
 

 

Book reviewed by Onno Van der Hart, PhD

From ESTD Newsletter Volume 5, Number 1, March 2016

Medical Muses describes the case histories of Jean-Martin Charcot’s three famous female patients in the Salpêtrière, Paris, during the second half of the 19th century. After having this book recommended, I looked for readers’ comments at Amazon.com and at Amazon.com. uk, and I was struck by the fact that it had evoked highly polarized reactions. With hardly any middle ground, approximately half of the reviews were extremely negative and the other half completely positive. Something must be the matter, then, I thought. One thing became immediately clear: all the negative ones, often including coarse language, were submitted first. They give the impression that a rather organized campaign was made against the author’s suggestion, at the end of her book, that present day ME/CFS (myalgic encephalomyelitis-chronic fatigue syndrome), among a few other illnesses, might be a successor of 19th century hysteria.

An independent scholar with a PhD in French literature from New York University, Asti Hustvedt has thoroughly studied these patients’ published and unpublished case histories, medical archives, relevant French 19th century literature, and a number of other sources. She delved into the history of this period of French psychiatry, including the functioning of Charcot’s neurology ward at the Salpêtrière. Central to the book are the sad but also fascinating case histories of these three “medical muses,” Blanche Wittmann, Augustine Gleizes, and Geneviève Legrand. The author describes their severely traumatic childhood histories and subsequent painful lives before being admitted to the Salpêtrière (Blanche at age 18, Augustine at age 14, and Geneviève at age 16), adding as much details of their life circumstances as she could find. To mention a few details, Blanche had an unemployed, mentally unstable and increasingly violent father, and a mother who suffered from frequent “attacks of nerves.” Five of her eight siblings died at an early age, and she herself suffered her first attack of convulsions at 22 months. She developed fits of anger, alternating with uncontrollable sobbing and laughing. At age 13 she was sexually assaulted by her employer. Augustine spent her first years with a wetnurse—a not uncommon practice in France at the time— and was subsequently sent to relatives, followed by a period of living in a convent school. (From a present-day attachment theory point of view, one wonders about the attachment trauma that she must have suffered.) There, being a wilful child, she often received punishments, such as having her hands tied down at night, solitary confinement, and being slapped. At age 10 she experienced a sexual assault. The most damaging sexual abuse, however, took place at age 13, when her mother willingly allowed Augustine’s stepfather to violently rape her. Soon after this (betrayal) trauma she developed “hysterical convulsions.” Born in Loudun, the village known for its 17th century exorcism drama, Geneviève started her life as an abandoned infant who was subsequently raised in a foster family. Much later she reported that she remembered little of that time, except for some brutal physical punishments and her ability not to feel pain. At age eight, she was sent to a convent—which was generally known as an abusive place—where she suffered severe maltreatment. Geneviève later expressed her belief that the rejection by her foster-parents was her own fault, due to her being a scatter-brained and difficult child. While staying in another foster family at age 14 she developed a passion for a boy—a relationship which ended when he died, affecting her deeply. Eventually she was sent to a hospital, where she received prolonged “hydrotherapy,” that is, a torturous combination of cold showers and prolonged baths, which was a frequently used therapeutic approach at the time, as well as a form of punishment for unruly patients. She subsequently found work with an employer, who showed undue sexual attention towards her. Around this time, the deeply religious girl who was very interested in reading about self-sacrificing saints, developed a pseudopregnancy, suffered from daily “hysterical attacks,” self-mutilation, self-starvation (anorexia), and urine retention. Several times she was admitted to a psychiatric hospital. She ended up in the Salpêtrière, probably as a last resort, where, among other things, a possession syndrome was observed, that is, alternations between episodes of extreme religiosity and “demonic behaviour.”

Altogether, upon admission in the Salpêtrière, these three adolescent girls not only had a history of severe childhood and subsequent traumatization, they also presented with a wide range of what we would call now somatoform (sensorimotor) and psychoform (cognitive-emotional) dissociative symptoms. Thus, as they existed prior to treatment, these symptoms were not iatrogenically-induced. However, the ways in which they were approached medically were not supportive of symptom resolution, but rather exacerbated and perhaps multiplied them.

With regard to the medical staff of the Salpêtrière, Hustvedt pays special attention to Jean-Martin Charcot himself. He was the most famous neurologist of his time, who identified, among others diseases, amyotrophic lateral sclerosis (ALS), discovering its precise pathology. His impressive strength in identifying and classifying symptoms of various neurological disorders helped him greatly in his descriptive studies of hysteria. In fact, it also became his Achilles heel: he remained an expert observer of the patients’ cognitive-emotional and sensorimotor (dys)functions, but as a neurologist he was not very interested in the psychological meaning of the symptoms. Nor did he did relate reported childhood traumatization to the present suffering of hysteria in these patients. That is, he did not consider symptoms of hysteria in his female patients to be a trauma-related mental disorder. However, he should have been aware that Augustine’s “hysterical attacks” included re-enactments of the rapes she suffered by her step-father, as her verbal utterances during such attacks were duly recorded by the attending staff. (This perpetrator even attended a clinical lecture open to the public in which Charcot demonstrated her; cf. De Marneffe, 1991.)

Curiously, Husvedt overlooks Charcot’s later view on a type of hysteria that he considered a trauma-related disorder, especially in male patients. This hysteria developed following a recent potentially traumatizing event, such as a railway disaster or traffic accident. He regarded this traumatic hysteria as similar to the traumatic neurosis, a diagnostic category labelled as such in Germany (Oppenheim, 1889). Actually, Charcot’s colleague at the Salpêtrière, Auguste Voisin, made a strong case for the relationship between traumatic experiences and the subsequent development of mental disorders, including hysteria, also in female patients (Voisin, 1883). It seemed that for Charcot and many of his “students”, that is, physicians working under his leadership, traffic accidents could be pathogenic, while (childhood) maltreatment, including sexual abuse, was not. Perhaps because such abuse was pervasive at the time, or there may have been beliefs that these experiences did not impact children negatively. The reasons remain unclear. However, Charcot and his staff must have been familiar with the work of AmbroiseTardieu, professor of legal medicine at the Faculty of Medicine in Paris: he reported many cases of children who were raped or otherwise severely abused and the extreme physical consequences (including death) (e.g., Tardieu, 1878). It is hard to understand why these medical men seemed unable to realize that survivors of such sexual and physical abuse would also be mentally traumatized.

Hustvedt’s sympathy is especially directed to Charcot’s junior collaborator, Désiré-Magloire Bourneville, who perhaps was the physician who demonstrated the most compassion for his patients. Not only was he attentive to the history of maltreatment and current adverse circumstances of his patients, including the three “muses” highlighted in this book, but he was also concerned with their current plight. Thus his compassion not only manifested in his treatment approaches, but also compelled him to take social action. Hustvedt seems somehow to follow Bourneville’s understanding that the cruel childhood history of these patients must have affected their hysteria, but she falls short of explaining his thoughts about this connection.

Hustvedt’s apparent lack of knowledge of dissociation and the dissociative disorders seems to underlie her suggestion that the patients with hysteria, suffering from the same symptoms, would currently be diagnosed with schizophrenia, conversion disorder or bipolar disorder. That may well be true, but she hardly pays any attention to the trauma-related dissociative nature of hysteria. (For example, we now know that conversion disorder is a dissociative disorder, that is, of movement and sensation.) This diagnostic awareness should perhaps not be expected from a scholar in French literature. However, the picture that she paints of these patients and their therapists should be complemented by an understanding of the relationship between chronic traumatization and dissociation of the personality, of which Bourneville himself made some observations in one of his books, to which Hustvedt also referred (Bourneville, 1896; cf., Van der Hart, Lierens, & Goodwin, 1996). Still, almost in passing does Hustvedt refer to dissociation. In her discussion of the views of Jules Janet, Pierre Janet’s younger brother and one of Blanche’s attending physicians, she notes that J. Janet believed that hysteria was generally explained by the presence of a double personality, a phenomenon also manifested by Blanche. Hustvedt also states that Azam’s famous multiple personality patient Félida X created something of a framing narrative for Janet’s diagnosis. What she overlooks, however, is that not only Bourneville, but also Charcot, Gilles de la Tourette, Alfred Binet, and Pierre Janet—all mentioned by her—came to regard dissociation of the personality or consciousness (“dédoublement de la personnalité” [doubling of the personality], in Bourneville’s words) as a major characteristic of hysteria. I wonder if Hustvedt did not really understand dissociation or whether she felt inclined to downplay its dynamics, given the severe prejudice against it among some other contemporary students of French 19th century psychiatry and hysteria, such as Ian Hacking (1995) and Elaine Showalter (1997), as well as some psychiatrists and psychologists.

Probably the greatest omission in this book is a serious discussion of Pierre Janet’s studies of hysteria. It is true that Janet was not at the Salpêtrière during the main period on which Hustvedt focuses (but still she refers to some of his publications). Only in 1889, after the very positive reception of his doctoral thesis, L’automatisme psychologique (Janet, 1889), did Charcot invite Janet to join him at the Salpêtrière and set up the first psychological laboratory there. Including some serious attention to his work might have offered some nuances in the overall picture that Hustvedt presents of the clinical culture in the Salpêtrière: a “theatre” in which both staff and patients, particularly the three “muses” collaborated, each in their own roles. The use of live, sometimes naked patients in group demonstrations, the dramatic provocation and classification of their symptoms, the application of hypnosis for medical research, and even for entertainment, were common. As for hypnosis, the belief at the time was that hysterical symptoms were the result of suggestion, thus could be hypnotically removed and reinstated at will. However, if it were that simple, these chronic patients should have been cured in the shortest amount of time, which was not the case.

Possibly with the exception of Bourneville’s efforts, effective therapy of these patients seemed not to exist. It was Pierre Janet who provided innovative and effective psychotherapy (Janet, 1898), based on a thorough understanding of the patients’ problems, their strengths and weaknesses. His work still is a source of inspiration for current-day clinicians in the field of trauma and dissociation. Janet also extensively used hypnosis; however, not for simple symptom removal but for therapeutic goals, including the resolution of traumatic memories underlying the symptoms. Janet regarded both the dissociation of the personality and the retraction of the field of consciousness—basic characteristics of hysteria-with the results of integrative failure. Hysteria, therefore, was as an “illness of personal synthesis” (Janet, 1907, p. 332). Constitutional vulnerability could play a role, as could physical illness and exhaustion. He regarded the vehement emotions inherent in traumatic experiences as the primary cause of this integrative failure. The more intense these emotions, the longer they last, and the more they are repeated, the stronger their disintegrative effects (Janet, 1909). These effects involve an ever more complex dissociation of the personality, that is, in our language, an increasing number of dissociative parts—with DID as the most complex form of dissociation. He argued that the lower the patient’s integrative capacity and the more complex the dissociation of the personality, the more treatment needs to involve a kind of phase-oriented approach.

In conclusion, I strongly recommend this book to ESTD members, who, after all, are all well-trained in the diagnosis and treatment of patients with dissociative disorders and who have a clear understanding of the relationship between trauma and dissociation. They have the clinical frame of reference from which to make sense of this central dynamic hidden in the rich history that the author presents of pivotal 19th-century encounters between dissociative patients, attending staff and other interested parties.

 

Force Majeure

Director Ruben Östlund (2014)

 

Film reviewed by Orit Badouk Epstein

From ESTD Newsletter Volume 5, Number 1, March 2016

In this atmospheric family drama, a Swedish family of four travels to the French Alps to enjoy a skiing holiday. On their second day at the resort, while sitting for lunch in a scenic sunny Alpine restaurant, an avalanche suddenly occurs, filmed in a single, breath-taking take. At this moment chaos erupts, with diners fleeing for their lives in all directions. The mother, Ebba, calls for her husband, Tomas, while she tries to protect their children. Tomas meanwhile grabs his cell phone and runs away.

It is from this frenzied moment that things unfold subtly in front of us. After Tomas has run away from the avalanche, it turns out that, what had appeared as a catastrophe, was just a side effect of a controlled explosion and the avalanche had stopped well short of the restaurant, but what it has actually done is to expose his ‘selfish‘ and ‘cowardly’ behaviour. This heart-stopping moment, which lasts less than 5 minutes, defines what takes place next. Ebba cannot get over what has happened. The children, looking upset and fearful, are the first to notice their father’s abandonment, and, distressed by this traumatic experience, later act out as the marriage buckles under the strain. What could have been a catastrophic event has turned into an internal torment for a family who on the surface seemed to be perfectly happy and ordinary.

In the aftermath, unable to fully acknowledge what happened, the family spend the remainder of their holiday imprisoned in their claustrophobic hotel room and relive their trauma in some dissociative bubble. Lit by the eerie, blue light from the snow outside, the room changes colour according to the time of day, from a pale grey to a darker charcoal colour; leaving the viewer feeling just as trapped as is this confused family.

Tomas tries to redeem himself but things seem to be irreparably broken and the family finds it difficult to come to terms with the psychological impact and its consequences upon them. It takes them a while to express what took place. Eventually, at dinner, in front of a strange couple, Ebba confronts Tomas. She does it feebly, minimizing the avalanche’s impact, in a passive-aggressive way, half-jokingly; she exposes Tomas’ cowardly behaviour. Tomas denies it altogether and claims that his recollection of the event is entirely different to Ebba’s. Later we see the horrified Tomas happened to catch it all on his iPhone. We also witness him having some sort of shame attack, embarrassingly trying to hide it outside their room, in the hotel corridor. Nevertheless, the hotel’s janitor somehow ends up being the couple’s only silent witness.

‘In times of disaster, as humans we are all organized to survive, if the fight/flight/freeze response is successful, we soon regain our internal equilibrium and gradually “regain our senses”’ (Van der Kolk, p.54). In questioning altruism in a time of survival, the director of this intelligent drama pushes the boundaries; he subtly teases our discomfort, leaving us with an irritating itch; what would we do in similar situation?

Being able to move and do something to protect oneself is a critical factor in determining whether or not a horrible experience will leave long-lasting scars (Van der Kolk, p. 55). But what about protecting others? Reciprocal altruism is a form of survival, yet what makes some people run for their lives and others to remain to save the life of another person, when our courage is being tested in a time of disaster? We can speculate but may never know the real answer to this. From an Attachment theory standpoint, what seems to be more poignant to this drama is the couple’s way of relating to one another in the aftermath. Their avoidance clearly has taken over and their communication to each other is silent, passive-aggressive and anxious. Avoidant attachment can be seen as silent developmental trauma when the child from a very young age learns to rely less on the caregiver’s responsiveness. Hence, Tomas’ fearful internal loneliness screams from afar whilst Ebba’s silent rage is hard to bridge, leaving them wondering and lost in their lonely islands of existence.

In an interview, the director said that before making this film he stumbled upon some statistics that showed a high divorce rate among couples who have been through traumatic experiences such as an aeroplane hijacking or other catastrophic events. In his latest book, ‘The Shadow of the Tsunami’, Philip Bromberg writes: ‘Everyone, to one extent or another, will continue to preserve the procedurally learned early attachment patterns upon which his core self rests in order to be recognizable as “himself” in all circumstances and during all phases of life’ (Bromberg, p. 58). The couple’s shared intersubjective connection has clearly been tested by the threat they have experienced together and their anxious attachment to each other.

The film exposes how, in times of crisis and disaster, technological mastery and safety precautions might be able to control nature, but not necessarily human nature.  At the end of the day, the “icy detachment” was the superior force.

 

Reference:

“The body keeps the score”, Bessel van der Kolk, Penguin Book, 2014

“The shadow of the tsunami”, Philip M. Bromberg, Routledge, 2011