Chapter 1: Healing the Divided Self

by Maggie Phillips, Ph.D. and Claire Frederick, M.D.

Healing the Divided Self

What is the Divided Self?

We believe that an understanding of the nature of the divided self is essential for the clinician who is practicing psychotherapy today. Far too often we consult with patients who have seen numbers of therapists but have received no substantive results for their efforts. A major reason for this is that their therapy overlooked problems of self-division and failed to identify what was most central to the patient. It is not surprising, in view of this, that their previous therapy was unable to reach the depth of discovery necessary for healing.

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Early Clinical Evidence for Personality Division

Until the 19th century, shamans, prophets, and medicine men attempted to help individuals afflicted with dissociative conditions by casting out demons. Exorcisms for these conditions has been featured in many cultures around the world; in fact, until relatively recent times, dissociative phenomena were deemed the proper domain of the church. For centuries exorcism was the recommended form of treatment in Western culture (Ellenberger, 1970), and even today several contemporary traditions exist for such treatment of MPD (Friesen, 1991; Hill & Goodwin, 1993).

In the late 19th and early 20th centuries clinicians began to treat and to write about dissociative disorders; these disorders, then called the "hysterias," included multiple personality disorder. Pierre Janet (1907), William James (1890), and Morton Prince (1906) published case studies about their work.

The most renowned theorizer of the time was Pierre Janet (1907, 1926), a philosopher turned physician. According to Janet, the conditions he and other clinicians were treating were caused by a process he called "dissociation." Dissociation was a separation of the thoughts, feelings, and perceptions associated with a particular event from the greater body of mental content. Janet believed that dissociation occurred when a biologically susceptible individual underwent trauma. He postulated dissociation as the mechanism lying behind many clinical phenomena, such as the hysterias, obsessive compulsive disorders, and psychasthenia, as well as multiple personality disorder. For Janet the cure occurred when the trauma was discovered (Janet, 1907; Frankel, 1990).

Breuer's work with Anna O. (Breuer & Freud, 1893-1895) launched another way of viewing division in the human mind. He and his collaborator, a young physician named Sigmund Freud, used their work with hysterical patients as material from which they introduced their concept of the unconscious mind and a form of treatment, psychoanalysis. Initially, Freud shared Janet's view about psychopathology. He thought that it was produced by trauma, and that remembering and catharsis provided the cure. Freud even had specific ideas that the nature of the trauma in the case of the hysterias was childhood sexual abuse (Freud, 1896). However, as he continued to elaborate his thinking, he found it necessary to repudiate this seduction theory. A preponderance of his patients, predominantly female, were reporting that sexual molestation by their relatives had occurred when they were children. A number of these accused perpetrators were Freud's colleagues and members of his social and academic circle. He concluded that such frequency of child sexual abuse was unlikely and turned to his theories of infantile sexuality and unconscious oedipal conflict and fantasy to explain the material he heard from his patients (Ellenberger, 1970). Freud's struggle about the meaning of the memory material he retrieved from his patients, often under hypnosis, continues to be echoed in vociferous debate within the professional community today.

The work of the other 19th-century dynamic clinicians, as well as the therapeutic use of hypnosis, was eventually swept into temporary oblivion by a number of historical developments. Among them were the proposed psychoanalytic theories of Freud, which involved an unconscious mind, repression, and the mental mechanisms of defense, and Pavlov's work with the conditioned reflex, which heralded the dawn of behaviorism. These important trends, together with the tremendous advances taking place in physiological and biochemical understandings of the human organism, turned the tide of psychological theory away from the work the 19th-century clinicians and dissociative theory. Therapeutic work with soldiers suffering from "battle fatigue" or "war neurosis" began during World War II, and it was amplified and studied further during the Korean and Vietnam conflicts. This work involved a revival of hypnosis as a therapeutic tool and paved the way for some exacting scientific work concerning the nature of hypnosis and of hypnotic susceptibility (Frankel, 1990; Hilgard, 1965; Orne, 1959).

Starting in the late 1960s, the women's movement brought a new freedom to reveal the prevalence of child sexual abuse. While astute clinicians had always been aware of its presence as a significant factor in the lives of many patients, the opening of the closet door on this social phenomenon made it clear that this kind of childhood trauma was widespread and cut across economic and social categories.

The publication of Ellenberger's vital and scholarly book, The Discovery of the Unconscious, in 1970 was a powerful factor in a revival of interest in the work of the early clinicians and their views concerning dissociation (Frankel, 1990). Clinicians were finding themselves in the position of having to reconsider some of the earlier ideas of the 19th- and early 20th-century clinicians and to refocus attention upon dissociation and the role of trauma in the production of human psychopathology (Ross, 1989). Some of the experimental evidence accrued in the past two centuries was also helpful in setting the stage for renewed interest in these topics.

The Emergence of Experimental Evidence for Division of Personality

The Dissociation Theory

The idea that the human personality is naturally divided or segmented was commonly held in the late 19th and early 20th centuries. Janet was the first investigator to use the term "subconscious" (Ellenberger, 1970; Janet, 1907). He (Janet, 1907) clearly described aspects of personality that had patterns of feeling and cognition, and which, unlike the alters of the patient with multiple personality disorder, could only be activated by hypnosis. This was very much like Jung's concept of the "complex" (Jung, 1969). One early clinician, the experimental and clinical psychologist Alfred Binet (1977a, 1977b) conducted a number of fascinating experiments in the field of hypnosis. Some of them had to do with the experimental creation of alter personalities. In a significant experiment with a highly hypnotizable subject he demonstrated that the subject could respond to visual stimuli without even being aware of them on a conscious level. Binet believed that a doubling of consciousness was a causative mechanism for the symptoms we might call dissociative. Similar phenomena were demonstrated by the American psychologist William James (1889), who also concluded that the mind operated under the control of several subpersonalities.

The Neodissociation Theory

Many years later Ernest Hilgard (1965-84) conducted careful experiments involving the perception of sound and pain under hypnosis. He also measured bodily responses in order to discover whether the body was responding physiologically to pain even when the hypnotized subject had anesthesia for it. Hilgard's experiments led him to the conclusion that cognitive functioning is the result of the interaction of many "subordinate control systems" (1973, p. 406). Hilgard posited the neodissociation theory to account for his experimental findings. This theory was completely compatible with Freudian theory. He hypothesized was that there were two kinds of defense mechanisms, with two different kinds of splits that could develop within the psyche. A vertical split represented the Freudian topographical map, which separates conscious from unconscious repressed material, and a horizontal split placed within the realm of the conscious mind separates dissociated material from the rest of conscious content (Figure 1). Hilgard named the main manifesting consciousness the "executive ego." Covert observing aspects of the mind activated experimentally under hypnosis were known as "hidden observers." According to Spiegel (1986), dissociation can be distinguished from repression "in terms of the relationships among the material which is kept out of conscious awareness" (p. 124). Repressed material does not necessarily exclude other types of intrapsychic material.

In comparing repression with dissociation, Terr (1990) reminds us that the American Psychiatric Association (1994) has classified repression and dissociation as different unconscious mental mechanisms of defense (Appendix B, DSM-IV). Repression is a concept used by Freud to account for the individual's pushing significant painful material into the unconscious mind where, although completely forgotten, it continues to affect mental processes such as thought, feeling and behavior, and may produce symptoms. The defense of repression is present in normal as well as abnormal human psychology. Dissociation, on the other hand, was Janet's concept of a "sidewise slippage from consciousness, with a partition between the dissociated event and the mental component that knows and remembers" (Terr, 1993, p. 66).

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The Dissociative Spectrum

Normal dissociative phenomena appear during the course of everyday life. Hilgard's (1973) example of a tune that runs, unbidden, through one's head is an excellent one. Ordinary daydreaming belongs on the dissociative spectrum, as does getting lost in an absorbing book or an exciting movie. Perfectly normal daily activities are probably dissociative whenever they involve automatic functioning, such as typing a paper or taking a trip by car. Some individuals have a greater capacity to dissociate. Here we find the "absent-minded professor" and many creative people who appear to be a little dreamy when they are involved in the creative process. Ross (1989) has cited not remembering getting up in the middle of the night to go to the bathroom as an example of normal organic dissociation.

Somewhere a little farther along the scale but for many still within the normal realm are certain dissociative reactions to traumatic situations. Among these are isolation of emotions during war situations, forgetting details of a hurricane or earthquake, or being paralyzed in the presence of a real physical threat. According to Ross (1989), amnesia after a concussion is normal biological dissociation. It should be located in this part of the spectrum. There is a defensive borderland where dissociation is being used to escape reality For example, a child might lose herself in Star Trek or in video games to escape the noise and static of a dysfunctional family. The "forgetting" of an unpleasant conversation also belongs here.

Acute dissociative disorders, such as somnambulism, the conversion disorders (e.g., hysterical paralysis or blindness), and fugue states, can be found further along the spectrum, as can depersonalization disorder, derealization, and not feeling or experiencing one's own body, as well as amnesia; also in this area of the more pathological part of the spectrum can be found profound and chronic dissociative disorders. Certain clinical syndromes that have not traditionally been placed within the dissociative spectrum are often the result of chronic dissociation. These include eating disorders, depression, obsessive compulsive disorder, phobias, and panic disorder. Multiple personality disorder (now renamed dissociative identity disorder by the American Psychiatric Association in DSM-IV) and similar dissociative disorders (not otherwise specified) are, of course, the extreme result of chronic dissociation. A schema of the dissociative spectrum can be seen in Figure 2.

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Trauma, Hypnosis, and Memory

The Lasting Effects of Trauma

Significant information about the relationship of trauma and dissociation can be found in reports from clinicians who have treated patients with pathological dissociation that is the result of trauma, usually experienced in childhood. Terr (1991) has reported four characteristics that can be identified in anyone who has been subjected to extreme childhood trauma: "They include repeated visualizations or other returning perceptions, repeated behaviors and bodily responses, trauma-specific fears, and revised ideas about people, life, and the future" (p. 19). She regards Type I trauma, the unanticipated single traumatic event, as the kind of trauma that is extremely common in childhood and of the type typically described by Anna Freud (1969). Type II traumata are repeated and longstanding, and a massive array of defense mechanisms is brought into play to help the child endure these unendurable events. Among the defenses are denial (often massive) and psychic numbing, self-hypnosis and dissociation, repression with subsequent identification with the aggressor, and aggression turned against the self (Terr, 1991).

True psychological trauma is an event of the greatest magnitude, beyond the minor traumata of everyday experience. When it occurs, it will profoundly affect the future and the actual course of the life of its recipient. Beahrs (1990) has noted the prominent feature of increased arousal in post-traumatic stress behaviors. Like Terr (1991), he has observed phenomena associated with a return or reliving of the trauma, numbing and dissociation, and some degree of splitting as defensive reactions to overwhelming trauma. Trauma leaves individuals with marked vulnerabilities and damage (van der Kolk, 1987c). Even when they appear "normal," there may be fluctuation between an arousal of active PTSD symptoms and periods of emotional constriction.

That victims of trauma dissociate in order to protect themselves from the overwhelming pain of the situation has been well-known since the 19th century (Ellenberger, 1970). This phenomenon has been noted with war neuroses (Fisher, 1945; Watkins, 1949), in concentration inmates (Jaffe, 1968), and in MPD patients. Kluft (1985b) has observed that the trauma of childhood abuse is the causative factor for the development of childhood MPD, and that its cessation is necessary if the child is to recover. Coons (1980), Putnam (1989), and Ross (1989) have also identified childhood trauma as the causative agent in adult MPD patients. It is hypothesized that trauma produces spontaneous trance reactions, and that the resultant hypnotic dissociation is adaptive (Beahrs, 1990). Certainly, post-traumatic patients can often be observed to enter trance spontaneously (Kluft, 1985c; Spiegel & Fink, 1979; Stutman & Bliss, 1985) during their therapy sessions.

Spontaneous trance and dissociation are both adaptive (Beahrs, 1990; Braun & Sachs, 1985; Kluft, 1984b; Putnam, 1989; Spiegel, 1986) and damaging (Hilgard, 1973; Spiegel, 1986). Hilgard (1973) was able to demonstrate experimentally that subjects maintaining dissociation under hypnosis could not perform certain motor tasks as well as subjects who were not maintaining dissociation. Understanding both these aspects of dissociation allows the therapist to work effectively with dissociative disorder patients.

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State-Dependent Learning and the Psychobiology of Memory

State-dependent learning (Overton, 1978) is a concept that refers to the connection between the learning experience and the biochemical and physiological state of the central nervous system at the time the learning is taking place. It has been a subject of investigation for over forty years (Rossi & Cheek, 1988). It has been noted repeatedly that certain drugs have profound effects on the retention and reinstatement of memory. For example, an individual under the influence of alcohol may not be able to remember the details of her "important philosophical conversation" until she falls into a similar state of inebriation. Hilgard (1977), aware of this, postulated that divided consciousness was in itself "the paradigm of state dependent learning." He noted, "The concept of dissociation employed by Overton is consonant with neodissociation theory. That is, two types of behavior may be isolated from one another because of different available information" (pp. 244-245).

An awareness of state-dependent learning and the role of informational substances released by the nervous system (Pert, 1981) makes way for an understanding of why hypnotherapeutic approaches can be so valuable in the treatment of dissociative disorders. Rossi (1993a) has postulated that hypnotic states allow informational substances within the nervous system to approximate their situations in earlier times. Thus memories can be revived and relived.

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Hypnosis and Memory

One of the more heated topics of debate among mental health and research professionals is whether memories obtained under hypnosis are valid. Age regression for the purpose of uncovering and reconstructing traumatic memories is a time-honored hypnotic technique frequently used with dissociative patients. However, there have been considerable objections to the validity of material obtained in this fashion both from scientific investigators (Pettinati, 1988) and from a group called the False Memory Syndrome Foundation, which is composed of professionals, family members who claim they have been falsely accused of perpetrating abuse, and others who are interested in the topic.

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The Nature of Memory

Memory is an extremely complex subject (Bowers & Hilgard, 1988). There are three stages of memory, each of which offers possibilities for distortion. The first is the acquisition stage. Memory can be encoded in a number of ways in this phase. For example, the encoding may be superficial or it may be deep, or it may be holistic or detail-oriented (Orne, Whitehouse, Dinges, & Orne, 1988). Material that is encoded through deep processing can usually be recalled and recognized more easily (Craik & Lockhart, 1972). Distortions can occur here for a variety of reasons, such as poor illumination, distance, expectation, etc. After memory is acquired, it is stored during the retention phase. Within this phase additional possibilities for distortion are present, as memories may lose their intensity or "fade," or be reworked, embellished, changed, or transformed by the unconscious mind for a variety of reasons.

Finally, distortions may occur during the stage of memory retrieval. The circumstances surrounding the retrieval can be extremely important. For example, false information supplied after an event can be accessed better than material previously remembered about the event. Thus an individual's version of an event can be revised in the light of information obtained after the details of the event have been stored in memory (Loftus, 1979; Loftus, Miller, & Burns, 1978). One form of information after the fact consists of leading questions; even when they are quite subtle (Loftus & Zanni, 1975), they are notorious for their ability to produce distortions that affect the validity of the retrieved memory (Bowers & Hilgard, 1988).

Memory can be long-term or short-term; also, there are thought to be two kinds of memory, episodic and semantic (Tulving, 1972). Episodic memory consist of events recalled by an individual within his life, whereas semantic memory is the memory of a general fund of information and techniques, such as how to brush one's teeth or ride a bicycle or what sugar is used for. The way an individual thinks and feels about the nature of what he produces as a recalled memory or mnemonic experience may bear some, little, or no correspondence to the accuracy of the material recalled. Thus, an individual may recall quite accurate material without realizing that there is any connection to its corresponding memory source of origin. This kind of memory is not perceived as something remembered, but rather as one's own original thinking (cryptamnesia). Memory material that emerges in this way can lead to accusations of plagiarism for the person who claims it as his own creative production. The other side of the coin is the situation in which a person may experience a "memory" with great confidence when there has been no corresponding experience in her history (confabulation). This "memory" is based on the person's inner life, associations, fantasies, wishes, etc. (Bowers & Hilgard, 1988). There is no doubt that memory can be the subject of many vicissitudes in each of its stages.

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The Effects of Hypnosis on Memory

Adding the element of hypnosis to memory opens possibilities for enhancing recall (hypnotic hypermnesia). Foundations for hypnotic hypermnesia are based on the work of such 19th-century clinicians as Janet, Freud, and Breuer, who used hypnosis for memory retrieval, and such contemporary researchers as Orne, Whitehouse, Dinges, and Orne (1988), who have noted that several experiments of a pioneering nature (Hull, 1933) appeared to confirm the clinical tradition. However, the use of hypnosis to improve recall is fraught with many possibilities for distortion. Orne et al. (1988) have reviewed a number of effects hypnosis has upon memory. Some the effects which must be taken into are:

1. "Normal reality-monitoring activities . . ." (Orne et al., 1988, p. 23) are relinquished within a calm and peaceful environment, as is immediate responsibility for one's actions. Material produced under hypnosis could be the result of the subject's feeling freer to report material she previously felt too uncertain to report in the waking state.

2. Essential to the hypnotic situation is the involvement of imagination and fantasy; consequently, in hypnosis there is an enhanced opportunity for fantasy and historically valid memory to become enmeshed.

3. Hypnosis increases suggestibility; consequently, there is a greater opportunity for hypnotically accessed memories to be intentionally or unintentionally contaminated through the nature of the questions, how they are asked, and many other potentially extremely subtle cues. The subject may not be able to distinguish between the details of her own memory and the material thus "implanted" by the questioner.

4. Critical judgment is reduced in hypnosis, while fantasy increases. This makes it much easier for the subject, especially if she believes that hypnosis can retrieve accurate memories, to be certain that particular visualizations or imaginations about what happened are indeed accurate when there is no objective basis for this.

5. Subjects may convincingly feign hypnosis and distort and lie; subjects who are truly hypnotized may also lie. Hypnosis is not a truth serum.

6. Confidence is increased in hypnosis. This, coupled with the heightened proneness to fantasy and the reduction in critical judgment also characteristic of hypnosis, can lead to firm belief that experiences without veridicality are truly being remembered.

Orne et al. (1988) have suggested that hypnotic age regression may facilitate the retrieval of memories by reinstating the encoding context and cues. Since hypnosis is a powerful tool for the mobilization of affect, it can be used to facilitate affect similar to the affect present during the storage of the memory material. Helping the subject get in touch with that affect could play a significant role in the retrieval process. There are many other factors that influence the role of hypnosis in memory retrieval, such as whether the material is meaningful or nonmeaningful, remote or recent, whether mood state dependency (Bower, 1981) exists, or whether the recall is forced (Orne et al., 1988).

There is experimental evidence that the trance state facilitates the introduction of false material into a recovered memory (Laurence & Perry, 1983). The controversy about the accuracy of "hypnotically refreshed" memories has led to extreme restraint in the use of hypnosis to recover material that will be used in courtroom testimony. Orne and his colleagues state good reasons for this. The first is the "fundamental unreliability" of hypnotically elicited memories. Secondly, these memories may persist in the waking state and be impossible for the witness to distinguish from what she recalled before she was hypnotized. Finally, the increased confidence that hypnosis bestows may give witnesses the appearance of unwarranted credibility to a jury.

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Clinical Context of Hypnosis and Memory

Our primary interest in the relationship between hypnosis and memory lies within the area of clinical work. Hypnotic phenomena offer the clinician unique opportunities to access the patient's inner mind and its memory material in order to locate and work with the conflicts and the resources that can be found there. Brown and Fromm (1986) remind us that the hypnotic process is highly cognitive when compared with other altered states of consciousness such as mindfulness meditation. In self-hypnosis, for example, the subject is able to utilize both primary process thinking to devise and produce the hypnotic experience and secondary process thinking for such things as self-suggestion for entering trance as well as for deepening (Brown, Forte, Rich, & Epstein, 1982-83). In heterohypnosis the patient's primary process cognition may produce unique imagery that does not spring directly from the suggestions of the hypnotist, even while the patient continues to use secondary process cognition for such things as planning how to respond to the hypnotist (Sheehan & McConkey, 1982; Spanos, 1982). Secondary process cognition continues throughout the hypnotic experience; however, there is a preponderance of primary process thinking (Brown & Fromm, 1986; Fromm, 1970).

Age regression is a hypnotic phenomenon that may be induced or occur spontaneously in trance and which may be accompanied by hypermnesia. Material that has been long repressed may become available in the trance state (Brown & Fromm, 1986; Fromm, 1970; Sheehan & McConkey, 1982). This reclaimed memory material may contain a richness of imagery not usually associated with the waking state (Fromm, 1979b).

Age regression is not characteristic of other altered states of consciousness (Brown et al., 1982-83). Its appearance during hypnosis is often accompanied by a greater than usual range of affect (Brown & Fromm, 1986). Thus, the uniqueness and richness of the hypnotic experience offer therapeutic opportunities not found within the waking state. "Hypnotized people have access to bodily sensations, emotions, memories, and fantasies that are usually beyond their grasp in waking consciousness. They also tend to think about such experiences in new ways while hypnotized. These factors contribute to the efficacy of hypnosis as an uncovering and an integrative method of therapy" (Brown & Fromm, 1986, p. 15).

Like psychoanalysis, hypnoanalysis works to uncover repressed and dissociated material. It differs from psychoanalysis in its ability to incorporate trance phenomena such as intensified imagery, age regression, and hypermnesia. In both psychoanalytic and hypnoanalytic work, memory material is worked through within the context of the transference and the defenses. Although memory material is produced with either method, hypnoanalysis has the advantage of more rapid access because of the unique phenomena associated with hypnosis. Even within the hypnoanalytic situation, however, memory material may appear slowly at times, and only incomplete or partial material may be available until the patient is strong enough to tolerate more information (Brown & Fromm, 1986). The hypnotherapist is obligated to be cautious during the uncovering process and to refrain from suggestion about what should be recalled. Patients need to be informed that memory material may not be at all precise, and that the decisions about its "truthfulness" or "not-truthfulness" belong to the patient.

It is also essential for the hypnotherapist to remember that legal issues about memory material are genuine. In many jurisdictions, material obtained during hypnosis, as well as before and after hypnosis is used, cannot be admitted into trial situations. It is recommended that informed consents about this issue be obtained from any patient before hypnosis is employed as a treatment modality.

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The "False Memory Syndrome"

The term "False Memory Syndrome (FMS)" was coined by the False Memory Syndrome Foundation (FMSF). The FMSF is located in Philadelphia and is composed of academics, scientific investigators, and others with special interests in memory, as well as family members who have been accused of abuse. They have organized to counteract the abuses and distortions resulting from the introduction of inaccurate memories retrieved during therapy into lawsuits and family relations. They are opposed to anyone who accepts the idea that the memories patients retrieve in therapy may possess validity, and have made a "straw man" of a self-help book written by two authors who are not licensed therapists, The Courage to Heal (Bass & Davis, 1988). One of their prestigious consultants is Elizabeth Loftus (1979, 1993), an academic researcher and a recognized expert in the field of memory. Loftus (1993) has rejected the validity not only of memories retrieved in psychotherapy but also of the concept of repression itself. In essence, the worth of all uncovering psychotherapy has come under attack, and this attack is receiving a great deal of attention in the popular press.

Gannon (1993) has viewed the FMS as a sociopolitical issue that must be confronted. Noting that the acceptance of abuse as a reality in our society is a relatively recent historical development, Gannon states that when any issue so previously repressed historically finally erupts into collective consciousness, it will undergo a process of continuous unfolding until it encounters resistances that place some limits on its further development. His concern is that with its political fervor the FMS movement could overshadow contemporary consciousness of child abuse and the status of adult survivors within the community. He cites Herman's (1992) view that, in the absence of a social movement to support its reality, knowledge that is "unpopular or disavowed" may be re-repressed by society. Herman refers to Freud's repudiation of the high frequency of sexual abuse in his female patients as an example of this. Gannon reminds us of the similar historical fate of MPD, whose acceptance as a clinical disorder has waxed and waned.

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Therapeutic Abuses of Memory Material

In total fairness, it must be said that there have been serious abuses in the eliciting of traumatic memory experiences and grave abuses by therapists in the management of material they have uncovered. Some therapists have invested too much of themselves in discovering trauma. This type of countertransference bias can lead to premature access to memory material with consequent increase in distortion, as well as to access of traumatic memory experiences even when they have not occurred. Through leading questions overzealous therapists can suggest to their patients events that did not transpire; this is especially easy to do with patients who are suffering from "hysteria." We have heard of a few therapists who go beyond suggestion with their patients, actually pressure them to "face the truth," and/or inform them that their personalities are identical with those of patients who have been abused.

We must never forget that the Malleus Malifacarum was actually written and used as a guide for the detection and prosecution of witches and sorcerers (Ellenberger, 1970; Zilboorg & Henry, 1941). Those witch hunts really did happen, and mass hysteria always carries the potential for the injury of innocent people.

Countertransference problems can also lead therapists to foster or even insist upon confrontational stances by patients on the basis of their memories. These confrontations can take place within the family, violently disrupting it, and may end with the patient ceasing to have contact with family members on a permanent basis, bringing criminal charges, and/or instituting civil suits. We think that confusion on the part of some therapists about what to do with uncovered memory experiences within the therapeutic situation has contributed to these abuses. As we shall subsequently discuss, the resolution of traumatic memories is an internal affair, not an external one; its management belongs within the therapeutic situation and not in a shoot-out situation in a court of law.

Child abuse is genuine and serious, and the fact that it exists has particular relevance for the kinds of patients we describe in this book. However, therapists have an obligation to remain objective in eliciting material, to avoid making suggestions or leading patients into any particular kind of memory material, to remain careful about their language, to keep open minds, and to view each case as a unique research opportunity. As Rossi (1993b) reminds us, if we do not adhere to careful standards to prevent therapeutic abuses of memory material, the therapeutic community could become the repository for the group projection of what is demonic or satanic in our society. Historically there have been trends in the treatment of mental illness that have waxed and waned over the centuries (Ellenberger, 1970; Gannon, 1993; Herman, 1992; Zilboorg & Henry, 1941). Having recovered humane and scientific approaches to dissociative disorders, the therapeutic community must act responsibly about their treatment, lest we assist in the demise of respect for our own profession as well as for the patients we treat.

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The Nature of Traumatic Memory Material

Some of the signs that may indicate some objective basis for memory material in actual past experiences are connected to the unique manner in which such material may appear. Usually it is accompanied by strong affect and cognitively structured in accordance with the age at which the trauma occurred (Brown & Fromm, 1986; Goodwin, 1993). Furthermore, traumatic memories are frequently accompanied by somatic phenomena and often remembered and reexperienced in the body itself.

According to Hammond (1993), memory research is frequently in conflict and what happens in the clinical situation may not be susceptible to experimental studies of memory functions. He concludes that the extreme positions of "false memory syndrome" proponents can have a beneficial effect on the field of hypnotherapy by engendering more relevant research and prompting greater carefulness by therapists during memory retrieval. He recommends a balanced middle position for the hypnotherapist on the FMS issue.

Hammond (1993) reminds hypnotherapists that there are probably good reasons for traumatic memory material to be available for recall with a fair degree of accuracy. One is that traumatic memories may be encoded differently from ordinary memories (van der Kolk, 1987a, 1994).

Another is that post-traumatic stress disorder (PTSD) is a biphasic condition. Victims of this disorder may be bombarded by intrusive memories and flashbacks during one phase, only to use their dissociative coping skills to separate themselves from these memories in the other phase (van der Kolk, 1987a, 1994).

Van der KolkÕs (1994) studies of memories associated with PTSD have led him to a neurological, biochemical, and developmental approach. According to van der Kolk, the limbic system within the brain stores traumatic memories. Within this system, a structure, the amygdyla, assigns and stores the meaning of traumatic events as semantic or procedural memory by allowing the nervous system to encode the emotional quality of the experience, while another structure, the septo-hippocampal system, records the spatial and temporal dimensions of experience; it also categorizes and stores material that is essential for episodic or declarative memory.

Childhood amnesia, as well as the lack of cognitive clarity for early memories, can be attributed to the developmental fact that the amygdyla matures much earlier than the hippocampus (which does not achieve full myelinization until the third or fourth year). The retrieval of traumatic memories that are processed through the amygdyla may contain many errors in details (van der Kolk, 1994).

The evidence for the dissociation or repression of childhood memory is compelling in the light of current clinical studies as well as the experiences of many therapists. Herman and Schatzow (1987) explored the problem from the standpoint of whether memories of sexual abuse retrieved in therapy could be objectively confirmed. In their sample, 74% of female victims were able to obtain objective confirmation many years later that the abuse had occurred, and 9% discovered strongly suggestive evidence for it. Interestingly enough, 11% of the patients in this sample made no attempt whatsoever to seek objective evidence of their abuse memories.

Williams (1992) conducted interviews with 100 adult females 17 years after they had received evaluations and treatment for suspected child sexual abuse. Within their charts could be found medical and forensic documentation suggesting that abuse had occurred. Using a protocol about childhood sexual experience in her interviews, Williams discovered that 38% of these women did not remember their abuse or had made a decision not to report it. Since a number of these women had revealed other highly personal material, it was concluded that amnesia for the abuse had probably occurred.

Like Spence (1982), Ganaway (1989) has distinguished narrative truth and historical truth. Narrative truth in psychotherapy, unlike historical truth, may be a mixture of "fact and fantasy." He cites Kluft's description of various kinds of memory material appearing in therapy: "photographic recall, confabulation, screen phenomena, confusion between dreams or fantasies and reality, irregular recollection, and willful misrepresentation. One awaits a goodness of fit among several forms of data and often must be satisfied to remain uncertain" (Kluft, 1984b, p. 14).

There will objections to this approach to material uncovered in therapy. For some it may suggest that we are imitating Freud and denying that abuse has occurred or that specific kinds of abuse such as mind control and other kinds of cultic abuse exist. We wish to state emphatically that we do not utilize the therapeutic relationship to gloss over or deny any kind of abuse. Like Sachs and Peterson (1993), we regard ourselves as engaging in a process that helps the patient reclaim her own life and history. We simply do not think that the therapist should attempt to play God in the matter of assigning meaning to memories appearing in the course of therapy. This is especially relevant in view of the complex nature of memory.

The crucial issue for the clinician is to understand that as a therapist she must accept what her patient is telling her and must not assume the role of arbiter of the nature of reality for her patient. Although this position may seem difficult, it is a necessary one for the therapeutic situation. The productions of the patient in therapy are gifts of self. The patient has had to overcome many feelings, such as shame, guilt, inner terror, and the fear of rejection by her therapist, to assume the vulnerable position of confiding sensitive memory material. The patient is not writing a history book; she is, rather, sharing with the therapist her innermost reality. In accepting this reality, the therapist accepts the patient in a way she may never have been accepted previously. Many of our patients were told they were liars, crazy, troublemakers, and disgusting when as children they attempted to reveal certain abuse. Accepting the patient's reality as the patient's reality is essential to the therapeutic alliance and to the work of therapy. It also means accepting the patient.

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Case Example: Theodore

Theodore had entered treatment with me (CF) because of the crippling symptoms of obsessive compulsive disorder. During the early weeks of treatment he learned self-hypnotic techniques, which he enjoyed using at home. During one self-hypnosis session in his hot tub he began to get the impression that he had been sexually abused as a child. Associated with this vague and troublesome impression were visual images of his favorite uncle. I (CF) encouraged him to keep an open mind about all of this material.

Theodore was quite disturbed that his uncle might turn out to have been his abuser and obsessed about whether he really wanted to know if this were the case. Again, I reassured him that we didn't really know what his vague impressions meant and that it was extremely important that we not decide ahead of time what kind of information, if any, might be found. I also made it clear to Theodore that he was the person who would decide if we would proceed with an exploration of the vague sense he had reported. Theodore made a decision to proceed because he felt that whatever "it" was had an important role in the production of
his symptoms.

Ego-State Therapy techniques were used in Theodore's therapy. An ego state or subpart of Theodore's personality was a child state that held the memories of a painful and terrifying incident in Theodore's childhood. With the help of other personality parts this child ego state was able to recall, and the patient reexperienced in hypnotic age regression, the patient's brutal anal rape by the family handyman. His uncle had appeared on the scene shortly after the rape, but Theodore had been threatened with murder and could not turn to his uncle for assistance.

In this case the therapist's refusal to jump to conclusions and her request that the patient join her in maintaining an open mind allowed aspects of the patient's unconscious mind to bring out memory material in an organic way and to avoid a facile, premature, and erroneous indictment of his uncle. The decision to explore or not to explore did not belong to the therapist; it was the patient's
to make.

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Diagnosis of the Divided Self

Making the diagnosis of a dissociative disorder is extremely important. Dissociative conditions are often confused with many other disorders, such as bipolar disorder, endogenous depression, and borderline personality disorder. Fortunately, the prognosis for dissociative conditions which receive appropriate treatment is usually quite good when contrasted with that of certain disorders with which they are often confused.

The most critical element in the diagnosis of problems reflecting self-division is an awareness of the possibility that dissociation could be involved as a causative agent of the presenting complaint. The clinician must be oriented also to contemporary thought concerning the prevalence of traumata in childhood and their sequelae in adult life. The Dissociative Experiences Scale (DES) (Bernstein & Putnam, 1986) and the Dissociative Disorders Interview Schedule (DDIS) (Ross, Heber, Norton, & Anderson, 1989) are valuable clinical tools for helping to make the diagnosis. The diagnosis of dissociative disorders is best done by clinicians who have received intensive training in this area. Membership in the International Society for the Study of Dissociation (ISSD) and subscription to the journal Dissociation are strongly recommended. We also strongly recommend specialized reading about the specifics of diagnosis for multiple personality disorder (Putnam, 1989; Ross, 1989), as well as training in its diagnosis and treatment. This can be obtained through the American Society of Clinical Hypnosis (ASCH), the Society for Clinical and Experimental Hypnosis (SCEH), the ISSD, and many local component societies of ASCH.

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Clues to the Presence of Dissociative Disorders

Many conversion disorders, fugue states, and other conspicuous amnestic disorders present few or no problems in diagnosis. However, making the diagnosis in less clear-cut situations can be challenging (Abse, 1966). Clues to the presence of dissociative disorders and ego-state problems include amnesia for significant portions of childhood, childhood recollections of trauma or information from family members that such trauma occurred, and a history of marked changes in behavior during childhood. Patients who are highly responsive to hypnosis should always be screened for dissociative symptoms. The presence of symptoms that are ego-dystonic is an important clue. So also is the presence of the "language of parts" within the interview situation. The patient who says, "a part of me wants to do this, and another part wants to do that," is expressing a divided self and may be a candidate for ego-state exploration, as is the patient who says, "I found myself doing thus-and-so, and it just wasn't like me at all."

Sometimes using the language of poetry and metaphor to describe symptoms (Frederick, 1993) for example, using terms such as "pools of sadness" or "wellings" to describe depressive symptoms is suggestive of dissociative problems. Intrusive behaviors such as muscular jerking or trembling, tics, spasms, tightness, a loss of motor power, or minimal voice changes should alert the therapist to the possibility of a dissociative disorder.

Within the sensory realm such phenomena as transient pain, parasthesias, itching, "weird" feelings of heaviness or lightness can suggest such problems. Other behaviors that raise an index of suspicion are certain psychophysiologic reactions indicative of post-traumatic stress, such as nausea, headache, diarrhea, or vasomotor changes. Marked changes of affect or affects out of proportion to the individual's current situation are also suspect. Finally, refractoriness or unresponsiveness to treatment should always lead the clinician to suspect an undetected dissociative condition meriting hypnotic exploration.

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Healing the Divided Self

We recognize that there are many ways that the "divided self" can be healed. Such healing took place before the advent of formal psychotherapy through the work of shamans, priests, and other nonprofessional healers (Ellenberger, 1970). Within the psychotherapeutic realm many approaches have been utilized, ranging from persuasion (Dubois, 1904) to psychoanalysis and psychoanalytic psychotherapy (Abse, 1966) and cognitive approaches (Jehu, Klassen, & Gazan, 1985). Within the Ericksonian realm emphasis has been placed on indirect hypnosis, metaphor, and internal resources (Dolan, 1991; Gilligan, 1987; Grove & Panzer, 1989). Hypnobehavioral imagery (Kroger & Fezler, 1976) and hypnoanalytic work (Brown & Fromm, 1986; Crasilneck & Hall, 1975) have also been valuable in dealing with these disorders.

We use both traditional and Ericksonian hypnotherapeutic approaches. Once the treatment parameters are established with the patient, the treatment process involves uncovering the traumata that are presumed to have caused the dissociative symptoms and strengthening the personality sufficiently to establish mastery over and integrate the uncovered material. Hypnosis is of unparalleled assistance in this process because it enables the patient to enter the psychological and biochemical state in which state-dependent learning originally occurred and permits activation of individual ego states for therapeutic work. We endeavor to help personality parts tolerate uncovering and abreaction without retraumatization, to master, renegotiate, and integrate the recollected experiences, to become strengthened, and to mature to such an extent that inner harmony can be restored. The balance between ego-strengthening in the present and uncovering of experiences from the past is critical.

We emphasize utilizing the patient's own internal resources and assist the patient in learning to direct those resources into mind/body discovery, correction, reorganization, and integration. In addition, we encourage interaction with the community, so that the patient learns to reach out beyond herself in appropriate ways and to form strengthening ties with others.

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