Deconstructing DID

Article excerpt

The author contends that a psychoanalytically informed approach to the patient with dissociative identity disorder (DID) can be very useful However, there are difficulties in conceptualizing this condition without extending existing theory or applying in new ways what is already known. It is also difficult to put DID in a proper context relative to all the other disorders known to occur in the human mind. Depending on one's clinical experience, level of skeptism, and appreciation Of history, DID may be seen as either.- a) the psychological 'missing link" that realizes Freud's goal of uniting the psychology of dreams with psychopathology, or b) a fraudulent condition that i@ wittingly or unwittingly manufactured in the therapist's office or c) a population of disturbed and disturbing patients, once the subject of great scientific interest, which, exiled like a 'Lost Tribe,' is now back in the fold of legitimacy. The author has had extensive clinical experience with psychic trauma, and bases his own views of DID on three assumptions: 1. that dissociation may be seen as a complex defense; 2. that DID may be thought of as a 'lower level dissociative character",- and 3. that there is a unique psychic structure, the 'dsisoctative seff' whose function is to create 'alter personalities' out of disowned affects, memories, fantasies, and drives. This 'dissociative self' must be dissolved in order for integration of "alter personalities' to occur A clinical vignette is offered to illustrate bow be addresses some of the challenges of developing a therapeutic alliance at this end of the dissociative-character-pathology continuum, and bow be grapples with the difficulty of integrating clinical phenomena, such as the appearance of "alters, " with the psychoanalytic model of the mind.

INTRODUCTION

For the past two decades, I have been involved in the psychoanalytic study of the effects of massive psychic trauma on mental functioning. My work started with adult survivors of the Holocaust and the transmission of their trauma to their children, i.e., the second generation. My research then extended into the realm of child survivors, as I participated in an international. interviewing project, collecting data on the longitudinal effects of profound early trauma on development (1). During this time I fortuitously met Richard P. Muft, M.D., at the Institute of Pennsylvania Hospital, whose historic work (which is reviewed on pp. 289-319 in this volume) with dissociative disorders had already come into prominence (2). His patients had also reported severe early trauma, but more often it was associated with domestic physical and sexual abuse, not the deprivation and atrocities associated with genocidal persecution. Furthermore, their seemingly bizarre altered states, different selves, amnesia, and suicidal aggression presented a different set of challenges to the treating clinician.

Adding to the complexity of these patients, many of whom seemed somewhere between borderline personality and schizophrenia, while also suffering from substance abuse or anorexia, was the fact that they were being treated by a different approach. This was a cognitively and psychodynamically informed hypnotherapy, which used a different language to describe the structure and function of the mind. Since a number of Dr. Muft's patients were admitted to my inpatient unit before he started his Dissociative Disorders Unit (DDU), it was not only an extraordinary opportunity but also an administrative necessity to try to understand what was going on with their care. It was bewildering and overwhelming at first, since I did not understand the paradigm being used and could not readily apply my psychoanalytic model of the mind to this psychopathology.

My background in Holocaust research taught me to tolerate my own pain while listening openly to horrendous stories of unspeakable atrocities, and to become aware that human beings are indeed capable of inhumane sadistic behavior. …