An Exploration of How Children with Dissociative Identities May Present in Psychotherapy
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DISSOCIATIVE IDENTITIES IN CHILDHOOD: An exploration of how children with dissociative identities may present in psychotherapy. Are there implications for psychoanalytic technique? JO RUSSELL Professional Doctorate in Child and Adolescent Psychotherapy University of East London MAY 2015 i ABSTRACT Children who have experienced early relational trauma in the realms of neglect and abuse may go on to develop a range of dissociative states of being as a consequence or as a defence. Child psychotherapists are frequently referred children struggling with such a legacy, yet for historical reasons dissociation is notably absent from the psychoanalytic literature and not a formal part of our professional training. This thesis aims to illuminate how dissociative children may present in psychotherapy sessions and to assess whether there are indications that traditional psychoanalytic child psychotherapy technique may need adjusting if treatment is to be most effective. Current theory regarding the aetiology of dissociative pathology is presented including the significant contributions from attachment and neuroscience research, and the slender view offered by psychoanalytic theory is elucidated. Case histories of two of the three participant children are presented with specific reference to attachment and trauma. Process recording notes from the psychotherapy of all three dissociative children are subjected to thematic analysis to arrive at two sets of patient and therapist related themes which are then recursively discussed in fine detail to determine what evidence the material provides. The conclusion is drawn that whilst dissociative children present with some distinct difficulties, these do not dominate the therapeutic endeavour and are largely similar to the presentation of traumatised and attachment disordered patients with whom child psychotherapists are very familiar. Furthermore it is suggested that whilst child psychotherapists treating dissociative children should consider psychoeducuative, organising and validating interventions, their core psychoanalytic skills of withstanding and analysing hostile and perverse transference material, together with their experience in creatively bringing all parts of the self to the child‟s conscious awareness are central to helping dissociative children recover. ii ‘La théorie, c’est bon, mais ça n’empêche pas d’exister’- Theory is good, but it does not prevent things from existing Charcot cited by Freud in his obituary 1893 iii DECLARATION I declare that while registered as a research degree student at UEL, I have not been a registered or enrolled student for another award of this university or of any other academic or professional institution. I declare that this thesis is my own work. iv CONTENTS Title Page…………………………………………………………………………………i Abstract………………………………………………………………………………….ii Declaration……………………………………………………………………………...iv Contents……………………………………………………………………………….....v Format…………………………………………………………………………….……..ix Abbreviations…………………………………………………………………………….x Acknowledgements……………………………………………………………………..xi Dedication……………………………………………………………………………...xii 1. Introduction……………………………………………………………….…………1 1.1 Dissociative disorders exist!……………………………………………………2 1.2 Traditional child psychotherapy is not always helpful………………………..3 1.3 Outline of chapters………………………………………………………………5 2. Theorising the Aetiology of Dissociative Disorders………………………………7 2.1 The Structural Dissociation Model…………………………………………..7 2.2 Building a developmental model……………………………………………10 2.2.1 Dissociative conditions as state-change disorders…………………………10 2.2.2 Dissociative disorders and disorganised attachment……………………11 2.2.3 The neurobiology of dissociation…………………………………………13 2.2.4 Silberg‟s Affect Avoidance Model of dissociation…………………………15 2.3 The Contribution from Psychoanalysis…………………………………….16 2.3.1 Breuer and Freud…………………………………………………………16 2.3.2 Ferenczi……………………………………………………………………..18 2.3.3 Fairbairn……….……………………………………………………………19 2.3.4 The Imaginary Twin – Bion……………..…………………………………21 2.3.5 The Pathological Organisation – Rosenfeld………………………………..23 2.3.6 The Cohabitee Twin – Michael Sinason…………………………………...24 2.3.7 Relational Psychoanalysis: Bromberg, Stern, Kluft………………………25 2.4 Summary…………………………………………………………………...….28 v 3. Case Histories: How „I‟ became „Us‟……………………………………………30 3.1 Kayleigh‟s Story……………………………………………………………30 3.1.1 A compromised parental landscape………………………………………..30 3.1.2 Surviving in shifting sands and high seas…………………………………31 3.1.3 Precipitating trauma………………………………………………………32 3.1.4 A compounding trauma……………..……………………………………33 3.1.5 A second precipitating trauma……….……………………………………34 3.1.6 Dissociative escalation…………………………………………………….36 3.2 Frank‟s Story…………………………………………………………………38 3.2.1 Compromised from before the beginning?………..………………………38 3.2.2 Primary neglect……………………………………………………………39 3.2.3 Physical and sexual abuse…………………………………………………41 3.2.4 Institutionalisation…………………………………………………………43 3.3 Robbie‟s Story………………………………………………………………….46 3.4 The participants and diagnosis............................................................................47 3.5 Summary - Dissociation three ways....................................................................49 4. Methodology……………………………………………………………………….51 4.1 Selecting the participants……………………………………………………51 4.2 Ethics and informed consent…………………………………………………51 4.2.1 Seeking consent from children in psychotherapy…………………………52 4.2.2 Seeking consent from participants with dissociative conditions…………55 4.2.3 Seeking consent from Kayleigh, Frank and Robbie……………………57 4.3 The Single Case Study methodology…………………………………………59 4.4 Process Recording as a method of gathering „raw‟ data………………………61 4.5 Selecting a sample……………………………………………………………63 4.6 Selecting a method of analysis………………………………………………65 4.6.1 Thematic Analysis…………………………………………………………65 4.6.2 Theoretical assumptions…….……………………………………………..67 4.6.3 Specific assumptions……………………………………………………....69 5. Initial Findings……………………………………………………………………70 5.1 Phase 1 - Findings from the familiarising „re-read‟…………………………70 5.2 Phase 2 - Generating initial codes……………………………………………71 5.3 Phase 3 - Refining initial codes to candidate themes…………………………74 vi 5.4 Phase 4 - Refining candidate themes…………………………………………79 5.4.1 Merger…………………………………………………………………….79 5.4.2 Sub-setting………………………………………………………………80 5.4.3 Candidate themes.…….....……………………………………………..….81 5.5 Summary ………………………………………………………………………83 6. Reviewing and Analysing Patient Themes (Phase 5 part 1)………………………84 6.1 Varying Capacities……………………………………………………………84 6.2 Switching……………………………………………………………………87 6.3 Amnesia………………………………………………………………………91 6.3.1 Amnesia and memory for traumatic events………………………………92 6.3.2 Pervasive forgetfulness……………………………………………………93 6.3.3 Secondary „forgetting‟……………………………………………………94 6.3.4 Forgetfulness on the part of the therapist…………………………………96 6.3.5 Is dissociative amnesia distinctive?………………………………………97 6.4 Alternative Identity Relations…………………………………………………97 6.5 Identity……………………………………………………………………102 6.5.1 The use of a „second skin‟………………………………………………103 6.5.2 Shared delight in emphatic „islands‟ of identity………………………104 6.5.3 The nature of identity and transformation………………………………108 6.6 Responsibility…………………………………………………………………110 6.6.1 Projection of responsibility………………………………………………110 6.6.2 Confusion over agency……………………………………………………111 6.7 Connectedness………………………………………………………………115 6.7.1 A counter-intuitive result………………………………………………115 6.7.2 Moments of re-connection………………………………………………117 6.7.3 Dissociated disconnection………………………………………………119 6.8 Parental Landscape…………………………………………………………120 6.8.1 Confusing / neglectful parenting………………………………………120 6.8.2 Perverse / abusive parenting……………………………………………123 6.8.3 Caring parenting…………………………………………………………124 6.8.4 What can I make of my therapist‟s parenting?…………………………126 6.8.5 Summary.....………………..……………………………………………..127 6.9 Summary of Patient Themes………………………………………………….127 vii 7. Reviewing Therapist Themes (Phase 5 part 2 )…………………………………130 7.1 Attitude to Alternative Identities .…………………………………………130 7.2 Attitude to Integration………………………………………………………136 7.3 Psychoeducation………………………………………………………………141 7.3.1 Is psychoeducation psychoanalytic?……………………………………141 7.3.2 Psychoeducation about sexual matters……………………………………143 7.3.3 Psychoeducation about dissociation………………………………………145 7.4 Organising……………………………………………………………………146 7.41 The Kleinian perspective…………………………………………………146 7.42 Organising resistance to anarchy…….…………………………….……147 7.43 Finding order - what are the „rules‟?………………………………………150 7.5 Resisting Abuse………………………………………………………………151 7.5.1 The value of saying „No!‟………………………………………………151 7.5.2 Resisting collusion, diminishing perverse excitement……………………152 7.5.3 Understanding and using the transference………….……………...……..153 7.6 Summary of Therapist Themes.........................................................................154 8. Conclusions………… …..………………………………………………………..156 8.1 Evaluation……………………………………………………….……………156 8.1.1 Shortcomings……………………………………………………………….156 8.1.2 Advantages…………………………………………………………………157 8.2 A Tentative Thematic Map…………………………………………………...159 8.3 Conclusions…………………………………………………………………...162 8.4 Implications for Future Research……………………………………………..163 8.5 Final Thoughts………………………………………………………………..163 References……………………………………………………………………….……166 Appendices……………………………………………………………………………181 viii FORMAT There are several formatting procedures employed for clarity which it may help the reader to be familiar with before embarking on the main text: 1. Participants‟ distinct personified