The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization (Norton Series on Interpersonal Neurobiology)

Let my say first that I love in-depth, useful theoretical perspectives. For a therapeutic theory to be useful in practice it should be general enough to be applied to a wide variety of cases, leaving plenty of room for the client's lifeworld, and specific enough to be an effective and efficient use of the client's time (i.e. progress in therapy need not take years and hundreds of thousands of dollars). I say this so that no one imagines my review is based on a reluctance to think outside of my own worldview.

To the point: The analysis in this book is shortsighted and excessively verbose breeding, in my opinion, unnecessary distinctions. It also attempts to be eclectic (although, ironically, it ignores certain insights from behavioral psychology, lest we forget exposure-based therapies are the gold standard and were born from a behavioral perspective). I would also say that it is limited in its appropriation of "systems theory." The authors don't clearly express what they mean by this, but my assumption is that they mean family therapy and its connection with "cybernetics." This is a topic that is beyond the scope of this review, but suffice to say the authors use a particularly rigid approach to complex systems (probably due to their simplified view of evolution and neglect of developmental plasticity). For readers interested in a well-developed systems theory, I highly recommend looking at B. Keeney's "Aesthetics of Change." For more complex, accurate, and context-sensitive works on evolutionary theory, I recommend works such as "Evolution in Four Dimensions" by E. Jablonka and M.J. Lamb and "The Symbolic Species" by T.W. Deacon. Along with these points (i.e. neglect of in-depth theory and/or theory supported by scientific evidence), the authors pretty much entirely ignore the importance of cultural and historical context, both of the patient and of psychotherapeutic theory and therapeutic psychology more broadly (I give broad recommendations that stand in as adequate replacements for this book at the end of this review).

The definition out the gate of trauma is: "a structural dissociation of the personality" (vii). Yikes. Already we know we're going to need a few philosophers on deck to wrangle this one in. Okay, let's get into this. Let me first say that the authors seem to accept uncritically the cluster of "dissociative disorders" found in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and proceed to organize (primary to tertiary) the severity of the individual's disorder based on the degree of lack of structural integrity of one's "personality." This is not the place to critique the DSM and I'm not making the tired argument that the DSM is a poor framework and therefore should be ignored. Therapeutic professionals have to engage with it whether they like it or not. They don't have to engage with it uncritically however, or rigidly accept its terms and definitions without comment or qualification. In fact, anyone well read in the literature should be providing those qualifications, but you won't find them here.

They also quickly introduce to us, without telling us so, the modular theory of mind from evolutionary psychology, which they accept as factual (this is quite problematic and almost certainly wrong, but this requires analysis beyond the scope of this review; See: "Sex and Death: An Introduction to Philosophy of Biology" by K. Sterelny and P.E. Griffiths for a more nuanced read on this subject, and evolutionary biology more generally; also see Deacon's text referenced above). I'm not going to introduce what I would call the verbose neural-compartmentalization verbiage that develops from their modular assumption, you'll find it in other reviews if you're interested. We are already on the shaky grounds of an incredibly unconscious naive realism. They seem to use this way of thinking about behavior influenced by our evolutionary history to examine the components that are in disarray within an individual's personality. Personality seems to be defined in terms of the structural integrity and internal consistency (my, in my opinion, much clearer verbiage) within the individual's body-mind "system." We are going in circles here even as the authors said they were going to cleanup the mess, which presumably meant developing definitions with more precision… Clearly not so. I’m not trying to argue there is something ‘bad’ about abstract concepts, but introducing layers of abstract concepts on top of each other with little to no grounding precision anywhere starts to sound like word play.

While I'm not in complete disagreement with their insights, this is already a patchwork job with items uncritically pulled from here and there, relying on a lot of authority from a variety of fields, and quite careless and presumptive assertions of fact. To the unknowing reader this will sound pithy and profound. Frankly, you may find some diamonds in this mud, but it's a hell of a lot of mud.

That being said, let me show you a diamond while we're on the subject: "[Trauma victims] must go on with a daily life that sometimes continues to include the very people who abused and neglected them. Their most expedient option is to mentally avoid their unresolved and painful past and present, and as much as possible maintain a facade of normality.“ (1). I think of this as one of those beautiful lines that gets right up close to an insight that seems obvious at first read, but is understated in the literature. They go on to make the (useful) distinction between the part of the person that must maintain a sense of being cohesive ("normal" meaning appearing cohesive while tolerating an incredible amount of pain) and the part that requires outlet and acts on impulse (my verbiage) from the emotions that must be regulated amidst a social public. Chronic avoidance of painful sensations, feelings, thoughts, and memories is thus presented to us a developed strategy for having to appear cohesive to others under threatening circumstances. Bravo! If we stayed with this without wandering into conceptually confused analysis and problematic notions of how the mind operates, we would be cooking!

As we move forward with the above convoluted definition of trauma they rightly argue that dissociation is used in a variety of ways in therapeutic literature that creates conceptual murkiness, even as we’ve developed certain psychometric means of assessing it. However, they go on to define dissociation, alongside Pierre Janet (their guru in this theory) as "division of the personality or of consciousness." (2). They elaborate, sure, but this is a 'getting back to the start' moment. What's incredible is that they uncritically accept his authority and proceed with his theories of energy and efficiency (let’s not get into this right now, I didn't personally find these terms of much help, and we're already up to our waist). His work with dissociation alone and the development of the ‘dissociative personality’ demands particular examination (I. Hacking's "Rewriting the Soul" covers this brilliantly), but so do the motives of his particular therapy, which may not be appropriate for all clients. It is as if we have lost our way, but Janet had it all right. I don't even want to take the reader through the details of this particular muck, but suffice to say the authors, in addition to more philosophical and historical depth, could use one of Occam's Razors here in discussing impulsive actions vs. actions in which 'mindful' awareness is operative (to be brief, if vague). They also more generally commit the fallacy that the earliest example of a definition is somehow the 'most right.'

It is also here that they introduce "substitute actions" (vs. "integrative action"), and I suspect this is where some of the reviewers with a trauma history became (rightly) agitated in the reviews. Behaviors such as "cutting" are "less adaptive than required when the challenges of life exceed the mental level of the patient." (10; can you believe we're only on page ten? You can move quickly when you just assert your “facts” without analysis).

This is an example of what is wrong with some cognitive theories, and certainly the theories of evolutionary psychology: They take the normative for granted (to say nothing of how sociocultural norms interact with our neurological development). There is also (arguably) a kind of problematic detachment on behalf of the writers here toward the "patient" which sounds quite dehumanizing. But back to the “normative”… adaptive according to what? That beautiful quote above demonstrated how the normal is relative to the patient's life history, but now the authors are using their mish-mash of theories to assert a "normal" based on some average, and using notions of evolution to do so. They also insert a kind of ‘objectively rational’ viewer into their elucidation. And so they depart from their start. Our theory is now one in which we are organizing the client’s behavior according to evolutionary (assuming you take such dubious assertions from evolutionary psychology to be so called) and (ostensibly the therapist’s) norms of “rationality.”

I'm sure we can all agree that impulsive and potentially harmful safety behavior (like cutting) needs to be replaced to reduce harm. We then need to work on helping the client develop mindful awareness of impulsive actions while working with exposure modalities to reduce emotional intensity and confront the emotional past the client is coping with (i.e. developing context-sensitive behavior). And overall, yes, to help the client to feel like a ‘whole’/cohesive person capable of regulating challenging emotions while moving in the direction of their life values. I don't think this theory does much but make a mess around trying to explain and justify (largely based on the authority of selected problematic figures and theories) the mind of the individual with complex post-traumatic stress.

They then take later take us through "phases of treatment" that are quite standard. Establish safety and rapport with the client, work with trauma memories, and then establish "personality integration and rehabilitation." For the record, I have found it tremendously useful to work with the competing 'fragments of mind' of the client. I think these "fragments" are best viewed as composed of the vulnerability and powerlessness associated with the early trauma, the protective defenses (the analytical part of the mind and the impulsive actions to immediately address the sensations that feel unsafe) and the part that aligns with the client's mindful awareness. Here "Internal Family Systems" has been helpful at addressing this sense of personal fragmentation that often accompanies complex post-traumatic stress.

As for the process, I think the authors are relatively rigid in their approach to cases, but this part of the book is the most sensible, in my opinion. It provides a road map that is found anywhere the word trauma is used, and therefore is probably ‘old hat’ for the experienced therapist. Complex PTSD is often presented as some kind of neglected new frontier. This book is no exception. And yet, we somehow always end up arriving in such texts to what is already commonly known by professionals to work for these conditions.

Admittedly I skimmed the middle parts, which just dive deeper into the above distinctions. When your starting point is presumptuous, the misconceptions merely reproduce more misconceptions.

All and all, if you like wordiness and managing an array of concepts regardless of their usefulness, if you can uncritically accept an author’s point of view and have no interest in how it is situated historically or culturally, if you don’t mind logical fallacies and careless appropriation of theory, you may like this book. I personally can’t think of anyone to recommend it to though.

My recommendation? Check out: "Treating Complex Traumatic Stress Disorders in Adults," edited by J.D. Ford and C.A. Courtois and "Culture and PTSD," edited by D.E. Hinton and B.J. Good. These texts will point the reader toward a variety of effective approaches (and problems with diagnostics and diagnosis) and theories with historical and cultural nuance in tact.