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Clinical & Theoretical Issues in the Treatment of
Pathological Dissociation and DID
Elizabeth Howell, Ph.D. & Sheldon Itzkowitz, Ph.D.
Class Location
Dr. Howell’s Office
225 East 26th St., Suite 5K
Between 2nd & 3rd Avenues
Time Of Class
Fridays 2:30 pm to 4:30 pm
As the 20th century came to a close, a reemergence in the
interest in dissociation as a defensive strategy to cope with
unsymbolizable experience in childhood began to develop.
Simultaneously, a theoretical shift in conceptualizing the
nature of mind emerged. Mind, once thought to be singular,
bounded and continuous, is now understood to be structured
as multiple, unbounded and discontinuous. This became the
foundation for replacing repression with dissociation as a
major means of defending the self from flooding and
overwhelming experiences; experiences that Sullivan would
have relegated to the “not me”. Gradually, those who worked
with dissociative disordered patients (Bromberg, Stern,
Howell, etc.) began to write about Dissociation not simply as a
means of defense but as a process by which the mind is
structured. Early studies of mother-infant dyadic interactions
lead to the study of the nature of attachment and its
implication for later development. More recently it has been
learned that dissociation and DID, result from disordered and
disorganized attachment during the earliest phases of life as
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well as from overwhelming traumatic experiences of
childhood.
This course is designed as a clinical, experiential and
theoretical venture to explore how the traumas of real life, not
merely fantasized experience in early childhood, structure the
mind dissociatively so that aspects of the child’s understanding
of the external world, internal experience and feelings become
unavailable to conscious attention, segmented, and/or
unformulated. Dissociative Identity Disorder (DID), a complex
defensive method of coping with overwhelming interpersonal
trauma is not so different in kind from more “normal”
dissociative segmentation of experience. Yet, DID involves the
development of different segments of experiencing that have
their own sense of separate identity—their own sense of an
“I”—including a sense of personal autobiographical memory;
and they may have different names. This division of the self
into different dissociated subjectivities puts people with DID at
a loss as to how to understand or explain their experience and
it often makes their lives very difficult to manage.
Recent studies (e.g., Brand, Classen, Lanius, et al., 2009) have
shown that the prevalence rates of dissociative disorders in
outpatients range from 12-38% of the population. Despite the
frequent denial of the existence of DID, current epidemiological
research sets the prevalence of DID at 1.1% to 3% of the
general population (ISST-D Guidelines, in press). However,
because of the paucity of training, clinicians are often at a loss
as to how to recognize, diagnose, and work with their highly
dissociative patients. All too frequently, when clinicians do
recognize that their patient has a serious dissociative disorder,
they fear that they will be unable to acquire the skills
necessary to treat dissociation and that they must refer their
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patient out. A therapeutic relationship may thus be
unnecessarily broken.
Candidates will learn about the early pre-analytic work done
on dissociation and the contributions to understanding the
“Dissociative Mind” from the Interpersonal and relational
models. Modern thinkers such as, Bromberg, Howell, Stern, and
Chefetz will be studied. Analytic case material in the form of
video clips from Dr. Itzkowitz’s clinical practice, as well as case
material from candidate’s practices, will be used to highlight
and demonstrate many of the concepts underlying the
treatment of DID. An exploration of neuroscience and cognitive
contributions to dissociation, along with contributions from
attachment theory will further inform the candidates
understanding of theory and practice. Finally, candidates will
learn, how to handle difficult clinical situations that inevitably
arise in the work with DID patients.
Treatment of Traumatic Dissociation and Dissociative
Identity Disorder:
Clinical & Theoretical Issues
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Elizabeth Howell, Ph.D. & Sheldon Itzkowitz, Ph.D.
Syllabus
Week 1. Dissociation: A Model of the Psyche
Brief Video Presentation-Itzkowitz
Readings:
1. Bromberg, P.M. (2001a), The Gorilla Did It: Some Thoughts
on Dissociation, the Real and the Really Real. Psychoanalytic
Dialogues, 11:385–404.
2. Howell, E. (2005) The Dissociative Mind. Hillsdale, NJ: The
Analytic Press.
a) Introduction: pp. 1-11.
b) Chap. 1, Dissociation: A Model of the Psyche, pp. 14-37
3. ___________(2011), Understanding and Treating Dissociative
Identity Disorder. NY Taylor & Francis
a) Introduction: pp. 3-8.
b) Chapter 2: The Dynamic Unconscious and the
Dissociative Structure of the Mind, pp. 27-38, sections on
Relationality and Multiplicity, Dissociative multiplicity,
and The construct of the unconscious.
4. Stern, D. (2010) Partners In Thought. NY: Taylor & Francis
Chapter1
Week 2. Early History of DID
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Brief Video Presentation-Itzkowitz
Readings:
1. Ferenczi, S. (1931). Child Analysis in the Analysis of Adults.
2. Ferenczi, S. (1932/1949). Confusion of Tongues Between the
Adult and the Child. International Journal of Psycho-Analysis,
30, 225–231.
3. Howell, E. (2011) Understanding and Treating Dissociative
Identity Disorder. NY: Taylor & Francis.
Chapter 2: The Dynamic Unconscious and the Dissociative
Structure of the Mind, pp. 38-54, “DID as the Cheshire Cat:
Now you see it, now you don’t: The Social and Historical
Context that Shaped our Understanding of DID.”
Week 3. Interpersonal Contributions And Relational
Traditions
Brief Video Presentation-Itzkowitz
Readings:
1. Sullivan, H. S. 1964 The illusion of personal individuality. In:
The Fusion of Psychiatry and Social Science. New York: W. W.
Norton and Company, Inc.
2. Howell, E. (2005) The Dissociative Mind. Hillsdale, NJ: The
Analytic Press.
Chapter 4:Interpersonal Contributions and Relational
Traditions: Sullivan, Bromberg, Davies and FrawleyO’Dea and Stern. Howell, E. (2005). Chapter 4, pp. 92-120.
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3. Hirsch, I. (1994) Dissociation and the Interpersonal.
Self Contemporary Psychoanalysis 30: 777-799
4. Hirsch, I. (1997) The Widening of the Concept of
Dissociation. Journal of American Academy of Psychoanalysis,
25:603-615
Week 4. Dissociated Self-States, Trauma, and
Disorganized Attachment
Brief Video Presentation-Itzkowitz
Readings:
1. Bromberg, P. (2008) Shrinking the Tsunami: Affect
Regulation, Dissociation And the Shadow of the Flood.
Contemporary Psychoanalysis, 44: 329-350
2. Lyons-Ruth, (2001). The two-person construction of
defenses: Disorganized Attachment Strategies, Unintegrated
Mental States, and Hostile/Helpless Relational Processes.
Psychologist Psychoanalyst, 21(1), 40–45.
Week. 5.
Dreams In DID
Brief Video Presentation
Readings:
1. Barrett, D. L. (1994), The Dream Character As A Prototype
For the Multiple Personality “Alter.” In: Dissociation, ed. S. J.
Lynn & J. Rhue. Washington, DC: American Psychological
Association Press, pp. 123–135.
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2. Barret, D.L. (1996), Dreams in Multiple Personality Disorder.
In: Trauma andDreams, ed. D. Barrett. Cambridge, MA: Harvard
University Press, pp.68–81.
3.Howell, E. (2011). Understanding and Treating DID, Ch. 13:
Dreams in DID
Week 6. Specific Issues In Treatment
Video Presentation-Itzkowitz
Readings:
1. Bromberg, P. (2001) Treating Patients with Symptoms and
Symptoms with Patience: Reflections on Shame, Dissociation,
and Eating Disorders. (11) 891-912.
2. Howell, E. F. (2002). Back to the 'States': Victim and Abuser
States in Borderline Personality Disorder," Psychoanalytic
Dialogues, 12:6, 921-957.
Week 7. Neurobiological Correlates of Dissociated SelfStates
Readings:
1. Howell, E. (2011) Some Neurobiological Correlates of the
Structure and Psychodynamics of Dissociated Self-States in:
Understanding and Treating Dissociative Identity Disorder NY:
Taylor & Francis pg. 109 – 131