Dialogues With Forgotten Voices: Relational Perspectives on Child Abuse, Trauma and Treatment of Dissociative Disorders (Book Review)

Author:  Schwartz, Harvey L.
Publisher:  New York: Basic Books, 2000
Reviewed By:  Johanna Krout Tabin, Summer 2004, pp. 61-63

When Only Psychoanalytic Understanding Will Do

The lead article in the Spring 2004 issue of Division 12’s journal, Clinical Psychology, deals with the often-raised question of whether repressed memories can exist. The overall conclusion seems to be that both repressed memories and false memories do exist. Harvey Schwartz would agree. In meticulous and scholarly fashion, he examines the extant studies on the subject from various points of view, defending expertly the truth of what we psychoanalysts take for granted: the significance to ego development of a child’s interpersonal experiences. The whole first third of his book is devoted to a balanced and quite thorough survey of the literature. In fact, reading this section would be tedious except for the highly organized presentation and clarity of his writing. It stands as a fine resource for anyone who is interested in further research about understanding and treating people whose psychological survival required them to hide childhood sexual traumas from their conscious memory.

The standard of scholarship continues throughout the book, with apt quotations from different theoreticians and clinicians augmenting Schwartz’s ideas. Nonetheless, clinical concerns and his own way of conceptualizing them are what most make the book valuable. As the title states, the patients about whom Schwartz writes are adult survivors of childhood sexual abuse. Most of the cases he details were victims of horrific ritual abuse.

The “dialogues with forgotten voices” (of the book’s title) occur as a development through the treatment process. Each separate voice expresses an aspect of personality, which the “host personality” cannot consciously recognize as such. Schwartz takes it as the therapist’s task to facilitate dialogue first with himself, leading to spoken dialogue between the voices. His position is to explore what each contributes to the psychological survival of the host. He tries to evoke curiosity about their meanings without a predetermined notion. As the patient’s need for a system of part-self states becomes explainable by the need to cope with overwhelming conditions, the object of treatment as he sees it is to restore the patient’s shattered sense of agency.

Schwartz applies the term relational in a few ways to understand what this requires. First, each alter represents a particular relationship, whether in the patient’s history, or in the scheme of inner balancing that assigns to that alter a particular role in relation to the whole ego structure. Relational also expresses the need for the therapist to maintain a therapeutic alliance through adamant respect for each part of the personality of the patient. Relational further addresses the way in which the therapist remains vigilant in recognizing the effects on the patient of whatever the therapist is dealing with internally that the patient may react to, our old friend counter-transference.

Schwartz repeatedly reminds the reader that what the patient makes of his or her perceptions of the therapist is what makes the perceptions important. Thus, it behooves the therapist to guard against becoming defensive with the patient, even though at times that might be challenging to maintain. Schwartz indicates that this kind of understanding can be found among those who use various labels for their psychoanalytic orientations by quoting Stolorow, Orange, Kohut, McWilliams, and others, as he integrates his text with case material. He even notes that Freud never eliminated sensitivity to what a patient might have experienced as a child, when it was from a patient’s report, rather than Freud’s own conjecture (as, for example, in the case of the Wolf Man).

The relational perspective lends itself to recognition of dissociated personalities since a multiplicity of selves is part of that tradition. On this basis, a unitary self can be called an illusion. Schwartz refers to it so. Yet, his avowed task is to foster integration of a whole self. Indeed, one might argue that it is multiplicity that is an illusion, albeit a significant one from the earliest time of a human being’s life. Sometimes Schwartz is selective in deciding what reflects only relational thinking. For example, on page 170, he notes that some traditional psychoanalysts might avoid talking with alters out of concern about reifying them; and then he generalizes upon this idea to assume that it is a characteristic of treatment by all those who do not call themselves relationalists. More accurately, Schwartz observes that there is an emergence of integrative and cross-fertilizing ideas in the psychoanalytic community that attests to the growing maturation of our field (p.171).

An interesting point made by the author is that we psychoanalysts are unified in that we all see therapy as a developmental process. This is dramatic in the needs of dissociative personalities. Alters, in Schwartz’s experience, tend to be mostly child representations. Comprehending the dissociative condition as analysts requires knowing that there is an unconscious to which repressed memories, thoughts, and feelings may be relegated, and that the ego must find a way to function without being stymied by the complexities and perplexities that are stored in that way.

How to deal with the problem of historical validity in patients’ accounts is significant for us regardless of theoretical orientation. Schwartz wisely maintains an open-minded attitude on this with a patient. He neither confirms belief in an account nor negates it. The book spells out the pitfalls in taking either position. Basically, going in either direction can have the effect of playing into the scripts that one aspect of the personality (or one alter or another) contributes, thus maintaining a dissociative structure. Schwartz maintains his function is to help the person to recognize the meanings for that person that the described events have had. His underlying assumption is that forming separate subunits of the personality solves the problem of overwhelmingly paradoxical experience. A perpetrator, for example, might also be a rescuer in different segments of the abuse pattern. The young ego could manage such a childhood only by evolving all-good and all-evil self-states. Schwartz shows respect for each manifestation, appreciating how they balance each other. He also tries to foster awareness of the psychic price the host personality pays for maintaining this kind of system in adult life.

With his focus on what any material means to a patient, and in his effort at balance in what he thinks, Schwartz sensibly points out that there is a continuum in memory between the extreme of high accuracy in reportage and the other extreme of complete fantasy. The memories of dissociated personalities may lie at various places along this continuum. It is another reason to keep an open mind on facts, using all of the material to probe for its significance to the patient rather than as an occasion to exercise forensic skills.

The case vignettes that Schwartz provides are impressive. He provides them always within the context of the particular point he makes about the rationale for his approach. For example, one transcription of a session appears as an example of what he calls “Linking and Delinking.” He also offers in several places lists of well thought out suggestions for being able to do this work. One is called “Clinical Postures that Foster Recognition.” Another is Guidelines for Working with Derailed Aggression.” Another, very important one, is a list of brainwashing techniques used by the Chinese and the CIA. The reader sees how the same dynamics are utilized by cult groups that exploited child survivors.

By the time one has finished reading this book, Schwartz has ingrained the importance of the ambience the therapist must strive for by avoiding traps that would put the therapist in a position of dominance. When it seems urgent for a patient to know what his reaction is to some material, Schwartz is careful to start with how the patient assesses it; and even if it seems appropriate to share his reactions, to keep the emphasis upon its meaning to the patient. When he does not feel it is appropriate to share his own feelings, he explains why. At all times, the patient is the ultimate arbiter of his or her own feelings, what to say or not to say. In a couple of places, a reader’s eyebrows might rise, as when Schwartz refers to the struggle to maintain the patient’s awareness of material already shared. Overall, however, his commitment to respect for the patient’s authority--without losing his own—is paramount. He emphasizes mutuality of respect as basic for the success of such work.

Only rarely, Schwartz’s care in dealing with concepts slips. In his discussion of abreaction (p. 181), for instance, he tries to differentiate abreaction from enactment on the basis that the latter stems from the unconscious while abreaction is in some way volitional. Starting with Freud’s origination of the term (Freud, 1893), a more accurate use of it is that abreaction is specific to the emotional memory of an event in the past of a person, while an enactment is a broader term that may encompass a range of previous concerns as well as the transference-countertransference moment in the treatment. In general, however, he is scrupulous in his definitions and his attributions to others’ thinking.

The gradual emergence of the observing ego, an important step in all psychoanalytic treatment, is especially notable in treatment of disassociated personalities. Schwartz discusses the dialectic between knowing and not-knowing. At the heart of the dissociative process is the host personality’s not being conscious of what seems beyond tolerance. In cases of DID, the child has been part of the atrocities, making personal agency too great a burden to be dealt with unless some mechanisms such as the development of alters can occur.

Schwartz mentions previous efforts at describing the stages which characterize treatment of DID. In keeping with the strong and effective degree of organization of this book, he then offers his own sense of how treatment develops. He presents several excellent lists to summarize his points in various discussions about paradoxical communications by the patient, of necessary attitudes of a therapist toward enabling useful treatment, and of end-products of treatment. He interprets Loewald’s observation that all that works in therapy is negotiation as meaning to create new conditions for the patient to react to in sorting out the patient’s old reactions (p. 245). Schwartz details the difficulties of negotiating with representatives of intrapsychic terrorism. He explores the bizarre situation in which the therapist may become a perpetrator to patients because the therapist’s efforts to unmask their underlying goodness makes them ashamed at not being malevolent enough.

The book touches on the use of hypnosis to try to manage the dissociative process. The problem with hypnosis as a form of treatment remains what Freud discovered, that simply accessing the disturbed parts of the self is insufficient for integrating the personality. That process, as Schwartz makes clear, is a fraught and lengthy one requiring tremendous dedication and skill.

Dialogues with Forgotten Voices contains so many intriguing and useful comments that it is tempting to give quote after quote. Instead, here is a sampler: In talking about the experience of finding that a satisfactory negotiation with one alter enables some patients to reintegrate the system: “For many survivors, certain linchpin beliefs and fantasies or perpetrator teachings hold many levels of disassociation in place at once. Just as in a game of pick-up sticks, the movement of a strategically positioned alter personality, fantasy, or belief can lead to the rapid rearrangement or even deflation of dissociative defenses (p. 203).” Sometimes the elegance of expression is a pleasure in itself, as when he says: “The shrapnel of the patient’s trauma may land squarely in the heart of the therapist’s most vulnerable psychological territory” (p. 470).

Among many intriguing insights, Schwartz points out that socially acceptable addictions like workaholism or perfectionism reinforce the higher functioning DID patient’s defenses. In such cases, a therapist’s insistence on staying in touch with dissociated parts of the personality becomes a two-way battle for the therapist. The patient is too afraid of retraumatization not to fight contact with isolated and threatening self-states; and critics may believe that a wrongful diagnosis is being imposed on the patient. (p. 178) Another frequent complication he discusses is the intensity of a person’s identification with a perpetrator introject, creating what van der Kolk called a trauma-bond. A patient may swing back and forth many times between holding onto this introject and being able to contemplate its significance to the host self--and the new relationship to the therapist (p. 304 and p. 468). The therapist’s search for the patient’s self can be construed by the patient as a mission of destruction (or seduction), ultimately bringing the therapist into a triple transferential role of seeker-destroyer, seeker-seducer, seeker-betrayer (p. 304). Schwartz’s typical discussion of such situations is consistently illuminating. Schwartz’s perilous but often-successful adventures with the wildly variant perceptions of his patients have resulted in production of a quite special book. I think that it will reward anyone in our field with the review of pertinent literature, thoughtful observations, and reinforcement of the fundamental philosophy of our enterprise.

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