This article was downloaded by: [Tufts University] On: 22 October 2014, At: 06:59 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
American Journal of Clinical Hypnosis Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujhy20
Dissociation and Displacement: Where Goes the “Ouch?” a
John G. Watkins Ph.D. & Helen H. Watkins
a
a
University of Montana , USA Published online: 21 Sep 2011.
To cite this article: John G. Watkins Ph.D. & Helen H. Watkins (1990) Dissociation and Displacement: Where Goes the “Ouch?”, American Journal of Clinical Hypnosis, 33:1, 1-10, DOI: 10.1080/00029157.1990.10402895 To link to this article: http://dx.doi.org/10.1080/00029157.1990.10402895
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/ page/terms-and-conditions
AMERICAN JOURNAL OF CLINICAL HYPNOSIS
VOLUME
33,
NUMBER I, JULY 1990
Dissociation and Displacement: Where Goes the "Ouch?"
Downloaded by [Tufts University] at 06:59 22 October 2014
John G. Watkins and Helen H. Watkins University of Montana Hypnosis is widely used to relieve pain. Current theory emphasizes its dissociative features. Multiple personality patients can eliminate pain in the primary personality by displacing it into underlying alters. The Hilgards demonstrated that normal hypnotized subjects can similarly dissociate pain into a covert cognitive structural system which they called the "hidden observer." The Watkins discovered that "hidden observers" appeared to be the same phenomenon as "ego states." "Ego-state theory" assumes that human personality develops through integration and differentiation. At one end of the continuum, "differentiation" is adaptive. Ego states possess relatively permeable boundaries as in normal moods. At the other end ego-state boundaries become less permeable. Normal "differentiation" becomes maladaptive "dissociation" and multiple personalities may be created. In the intermediate range of the differentiation/ dissociation continuum, "covert" ego states can be found in many normal subjects who volunteer for hypnotic laboratory experiments. Normal individuals, like multiple personalities and "hidden observer" subjects, can displace (dissociate) pain into "covert" ego states. The pain is not eliminated. This suggests that when we remove pain by hypnosis we may not be getting away "scot-free."
Relief from pain has been a never-ending search by mankind. We spend billions of dollars a year on analgesics and anes-
For reprints write to John G. Watkins, Ph.D., 413 Evans Street, Missoula, MT 59801. Received November 2, 1988; revised April 12, 1989; second revision November 25, 1989; accepted for publication January 19, 1990.
thetics plus additional millions advertising them. Researchers seek both more effective medications and psychological procedures for pain reduction. Pain can result from tissue lesions, organic dysfunction, psychological conflicts, or some combination of these. The power of internal conflicts to cause a wide range of psychophysiologic disorders has been well documented over the years (Alexander, 1950; Dunbar, 1947;
WATKINS AND WATKINS
2
Lipowski, Lipsitt, & Whybrow, 1977). It needs no further proof here. Experienced pain may have relative physical and psychological components (Sternbach, 1963). However, psychological approaches (including hypnosis) have been used successfully to moderate or eliminate various types of suffering (Hilgard & Hilgard, 1975). These include physical pain, such as burns (Crasilneck & Hall, 1975), as well as those of psychogenic origin.
Downloaded by [Tufts University] at 06:59 22 October 2014
Pain and Emotion There is evidence that pain can be emotionally initiated or aggravated in cases of presumably physical causes, including tissue damage (Hilgard & Hilgard, 1975). Rossi and Cheek (1988) presented a number of clinical reports and experimental findings demonstrating that perceived pain (both physical and psychological) may often be related to guilt, anger, or other affective states, the emotional condition frequently requiring treatment before the pain could be alleviated. Following is a brief example from one of our own clinical cases illustrating the effect on a headache of the abreactive release of anger. This 27-year-old patient came to the session complaining of a severe headache and requested aspirin. Instead of giving it to him the therapist (H. W.) promised to remove the headache. The patient was then hypnotized and regressed to a 3-year-old state where he reported and re-experienced abuse from his mother. Because of his fear of the mother on whom he was dependent, he was unable to express any anger toward her. After the therapist allied herself with the 3-year-old child state and offered to "hold the mother" and prevent her from striking him with his belt (as she had so often done), he asked for "permission" to "beat her with the belt." On receiving this from the therapist, with
much glee and shouting he beat the therapist's couch, until he spontaneously emerged from hypnosis exclaiming, "You're right. My headache is gone." This example is but one of a number of similar clinical cases we have observed. Hypnotic Relief from Pain In addition to pain relief with burns, there are numerous reports of the use of hypnosis to relieve pain in such cases as carcinoma, rheumatoid arthritis, surgery, whiplash, back pain, obstetrics, dentistry, and many others. We may conclude that psychological intervention in the form of hypnosis has often been effective in alleviating pain, whether functionally or organically caused (Brown & Fromm, 1987; Crasilneck & Hall, 1975; Hilgard & Hilgard, 1975; Kroger, 1977; Rossi & Cheek, 1988, to cite but a few sources). The question to be posed here is whether by such treatment we are getting off "scotfree," with the pain eliminated, or whether this. pain may simply be unconsciously "displaced" to some other area in the psychophysiologic structure of the patient with possible sequelae. Hypnosis and Dissociation Recent research by Hilgard (1986) has proposed a theory in which hypnosis is considered as a specialized form of dissociation. Ever since Janet (1907), the close relationship of hypnosis to dissociation has been recognized, and recent clinical and experimental studies with multiple personality disorders (MPD) have reported that MPD cases are characterized by high hypnotizability (Kluft, 1987; Bliss, 1986). In fact, the disorder has even been defined by some as one of "spontaneous hypnosis" (Beahrs, 1982; Bliss, 1986). However, there is little evidence that
Downloaded by [Tufts University] at 06:59 22 October 2014
DISSOCIATION AND DISPLACEMENT
hypnosis can "create" a true multiple personality with its full range of behaviors (Braun, 1984), although it is commonly employed by therapists to understand and treat MPD. Many of the dissociative features of multiple personality can be duplicated through hypnosis, and the study of the one has enabled us to discover characteristics of the other. If we regard hypnosis as a controlled dissociation, and multiple personality as a self-induced and uncontrolled one, then what can the study of multiple personalities tell us about the dissociation of pain, and thus the possible effects of hypnotically dissociated pain?
Dissociation by Self-Hypnosis Many individuals are able to hypnotize themselves, and self-hypnosis has been added as an accepted therapeutic procedure (Fromm, et. aI., 1981). Beahrs (1986) has described the dissociative process in multiple personalities as a form of selfhypnosis that is designed to protect themselves from the pain and abuse they received as children. In other words, when confronted by more pain, guilt, and rage than they can tolerate, abused children may dissociate this mental "hazardous waste" into alters created for the purpose of providing internal "garbage cans." The original and primary personality now no longer feels the misery. The mechanism when initially employed was adaptive and helped the child cope with an overwhelmingly hostile social environment. Dissociation in this more severe form, however, has then become maladaptive and symptom causing. In the true multiple personality the skill of dissociating pain learned as a child may continue to be practiced as an adult. Diana, the major alter in a multiple per-
3
sonality which normally did not experience much pain, complained at a therapy session that she had a severe headache. "Well, Diana," I (J.W.) replied, "you know how to eliminate pain, don't you? You have practiced this for many years. " "Of course I do," she responded. "Well, why don't you do that right now." Diana closed her eyes and lowered her head. In a few moments she looked up and brightly volunteered, "O.K. It doesn't hurt now." I then asked, "Is there anybody who knows about Diana's pain?" Mary, a misery-ridden child alter, emerged shouting, "Damn you, my head just started to hurt." For years, Mary, who "lived in the (selfhouse) basement," had been receiving the pain and rage that Diana, the jolly primary state, did not want to experience. How many sessions we had had where Diana, with her easy-going smile and friendly manner, reported the good events of the day, or if they were bad, never seeming to suffer from them. And how many times later in that same session would Mary appear, often spontaneously, enraged, crying, and suffering from these same incidents. Since childhood, Diana had learned to dissociate her pain and anger by displacing them into other alters, primarily Mary. Mary was both suicidal and homicidal, and we spent many worrisome days and nights wondering whether she might emerge and kill her own (Diana's) children or herself. Dissociation in Multiple Personalities
Dissociation Reinforcement in MPD If this defensive operation of displacing pain to an "unconscious" alter is successful, it is reinforced by a lowering of tension. A reinforced process is self-perpetuating. The more adaptive it is for the time being, the more it tends to be uti-
Downloaded by [Tufts University] at 06:59 22 October 2014
4
lized. The individual begins to employ dissociation increasingly in coping with lesser problems, such as the need to avoid criticism, the desire to exercise an athletic, artistic, or other ability, without cognitive dissonance from contrary motivations. More and more alters are created to solve problems of living, and the personality is split into ever-increasing, discrete segments, isolated and uncommunicative with each other. Walls of amnesia are erected between the different states as the multiple personality structure develops increasing complexity. It is like a psychological cancer which feeds on itself, and yet its function is designed to be protective of the system.
Dissociation of Organic Pain in MPD It may be argued that Diana's "headache" was probably a functionally caused pain. What would happen if it had a demonstrated organic origin? Shortly afterward, Diana provided some data on this question. She reported that the day before she had burned a finger on her hand by touching a frying pan on the stove. In fact, it was severely blistered. Her immediate reaction on feeling the pain was to "turn it off," which she described as her habitual response to discomfort. Because of our previous experience with the headache, which had been displaced to Mary, I asked Diana just who had received the burn pain. She didn't seem to know. Accordingly, she was hypnotized and we "polled" the other alters. To my surprise we discovered that the pain had been sent first to Mary who refused to take it. It was then transferred to Karl, a 4-year-old child alter. Karl "cried and yelled so loud" that Danny, a 12-yearold alter who was characterized by his toughness and courage, shouted to Karl, "Shut up! I'll take it." And there the pain
WATKINS AND WATKINS
remained - in Danny. Later that day the patient went bowling. Neither Diana nor " Alex," the adolescent athlete alter who did most of the bowling, experienced any pain in handling the ball, even though the blister broke in the process. Danny had the pain, and he wasn't "present" during the bowling. David, a multiple personality, had an alter, "Dr. Paul," who was developed when David as a teenager had served on a ski patrol. There he learned first aid by reading medical books, sometimes even setting broken limbs. David was amnesic to the times when Dr. Paul was "out" but through therapy had recovered some of the events which took place at that time. Many hate and rage abreactions were undertaken as part of our treatment. Dr. Paul was most helpful in letting us know just how much suffering David could confront at anyone time, and he regulated the intensity of these experiences. Once, he even prescribed a day of rest. Three years earlier with another therapist David had discovered a 6-year-old alter by the name of "Davy." Ever since the activation of Davy, he had suffered recurrent headaches and tinnitus. During a recent session he recovered an event from the age of 6. While playing tag with his sister, she threw a blanket over his head, and he had run into a large maple tree knocking himself unconscious. He had been amnesic to this incident for almost 30 years. As he recalled the experience his tinnitus returned. His shoulder and left foot hurt, and he began suffering a very severe headache. It was apparent that he was now re-experiencing the headache pain, the tinnitus, plus the shoulder and foot pains which had been dissociated into "Davy" since the age of 6. The original creation of the Davy alter was actually an exercise
5
Downloaded by [Tufts University] at 06:59 22 October 2014
DISSOCIAnON AND DISPLACEMENT
in pain control by self-hypnosis, and the suffering of that period had never been eliminated, only dissociated and postponed for 30 years. David had been refusing the nurse's offer for Tylenol. "Dr. Paul," the wise inner-physician alter, said, "If multiple personalities are medicated they don't experience the feelings they should feel to get well." We initiated pain abreactions, which David experienced and worked through. His tinnitus ceased. His sufferings diminished and soon after disappeared. Diana, too, found medication (Tylenol, aspirin) of much less help than dissociation in relieving all kinds of pain. It should not be surprising that multiples can dissociate pain into underlying alters. They were created in the first place to deal with unbearable child abuse physical, sexual, and psychological. The essence of therapy for the integration of multiples is that the primary personality must re-assume responsibility and control of its own memories, experiences, and feelings, especially the pain, fear, and rage with which it could not cope as a child. "Diana" must take back the pain and anger which resulted from abuse, and she must likewise assume responsibility for pains coming from the present. She must cease pushing these down into "Mary" or "Danny" if integration is to be achieved. Diana reluctantly accepted the pain back from Danny, and in time it went away. We shall not pursue the treatment of Diana or David further. But what has all this to do with pain that has been eliminated in "normals" through hypnosis? Perhaps experiments on ego states (Watkins & Watkins, 1979-80, 1980) and the "hidden observer" phenomenon (Hilgard, 1986) may provide some relevant data on this question.
Dissociation and Displacement Dissociation as a psychological defense mechanism is not restricted only to multiple personalities. Disorders with a primarily psychological etiology can be "displaced" from one system to another in patients having nothing to do with multiple personality. A previously unreported case of "neurodermatitis" was aggressively treated by the dermatological specialist in a V.A. hospital. He would recover from his skin disorder only to manifest an overt psychotic reaction. This condition could be relieved in our psychiatric service by electroconvulsive therapy, whereupon his skin would break out again. Some individuals seem able to displace dysfunction from one organ system to another-even as the multiple displaces (dissociates) pain from the primary personality into an alter. Ego States: Theory and Therapy Ego-state theory starts from the assumption that personality develops by two basic processes: integration (a putting together) and differentiation (a separation or taking apart). Through a "putting together" of cat, dog, cow, and other animals, the child learns the concept of "animal." Through differentiation he learns to discriminate between a cat and a rabbit or between what is good to eat and what is not. As he integrates and differentiates he develops into an increasingly complex personality. Most psychological processes (anxiety, depression, motivation, etc.) are not an either-or; they exist on a continuum. And most in their lesser intensities (like anxiety) are constructive. It is their excesses that are destructive. Differentiation (the separating process) up to a certain point is adaptive. Beyond that, it becomes de-
Downloaded by [Tufts University] at 06:59 22 October 2014
6
fensive, then increasingly maladaptive. When still further intensified we call it "dissociation." It becomes pathological and in its extreme form results in multiple personalities. Federn (1952) held that personality is organized into patterns which he called "ego states." We (Watkins & Watkins, 1981, 1982, 1986) have defined an ego state as "a body of behaviors and experiences bound together by a common principle and separated from other such entities by a boundary which is more or less permeable." At the lower end of the distribution the boundaries between ego states are very permeable, and each may be more like a normal mood that varies from time to time. One ego state may be activated Tuesday at work and another be "executive" at a party Saturday night, which is why we feel, think, and behave differently at one time than another. Normal ego states may be compared to geographic states, like school districts, cities or geographic states (Montana or Idaho). They are differentiated and adaptive for administrative efficiency. Their boundaries are not rigid. Mutual awareness and communication between them relatively prevails. We have many recorded excerpts which show that ego states, when activated, behave in very surprising ways that are frequently quite contrary to therapist expectations or requests (Watkins & Watkins, 1980). Their responses indicate that they are much more than suggested artifacts. As the rigidity of their boundaries increases, awareness and communication between them deteriorates, and normal differentiation changes into dissociation. In the extreme form, multiple personalities, little or no mutual awareness or communication takes place (as in East and West
WATKINS AND WATKINS
Germany during the days of the Berlin Wall). Ego-state theory will not be pursued further here except to note that the intermediate range on the differentiation-dissociation continuum contains ego states which, unlike multiple personality alters, do not emerge overtly, spontaneously. They require hypnotic activation and, when so discovered by hypnotherapists, are often mistakenly diagnosed as "multiple personalities." These entities, however, do function like "covert multiples" with discernable boundaries, contents, and identities. "Ego-state therapy" is the use of group and family therapy techniques (usually under hypnosis) to resolve conflicts between the different ego states which constitute a "family of self" within a single individual. The previously cited references by Watkins and Watkins discuss this theory and therapy in much greater detail with research findings and case illustrations. Suffice it to say that ego states are frequently found in the hypnotherapeutic treatment of many problems, ranging from normal (stop smoking, weight reduction, study habits) through various neurotic and psychophysiologic conditions to true multiple personalities (Edelstein, 1982; Newey, 1986; Torem, 1987; Watkins & Watkins, 1981, 1982, 1988). Experimental.support for the existence and behavior of ego states comes from the Stanford studies on "hidden observers." The "Hidden Observer" Phenomenon
In the Stanford studies Hilgard and Hilgard (1975) discovered that painful stimuli, such as that imposed by restriction of circulation or by immersion in ice water, could still be perceived "unconsciously" after hypnoanesthesia had apparently rendered the subject pain-free. Hilgard at-
Downloaded by [Tufts University] at 06:59 22 October 2014
DISSOCIATION AND DISPLACEMENT
tributed this awareness to an underlying, covert "cognitive structural system" which he called "the hidden observer." Beahrs (1982) termed this phenomenon "co-consciousness," one segment of "the self" being aware of the pain, while simultaneously another segment (the normally conscious part) was unaware of it. The relevant finding here is that pain which has apparently been eliminated by hypnotic suggestion is still retained within a covert "cognitive structural system." This dissociation (or displacement) of pain was demonstrated with normal volunteers (college students) who were not multiple personalities. It occurred to us that this "cognitive structural system" might well be one of the "ego states" with which we had been working therapeutically.
Ego States and Hidden Observers We (Watkins & Watkins, 1979-80; 1980) activated hidden observers using Hilgard's cold-pressor pain procedure on five subjects previously treated a year earlier by ego-state therapy. Anesthesia was suggested in the hypnotized subject's right hand, and it was thrust into ice water with instructions to remove it when the cold could no longer be endured. One subject kept the hypnotically anesthetized right hand in the ice water five times as long as he did with the unanesthetized left hand and then developed a severe stomach ache. The pain had apparently been displaced from the hand to the stomach. A recorded excerpt from this case is as follows: A known ego state, "Old One," previously studied in therapy, emerged and reported that the hypnotic instructions were that he would not feel any pain "in the hand," so when he did feel it, it was in the stomach. When asked whether "some other part" experienced the pain, another
7
known ego state, 3-year-old "Sandy," emerged and said, "Yeah." "Tell me about it, Sandy," I said. "Well, it hurt." "It did?" "Yeah! What do you expect? lese." "Well, Ed" (the overt subject) "didn't seem to feel pain in his hand." "Well, I did," Sandy complained, "and I didn't like it at all." The patient, Ed, was not a multiple personality but a college student who came to therapy to resolve certain neurotic symptoms including an inability to concentrate on his studies. His various ego states could be contacted only under hypnosis. His study problems were found to stem from interference by Sandy who resented not being able to "play." They were resolved when the therapist (H. W.), using ego-state therapy, arranged to have Sandy's play needs satisfied. In this case we see a pain being displaced from one bodily organ to another (hand to stomach) and also displaced from the primary cognitive structural system (Ed) to other "hidden observers" or ego states (Old One and Sandy). That pain is not necessarily eliminated by hypnotic suggestion but may be displaced into other segments of the personality has many implications, not only for the treatment of multiples, but for the therapy of pain in general. Such displacements seem more widely possible since ego states have been found to be a part of normal adaptation in many individuals who have come to us for relatively nonpathological conditions: study habits, stop smoking, or weight reduction and in some cases professional therapists who merely wished to improve their own functioning, as do analysands who take "training" psychoanalyses. An interesting situation occurred with Wendy, a 35-year-old woman who suffered continuous abdominal pain related
Downloaded by [Tufts University] at 06:59 22 October 2014
8
to a clostridium condition in the bowel. To control the pain, and to help her reduce the use of medication, she was taught self-hypnosis. Wendy was not a multiple personality, but she was aware of a child ego state, called "Sally," which she had discovered under hypnosis. Wendy and Sally became close, affectionate friends, communicating with each other, but only under hypnosis. It was very distressing to Wendy when she discovered that if she, Wendy, relieved her pain through self-hypnosis, Sally when activated would emerge weeping, bitterly complaining of severe suffering. Sally then would seek support and nurturance from the therapist. Wendy, herself, rarely cried. Wendy decided consciously that her relationship with her own "child ego state" was so important that she would use selfhypnosis to lessen but not eliminate the pain, thus giving only part of it to Sally. Subsequently she used self-hypnosis merely to take the severe edge off the pain, making it tolerable - and Sally expressed gratitude to Wendy that her severe suffering was lessened. Wendy told us she felt that if she transferred all the pain into Sally she would be "denying" Sally and that in time she would become increasingly separated and "lose all contact with her." This observation is an interesting bit of insight by the patient, suggesting an awareness that if she practiced greater dissociation she might become a true multiple. In psychoanalytic therapy it has been a matter of established belief that repressed anxiety (as opposed to consciously activated, "worked-through," and released anxiety) may permit the patient to feel better for the present but at the cost of energy tied up in the repressing process, hence leaving less energy for other things
WATKINS AND WATKINS
and lowering the efficiency of living. A similar situation may exist when pain is repressed (or dissociated) rather than confronted and "worked-through." We are left with an intriguing question. How many people with normal ego states relieve their sufferings (current or "memory" pains) by aspirin, Tylenol, Advil, hypnotic suggestion, or self-hypnosis, rather than by confronting and wearing them out. Could it be that patients whose pain has been removed by hypnotic suggestion (or even by pharmacological intervention) may merely be postponing suffering by dissociating it into covert "cognitive structural systems," thus storing up future "ouches," reducing their energy for living, and simultaneously reinforcing emotional immaturity in their own selves? Summary That emotions and conflicts can create or increase painful symptoms has been well established. Hypnotherapy has been widely used to alleviate both physically caused and psychogenic pain. This includes selfhypnosis. Recent developments in hypnosis theory have placed increasing emphasis on its dissociative features. Some theorists have considered it a "controlled dissociation" as contrasted to multiple personality, which is an "uncontrolled dissociation." Multiple personality cases have been presented here showing that they are capable of eliminating pain in the primary personality by displacing it into covert alters. This process may involve a kind of self-hypnosis. When the alters are then activated they often report having "received" the pain and complain bitterly. The Hilgards demonstrated that normal experimental subjects, when hypnotized, can similarly dissociate or displace pain
Downloaded by [Tufts University] at 06:59 22 October 2014
DISSOCIATION AND DISPLACEMENT
into a covert cognitive structural system within the personality. They termed this phenomenon "the hidden observer." Working hypnoanalytically with patients (and with volunteer experimental subjects) the Watkins, (who started with the theoretical concepts of Federn, a close associate of Freud's) discovered that ego states, internal personality segments, behaved both like Hilgard's hidden observers and "covert" multiple personalities. The ego states demonstrated behavioral and experiential content and when interviewed under hypnosis reported individual self-identity. Moreover, they could also dissociate (or displace) pain from the normally primary or "executive" state to substates (cognitive structural systems)-even as did "hidden observers" and true multiple personalities. A therapeutic system was developed which the Watkins called, "ego-state therapy." This technique involved the resolution (primarily under hypnosis) of conflicts between the various ego states that were causing symptoms and maladaptive behaviors. The approach has been effective in treating a number of disorders and behavioral problems, ranging from unsatisfactory study habits, smoking, obesity, or various psychophysiologic and neurotic disorders, up to and including true, overt multiple personalities. "Ego-state theory" is based on the assumption that human personality structure develops through integration and differentiation, hence putting together and separating apart. Out of these processes personality segments arise for purposes of adaptation and defense. Most psychological processes exist on a continuum. They tend initially to be adaptive but become less so when excessive (e.g., anxiety). So also it is with integration and differentiation.
9
At one end of the continuum, differentiation is adaptive with personality segments (ego states) possessing relatively permeable boundaries through which communication and constructive interaction can take place-as in normal mood states. As the segmentation becomes more defensive, the boundaries separating ego states become more rigid and less permeable. At the other end of the continuum we call the separating process "dissociation." The ego states are no longer aware of or in communication with one another, and true, overt multiple personalities may be created. Covert ego states, representing the intermediate range of the differentiationdissociation continuum, can be found in many normal subjects who volunteer for hypnotic laboratory experiments, as well as in patients in psychotherapy. Dissociation is associated with hypnotizability. Hence, the ability to displace pain into sub ego-states may inhere in many normal individuals who are hypnotically treated for pain. This suggests that when we remove pain by hypnosis we may not be getting away "scot-free." Perhaps it is being displaced into underlying ego states and stored there with the possibility of noxious sequelae or later return in some other undesirable form. Such a possibility needs further investigation if we are to use hypnosis for the relief of pain, whether physically or psychologically caused. It also raises questions about suffering that is alleviated by the many pain medications now marketed. References
Alexander, F. (1950). Psychosomatic medicine: Its principles and applications. New York: Norton. Beahrs, J. O. (1982). Unity and multiplicity:
Downloaded by [Tufts University] at 06:59 22 October 2014
10
Multilevel consciousness ofselfin hypnosis, psychiatric disorder and mental health. New York: Brunner/Maze\. Beahrs, J. O. (1986). Limits of scientific psychiatry: Role of uncertainty in mental health, pp. 86-113. New York: Brunner/Maze\. Bliss, E. L. (1986). Multiple personality, allied disorders and hypnosis. New York: Oxford University Press. Braun, B. G. (1984). Uses of hypnosis with multiple personality. Psychiatric Annals, 14, 34-40. Brown, D. P. & Fromm, E. (1987). Hypnosis and behavioral medicine. Hillsdale, NJ: Lawrence Erlbaum. Crasilneck, H. B. & Hall, 1. A. (1975). Clinical hypnosis: Principles and applications. New York: Grune & Stratton. Dunbar, F. (1947). Mind and body: Psychosomatic medicine. New York: Hoeber. Edelstein, M. G. (1982). Ego-state therapy in the management of resistance. American Journal of Clinical Hypnosis, 25, 15-20. Fedem, P. (1952). Ego psychology and the psychoses. (E. Weiss, Ed.). New York: Basic Books. Fromm, E., Brown, D. P., Hurt, S. W., Oberlander, J. Z., Boxer, A. M., & Pfeifer, G. (1981). The phenomena and characteristics of self-hypnosis. International Journal of Clinical and Experimental Hypnosis, 29, 189-246. Hilgard, E. R. (1986). Divided consciousness: Multiple controls in human thought and action. New York: Wiley. Hilgard, E. R. & Hilgard, J. R. (1975). Hypnosis in the relief of pain. Los Altos, CA.: William Kaufmann. Janet, P. (1907). The major symptoms of hysteria. New York: Macmillan. Kluft, R. P. (1987). An update on multiple personality disorder. Hospital and Community Psychiatry, 38, 363-373. Kroger, W. S. (1977). Clinical and experimental hypnosis. Philadelphia: Lippincott.
WATKINS AND WATKINS
Lipowski, Z. J., Lipsitt, D. R., & Whybrow, P. S. (Eds.). (1977). Psychosomatic medicine: Current trends and clinical applications. New York: Oxford Univ. Press. Newey, A. B. (1986). Ego state therapy with depression. In B. Zilbergeld, M. G. Edelstein, & D. L. Araoz (Eds.), Hypnosis: Questions and answers. New York: Norton, pp. 197-203. Rossi, E. L. & Cheek, D. B. (1988). Mindbody therapy: Ideodynamic healing in hypnosis. New York: Norton. Sternbach, R. A. (1963). Congenital insensitivity to pain: A critique. Psychological Bulletin, 60, 252-264. Torem, M. S. (1987). Ego-state therapy for eating disorders. American Journal of Clinical Hypnosis, 30, 94-104. Watkins, 1. G. & Watkins, H. H. (1979-80). Ego states and hidden observers. Journal of Altered States of Consciousness, 5, 3-18. Watkins, 1. G. & Watkins, H. H. (1980). I. Ego states and hidden observers. II. Egostate therapy: The woman in black and the lady in white (audio tape and manuscript). New York: Jeffrey Norton. Watkins, J. G. & Watkins, H. H . (1981). Ego-state therapy. In R. J. Corsini (Ed.), Handbook of innovative psychotherapies. New York: Wiley-Interscience. Watkins, J. G. & Watkins, H. H. (1982). Egostate therapy. In L. E. Abt & I. R. Stuart (Eds.), The newer therapies: A sourcebook. New York: Van Nostrand Reinhold, pp. 137155. Watkins, J. G. & Watkins, H. H. (1986). Hypnosis, multiple personality and ego states as altered states of consciousness. In B. W. Wolman & M. Ullman (Eds.), Handbook of states of consciousness. New York: Van Nostrand Reinhold. Watkins, J. G. & Watkins, H. H. (1988). The management of malevolent ego states in multiple personality. Dissociation, 1, 6772.
American Journal of Clinical Hypnosis Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujhy20
Dissociation and Displacement: Where Goes the “Ouch?” a
John G. Watkins Ph.D. & Helen H. Watkins
a
a
University of Montana , USA Published online: 21 Sep 2011.
To cite this article: John G. Watkins Ph.D. & Helen H. Watkins (1990) Dissociation and Displacement: Where Goes the “Ouch?”, American Journal of Clinical Hypnosis, 33:1, 1-10, DOI: 10.1080/00029157.1990.10402895 To link to this article: http://dx.doi.org/10.1080/00029157.1990.10402895
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/ page/terms-and-conditions
AMERICAN JOURNAL OF CLINICAL HYPNOSIS
VOLUME
33,
NUMBER I, JULY 1990
Dissociation and Displacement: Where Goes the "Ouch?"
Downloaded by [Tufts University] at 06:59 22 October 2014
John G. Watkins and Helen H. Watkins University of Montana Hypnosis is widely used to relieve pain. Current theory emphasizes its dissociative features. Multiple personality patients can eliminate pain in the primary personality by displacing it into underlying alters. The Hilgards demonstrated that normal hypnotized subjects can similarly dissociate pain into a covert cognitive structural system which they called the "hidden observer." The Watkins discovered that "hidden observers" appeared to be the same phenomenon as "ego states." "Ego-state theory" assumes that human personality develops through integration and differentiation. At one end of the continuum, "differentiation" is adaptive. Ego states possess relatively permeable boundaries as in normal moods. At the other end ego-state boundaries become less permeable. Normal "differentiation" becomes maladaptive "dissociation" and multiple personalities may be created. In the intermediate range of the differentiation/ dissociation continuum, "covert" ego states can be found in many normal subjects who volunteer for hypnotic laboratory experiments. Normal individuals, like multiple personalities and "hidden observer" subjects, can displace (dissociate) pain into "covert" ego states. The pain is not eliminated. This suggests that when we remove pain by hypnosis we may not be getting away "scot-free."
Relief from pain has been a never-ending search by mankind. We spend billions of dollars a year on analgesics and anes-
For reprints write to John G. Watkins, Ph.D., 413 Evans Street, Missoula, MT 59801. Received November 2, 1988; revised April 12, 1989; second revision November 25, 1989; accepted for publication January 19, 1990.
thetics plus additional millions advertising them. Researchers seek both more effective medications and psychological procedures for pain reduction. Pain can result from tissue lesions, organic dysfunction, psychological conflicts, or some combination of these. The power of internal conflicts to cause a wide range of psychophysiologic disorders has been well documented over the years (Alexander, 1950; Dunbar, 1947;
WATKINS AND WATKINS
2
Lipowski, Lipsitt, & Whybrow, 1977). It needs no further proof here. Experienced pain may have relative physical and psychological components (Sternbach, 1963). However, psychological approaches (including hypnosis) have been used successfully to moderate or eliminate various types of suffering (Hilgard & Hilgard, 1975). These include physical pain, such as burns (Crasilneck & Hall, 1975), as well as those of psychogenic origin.
Downloaded by [Tufts University] at 06:59 22 October 2014
Pain and Emotion There is evidence that pain can be emotionally initiated or aggravated in cases of presumably physical causes, including tissue damage (Hilgard & Hilgard, 1975). Rossi and Cheek (1988) presented a number of clinical reports and experimental findings demonstrating that perceived pain (both physical and psychological) may often be related to guilt, anger, or other affective states, the emotional condition frequently requiring treatment before the pain could be alleviated. Following is a brief example from one of our own clinical cases illustrating the effect on a headache of the abreactive release of anger. This 27-year-old patient came to the session complaining of a severe headache and requested aspirin. Instead of giving it to him the therapist (H. W.) promised to remove the headache. The patient was then hypnotized and regressed to a 3-year-old state where he reported and re-experienced abuse from his mother. Because of his fear of the mother on whom he was dependent, he was unable to express any anger toward her. After the therapist allied herself with the 3-year-old child state and offered to "hold the mother" and prevent her from striking him with his belt (as she had so often done), he asked for "permission" to "beat her with the belt." On receiving this from the therapist, with
much glee and shouting he beat the therapist's couch, until he spontaneously emerged from hypnosis exclaiming, "You're right. My headache is gone." This example is but one of a number of similar clinical cases we have observed. Hypnotic Relief from Pain In addition to pain relief with burns, there are numerous reports of the use of hypnosis to relieve pain in such cases as carcinoma, rheumatoid arthritis, surgery, whiplash, back pain, obstetrics, dentistry, and many others. We may conclude that psychological intervention in the form of hypnosis has often been effective in alleviating pain, whether functionally or organically caused (Brown & Fromm, 1987; Crasilneck & Hall, 1975; Hilgard & Hilgard, 1975; Kroger, 1977; Rossi & Cheek, 1988, to cite but a few sources). The question to be posed here is whether by such treatment we are getting off "scotfree," with the pain eliminated, or whether this. pain may simply be unconsciously "displaced" to some other area in the psychophysiologic structure of the patient with possible sequelae. Hypnosis and Dissociation Recent research by Hilgard (1986) has proposed a theory in which hypnosis is considered as a specialized form of dissociation. Ever since Janet (1907), the close relationship of hypnosis to dissociation has been recognized, and recent clinical and experimental studies with multiple personality disorders (MPD) have reported that MPD cases are characterized by high hypnotizability (Kluft, 1987; Bliss, 1986). In fact, the disorder has even been defined by some as one of "spontaneous hypnosis" (Beahrs, 1982; Bliss, 1986). However, there is little evidence that
Downloaded by [Tufts University] at 06:59 22 October 2014
DISSOCIATION AND DISPLACEMENT
hypnosis can "create" a true multiple personality with its full range of behaviors (Braun, 1984), although it is commonly employed by therapists to understand and treat MPD. Many of the dissociative features of multiple personality can be duplicated through hypnosis, and the study of the one has enabled us to discover characteristics of the other. If we regard hypnosis as a controlled dissociation, and multiple personality as a self-induced and uncontrolled one, then what can the study of multiple personalities tell us about the dissociation of pain, and thus the possible effects of hypnotically dissociated pain?
Dissociation by Self-Hypnosis Many individuals are able to hypnotize themselves, and self-hypnosis has been added as an accepted therapeutic procedure (Fromm, et. aI., 1981). Beahrs (1986) has described the dissociative process in multiple personalities as a form of selfhypnosis that is designed to protect themselves from the pain and abuse they received as children. In other words, when confronted by more pain, guilt, and rage than they can tolerate, abused children may dissociate this mental "hazardous waste" into alters created for the purpose of providing internal "garbage cans." The original and primary personality now no longer feels the misery. The mechanism when initially employed was adaptive and helped the child cope with an overwhelmingly hostile social environment. Dissociation in this more severe form, however, has then become maladaptive and symptom causing. In the true multiple personality the skill of dissociating pain learned as a child may continue to be practiced as an adult. Diana, the major alter in a multiple per-
3
sonality which normally did not experience much pain, complained at a therapy session that she had a severe headache. "Well, Diana," I (J.W.) replied, "you know how to eliminate pain, don't you? You have practiced this for many years. " "Of course I do," she responded. "Well, why don't you do that right now." Diana closed her eyes and lowered her head. In a few moments she looked up and brightly volunteered, "O.K. It doesn't hurt now." I then asked, "Is there anybody who knows about Diana's pain?" Mary, a misery-ridden child alter, emerged shouting, "Damn you, my head just started to hurt." For years, Mary, who "lived in the (selfhouse) basement," had been receiving the pain and rage that Diana, the jolly primary state, did not want to experience. How many sessions we had had where Diana, with her easy-going smile and friendly manner, reported the good events of the day, or if they were bad, never seeming to suffer from them. And how many times later in that same session would Mary appear, often spontaneously, enraged, crying, and suffering from these same incidents. Since childhood, Diana had learned to dissociate her pain and anger by displacing them into other alters, primarily Mary. Mary was both suicidal and homicidal, and we spent many worrisome days and nights wondering whether she might emerge and kill her own (Diana's) children or herself. Dissociation in Multiple Personalities
Dissociation Reinforcement in MPD If this defensive operation of displacing pain to an "unconscious" alter is successful, it is reinforced by a lowering of tension. A reinforced process is self-perpetuating. The more adaptive it is for the time being, the more it tends to be uti-
Downloaded by [Tufts University] at 06:59 22 October 2014
4
lized. The individual begins to employ dissociation increasingly in coping with lesser problems, such as the need to avoid criticism, the desire to exercise an athletic, artistic, or other ability, without cognitive dissonance from contrary motivations. More and more alters are created to solve problems of living, and the personality is split into ever-increasing, discrete segments, isolated and uncommunicative with each other. Walls of amnesia are erected between the different states as the multiple personality structure develops increasing complexity. It is like a psychological cancer which feeds on itself, and yet its function is designed to be protective of the system.
Dissociation of Organic Pain in MPD It may be argued that Diana's "headache" was probably a functionally caused pain. What would happen if it had a demonstrated organic origin? Shortly afterward, Diana provided some data on this question. She reported that the day before she had burned a finger on her hand by touching a frying pan on the stove. In fact, it was severely blistered. Her immediate reaction on feeling the pain was to "turn it off," which she described as her habitual response to discomfort. Because of our previous experience with the headache, which had been displaced to Mary, I asked Diana just who had received the burn pain. She didn't seem to know. Accordingly, she was hypnotized and we "polled" the other alters. To my surprise we discovered that the pain had been sent first to Mary who refused to take it. It was then transferred to Karl, a 4-year-old child alter. Karl "cried and yelled so loud" that Danny, a 12-yearold alter who was characterized by his toughness and courage, shouted to Karl, "Shut up! I'll take it." And there the pain
WATKINS AND WATKINS
remained - in Danny. Later that day the patient went bowling. Neither Diana nor " Alex," the adolescent athlete alter who did most of the bowling, experienced any pain in handling the ball, even though the blister broke in the process. Danny had the pain, and he wasn't "present" during the bowling. David, a multiple personality, had an alter, "Dr. Paul," who was developed when David as a teenager had served on a ski patrol. There he learned first aid by reading medical books, sometimes even setting broken limbs. David was amnesic to the times when Dr. Paul was "out" but through therapy had recovered some of the events which took place at that time. Many hate and rage abreactions were undertaken as part of our treatment. Dr. Paul was most helpful in letting us know just how much suffering David could confront at anyone time, and he regulated the intensity of these experiences. Once, he even prescribed a day of rest. Three years earlier with another therapist David had discovered a 6-year-old alter by the name of "Davy." Ever since the activation of Davy, he had suffered recurrent headaches and tinnitus. During a recent session he recovered an event from the age of 6. While playing tag with his sister, she threw a blanket over his head, and he had run into a large maple tree knocking himself unconscious. He had been amnesic to this incident for almost 30 years. As he recalled the experience his tinnitus returned. His shoulder and left foot hurt, and he began suffering a very severe headache. It was apparent that he was now re-experiencing the headache pain, the tinnitus, plus the shoulder and foot pains which had been dissociated into "Davy" since the age of 6. The original creation of the Davy alter was actually an exercise
5
Downloaded by [Tufts University] at 06:59 22 October 2014
DISSOCIAnON AND DISPLACEMENT
in pain control by self-hypnosis, and the suffering of that period had never been eliminated, only dissociated and postponed for 30 years. David had been refusing the nurse's offer for Tylenol. "Dr. Paul," the wise inner-physician alter, said, "If multiple personalities are medicated they don't experience the feelings they should feel to get well." We initiated pain abreactions, which David experienced and worked through. His tinnitus ceased. His sufferings diminished and soon after disappeared. Diana, too, found medication (Tylenol, aspirin) of much less help than dissociation in relieving all kinds of pain. It should not be surprising that multiples can dissociate pain into underlying alters. They were created in the first place to deal with unbearable child abuse physical, sexual, and psychological. The essence of therapy for the integration of multiples is that the primary personality must re-assume responsibility and control of its own memories, experiences, and feelings, especially the pain, fear, and rage with which it could not cope as a child. "Diana" must take back the pain and anger which resulted from abuse, and she must likewise assume responsibility for pains coming from the present. She must cease pushing these down into "Mary" or "Danny" if integration is to be achieved. Diana reluctantly accepted the pain back from Danny, and in time it went away. We shall not pursue the treatment of Diana or David further. But what has all this to do with pain that has been eliminated in "normals" through hypnosis? Perhaps experiments on ego states (Watkins & Watkins, 1979-80, 1980) and the "hidden observer" phenomenon (Hilgard, 1986) may provide some relevant data on this question.
Dissociation and Displacement Dissociation as a psychological defense mechanism is not restricted only to multiple personalities. Disorders with a primarily psychological etiology can be "displaced" from one system to another in patients having nothing to do with multiple personality. A previously unreported case of "neurodermatitis" was aggressively treated by the dermatological specialist in a V.A. hospital. He would recover from his skin disorder only to manifest an overt psychotic reaction. This condition could be relieved in our psychiatric service by electroconvulsive therapy, whereupon his skin would break out again. Some individuals seem able to displace dysfunction from one organ system to another-even as the multiple displaces (dissociates) pain from the primary personality into an alter. Ego States: Theory and Therapy Ego-state theory starts from the assumption that personality develops by two basic processes: integration (a putting together) and differentiation (a separation or taking apart). Through a "putting together" of cat, dog, cow, and other animals, the child learns the concept of "animal." Through differentiation he learns to discriminate between a cat and a rabbit or between what is good to eat and what is not. As he integrates and differentiates he develops into an increasingly complex personality. Most psychological processes (anxiety, depression, motivation, etc.) are not an either-or; they exist on a continuum. And most in their lesser intensities (like anxiety) are constructive. It is their excesses that are destructive. Differentiation (the separating process) up to a certain point is adaptive. Beyond that, it becomes de-
Downloaded by [Tufts University] at 06:59 22 October 2014
6
fensive, then increasingly maladaptive. When still further intensified we call it "dissociation." It becomes pathological and in its extreme form results in multiple personalities. Federn (1952) held that personality is organized into patterns which he called "ego states." We (Watkins & Watkins, 1981, 1982, 1986) have defined an ego state as "a body of behaviors and experiences bound together by a common principle and separated from other such entities by a boundary which is more or less permeable." At the lower end of the distribution the boundaries between ego states are very permeable, and each may be more like a normal mood that varies from time to time. One ego state may be activated Tuesday at work and another be "executive" at a party Saturday night, which is why we feel, think, and behave differently at one time than another. Normal ego states may be compared to geographic states, like school districts, cities or geographic states (Montana or Idaho). They are differentiated and adaptive for administrative efficiency. Their boundaries are not rigid. Mutual awareness and communication between them relatively prevails. We have many recorded excerpts which show that ego states, when activated, behave in very surprising ways that are frequently quite contrary to therapist expectations or requests (Watkins & Watkins, 1980). Their responses indicate that they are much more than suggested artifacts. As the rigidity of their boundaries increases, awareness and communication between them deteriorates, and normal differentiation changes into dissociation. In the extreme form, multiple personalities, little or no mutual awareness or communication takes place (as in East and West
WATKINS AND WATKINS
Germany during the days of the Berlin Wall). Ego-state theory will not be pursued further here except to note that the intermediate range on the differentiation-dissociation continuum contains ego states which, unlike multiple personality alters, do not emerge overtly, spontaneously. They require hypnotic activation and, when so discovered by hypnotherapists, are often mistakenly diagnosed as "multiple personalities." These entities, however, do function like "covert multiples" with discernable boundaries, contents, and identities. "Ego-state therapy" is the use of group and family therapy techniques (usually under hypnosis) to resolve conflicts between the different ego states which constitute a "family of self" within a single individual. The previously cited references by Watkins and Watkins discuss this theory and therapy in much greater detail with research findings and case illustrations. Suffice it to say that ego states are frequently found in the hypnotherapeutic treatment of many problems, ranging from normal (stop smoking, weight reduction, study habits) through various neurotic and psychophysiologic conditions to true multiple personalities (Edelstein, 1982; Newey, 1986; Torem, 1987; Watkins & Watkins, 1981, 1982, 1988). Experimental.support for the existence and behavior of ego states comes from the Stanford studies on "hidden observers." The "Hidden Observer" Phenomenon
In the Stanford studies Hilgard and Hilgard (1975) discovered that painful stimuli, such as that imposed by restriction of circulation or by immersion in ice water, could still be perceived "unconsciously" after hypnoanesthesia had apparently rendered the subject pain-free. Hilgard at-
Downloaded by [Tufts University] at 06:59 22 October 2014
DISSOCIATION AND DISPLACEMENT
tributed this awareness to an underlying, covert "cognitive structural system" which he called "the hidden observer." Beahrs (1982) termed this phenomenon "co-consciousness," one segment of "the self" being aware of the pain, while simultaneously another segment (the normally conscious part) was unaware of it. The relevant finding here is that pain which has apparently been eliminated by hypnotic suggestion is still retained within a covert "cognitive structural system." This dissociation (or displacement) of pain was demonstrated with normal volunteers (college students) who were not multiple personalities. It occurred to us that this "cognitive structural system" might well be one of the "ego states" with which we had been working therapeutically.
Ego States and Hidden Observers We (Watkins & Watkins, 1979-80; 1980) activated hidden observers using Hilgard's cold-pressor pain procedure on five subjects previously treated a year earlier by ego-state therapy. Anesthesia was suggested in the hypnotized subject's right hand, and it was thrust into ice water with instructions to remove it when the cold could no longer be endured. One subject kept the hypnotically anesthetized right hand in the ice water five times as long as he did with the unanesthetized left hand and then developed a severe stomach ache. The pain had apparently been displaced from the hand to the stomach. A recorded excerpt from this case is as follows: A known ego state, "Old One," previously studied in therapy, emerged and reported that the hypnotic instructions were that he would not feel any pain "in the hand," so when he did feel it, it was in the stomach. When asked whether "some other part" experienced the pain, another
7
known ego state, 3-year-old "Sandy," emerged and said, "Yeah." "Tell me about it, Sandy," I said. "Well, it hurt." "It did?" "Yeah! What do you expect? lese." "Well, Ed" (the overt subject) "didn't seem to feel pain in his hand." "Well, I did," Sandy complained, "and I didn't like it at all." The patient, Ed, was not a multiple personality but a college student who came to therapy to resolve certain neurotic symptoms including an inability to concentrate on his studies. His various ego states could be contacted only under hypnosis. His study problems were found to stem from interference by Sandy who resented not being able to "play." They were resolved when the therapist (H. W.), using ego-state therapy, arranged to have Sandy's play needs satisfied. In this case we see a pain being displaced from one bodily organ to another (hand to stomach) and also displaced from the primary cognitive structural system (Ed) to other "hidden observers" or ego states (Old One and Sandy). That pain is not necessarily eliminated by hypnotic suggestion but may be displaced into other segments of the personality has many implications, not only for the treatment of multiples, but for the therapy of pain in general. Such displacements seem more widely possible since ego states have been found to be a part of normal adaptation in many individuals who have come to us for relatively nonpathological conditions: study habits, stop smoking, or weight reduction and in some cases professional therapists who merely wished to improve their own functioning, as do analysands who take "training" psychoanalyses. An interesting situation occurred with Wendy, a 35-year-old woman who suffered continuous abdominal pain related
Downloaded by [Tufts University] at 06:59 22 October 2014
8
to a clostridium condition in the bowel. To control the pain, and to help her reduce the use of medication, she was taught self-hypnosis. Wendy was not a multiple personality, but she was aware of a child ego state, called "Sally," which she had discovered under hypnosis. Wendy and Sally became close, affectionate friends, communicating with each other, but only under hypnosis. It was very distressing to Wendy when she discovered that if she, Wendy, relieved her pain through self-hypnosis, Sally when activated would emerge weeping, bitterly complaining of severe suffering. Sally then would seek support and nurturance from the therapist. Wendy, herself, rarely cried. Wendy decided consciously that her relationship with her own "child ego state" was so important that she would use selfhypnosis to lessen but not eliminate the pain, thus giving only part of it to Sally. Subsequently she used self-hypnosis merely to take the severe edge off the pain, making it tolerable - and Sally expressed gratitude to Wendy that her severe suffering was lessened. Wendy told us she felt that if she transferred all the pain into Sally she would be "denying" Sally and that in time she would become increasingly separated and "lose all contact with her." This observation is an interesting bit of insight by the patient, suggesting an awareness that if she practiced greater dissociation she might become a true multiple. In psychoanalytic therapy it has been a matter of established belief that repressed anxiety (as opposed to consciously activated, "worked-through," and released anxiety) may permit the patient to feel better for the present but at the cost of energy tied up in the repressing process, hence leaving less energy for other things
WATKINS AND WATKINS
and lowering the efficiency of living. A similar situation may exist when pain is repressed (or dissociated) rather than confronted and "worked-through." We are left with an intriguing question. How many people with normal ego states relieve their sufferings (current or "memory" pains) by aspirin, Tylenol, Advil, hypnotic suggestion, or self-hypnosis, rather than by confronting and wearing them out. Could it be that patients whose pain has been removed by hypnotic suggestion (or even by pharmacological intervention) may merely be postponing suffering by dissociating it into covert "cognitive structural systems," thus storing up future "ouches," reducing their energy for living, and simultaneously reinforcing emotional immaturity in their own selves? Summary That emotions and conflicts can create or increase painful symptoms has been well established. Hypnotherapy has been widely used to alleviate both physically caused and psychogenic pain. This includes selfhypnosis. Recent developments in hypnosis theory have placed increasing emphasis on its dissociative features. Some theorists have considered it a "controlled dissociation" as contrasted to multiple personality, which is an "uncontrolled dissociation." Multiple personality cases have been presented here showing that they are capable of eliminating pain in the primary personality by displacing it into covert alters. This process may involve a kind of self-hypnosis. When the alters are then activated they often report having "received" the pain and complain bitterly. The Hilgards demonstrated that normal experimental subjects, when hypnotized, can similarly dissociate or displace pain
Downloaded by [Tufts University] at 06:59 22 October 2014
DISSOCIATION AND DISPLACEMENT
into a covert cognitive structural system within the personality. They termed this phenomenon "the hidden observer." Working hypnoanalytically with patients (and with volunteer experimental subjects) the Watkins, (who started with the theoretical concepts of Federn, a close associate of Freud's) discovered that ego states, internal personality segments, behaved both like Hilgard's hidden observers and "covert" multiple personalities. The ego states demonstrated behavioral and experiential content and when interviewed under hypnosis reported individual self-identity. Moreover, they could also dissociate (or displace) pain from the normally primary or "executive" state to substates (cognitive structural systems)-even as did "hidden observers" and true multiple personalities. A therapeutic system was developed which the Watkins called, "ego-state therapy." This technique involved the resolution (primarily under hypnosis) of conflicts between the various ego states that were causing symptoms and maladaptive behaviors. The approach has been effective in treating a number of disorders and behavioral problems, ranging from unsatisfactory study habits, smoking, obesity, or various psychophysiologic and neurotic disorders, up to and including true, overt multiple personalities. "Ego-state theory" is based on the assumption that human personality structure develops through integration and differentiation, hence putting together and separating apart. Out of these processes personality segments arise for purposes of adaptation and defense. Most psychological processes exist on a continuum. They tend initially to be adaptive but become less so when excessive (e.g., anxiety). So also it is with integration and differentiation.
9
At one end of the continuum, differentiation is adaptive with personality segments (ego states) possessing relatively permeable boundaries through which communication and constructive interaction can take place-as in normal mood states. As the segmentation becomes more defensive, the boundaries separating ego states become more rigid and less permeable. At the other end of the continuum we call the separating process "dissociation." The ego states are no longer aware of or in communication with one another, and true, overt multiple personalities may be created. Covert ego states, representing the intermediate range of the differentiationdissociation continuum, can be found in many normal subjects who volunteer for hypnotic laboratory experiments, as well as in patients in psychotherapy. Dissociation is associated with hypnotizability. Hence, the ability to displace pain into sub ego-states may inhere in many normal individuals who are hypnotically treated for pain. This suggests that when we remove pain by hypnosis we may not be getting away "scot-free." Perhaps it is being displaced into underlying ego states and stored there with the possibility of noxious sequelae or later return in some other undesirable form. Such a possibility needs further investigation if we are to use hypnosis for the relief of pain, whether physically or psychologically caused. It also raises questions about suffering that is alleviated by the many pain medications now marketed. References
Alexander, F. (1950). Psychosomatic medicine: Its principles and applications. New York: Norton. Beahrs, J. O. (1982). Unity and multiplicity:
Downloaded by [Tufts University] at 06:59 22 October 2014
10
Multilevel consciousness ofselfin hypnosis, psychiatric disorder and mental health. New York: Brunner/Maze\. Beahrs, J. O. (1986). Limits of scientific psychiatry: Role of uncertainty in mental health, pp. 86-113. New York: Brunner/Maze\. Bliss, E. L. (1986). Multiple personality, allied disorders and hypnosis. New York: Oxford University Press. Braun, B. G. (1984). Uses of hypnosis with multiple personality. Psychiatric Annals, 14, 34-40. Brown, D. P. & Fromm, E. (1987). Hypnosis and behavioral medicine. Hillsdale, NJ: Lawrence Erlbaum. Crasilneck, H. B. & Hall, 1. A. (1975). Clinical hypnosis: Principles and applications. New York: Grune & Stratton. Dunbar, F. (1947). Mind and body: Psychosomatic medicine. New York: Hoeber. Edelstein, M. G. (1982). Ego-state therapy in the management of resistance. American Journal of Clinical Hypnosis, 25, 15-20. Fedem, P. (1952). Ego psychology and the psychoses. (E. Weiss, Ed.). New York: Basic Books. Fromm, E., Brown, D. P., Hurt, S. W., Oberlander, J. Z., Boxer, A. M., & Pfeifer, G. (1981). The phenomena and characteristics of self-hypnosis. International Journal of Clinical and Experimental Hypnosis, 29, 189-246. Hilgard, E. R. (1986). Divided consciousness: Multiple controls in human thought and action. New York: Wiley. Hilgard, E. R. & Hilgard, J. R. (1975). Hypnosis in the relief of pain. Los Altos, CA.: William Kaufmann. Janet, P. (1907). The major symptoms of hysteria. New York: Macmillan. Kluft, R. P. (1987). An update on multiple personality disorder. Hospital and Community Psychiatry, 38, 363-373. Kroger, W. S. (1977). Clinical and experimental hypnosis. Philadelphia: Lippincott.
WATKINS AND WATKINS
Lipowski, Z. J., Lipsitt, D. R., & Whybrow, P. S. (Eds.). (1977). Psychosomatic medicine: Current trends and clinical applications. New York: Oxford Univ. Press. Newey, A. B. (1986). Ego state therapy with depression. In B. Zilbergeld, M. G. Edelstein, & D. L. Araoz (Eds.), Hypnosis: Questions and answers. New York: Norton, pp. 197-203. Rossi, E. L. & Cheek, D. B. (1988). Mindbody therapy: Ideodynamic healing in hypnosis. New York: Norton. Sternbach, R. A. (1963). Congenital insensitivity to pain: A critique. Psychological Bulletin, 60, 252-264. Torem, M. S. (1987). Ego-state therapy for eating disorders. American Journal of Clinical Hypnosis, 30, 94-104. Watkins, 1. G. & Watkins, H. H. (1979-80). Ego states and hidden observers. Journal of Altered States of Consciousness, 5, 3-18. Watkins, 1. G. & Watkins, H. H. (1980). I. Ego states and hidden observers. II. Egostate therapy: The woman in black and the lady in white (audio tape and manuscript). New York: Jeffrey Norton. Watkins, J. G. & Watkins, H. H . (1981). Ego-state therapy. In R. J. Corsini (Ed.), Handbook of innovative psychotherapies. New York: Wiley-Interscience. Watkins, J. G. & Watkins, H. H. (1982). Egostate therapy. In L. E. Abt & I. R. Stuart (Eds.), The newer therapies: A sourcebook. New York: Van Nostrand Reinhold, pp. 137155. Watkins, J. G. & Watkins, H. H. (1986). Hypnosis, multiple personality and ego states as altered states of consciousness. In B. W. Wolman & M. Ullman (Eds.), Handbook of states of consciousness. New York: Van Nostrand Reinhold. Watkins, J. G. & Watkins, H. H. (1988). The management of malevolent ego states in multiple personality. Dissociation, 1, 6772.
