This week on the podcast, we discussed an article published by Sarah Clark of the Stronghold System on their website, PowerToThePlurals.com, and shared in her facebook support group AlterNation.
Their article discusses the Theory of Structural Dissociation.
In the article, they consider it to almost be a theory of structural integration instead, and call the theory out for being ableist due to it emphasis on functioning through one ANP in therapy rather than whoever presents, and because of the emphasis on integration as the only treatment option. As they said in the podcast interview, the theory of structural dissociation is being used to push integration as the only option “because it sets up the idea we were never “split off” in the first place, so it’s easier to integrate us back to together again”. Here’s the quote from their article that they reference in the podcast:
We read in the same book (page 7) ‘’Structural dissociation involves hindrance or breakdown of a natural progression toward integration of psychobiological systems of the personality that have been described as discrete behavioral states.’’ (Putnam, 1997).
This is what most people refer to when explaining that we are not broken, not split off. We are all born with different states and early childhood trauma survivors can’t integrate in early childhood due to that trauma. But as you can see it was actually Putnam in 1997 who introduced this idea.
They also say that the authors of the theory appropriated or borrowed terms from other authors who used them much earlier. Here’s a quote from their article:
Charles Samual Myers, who in 1916 wrote about Apparently Normal Part (ANP) and Emotional Part (EP) after acute trauma in WW1. So it is fair to say that the theory of Structural dissociation borrowed these terms, not introduced them, as is readable in the haunted self. (page 4)
Drawing conclusions from this, they clarify that you can accept parts of the theory from the original authors, rather than crediting this theory for your understanding.
They go on to say that the Theory of Structural Dissociation is a model about trauma, not a model about dissociation. Here’s the quote from the article:
It is also good to realize that the theory of Structural dissociation is neither about DID, nor is it about alters, as many of us Plurals know them. They speak of ‘dissociative parts of the personality’, caused by trauma. Nota bene, not early childhood trauma, trauma in general. As this theory also explains single trauma, repeated trauma in adulthood and (early) childhood trauma. It is used to describe changes that are diagnosed as (c)PTSD, trauma related borderline personality disorder, DID and more.
This, along with their perspective that because of DSM5 criteria, DID does not actually have to be a “disorder” if the person’s System is not distressed by it and functioning well. From this, they issue a call to the community to refer to themselves as “Plural” culturally, rather than DID therapeutically. They also are calling for “Functional Multiplicty” to be an option in treatment, rather than integration pushed as the goal.
This, they say, is more effective for positive cooperation amongst a system and healthy functioning as a system, with greater participation in therapy than what the Theory of Structural Dissociation offers. They say:
The theory of Structural dissociation idolizes integration. And although they say that ‘’no one has to go away’’, they also clearly explain to therapists, to not engage with us ‘dissociative parts of the personality,’ unless absolutely needed. Instead it is suggested that the therapist speaks whenever possible, through the ANP fronting…
… And in DID, in particular, requiring all communications to relay through one particular (perhaps malleable or favored) ‘alter’ that sounds a lot like silencing to me. Because the therapist (or any other outside person,) can never know (for sure) whether the part who is presenting, is truly conveying all information which is coming from inside. This book talks a lot about shame, but forgets that our ANPs might not feel comfortable repeating what those EPs just said inside, and that the information may be so overwhelming for them as to cause them to have intense dissociative symptoms.
You can see in the article that they use a picture of a slide from a presentation by Kathy Steele to show that the Theory of Structural Dissociation is being taught to only talk to one ANP and focus on integration in that way.
Following this perspective and logic, they conclude in their article, that the Theory of Structural Dissociation is ableist:
We know from a 6 year follow up study that only 12.8% of participants were able to reach integration as described in the theory of Structural dissociation. (page 4 )
That is a very low percentage. In any scientific research for medicine or therapy for example, a 12.8% positive outcome would not be tolerable. Yet the whole theory of treatment within Structural dissociation is based on it.
A chronic disorder, often debilitating, with a much-respected and idolized healing option with only 12.8% success rate, sounds ableist to me.
A 12% success rate is definitely a call for improved access to and quality in treatment, absolutely, and worth talking about - that’s why we shared it on the podcast.
That said, I don’t know how someone would pin-point integration on a timeline, when to us it feels more like a process than an event (Dr. Siegel said this on our podcast!) - so that 12% seems interesting to qualify with things like how they defined integration and what kind of follow-up support they received and who continued maintenance therapy or not and what kind of life stressors they had and those kinds of questions.
However, there is more to this piece we need to look at to see everything. This study mentioned is one of Bethany Brand’s from Top DD Studies, and I interviewed her earlier for the podcast last summer - unfortunately, it was one of the lost episodes because of technology glitches. But what I know from this study is that it does give a 12% success rate for integration, but it also mentions ANOTHER 12% who are “successful” without integration in a final-fusion kind of way. Further, the study also emphasizes other ways success can be measured and were noticed in the study, including: reduced hospitalizations, reduced suicide attempts, and improved GAF (global assessment of functioning) scores. These are significant and worth mentioning.
But, following this discussion on the podcast, Dr. Peter Barach reached out to us (as a friend and colleague, not in any clinical role) in response with more information. He also clarified that:
I think she has some incorrect ideas about what is generally recommended these days as treatment for DID. I think if you take a look at the ISSTD treatment guidelines, you won’t find what she says to be there. The term “integration” refers to “better integrated functioning ,” not to “fusion” of all the alters I to one.
Kluft argues that fusion leads to the most stable outcome of treatment—that’s his opinion, but the only data on that point comes from a series of people he treated himself. Fusion doesn’t always happen, and it’s also clear that some people with DID don’t want it.
He also shared further insights that we shared in the episode “Clinical Response” in the episode following the interview with the Stronghold System. Here is some of what he clarified in response:
Charles Myers wrote a book (1940) describing veterans of World War I in France who had shell shock, which of course is now called PTSD. He said that there are "emotional" personalities, referring to behavior during flashbacks and trauma-related nightmares, and "apparently normal" personalities who are detached from the experiences of reliving trauma.
I think he used the term "personality" in a much looser sense than we think of parts or alters, whatever word we use, in DID. He was not talking about survivors of childhood trauma.
Myers was not talking about parts or alters with different names and ages. An example of this is a veteran with PTSD working as an auto mechanic who hits the ground when there is a loud noise at work, such as a tire popping suddenly off its rim. This is an automatic response without thinking or planning, and leaves the veteran feeling embarrassed.
Here Dr. Barach clarifies that Myers was not talking about DID, but about a PTSD kind of response. In a plural system, the ANP and EP are distinct personalities as in parts or alters, as in distinguished by identity (age, gender, name, etc.), whereas what Myers was referring to was functioning - the veteran being able to function in a work setting upon returning from war (ANP), but having a limbic response triggered (EP). When Van der Hart uses the terms ANP and EP, he is applying them in an extended way to explain the continuum of dissociation.
Further, Dr. Barach points out that Van der Hart does give Myers credit when using the ANP and EP terminology, so it is neither appropriated or used without acknowledging the source.
Van der Hart always mentions Myers when he uses those terms ANP and EP, so I disagree that he and his coauthors have appropriated or stolen these labels. Van der Hart is also clear that the structural theory of dissociation is talking about ANPs and EPs that are more elaborated than the ANP and EP ideas of Myers.
He then explains this here, using quotes from both Myers and Van der Hart:
Here's what Myers wrote:
"“Now and again there occur alterations of the 'emotional' and the 'apparently normal' personalities, the return of the former often heralded by severe headache, dizziness or by a hysterical convulsion. On its return, the 'apparently normal' personality may recall, as in a dream, the distressing experiences revived during the temporary intrusion of the 'emotional' personality.”
Here's an excerpt from a 2010 article by van der Hart and others:"the EP range in forms from reexperiencing unintegrated (aspects of) trauma in cases of acute and posttraumatic stress disorder (PTSD), to traumatized dissociative parts of the personality in dissociative identity disorder (DID; APA, 1994)."
Dr. Barach then concludes that it’s not accurate to say that Myers was talking about the same thing as DID when he wrote about ANP’s and EP’s, even though that was the original source of the terminology.
He also explained that he wouldn’t consider the OSDD diagnosis as something being used to “step-down” a DID diagnosis, but rather it being related to how the system itself is presenting within the context of what they are dealing with at any given time. He said:
The DSM is a bunch of cubbyholes with labels on them, but the disorders aren't "real" in the same way that a flower or ice cream is real. The DSM is a system of categories. That's all it is.
How things end up in one category or another is a matter of psychiatric politics. For example, PTSD used to be classified as an anxiety disorder. But now it's in the trauma disorder category.
… Well over 95% of people with DID report a history of extensive childhood trauma; there are even some studies confirming the trauma histories of groups of people with DID. But DID is not in the trauma disorders category. It's in the dissociative disorders category. Go figure.
Also the whole issue of OSDD versus DID to me exists only because some psychiatric folks wanted two categories! There are people diagnosed with OSDD whose inner parts never "front," and who don't lose time, unless there is heavy stress. So if I evaluate them on a low stress day, the diagnosis might be OSDD, but an evaluation on a higher stress period of life might lead to a diagnosis of DID.
In regards to whether someone can have DID but it not be a “disorder”, Dr. Barach clarifies that:
“every diagnosis in the DSM requires either "clinically significant distress" or "functional impairment."
So, if one were going for “functional multiplicity”, then that functioning needs to include being able to work, manage relationships, and other ways of functioning. He said:
If someone had parts, wasn't distressed by having them, but wasn't functioning well in relationships or work because of the parts fighting for control or switching a lot, that would count as a disorder.
This put into words what we were trying to explain in the podcast in the follow-up episode, about how (for us) functional multiplicity becomes a natural part of the healing process as internal cooperation and collaboration improves.
In that way, for us, functional multiplicity is a part of the process rather than an end goal alternative to the end of treatment. We - only speaking for our system - are not far enough in treatment to know, experience, or be able to speak of anything else or what we will choose at the end of treatment or understand what that will look like.
However, we understand from our own experience of searching for a good therapist for over a decade, that there is a critical time period where plural systems - especially those in areas without access to treatment - are, indeed, functioning for years and years as multiples (or “Plural”). Even if you are able to find a good therapist, and begin treatment, therapy takes years and years. It makes sense that Functional Multiplicity would be a fantastic goal during this time, regardless of what the “end of treatment” looks like, we think. This is a quality of life issue, in those years after the trauma that caused the multiplicity (or “plurality”), the decades of waiting for help and access to treatment, and the years and years of treatment itself.
In regards to whether DID requires a trauma history, Dr. Barach went on to say that:
She said that there are people who have DID without a trauma history. Well, maybe so, but that is actually an empirical question--and where's the data? There are a number of published case series showing an extremely high rate of childhood trauma (like 95% or more) reported by people in clinical settings who have DID. There are also some people who believe they have DID, but actually they don't--they have just assigned names to aspects of themselves.
We would add that there may be Plural systems who deny trauma as part of the dissociative process, who just do not know yet about their own trauma.
That said, there are people who identify as “Plural” who report no trauma history, who say they have no disorder because they are not distressed by it and functioning just fine.
This is an important cultural development clinicians need to know about, whether they agree with it or not, just for cultural competency, that there are people in the “Plural Community” who do not consider themselves to have DID.
That said, if these people are functioning just fine and not distressed about being Plural, then they would not be seeking treatment for DID - which is likely why clinicians are less familiar with this (more recent) cultural population.
Finally, Dr. Barach responded to one last point:
Although the proponents of the structural theory may say that treatment should take place through the ANP, that treatment idea does NOT necessarily follow from the theory. And while the structural dissociation folks may be teaching therapists to work directly only with an ANP, that is not what a lot of other experienced teachers in the dissociation field are teaching (including me). I well remember Richard Kluft saying very clearly that you cannot treat someone with DID unless you are working with the "alters" (to use his preferred term).
In fact, when I reached out to Kathy Steele herself, to clarify what she was teaching from the slide used in the Stronghold System’s article, she was very responsive.
I try to work with the "adult self" to the degree possible, but do work with parts. I have a sequence of decisions on when you can work through the adult, when to work with a group of parts together and when to work with a single one, and then I work my way back up the ladder. I have never said I only work with the adult part or only ANPs.
We can say that we saw Kathy Steele present in Kansas City, in which the same slide used in the Stronghold System article was also displayed. But throughout the presentation, she did give many examples of how to work with different kinds of parts. So we followed up on this, and not only did she clarify further, but she also was eager to adapt her language so that would be more clear in the future what she meant::
I do emphasize that an "adult" needs to be active in therapy, which is maybe where the confusion comes in. By this, I do not mean any one part, but rather am focused on capacities necessary for successful therapy: the ability to contain behaviors, the ability to reflect, the ability to cooperate on mutually shared therapeutic goals. And in early therapy I always focus on helping the client as a whole to find those capacities and use them. I don't think any diagnosis - no matter which one - precludes these, and these capacities are either explicit or implicit in every single therapeutic approach.
I will think about maybe not using the term "adult" for these capacities to avoid further confusion.
This is why we do the podcast, for this kind of exploring and these kinds of conversations.
Working to understand the article on Power to the Plurals is important for understanding the client experience and cultural implications, while advocating for improved care and quality of treatment.
Working to understand the clinical response helps us to engage in treatment as we understand what is going on and why we are doing the things we are doing, and to better educate other clinicians and those still waiting for access to treatment.
This is empowering to us all, and a beautiful thing when we work together, even good practice at attunement and being receptive and attending to one another. Well done, everyone!
