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  Integral Therapy: With Dissociative Patients
  

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By: Marko van Gerven, M.D.
Integral Therapy:
The Working Together of Experiential and Consciousness-Raising Therapies in Therapeutic Processes With Dissociative Patients (Translated from the Dutch by Christa van Tellingen-van Heek, M.D.)

Introduction
This article is meant to explore how cooperation can lead to a wholeness in therapy. The question: which points of view transcend the effects of the separate efforts of therapists? is examined in light of the clinical picture of Dissociative Identity Disorder (DID, formerly multiple personality disorder). In this illness, the self seems to be fragmented, which manifests itself as either the experience of several aspects of the self that seem to be disconnected from each other or as the appearance of seemingly autonomous fragments of one's own personality. For that reason, no other illness in psychiatry seems to ask so clearly for cooperation among the therapists.

In this essay, the second phase of the treatment, which is usually not clinical, is specifically used as the point of departure. (For further information on the phases, see Van der Hart(8)). We will not speak about the more general conditions of the first phase of the treatment of dissociative patients: setting limitations, cooperation, and safety issues. The third phase of integration and recovery will also not be considered extensively.

Spiritual Sources
In the Spiritual Sources of Art,(5) Rudolf Steiner describes the background dimensions out of which the different arts affect the human being. As arts he mentions: architecture, modeling or sculpturing, painting, music, poetry and eurythmy. Architecture and modeling or sculpturing arts are directed especially toward the forces from before birth (by means of the forces of the physical body and of the formative body). Music and poetry are especially directed towards that which is around us as "soul substance" (the area of the after-death forces). The art of painting is directed toward what hides behind the sense-perceptible world and, thus, connects us with the world of spiritual beings. Eurythmy brings the body itself into movement and brings us into direct contact with the supersensible world. In order to understand the way in which art can be used, it is helpful to make a distinction between the use of art to make an emotion visible and art working out of a spiritual source.

Art therapy is often used to elaborate on emotions and to try to give them form. The media that is used to express these emotions is of secondary importance to the effect or the aim that is intended. Drawing can have the effect that a "story" is told, while in modeling an experience is recreated and therefore brings a different intensity, touching on another dimension. When one aims at a healing effect on the patient, the material and the art are then direct mediators of a spiritual working. Then, one heals out of the dimensions that were mentioned above.

Psychotherapy is not one of the original arts. To begin with, psychotherapy is a derived art form. In this form of art, both elements of knowledge of the process of illness in the human being and educational aspects and ritual elements play a role. For many people the psychotherapist has taken the place of the priest. The special characteristic of psychotherapy is the unique mixture of the above-mentioned ingredients adjusted to the patient. This adjustment is then given form methodologically in a time period.

Psychotherapy tries to give meaning to what is happening by explaining it, often with the help of artistic processes or elements. Psychotherapy can be seen as the synthesis of the above mentioned arts in which everything is brought together with a biographical dimension. Seen in this way, psychotherapy is the seventh art.

Aesthetic Structuring
In his book Therapy as Art,(2) Petersen describes the use of art as a principle that can arrange aesthetically. Art is used to re-structure the lost relationship with one's own body and to enrich the old, often dulled experiences through sensory observation. This is a universal effect: depending on the individual responsiveness, every patient can undergo this working. The effect arises because the individual can mirror him- or herself again in the archetypal images that are working in the spiritual world. In spite of all the conscious-awakening in the soul, the pathology, the fragmenting, would remain if it were not for these wholesome aspects of integral therapy.

In the Young Doctors Course of 1924, Rudolf Steiner points to two principles during the healing process. On the one hand, the therapeutic answer must be found for the shifts which happen during the process of illness out of insight into the pathology. On the other hand, a further ripening process must happen after the cure itself. If the latter is skipped, then the chance is missed to find the answer to the process of becoming ill. As a consequence, the aesthetic structuring could result in that the physiological breaking up, that happens as one goes through the planetary spheres at night, does not happen because of the longing for a connection with the spiritual world that has been evoked and through being filled with respect for the forces that underlie existence. (Rudolf Steiner in the Hague(6)).

In the nightly journey between the planetary spheres, the failing religious images specific to our materialistic culture cause the self to have insufficient force to hold itself together. The splintering of the self appears even as a typical sign of our time! A "correct" orientation at night can help the spiritual core to pull itself together again and find the strength to give meaning to the oppositions encountered in life.

The Seven Free Arts
The seven free arts that were practiced in the Middle Ages at the universities were aimed at educating the human being to be a "homo-universalis." Walter Johannes Stein(4) is to be credited for having linked these seven arts to the seven planetary processes. Starting from the seven medieval arts he comes to a path in seven phases which is protected by Michael. This archangel stands directly behind the visible world, the world of facts. As Sun spirit he connects us via the sensory joy and wakefulness in observation with the processes that form the foundation of the visible world. Through the Jupiter process we enter the area of feeling/dreaming both in sleep as well as in our feelings and emotions experienced during the day. The constantly-changing phases of the moon which continually illuminate the earth from a different perspective stands for the image-less thinking. Through thinking, subjective experience becomes objective. Mercury leads the human being to the essential and to knowledge of the laws of his own karma.

If the will (Mars) is addressed, the inner stagnation is transformed into the development of one's own activity. The force of the Venus sphere can open the soul anew to the experience of the other.

The force of Saturn finally grants us the possibility "through living in god" to come into contact with our own spiritual core and, therefore, with our real "mission".

Eventually every therapeutic process draws from these planetary or time-process laws. Cooperation between the different therapists and working with diverse therapeutic methods will enlarge the chance that the patient will be able to orient him- or herself again towards the "archetypal images."

Therapeutic Process
Christine Spalleto in her article about DID patients and creative therapy(3) describes that the conflict can be re-experienced, dissolved and integrated in the creative act. Creative therapy, like psychoanalysis and hypnosis, uses the method of "free association". This method enables the recognition of (unconscious) conflicts as well as the release of tensions through active expression. According to Spalleto, verbal communication requires more logical time sequence than creative expression. Creative therapy gives more direct access to the consequences of dissociation, isolation, and identification with the aggressor.

In Therapy As Art, Peterson describes six phases in every therapeutic process. To me, these phases seem to be derived from the above-mentioned journey through the planetary spheres. It is good to realize that these and further steps can be seen as parts of a total therapeutic process as well as parts of every therapeutic session.

1. The Disturbance
Every healing process starts with becoming ill - becoming aware of pain, fear, depression, having lost time, and of unexplained feelings of rage. In this way, the step to ask for help is taken.

2. The Diagnosis
If one has seen DID patients struggling with their diagnosis, one understands that to recognize oneself as being in a certain illness concept is not merely a cerebral process. One of the consequences of recognizing that one is ill means admitting loss of control and other dissociative mechanisms such as hearing voices. There is a heightened consciousness of an inwardly splintered, contradictory and frightening world.

3. The Catharsis
To begin with, the increased communication with one's own inner world brings an increase of feelings such as despair and contradiction as well as chaotic behavior. Now, the crisis is really there. For this reason it is of the greatest importance that the therapist place this phase in the right moment of the session. Furthermore, every therapist must have techniques at his or her disposal with which patients can be brought out of this experience and can go home safely.

4. Renunciation, Giving Up
One of the most painful phases comes when, through increased consciousness, many escape mechanisms have to be released. Usually, alters react incredibly fast to painful events and in this way protect the patient against experiences that are too overwhelming. Dissociative mechanisms help to continue the myth of a happy youth and good parents. Moreover, this phase also brings the consciousness that one does not only have the feelings of the victim but also the feelings of the perpetrator. The attack that is undertaken on one's karmic course asks not only for a way out of the experience but also for an answer to the question of why this attack took place. In a group of cooperating therapists a diversity of points of view can be found.

5. Transformation
Because of the loss of the escape mechanisms and the heightened consciousness, the possibility arises to look at the experiences consciously and to listen to what wants to announce itself behind these experiences. After going through a session, the patient may need to give form to new feelings such as the recognition that behind powerlessness stands vulnerability, which is characteristic of human existence. One has the opportunity to come out of the victim position by resolving to take action for oneself and by giving new meaning to one's deeds.

6. New Communication
New experiences and insights can lead to a form of inner acceptance as well as an increased feeling of responsibility. In this way, one can discover which steps one wants to take in life out of the awareness gained from the experienced trauma and the process of becoming whole again. This is probably what is meant by the saying that the experienced grief is written into the biography and does not stay unreachable through the dissociative mechanisms. Connie Palmen(1) describes our time as the century "of the acquittal, of the taboo on guilt." "Philosophy begins the moment that you are really able to know, to choose to carry through your will, to have power, to become master or slave, to be responsible and because of that to take the risk to become guilty." One of the most painful moments in the treatment of traumatized patients is the discovery of the identification with the feelings and actions of the aggressor. Trauma therapy seems to be successful only when the position of the offender can also be understood.

Verbal Psychotherapy
The violated trust in one's fellow man can be healed when one's own boundaries can again be experienced safely within a meaningful relationship. The transferred feelings play a role in this as does the archetypal dynamics of giving and receiving.

Verbal psychotherapy also can objectify what was experienced and lived through. This can happen through the different techniques that are used as well as through connecting the general laws of human life lovingly with the individual human experience. This insight, then, is perhaps equally as healing.

Marko van Gerven, M.D.
Bernard Lievegoed Klinik
Prof. Bronkhorstlaan 10
3723 MB Bilthoven, Holland

References
1 Palmen, Connie. The Friendship. Prometheus. March 1995.
2 Petersen, Peter. Therapy as Art. 1990. Vry Geestesleven. Zeist.127-148.
3 Spaletto, Christine. Expressive and Functional Therapies in the Treatment of Multiple Personality Disorder. 1993. Charles Thomas, ed.
4 Stein, Walter Johannes. Merlin's Death. Thomas Meyer, ed.
5 Steiner, Rudolf. The Spiritual Sources of Art. Lecture of Sept 12,1920.
6 Steiner, Rudolf. Supersensible Man. Lecture of November, 1923 in The Hague.
7 Steiner, Rudolf. Course for Young Doctors. 1994. tr. unknown. Mercury Press. Spring Valley.
8 van der Hart, Onno. in Trauma, Dissociation and Hypnosis. 1995. Swets and Zeitlinger.





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