By Hélène Dellucci
When Jacques Joseph Moreau, a French psychiatrist from Tours, first used the concept of dissociation in France in 1845 in his research on the benefits of cannabis for understanding the psyche, he described a phenomenon of psychological disaggregation.
We owe this reference to Pierre Janet (1859 – 1947), one of the early forerunners working in the dissociation field, whose research into the domains of hysteria and hypnosis brought us these original concepts (Van der Hart & Nijenhuis, 2009).
Pierre Janet : from the study of hysteria to the conceptualization of dissociation
The considerable body of work of the French doctor, psychologist and philosopher Pierre Janet, rediscovered by international authors (Ellenberger, 1970 ; Binet, 1980 ; Van der Hart et al. 1989 ; Van der Hart & Horst, 1989 ; Van der Kolk et al. 1989 ; Van der Hart, Nijenhuis & Steele, 2006/2010) is currently undergoing something of a revival. Sixty years of work (1887 – 1947) have allowed concepts to emerge that are still relevant today and have given rise to his “psychology of conduct.”
Even though the relevance of Janet’s work is now widely recognized, the concept of dissociation has long been misunderstood, particularly where the traumatic origins of dissociative problems are concerned. Already in 1907, Pierre Janet was defining dissociation as “a personal synthesis illness,”... “a type of mental depression characterized by a retraction of the field of consciousness and a tendency to dissociate and emancipation of the systems of ideas and functions that constitutes personality.” (Van der Hart & Nijenhuis, 2009).
Janet’s thinking is now the foundation stone of one of the most precise and exhaustive theories, helping to clarify the concept of dissociation as much as possible: the theory of structural dissociation of the personality (Van der Hart, Nijenhuis & Steele, 2006). This seminal text was translated into French in 2010 and is now available to French-speaking professionals and laypersons. Janet’s work also remains alive and well through the Pierre Janet Institute in Paris, directed by Isabelle Saillot, as well as the Janetian Studies Journal, created in 2004, whose goal is to promote a better understanding of Janet’s work and his specialty, dynamic psychology. In 2011 the Institute became the Pierre Janet network, continuing to disseminate Janet’s work. Isabelle Saillot continues to be a dynamic force within this network.
Dissociation in France today
The world of psychotraumatology dealing with dissociation has been primarily an international world, with most work being done in English and also in German. There are publications in French, though they are limited in number. Essays on dissociation have appeared in journals (Nijenhuis, Van der Hart, Steele, De Soir & Matthess (2006), Van der Hart, Steele, De Soir & Nijenhuis (2009), in the Revue Francophone du Stress et du Trauma [The French Journal of Stress and Trauma]), but also as chapters of several books (Kedia, Sabouraud-Séguin et al., 2008/2013 ; Matthess & Dellucci, 2011; Salmona, 2012), as well as entire books devoted to the subject (Van der Hart, Nijenhuis & Steele (2006/2010), Kedia, Vanderlinden, Lopez & al., (2012)). In France where psychopathology was mainly oriented towards Freudian and Lacanian psychoanalysis as well as the structuralism of Bergeret, talk of dissociation amounted to a discussion of either psychosis or hysterical neurosis, and this with a degree of determinism such that only management of these problems was envisaged, and rarely the possibility of actually being free of them. During the 19th Century, the terms ‘dissociation of consciousness ‘ and ‘dissociation of the personality’ were used interchangeably. Notably in the field of hypnosis, no distinction is made between the non-pathological aspects of dissociation, a common element of psychological functioning, and pathological dissociation, which is involuntary and leads to dysfunction.
In France also, these multiple, varied uses of the concept of dissociation have entailed confusion and misunderstanding between the professionals using these terms. A real effort will be necessary, as much to define as to agree upon a precise, comprehensible usage of the concept of dissociation and its psychotraumatological implications. This psychotraumatological etiology opens up another field entirely, where dissociation is included within a complex, chronic psychotraumatology, essentially stemming from adverse events during childhood.
Studies carried out in France in the field of dissociation are few and far between. Nonetheless, mention should be made of a study published in 2002 by El-Hage, Darves-Bornoz, Alliaire & Gaillard in a specialized English language journal, which included 140 patients hospitalized in a psychiatric unit at the University Hospital of Tours and which made the link between somatoform dissociation and trauma. Only recently have other studies been carried out at the University of Lorraine, notably through theses in psychotraumatology. What is particular about psychotherapeutic healthcare in France, is that for the vast majority, these types of treatment are not reimbursed by the national health service. In public psychiatric centres, such as the Centres Médico Psychologiques, consultations with National Health Service psychiatrists are covered by Social Security. However, there is a great deal of demand and these centres are overloaded to such a degree that there is often a long wait to get an appointment. Independent mental health professionals thus represent an invaluable resource.
With David Servan-Schreiber (2003), the French field of psychotraumatology saw an unprecedented expansion through the popularization of EMDR therapy and the ideas of trauma, both with the general public and with healthcare professionals. Among the numerous therapies taking psychological trauma into account, EMDR practitioners and those already trained in psychotraumatology currently seem to be particularly in demand for learning how best to work with patients presenting dissociative disorders. Much effort has been made to adapt EMDR therapy, with its recognized efficacy in the field of psychotraumatology, to complex, chronic trauma. Other approaches, taught in particular through Continuing Education, have included dissociation concepts within their teaching : Lifespan Integration (P.Pace), Sensorimotor Psychotherapy (P.Ogden, K.Minton & C.Pain), Somatic Experiencing (P.Levine), the Ego State Therapy (M.Phillips & C.Frederick), Internal Family Systems Therapy (R.Schwartz).
Dissociation training in France
It is among those professionals working predominantly in private practice, that the demand for training in psychotraumatology seems to be highest, even though more and more public mental healthcare professionals are trained in the field, and little by little, those professors teaching in schools of psychology and psychiatry now include the concept of dissociation in their courses. Even though such efforts remain modest, at least they are there, and we may hope that the interest generated in dissociation will both enable professionals to learn more efficient techniques and the needs of patients suffering from dissociative disorders to be more fully addressed.
Training institutes that have specifically integrated the study of dissociation into their curricula are the IETSP (Institut Européen de Thérapies Somato-Psychiques - the European Institute for Somatopsychological Therapies) and the French EMDR Institute in Paris. These training centres offer wide-ranging training programmes by inviting internationally renowned authors working in the field of dissociation, as well as making their work accessible to French-speaking professionals, notably by means of translation. Conferences on the theme of dissociation have taken place as well as study and research days organized by the University of Lorraine (2011, 2012, 2013), but also recently by the French Federation of Psychotherapy and Psychoanalysis in October 2013.
In November 2011, a French-speaking ESTD day was organized by the IETSP and the ESTD. In 2007, at the EMDR Europe Conference in Paris, a sizeable part of the programme was given over to dissociation, both in plenary conferences but also in the workshops.
L’ALFEST (L’Association de Langue Française pour l’Etude du Stress et du Traumatisme - The French Language Association for the Study of Stress and Trauma) has organized two study days where specific mention was made of dissociation, since the title was “Dissociation, Stress and Trauma and the Clinical Work with Dissociative Disorder.”
Beyond the borders of France, a European Frenchspeaking contingent has organized training programmes in Switzerland and Belgium, enabling therapists and supervisors working in France to train with some of the foremost specialists in the field.
The good news is that not only are therapists getting trained but supervisors too, demonstrating a deliberate intention to include notions of dissociation in their practice as well as that of those of their supervisees.
Certain practitioners, psychiatrists and psychologists working within a hospital setting are also choosing to train in psychotraumatology, typically beginning by training in EMDR. Once they see the efficiency of this therapeutic approach and the difficulty in applying it to people presenting dissociative disorders, they become interested in dissociation and thus continue to develop and perfect their therapeutic techniques. Recently, the entire team of a Lyon clinic requested supervision and training specifically focused on dissociation, indicating a real desire to progress as a team in their approach to patients presenting this complex problem. These are genuine first steps that we hope will bear fruit.
The academic world is also opening its doors to teaching about dissociation. The University of Lorraine has notably included courses specifically mentioning “Trauma and Dissociation” in their curriculum for the Masters 2 in Clinical Psychology and Health Psychology, as well as in that of the university degree in Psychotraumatology. Beyond study days and the supervision of doctoral theses in Psychotraumatology, a genuine will now exists to integrate the study of dissociation in the training of future healthcare professionals. A team of researchers is currently working to develop acomplex trauma diagnostic assessment grid in French.
The concept of dissociation came into being in France, more than a hundred and fifty years ago, and one of key authors in the field was French. Yet it has been authors and clinicians from outside of France who have contributed the most to the theorization and clinical research into dissociation. In France today, though more needs to be done in terms of conceptual clarification, training in dissociation has become accessible and the the interest of clinicians in pursuing training in the subject is on the rise. Apart from the inclusion of ideas of dissociation in approaches designed to treat psychological trauma, the central debate in France today focuses upon the more or less successful delimitation and differentiation of dissociative disorders and psychotic disorders.
I wish to extend my warm thanks to Isabelle Saillot and Joanna Smith for their valuable feedback on the French context of psychotraumatology and the world of dissociation.
From ESTD Newsletter Volume 3 Number 8, September 2014