Disbelief dissociation and modularisation

The first thing I would do if I were returning to teaching and practising psychotherapy is remind myself that the modularity of emotions is central to understanding and treating a number of human problems. The principle of modularity means that each emotion exists as a relatively independent and dissociable module with powers for organising and motivating specific sorts of cognition and action. (Izard, 1994, p. 149, author's own italics)

Izard's advice to himself is completely in tune with the message that we have argued for in this book; namely, that many of the current therapeutic approaches work with an inadequate theory of emotion (see Chapter 4), an inadequacy that, in turn, will invariably lead to problems in therapeutic practice. The first principle to remember in the development of emotion is, as with any other cognitive skill, the tendency towards modular organisation, which is an inherent characteristic of the functional organisation of the brain (Fodor, 1983; Gazzaniga, 1988; Power & Brewin, 1991). That is, we are emphasising a potential for the equivalent of software or functional modularity rather than hardware modularity. The tendency towards modularisation, and perhaps therefore of dissociation, remains an inherent capacity of the functional architecture throughout life, although the capacity clearly decreases with age. This capacity, we suggest, is evident in the initial responses in all individuals to severe losses, traumatic events (Dalgleish, 2004), and even to extreme positive events such as winning the National Lottery until the event "sinks in". As we saw in the discussion of bereavement (Chapter 7) and of post-traumatic stress disorder (Chapter 6), the initial experience is of shock and disbelief to these extreme losses or life-threatening events: the disbelieved experience is held separate to the self in a mildly dissociated form, because of the extent of the impact on the individual's important goals and plans. The individual may remain in this state of disbelief for some time, and continue with normal activities in a trance-like state (cf. Hilgard, 1986). However, the initial phase of disbelief subsequently recedes as the normal individual begins to integrate the loss or trauma, and its implications, into the self. This process is an extremely painful one in which the individual feels overwhelmed by a range of emotions, in particular, sadness and anger in the case of loss (see Chapter 7), and fear, anger, and disgust in the case of trauma (Dalgleish & Power, 2004b); these are not the only emotions, but rather the ones that are most commonly experienced (e.g., many traumatic experiences may involve multiple losses).

Many individuals seek professional help at a point where the mix of disbelief and overwhelming emotion feels too great a burden. The seeking of help at this point may reflect a mix of intra- and inter-personal factors; as we discussed in relation to sadness and loss, one of the socially cohesive actions associated with sadness is to seek out and express one's feelings to others within one's social network. If, however, the lost person was the individual's key confidant, the individual may feel too ashamed to burden other members of the network and, equally, other members of the network may feel unable to support the individual through the grieving process. The key components of therapy in such cases are: first, to provide a supportive relationship in which the client can work through and integrate the trauma or loss into the self; second, to help the client to experience and express emotions that may feel overwhelming and not to reject these emotions as in some way abnormal; and eventually, to encourage the individual to develop new plans and goals that can replace those that have been lost, in order to develop a new sense of value and purpose in life (Power, 2002). These points are of course simple, straightforward ones and, we hope, they should seem self-evident to most therapists!

The more difficult clinical cases are those in which the initial disbelief strengthens into a dissociative exclusion of the material from the self; for example, Vaillant's (1990, 2002) study of college men followed up for half a century, that we noted earlier, showed the use of dissociation was the strongest predictor of a wide range of mental and physical health problems, unstable relationships, and alcohol abuse. The use of such extreme denial also means that these individuals are less likely to seek help early on in response to loss or trauma. Instead, if they appear in therapy it will be much later and with a variety of diffuse physical, psychological, and social problems which typically leave the individual perplexed (see e.g., Altrocchi, 1998, for an overview of a range of dissociative and related conversion disorders that may result).

The most difficult cases are those in which the experience or expression of one or more of the modularised emotions is either completely inhibited or only ever experienced as a terrifying ego-alien dissociated state. This early developmental pathway can occur for a variety of reasons, including the experience of childhood trauma (Low et al., 2000), childhood neglect, and the combination of parental and cultural attitudes towards "acceptable emotions". One of the most extreme of the dissociative disorders, dissociative identity disorder, has been shown to be associated with the highest rates of physical and sexual abuse in comparison to any other psychiatric disorder (e.g., Ross et al., 1990).

There are now a wide range of cognitive, cognitive-behavioural, psychoanalytic, and other therapies that have been developed to deal with dissociative disorders (e.g., see Lynn & Rhue, 1994). In addition, we propose that a number of more common emotional disorders, such as those relating to anxiety and depression, may reflect the modularisation of basic emotions. For example, the early experience that emotions such as sadness, anger, or fear are not acceptable, or that they are shameful and need to be eliminated from the self, means that when these emotions are experienced in later life, the consequent autonomous nature of the emotion modules puts the individual in an emotional state that is difficult to escape from (Power et al., 2002), especially, as we have argued, when the emotion modules become coupled and continually activate each other. We have shown that disgust, in particular, may become coupled not only with other emotions in this way, but also with basic drives such as those related to food in anorexia and bulimia, and those related to sex in a number of sexual disorders (see Chapter 9). Again, we would argue that the basic principles that should be followed in any successful therapy, of whatever form, should be the same: namely, that the therapist needs to establish a safe therapeutic relationship with the client; that the client begins to re-experience the rejected emotions and memories in this safe environment; and that the client is gradually encouraged to integrate these memories and emotions back into the self (Power, 2002). The more damaged the client, then of course the more difficult the process of therapeutic change and the longer it may take. In addition to these basic principles, however, there are a number of other implications of the SPAARS approach that need to be considered in relation to the theory and practice of therapy.

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Breaking Bulimia

Breaking Bulimia

We have all been there: turning to the refrigerator if feeling lonely or bored or indulging in seconds or thirds if strained. But if you suffer from bulimia, the from time to time urge to overeat is more like an obsession.

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