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The Way We Are: How States of Mind Influence Our Identities, Personality and Potential for Change. Frank W. Putnam. International Psychoanalytic Books, 2016, 448 pp.

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Reviewed by:

Pam Stavropoulos, PhD, Counsellor and Consultant, Private Practice, Sydney, New South Wales

 

In an age of hyperbole and incessant demands on our attention, recommendation of a ‘must read’ book can seem an imposition as well as a cliché. Yet I do not hesitate to make that endorsement in this case. Frank Putnam’s The Way We Are is his magnum opus after years of service to the field of psychotherapy in general and study of the dissociative disorders in particular. It is a ground-breaking work that proposes what amounts to nothing less than a paradigm shift in the way we conceptualise and respond to the workings of the mind per se.

Professor of Psychiatry at the University of North Carolina and Emeritus Professor of Pediatrics at Cincinnati Children’s Hospital, Putnam is best known for his pioneering 1989 text on diagnosis and treatment of what was then called Multiple Personality Disorder, now Dissociative Identity Disorder (DID). He avowedly wrote this text following “daily phone calls” from therapists seeking assistance for the manifold challenges of treating this disorder, and from “repeating the same information over and over again, typically three to four times a week and often three to four times a day” (1989, p. vii).

It is fitting, then, that his ground-breaking text of over a quarter of a century later conceptualises DID as “an extreme example that allows us to see more deeply into the state nature of personality” we all share (2016, p. 159). In a reading of the psyche which is as democratic as it is path-breaking, Putnam concedes that “[w]e are all multiple to some degree or another” (p. 121). And that it is “how well we can keep it together, how harmoniously we can bridge, coordinate and even integrate the different parts of ourselves that determines how functional we are” (p. 121).

For those whose perception of DID has been (mis)shaped by the distorting lens of Hollywood movies (from Sybil to the currently screening Split) this will be an arresting and also unsettling claim. But when it is made by a doyen of the field of the dissociative disorders (the famous description of dissociation as ‘the escape when there is no escape’ was coined by Putnam) we are forced to pay heed.

It is arresting and exciting that the state model of personality he elaborates, which “defines personality as the collective dynamics of a person’s set of identity, emotional and behavioural states” (p. 159), is supported by the findings of diverse evidence bases—from neuroscience to attachment theory—in which Putnam is proficient and on which he also draws. We are not one; we are many. And The Way We Are tells us why.

One of the benefits and also joys of this richly woven work is the author’s capacity to distil a veritable treasure trove of research insights into accessible prose. As he nears the end of his professional life (and as he faces the end of his life per se, on which he provides a moving and also fascinating Epilogue in this text) The Way We Are conveys an urgency to communicate to current and future readers the often hard-won insights of years of work in the field.

The gift is inestimable. There are few areas in which there has been as little support for understanding and treatment as that of the dissociative disorders. As Putnam points out, funding continues to be blocked at the grant review level of the US National Institute of Mental Health, and the NIMH “unofficially discourages dissociative disorder treatment research at the program level such that preliminary inquiries about NIMH’s interest in potential dissociative disorders treatment studies are quickly nipped in the bud” (p. 245).

This is not the place to elaborate the challenges that trauma-related dissociation in particular has long posed, nor the challenges with which clinicians, researchers and clients continue to contend. One of the many contributions of the state based theory of personality presented here is the impetus it provides for serious and well deserved consideration of the phenomenon of dissociation more broadly, rather than the usual focus on its more extreme variants.

Putnam states that “[w]e are all prone to this process to a greater or lesser extent” (p. 139), that “[a]ll of us are—always—in one or another state of being” (p. 160), and that “[i]t is the rare person who can achieve the psychological distance from which to carefully examine the contradictions in his or her behaviour” (p. 139). If this is the case, we are not talking about a phenomenon of limited interest and prevalence. Rather we are referencing a process which, even in the ‘extreme’ case of DID, is both more subtle and more common than is realised by and within the sector of mental health.

Putnam’s lifetime of accumulated knowledge and experience, his conversance with current research in a range of fields, and his eagerness to ‘pay forward’ the extraordinary legacy this represents, imparts a lucidity to his prose which encapsulates the salient features of the diverse insights he conveys. It also conveys the high stakes that engagement with his contrasting state theory of personality represents.

So why is the state model of personality important, and what advantages does it present relative to other theories of personality with which we may be more familiar? As Putnam explains, notwithstanding their differences standard psychological approaches show a bias toward a stable and enduring conception of personality which is unable to account for discrepancies such as discontinuities and shifts and the differences between private and public selves:

“All of the current ways of thinking about personality require that it be viewed as a set of fixed, persistent, and globally defining traits that pervade all of the person’s interactions with the world” (p. 159). This includes the otherwise contrasting developmental and dimensional models respectively, where the former draws on attachment dynamics with early caregivers (“how we come to be who we are”, p. 151) and the latter “view people along continuums . . . how you are now without regard to your history” (p. 155).

By contrast, the state model ”allows a far wider range of disparate behaviours, and . . . can account for abrupt personality changes” (p. 159). It also “incorporates most of the phenomena covered by the current developmental and dimensional approaches” (p. 159). This includes the phenomenon of DID, which as noted previously, comprises “a collection of separate and distinct identity states that may have little or no awareness of each other and thus often behave in conflicting, contradictory, and self-defeating ways” (p. 159)

On the face of it, differences between the numerous disruptive self-states of DID and the fewer and more seamless states we all navigate on a daily basis may seem so great as not to be comparable at all. Yet is equating them in some senses really such a long bow to draw? The power of Putnam’s account is that he invites us to ponder the question:

We change our state of being many times during the course of a typical day as we change contexts and roles. For the most part, this is a natural process that occurs in the background as we traverse our daily routines. Indeed, `normality’ and `abnormality’ can be defined in terms of how well someone instinctively matches his state of being to the daily flow of changing social situations (p. 121).

To put it another way, the social requirement to shift roles has become normalised. This is to the point that “not being able to switch when the situation demands is a problem for some people” (Steinberg, 2001, p. 105; emphasis added). As Steinberg (2001) reminds us, “although most people still subscribe to the idea of a core sense of self . . . flexibility of self-concept . . . is a sign of our times” (p. 83).

The state model of personality is able to speak to this situational requirement for flexibility in a way that alternative conceptions of personality do not. But this is not at the expense of the whole constellation of a person’s identity, i.e. “emotional, cognitive and other relevant states of being weighted by the history of their recurrent interactions with the person’s inner and outer worlds integrated over time” (p. 160). It thus attunes to “the possible range and complexity of a person’s behaviour at a given point in their life” (p. 160).

When seen in this light, it becomes easier to appreciate how suboptimal relational experiences—and particularly early life attachment trauma with primary caregivers—impede a person’s ability to segue to and from diverse self-states (because it is precisely such flexibility that the impact of trauma disrupts).

Putnam’s state theory builds on his earlier work regarding states as the building blocks of personality, and where the links between mental states are forged by interpersonal connections. This dovetails with what Howell (2005) describes as “a sea change in the way we think about psychopathology” (p. ix). ‘Good enough’ early caregiving assists self-coherence and continuity in the transition between self-states while unrepaired ruptures impede it. The greater the need to defend against overwhelming experience, the greater the dissociation and the increased potential for compromised psychological functioning.

The aetiology of DID—the most numerous and ‘extreme’ of the disconnections between self-states—in severe early life trauma attests to the pivotal role of positive relational experience in the melding of identity and of personality per se. But the dissociative basis of diverse psychological disorders is now being investigated, as per Meares’ (2012) work on Borderline Personality Disorder (BPD) and research which suggests that psychosis, as well as personality disorders, represents “the failure of dissociation” (Koehler, 2016, p. 259).

Yet as the state theory of personality proposed by Putnam makes clear, normative states (and not just ‘disorders’) are likewise illuminated by emphasis on “the collective dynamics” (p. 159) of identity, emotional and behavioural states which comprise personality, and for which traditional theories of personality, in their limiting insistence on unity, stability and durability, are unable to account. How, he asks, are we to explain:

people like the anti-gay politician who is gay himself, the minister who preaches hellfire and damnation yet embezzles church funds, the timid librarian who moonlights as a stripper, or the nationally beloved father figure who leads a secret life drugging and raping aspiring actresses? (p. 159).

Reference to hypocrisy and ‘atypical behaviour’ can only take us so far before we potentially need to examine our conceptualisations and understandings of personality per se.

To a greater or lesser extent (and depending on a range of variables, the degree and impacts will vary markedly) large numbers of people have their feet in at least two worlds: a public world in which “socially approved character attributes and behaviours” are displayed, and a private realm in which secret, socially deviant, and potentially illegal behaviours are engaged in (So which is their real personality? p. 159).

As “[w]e are all multiple to some degree” (p. 121), and to the degree that social life requires a range of personality state shifts, we do not need to be engaging in criminal behaviour for this question to be asked of us. To the extent that public and private realms intersect and are decreasingly discrete, the implications are wide-ranging at many levels.

The state theory of personality describes otherwise difficult to account for behaviours, affects and shifts in all of us. Attuning to “the collective dynamics of a person’s set of identity, emotional and behavioural states” (p. 159) and thus to the unfolding fluctuations and ostensible contradictions of psychic life, also sheds light on whole realms of human experience. Together with “secret lives” (the title of Chapter Six) these range from health to disorder to spirituality and the search for “peak” experience (the book includes fascinating chapters on drugs and addictions and on Exceptional States of Being, Chapter Ten).

The potential applications of this concept are wide indeed, and the final chapter (Using What We Know) sketches this as yet uncharted terrain. For counsellors and clinicians addressing distress and disorder, “[t]he key to effective treatment is to identify and engage these multiple mental states in psychotherapy” (p. 140). But identification and engagement of multiple mental states has relevance far beyond the consulting room and the sector of mental health. We owe a huge debt of gratitude to Frank Putnam for elaborating why.

References

Howell, E. F. (2005). The Dissociative Mind. New York: Routledge.

Koehler, B. (2016) Speaking one’s dissociated mind. In Howell, E., & Itzkowitz, S. (Eds.)., The dissociative mind in psychoanalysis: Understanding and working with trauma (pp. 253–262). New York: Routledge.

Meares, R. (2012). A Dissociation Model of Borderline Personality Disorder. (Norton Series on Interpersonal Neurobiology). New York: Norton.

Putnam, Frank W. (1989). Diagnosis and Treatment of Multiple Personality Disorder. New York: Guilford Press.

Steinberg, M., & Schnall, M. (2001). The Stranger in the Mirror: Dissociation—The Hidden Epidemic. New York: Harper Collins.

 

 


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