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Trauma and Dissociation Informed Psychotherapy: Relational Healing and the Therapeutic Connection
A fresh look at the importance of dissociation in understanding trauma. A new model of therapeutic action, one that heals trauma and dissociation, is overtaking the mental health field. It is not just trauma, but the dissociation of the self, that causes emotional pain and difficulties in functioning. This book discusses how people are universally subject to trauma, what trauma is, and how to understand and work with normative as well as extreme dissociation. In this new model, the client and the practitioner are both traumatized and flawed human beings who affect each other in the mutual process that promotes the healing of the client―psychotherapy. Elizabeth Howell explains the dissociative, relational, and attachment reasons that people blame and punish themselves. She covers the difference between repression and dissociation, and how Freud’s exclusive focus on repression and the one-person fantasy Oedipal model impeded recognition of the serious consequences of external trauma, including child abuse. The book synthesizes trauma/dissociation perspectives and addresses new structural models.
264 pages, Hardcover
First published April 28, 2020
22 people are currently reading
171 people want to read
About the author
Elizabeth F. Howell
8 books22 followersA psychoanalyst and traumatologist who specializes in the treatment of dissociative disorders, Elizabeth Howell, Ph.D., is Associate Editor of the Journal of Trauma and Dissociation and Co-Director of the Dissociative Disorders Psychotherapy Training Program of the International Society for the Study of Dissociation. Dr. Howell is a faculty member of the National Institute for the Psychotherapies Trauma Studies Program and an adjunct associate professor in the psychology department of New York University. She has written and lectured widely on various aspects of trauma and dissociation. The author of The Dissociative Mind (Analytic Press, 2005), she has been awarded the Print Media Award for her work.
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Displaying 1 - 13 of 13 reviews
August 5, 2022
This book certainly deserves more of a review than this.
But this is all I have to give at the moment.
I’m 100% occupied by (a) work, (b) dissertation, (c) Netflix.
Not necessarily in that order.
In a nutshell.
This is a terrific read on trauma and dissociation from a psychodynamic perspective.
The book ends with this quote.
“Ask not what you can do for the world, but what you can do to feel alive, because the world needs more alive people.”
- Lyn Preston
I was about to say ‘that says it all’
But it actually doesn’t.
So anyway.
Why 4 (as opposed to 5) stars?
No idea.
But there.
I know this review fucking BLOWS!
It’s my 666th good read review BTW.
So that’s cool right?
But like a said.
I’m spent.
I apologize.
I’m going to play video games now.
But this is all I have to give at the moment.
I’m 100% occupied by (a) work, (b) dissertation, (c) Netflix.
Not necessarily in that order.
In a nutshell.
This is a terrific read on trauma and dissociation from a psychodynamic perspective.
The book ends with this quote.
“Ask not what you can do for the world, but what you can do to feel alive, because the world needs more alive people.”
- Lyn Preston
I was about to say ‘that says it all’
But it actually doesn’t.
So anyway.
Why 4 (as opposed to 5) stars?
No idea.
But there.
I know this review fucking BLOWS!
It’s my 666th good read review BTW.
So that’s cool right?
But like a said.
I’m spent.
I apologize.
I’m going to play video games now.
July 14, 2024
This is very good if you're new to dissociation-based psychotherapy. It's essentially a 200 page literature review of the field, placing early thinkers like Pierre Janet, Sándor Ferenczi, Ronald Fairbairn, Harry Stack Sullivan, and John Bowlby alongside later developments like sensorimotor psychotherapy, polyvagal theory, relational psychoanalysis, internal family systems, complex trauma, and structural dissociation. The sacrifice of such a format is that there is much less depth here compared with Howell's previous works.
Regardless, I love Elizabeth Howell and Judith Herman for dethroning Freud as the grand papa of psychoanalysis. Howell notes that the unconscious as a concept has existed since the 1500s, and that much of the work done during the 1800s (Mesmer, Charcot, Janet) was buried by Freud and his followers. Frederick Douglas used the unconscious to speak about racism years before Freud's birth. Freud's repression was heavily modelled after Janet's dissociation, an influence he mentioned less and less as time passed, until he lapsed into silence (a curious mimicry of repression).
As with Herman, Howell sees Freud and Breuer's paper on hysteria as a turning point in psychoanalysis. In it, Freud and Breuer posit child abuse and pedophilia as the origins of hysteria in women. The number of patients with this condition implied a systemic and pervasive injustice occurring beneath the prim civility of bourgeois society. After much backlash by the psychoanalytic community, Freud changed his stance, arguing instead that the traumatic flashbacks of his patients were wish fulfilment, phantasmic transgressions of the incest taboo that generated neurotic guilt. In other words, hysterics caused their own hysteria. Breuer continued arguing for the traumatic origins of hysteria. He was chased out of the psychoanalytic community.
tl;dr: we have Freud to thank for 100 years of victim-blaming, gaslighting, and traumatic invalidation.
So, the issue with the unconscious is that it implies agency, albeit an agency bereft of conscious control. As with Oedipus, you make things happen, because you avoid them. What is repressed remerges as symptoms, signs of your true desire. Another issue with the unconscious is its isolation from reality. Desire cathects to external objects, but the movement of desire is derived from internal fantasies, driven by the contradictory movements of the pleasure principle and the death drive. You are at the mercy of intrapsychic forces, all the more powerful due to their repression. It's an incredibly cynical, antihumanist, and atomised understanding of human behaviours, that places all the onus on the client, even as it renders them impotent.
Dissociation, however, bases its theory on trauma and attachment. Whereas repression is something we do to ourselves, dissociation arises from trauma, an external force. There are many forms of trauma: war trauma, sexual trauma, developmental trauma, relational trauma. While a single instance of trauma can lead to PTSD, persistent trauma across multiple years can lead to borderline personality disorder and dissociative identity disorder (forms of complex-PTSD). Dissociation is the partitioning of unbearable experiences from narrative memory, so that their intrusions are experienced as totally alien. As these dissociated parts aren't incorporated into narrative memory, they live in an eternal present, and are re-experienced as immediate. This is what it is to be triggered. Howell notes that symptoms of psychosis, such as delusions and hallucinations, may in fact be traumatic flashbacks. Such dissociation can also adhere to the body as crippling physical debilitations, induced by years of traumatic stress. There are many physiological mechanism that drive this: one of them is an increase in cortisol levels, which operates to disable "the immune system, pain perception, and digestion" leading to autoimmune and gastrointestinal diseases.
The process of therapy is a process of re-integration. What's unique about dissociation-based treatments is their focus on symptom reduction, prior to meaning-making. The patient must be secure in their relationship with the therapist, before they can explore affectively overwhelming memories. These emerge as parts, dissociated to varying degrees depending on the patient's trauma. Therapy operates as a site of witnessing, of sharing a burden unbearable for the patient alone, and of articulating meaning through a process of grief—grief for the life lost due to the traumatic events, as well as compassion for the child who had to survive such circumstances alone. Through grief, dissociated experiences are integrated into narrative memory and placed firmly in the past. They lose their immediate, traumatising quality. To witness is also to validate. Through validation, parts may change their roles in the internal family system and become sites of support and wisdom, rather than terror and helplessness. A part that once induced self-hatred or shame ("I'm a fuck up, they'll think I'm disgusting the moment they get close"), may become a site of knowledge ("I really treasure this relationship, and am terrified of losing it through my own actions"). Though still intruding, such a part reveals a deep anxiety and intimate attachment to another, rather than simply a desire to retreat and die. Such shifts in the role of parts coincide with shifts in attachment style. Abuse is decoupled from intimacy. Ultimately, dissociation-based treatment counters fragility with vulnerability.
Regardless, I love Elizabeth Howell and Judith Herman for dethroning Freud as the grand papa of psychoanalysis. Howell notes that the unconscious as a concept has existed since the 1500s, and that much of the work done during the 1800s (Mesmer, Charcot, Janet) was buried by Freud and his followers. Frederick Douglas used the unconscious to speak about racism years before Freud's birth. Freud's repression was heavily modelled after Janet's dissociation, an influence he mentioned less and less as time passed, until he lapsed into silence (a curious mimicry of repression).
As with Herman, Howell sees Freud and Breuer's paper on hysteria as a turning point in psychoanalysis. In it, Freud and Breuer posit child abuse and pedophilia as the origins of hysteria in women. The number of patients with this condition implied a systemic and pervasive injustice occurring beneath the prim civility of bourgeois society. After much backlash by the psychoanalytic community, Freud changed his stance, arguing instead that the traumatic flashbacks of his patients were wish fulfilment, phantasmic transgressions of the incest taboo that generated neurotic guilt. In other words, hysterics caused their own hysteria. Breuer continued arguing for the traumatic origins of hysteria. He was chased out of the psychoanalytic community.
tl;dr: we have Freud to thank for 100 years of victim-blaming, gaslighting, and traumatic invalidation.
So, the issue with the unconscious is that it implies agency, albeit an agency bereft of conscious control. As with Oedipus, you make things happen, because you avoid them. What is repressed remerges as symptoms, signs of your true desire. Another issue with the unconscious is its isolation from reality. Desire cathects to external objects, but the movement of desire is derived from internal fantasies, driven by the contradictory movements of the pleasure principle and the death drive. You are at the mercy of intrapsychic forces, all the more powerful due to their repression. It's an incredibly cynical, antihumanist, and atomised understanding of human behaviours, that places all the onus on the client, even as it renders them impotent.
Dissociation, however, bases its theory on trauma and attachment. Whereas repression is something we do to ourselves, dissociation arises from trauma, an external force. There are many forms of trauma: war trauma, sexual trauma, developmental trauma, relational trauma. While a single instance of trauma can lead to PTSD, persistent trauma across multiple years can lead to borderline personality disorder and dissociative identity disorder (forms of complex-PTSD). Dissociation is the partitioning of unbearable experiences from narrative memory, so that their intrusions are experienced as totally alien. As these dissociated parts aren't incorporated into narrative memory, they live in an eternal present, and are re-experienced as immediate. This is what it is to be triggered. Howell notes that symptoms of psychosis, such as delusions and hallucinations, may in fact be traumatic flashbacks. Such dissociation can also adhere to the body as crippling physical debilitations, induced by years of traumatic stress. There are many physiological mechanism that drive this: one of them is an increase in cortisol levels, which operates to disable "the immune system, pain perception, and digestion" leading to autoimmune and gastrointestinal diseases.
The process of therapy is a process of re-integration. What's unique about dissociation-based treatments is their focus on symptom reduction, prior to meaning-making. The patient must be secure in their relationship with the therapist, before they can explore affectively overwhelming memories. These emerge as parts, dissociated to varying degrees depending on the patient's trauma. Therapy operates as a site of witnessing, of sharing a burden unbearable for the patient alone, and of articulating meaning through a process of grief—grief for the life lost due to the traumatic events, as well as compassion for the child who had to survive such circumstances alone. Through grief, dissociated experiences are integrated into narrative memory and placed firmly in the past. They lose their immediate, traumatising quality. To witness is also to validate. Through validation, parts may change their roles in the internal family system and become sites of support and wisdom, rather than terror and helplessness. A part that once induced self-hatred or shame ("I'm a fuck up, they'll think I'm disgusting the moment they get close"), may become a site of knowledge ("I really treasure this relationship, and am terrified of losing it through my own actions"). Though still intruding, such a part reveals a deep anxiety and intimate attachment to another, rather than simply a desire to retreat and die. Such shifts in the role of parts coincide with shifts in attachment style. Abuse is decoupled from intimacy. Ultimately, dissociation-based treatment counters fragility with vulnerability.
October 30, 2024
4.5 Stars
I had to get it done as quickly as I could, which is unfortunate because this was an excellent resource. Some of the case studies may be difficult to listen to, so please be aware before giving it a chance.
I had to get it done as quickly as I could, which is unfortunate because this was an excellent resource. Some of the case studies may be difficult to listen to, so please be aware before giving it a chance.
May 13, 2021
Far too commonly, patients leave a "successful" psychiatric or psychotherapeutic treatment only to discover an ongoing and only briefly interrupted sense of emptiness, of not knowing themselves and of remaining out of control.
By clearly and humanely synthesizing relational and trauma therapy models, Elizabeth Howell invites us to meet the many unknown or vaguely known parts of ourselves. We discover how these parts, always present, were more sharply defined by the harsh events of life, and how they continue to determine much of our lives unawares, until they are addressed.
Within a healing therapeutic relationships, the dissociated and lost parts of ourselves can be gathered into a new whole.
The writer finishes with a discussion of the myth of Isis and Osiris, reminding us that healing involves reconnecting what has been broken and damaged within the fabric of ourselves, in the caring and compassionate presence of another.
By clearly and humanely synthesizing relational and trauma therapy models, Elizabeth Howell invites us to meet the many unknown or vaguely known parts of ourselves. We discover how these parts, always present, were more sharply defined by the harsh events of life, and how they continue to determine much of our lives unawares, until they are addressed.
Within a healing therapeutic relationships, the dissociated and lost parts of ourselves can be gathered into a new whole.
The writer finishes with a discussion of the myth of Isis and Osiris, reminding us that healing involves reconnecting what has been broken and damaged within the fabric of ourselves, in the caring and compassionate presence of another.
January 13, 2023
What I liked: I enjoyed her prelude into Freud's fallacies and that she did not cling onto Freud as the bee all and end all. Instead she held a very critical yet nuanced approach. I enjoyed how she discussed the overuse of the word 'trauma' and how the word is losing it's meaning. She said it can neither be tied to objective external events defined in a specific level of threat (as in DSM), nor be completely subjective (the "everything can be traumatic"). Instead, she defines trauma as what causes dissociation (in a more extreme form than daydreaming etc). So it causes a deficit in affect regulation and our ability to make sense of things. This is why someone who might be under ongoing trauma might seem to be functioning well, because the other part is dissocated/suppressed/compartmentalised in some moments.
I liked that she explained the importance of taking meaning from traumatic experiences, and that not everyone develops PTSD. She writes a lot about attachment styles, and how interestingly people in attachment bonds of various kinds can paradoxically develop stronger bonds with an abuser (e.g., trauma bonding) when they feel in danger. She shares case vignettes and talks about the importance of compassion in growing from trauma.
What I disliked: I felt it was lacking a more critical view on repression, which is a very controversial topic. Also, a lot of research highlights how memory of traumatic events is often STRONGER rather than weaker, not in the sense of a video-recorder and accuracy, but people are more likely to remember difficult experiences. However, people might have different attentional focus and if they dissociate may not be present in the moment to actual encode other important information - hence it might seem like details have been repressed when in actuality they might not have been encoded in the first place. I wish she wrote more about these issues.
I liked that she explained the importance of taking meaning from traumatic experiences, and that not everyone develops PTSD. She writes a lot about attachment styles, and how interestingly people in attachment bonds of various kinds can paradoxically develop stronger bonds with an abuser (e.g., trauma bonding) when they feel in danger. She shares case vignettes and talks about the importance of compassion in growing from trauma.
What I disliked: I felt it was lacking a more critical view on repression, which is a very controversial topic. Also, a lot of research highlights how memory of traumatic events is often STRONGER rather than weaker, not in the sense of a video-recorder and accuracy, but people are more likely to remember difficult experiences. However, people might have different attentional focus and if they dissociate may not be present in the moment to actual encode other important information - hence it might seem like details have been repressed when in actuality they might not have been encoded in the first place. I wish she wrote more about these issues.
October 29, 2024
Trauma and Dissociation Informed Psychotherapy: Relational Healing and the Therapeutic Connection by Elizabeth F. Howell explores the complex dynamics of trauma and dissociation and their effects on mental health and relationships. Howell presents trauma-informed approaches to psychotherapy, focusing on creating a safe and healing therapeutic relationship. Through case studies and clinical insights, she explains how dissociation serves as a survival mechanism in response to overwhelming trauma and emphasizes the importance of a compassionate, relational approach to help clients process and reintegrate their experiences. The book guides how therapists can support clients in reconnecting with themselves and others in meaningful ways.
This book was incredibly informative and deepened my understanding of trauma and dissociation. It added real value to my knowledge about how dissociation acts as a protective mechanism, pulling us out of our own stories to survive life’s most challenging moments. Howell’s focus on relational healing was insightful, showing how crucial the therapeutic connection is for helping clients feel safe enough to address their trauma. It’s a powerful resource for understanding how trauma-informed care can guide individuals back to a sense of wholeness.
This book was incredibly informative and deepened my understanding of trauma and dissociation. It added real value to my knowledge about how dissociation acts as a protective mechanism, pulling us out of our own stories to survive life’s most challenging moments. Howell’s focus on relational healing was insightful, showing how crucial the therapeutic connection is for helping clients feel safe enough to address their trauma. It’s a powerful resource for understanding how trauma-informed care can guide individuals back to a sense of wholeness.
July 3, 2021
Interesting read. I particularly liked her take on Freud focusing on the wrong part of the Oedipus story, and the emphasis on Osiris. I previously read another one of Elizabeth Howell’s dissociation books, and some of this one felt a little too similar in terms of parts of the historical context.
March 29, 2024
This book is synthetic and essential for any modern psychotherapist. Should have been published centuries ago, when trauma was rampant and its consequences – including dissociation – not at all recognized or hypothesized. XD
January 28, 2023
i like the second half a lot better than the first half, talks often about freud and janet
November 5, 2023
Loved it but there is some DID misinformation, you only need 2 alters minimum to have DID. It was only published 3 years ago so there's really no excuse
October 17, 2024
I really like how this read as almost a glossary or itemized library of dissociation terms and how they fit in with each other.
April 20, 2025
This book is essentially a summary of a lot of different literature and models for dissociation informed trauma healing. Its thesis is that everyone dissociates, and integration requires one to build awareness and a mutual body of knowledge shared among all of ones' "selves." As someone relatively new to dissociation literature, I found the distinction of dissociation as a process as well as a structure very demystifying. Additionally, it gave me a lens for gaps which might occur in other various trauma models I have read about. It's best to read it in order, but I would say if you have one chapter you find especially interesting, each one can stand well enough on its own. This rhetorical structure of little self contained chapters which all have some version of the same knowledge at different levels, that one benefits most from reading together, is reflective of Howell's overall message about the understanding of dissociation. At first I found that structure a bit off putting, but by the end, understood the genius of it.
August 13, 2023
This was a great summary of her previous work.
Displaying 1 - 13 of 13 reviews