History of Dissociation

Dissociation has long been somewhat of an intrigue to clinicians and the general public. In the United States, as far back as 1860 (i.e., the case of Mary Reynolds), cases have been reported in which clients experienced state specific dissociative disorders. It was in the mid 1970's however, that clinicians began recognizing considerable numbers of clients with symptoms of dissociation that resembled Dissociative Identity Disorder (previously known as Multiple Personality Disorder.) At that time it was estimated that the prevalence of the disorder was about one in a thousand.

In the mid-eighties, the number of clients with Dissociative Identity Disorder in treatment began to increase. There has been a great deal of speculation offered as explanation. One thought is that as clinicians become more aware of the disorder and its symptoms, the more able they are to detect and treat it. Others believe that DID has been over diagnosed, especially with those clients who are highly suggestible. Dissociative Identity Disorder is diagnosed up to nine times more often in females than in males. It wasn’t until the 1970's, when the women’s movement began to bring child abuse issues to public awareness that clinicians became open to the idea of a trauma induced disorder. DID has been shown to have a strong link to severe trauma, especially sexual and physical childhood abuse.

What is Dissociation?

The essential feature of a Dissociative Disorder is a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. The disturbance may be sudden or gradual, transient or chronic. In other words, an event is processed in a way that breaks up the pieces of the event into differing states of consciousness.

Dissociation is common and nearly everyone experiences mild dissociation from time to time. If you have ever had the experience of driving somewhere, and suddenly you realize that you have little or no memory of driving the last few minutes. Perhaps you even passed your exit. Your driving ability wasn't hindered because the mind was still utilizing the part of the brain that was needed to drive the car. However, instead of your thinking-mind focusing on the driving, it was somewhere else. That is dissociation. Daydreaming is a very mild form of dissociation.

On the other end of the dissociation-continuum, dissociation is often a way for the brain to tear apart the sensations, or the memory of a traumatic event in order to survive the situation with as little damage as possible. For instance, the actual memory might be put so far back in the subconscious mind, that it is perceived as being forgotten. However, the body sensations may still be present and may be experienced from time to time as somatic eruptions, body memories. The feelings related to the trauma may be "switched off," generally taking with it the individuals ability to experience other feelings later in life.

Marla - A Case Study

Marla Anderson is a 38 year old, Caucasian, divorced, mother of two. For the past several years she has been taking courses at the university and working part time at a variety of secretarial positions. She lives with her daughter, age 15, in a small rural town. Her son recently joined the Marines. She was initially referred to treatment by a professor after reading an essay she had written about being severely sexually abused by her father, from age five until after she had her first child. Over a series of sessions her therapist noticed that her moods seemed to vary widely and she vacillated quickly from anger and irritability to severe depression. She frequently complained of headaches, sleep difficulties, dizziness, and breathing problems. She also exhibited several somatic symptoms including swollen eyes and painful and hive-like blotches on her arms and chest that could not be explained. She reported many inconsistencies. For instance, she vehemently denied that she ever drank alcohol; although she often found empty beer cans in the back of her car. She had gaps in memory which she couldn’t explain, and she often felt suicidal.

Throughout her first year of treatment, her symptoms became more severe. It was about this time when her therapist received a call from a woman named Sharla who asked if she could come and discuss Marla's’s case with him. Later, upon questioning, Marla denied knowing anyone by that name, and so the therapist did not pursue the call. About two weeks later, her therapist decided to use hypnosis in an effort to bridge some of the gaps in Paula’s memory. It was at this time that “Sharla” first presented herself to him. Sharla told the therapist that she had wanted to speak with him, but because he had not returned her call she was concerned that he did not want to hear what she had to say.

Upon awakening, Marla reported having no memory of the conversation between Sharla and the therapist. Session by session, several of Marla’s “alter” personalities came out and introduced themselves. Each seemed to have a separate set of experiences and memories. Each was a different age than Marla and each had their own set of talents and mood characteristics. At first, the therapist felt that Marla might be malingering. Upon closer reflection, he realized that she had neither the motive nor the prior knowledge of the disorder to manufacture her “alter” experiences. He recognized however, that his experience in this area was minimal and so he felt the need to seek professional mentoring.

Assessment

Other diagnosis are often wrongly ascribed to the client (i.e. Borderline Personality Disorder or a psychotic disorder). A careful assessment needs to be done to rule out all other possible diagnosis. The assessment process may include neurological testing and a complete medical exam. Also, Administering assessment tools such as the MMPI, the Dissociative Experiences Scale (DES), the Structured Clinical Interview for Dissociative Disorders (SCID-D) and the Dissociative Disorders Interview Schedule (DDIS) should be considered by clinicians treating possible DID clients.

A careful assessment would cover the basic issues of Marla’s history, inquiring about her sense of self, other symptoms such as depression, anxiety, rage, flashbacks, intrusive memories, inner voices, amnesia, nightmares or recurrent dreams. It would also include issues around safety, hers and those around her, any relationship problems, substance abuse, eating disorder behaviors, and her current support network.

Treatment

One of the most commonly cited treatment orientations for Dissociative Identity Disorder is psychodynamically aware psychotherapy. This approach often eclectically incorporates other techniques, while still understanding the client according to the psychoanalytic model. For example, cognitive therapy techniques can be modified to help patients explore and alter their dysfunctional, trauma-based belief systems, and can be modified to fit dissociative clients.

According to John Turkus M.D. “the heart of the treatment of dissociative disorders is long-term psychodynamic/cognitive psychotherapy facilitated by hypnotherapy.” It is often the case that survivors need three to five years of intensive therapy work with this approach.

The goals of this approach are:

1. symptom stabilization
2. control of dysfunctional behavior
3. restoration of functioning
4. improvement of relationships
5. to prevent further fragmentation and
6. to facilitate integration of the different states of consciousness.

This approach to treatment aims to resolve the dissociative episodes and to integrate the alter personalities into one fully functioning personality. This might involve recall and exploration of previous traumatic experiences that seemed to be responsible for particular splits in the client's personality. Psychoanalytic approaches suggest that the dissociative experiences may be alleviated or better controlled if the client is made aware of them and helped to work through them. This is done by breaking down the barriers that were developed in an attempt to prevent the client from exchanging information from one alter to another (or to her). The client needs to become aware of the alter personalities and begin to accept their presence in her life. Finally the client needs to learn to react to stress and conflict in a more adaptive way. The therapist needs to attend to the client’s feelings of depravation and her sense of internal conflict, as well as to her experience of alter personalities and history of trauma.

Developing a cognitive framework is an essential part of stabilization. This involves sorting out how an abused child thinks and feels, undoing the client's damaging self-concepts, and learning about what is "normal." Stabilization is a time to learn how to ask for and seek help and build support networks. The stabilization stage may take a year or longer--as much time as is necessary for the patient to move safely into the next phase of treatment.

The clinician needs to carefully reframe DID as a creative survival tool rather than as a disease or stigma. The client needs to be guided to a place where she can accept each of her alters and develop a healthy respect for each of them as a part of her internal system. Each alter must also be treated equally by the clinician, whether it presents as a delightful child or an angry persecutor.

In the second stage of treatment the client would learn mastery over and detoxification of her traumatic experiences. This needs to be done slowly enough so not to disrupt her ability to function optimally. Stage three is where the work of integration begins. Interpersonal problems are resolved and the therapeutic dynamics and the transference issues take on classic psychoanalytic patterns. According to Richard Kluft, it is in this phase that the client would be helped to learn to live without the intrusions of alter personalities and would learn to make decisions and to experience feelings on her own without reservation or fear.

Enabling the client to retrieve and rework early trauma is often referred to as abreactive therapy. Abreactions are a way in which the client might be able to release her trauma induced, emotional pain and allow her dissociated trauma to flow back into the “normal memory track.” An abreaction might be described as “the vivid re-experiencing of a traumatic event accompanied by the release of related emotion and the recovery of repressed or dissociated aspects of that event” (Steele & Colrain, 1990). Hypnosis might help the client to safely contain the abreaction and to release the painful emotions more quickly. This type of work needs to be done skillfully and cautiously, in a way that prevents retraumatization and gives the client a feeling of mastery. The reworking of the trauma involves the client sharing her “abuse story,” and disabling unnecessary shame and guilt (Kluft, 1993) Throughout this level of work, the integration of memories and may occur. This is where the client may begin to substitute healthy coping skills for dissociative ones; and begin to learn new life skills.