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YARRA VALLEY COUNSELLING CENTRE
13.09.05 Seminar
DISSOCIATION
Compiled by Helene Richardson (2005)
Dissociation can be a useful coping mechanism and we all use it to varying degrees.
However, it becomes distressing for many who experience the more extremes forms of
dissociation. In our discussion we will attempt to examine a number of issues.
What dissociation is (the short definition!):
Braun (1988a) argued that dissociation is the opposite of association. Association is the
ability for memories to be brought to conscious awareness by way of association of
ideas. Dissociation occurs when an idea or thought process is separated from the main
stream of consciousness.
Dissociation is a coping mechanism that many of us use from time to time, and can be
anything from daydreaming or getting "lost" in a movie or book, to profound alterations
in memory and identity that can result in serious impairment or inability to function.
In fact, dissociation is a handy coping mechanism to help us "unwind" or de-stress. It is
like a form of hypnosis, and is very handy if you can do it in the dentist's chair to
dissociate from the pain!!
History
The recognition of the dissociative disorders as a diagnosis has not been a smooth
process. Colin Ross says there is evidence of DID being present in most cultures
throughout history, eg. In cultures as diverse as the Romans and the Native American
Indians.
Back in the 19thC, Freud and Janet were treating patients with what they called
"hysteria", and during the 19th century, much research and experimentation was
conducted on dissociation.
As early as 1816, the idea of "double consciousness" emerged, where a kind of
somnambulism was described - people could contain more than one distinct personality
within the one body. The term multiple personality disorder emerged out of the theory of
double consciousness (Mohr, 2002).
A number of early clinicians such as Janet, Binet, Prince, James, Breuer, and Freud, all
made important contributions to the study of dissociative disorders. Breuer (1881, in
Braun, 1988) concluded that a splitting of consciousness is present in every hysteria.
The basic phenomenon of hysteria is a tendency to dissociation and abnormal states of
consciousness.
Breuer and Freud in their writings originally agreed that the symptoms of dissociation
were linked to sexual abuse. However, Freud rejected this theory, thus invalidating the
clinical realities of sexual abuse victims. However, it allowed Freud to invent a new
theory of complex metapsychology. Freud was one of the leading instigators in the
discrediting of dissociation and the diagnosis fell out of favour until as recently as the
1980's.
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There were also some misconceptions bandied around in the 19th century that
contributed to the fall in favour of the diagnosis of DID. First, Janet, while believing that
dissociation originated from real trauma, also believed that trauma victims developed
dissociation because of a biological predisposition or inherent defect. Another was that
the best way to treat DID was to force most alters to disappear. This meant getting rid of
"bad" alters and keeping "good" alters. This approach overlooked the fact that both
good and bad alters are a necessary part of the whole and each has an important
function.
After 1910, DID patients who were not classified as oedipal hysterics (sounds like a
name coined by Freud!!), were likely to be diagnosed as schizophrenic, which led the
confusion surrounding the use of the word schizophrenia (Greek meaning "split mind")
and its linking in people's minds with multiple personality. Schizophrenia, however,
would be better named "dementia praecox" because it is characterised more by earlyonset dementia than a split personality (Ross, 1997). Still today, schizophrenia and DID
are confused because of the voices heard by both. However, the voices heard by a
schizophrenic are usually from outside the head, and those of a DID client are usually
inside their heads. Usually the DID client is not psychotic (seeing hallucinations and
experiencing delusions or paranoia - although they can have those things and that
complicates things somewhat.
Stengel even declared Multiple Personality extinct in 1943 (Kluft, 1996). This confusion
continued until the 1970's and early 1980's. In the 1970's, Hilgard, (1986) inaugurated
the modern study of dissociation, and was assisted by three other factors:

the revival of interest in hypnosis after WWII;

the increased interest in traumatic stress after the Vietnam War;

and prevalence of child abuse and incest, highlighted by the Women's
Movement.
In 1980 the disorder was given official diagnostic status in DSM-III, and four important
papers were published by leading psychiatric journals (Bliss, 1980; Coons, 1980;
Greaves, 1980;Rosenbaum, 1980, in Ross, 1997). Up until 1979, only 200 documented
cases of MPD were reported in the medical literature (Mohr, 2002). According to
Greaves there were 33 cases of DID reported from 1901 to 1944 and only 14 from 1944
to 1969 worldwide. From 1971 to 1980, Greaves found there were 50 reported cases of
DID. Thus began an exponential increase in the rate of diagnosis of DID (Greaves,
1980).
However, even in 2002, according to Mohr (2002), dissociation is still poorly
understood, there is a lack of systematic study, there is little empirical information
available, studies are poorly designed, and controversial arguments and anecdotal
experience are used. In addition, most psychiatrists believe DID is a rare condition
when occurring spontaneously, and easy to create iatrogenically, that is to be created
by therapists during treatment. More of that later.
What the different dissociative disorders are:
Marlene Hunter (2004), a Canadian physician (who calls DID patients "the thick chart
patient") says that to have a dissociative disorder means that you have an incredible
ability to compartmentalise your mind, to the point where it becomes dysfunctional
rather than useful.
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Dissociative identity disorder does not mean having different personalities, but having a
personality structure that is separated into neat categories and with each perhaps not
aware of each other. Most of us have different ways of acting in different circumstances
(eg. Me as mother, wife, psychologist, pastor's wife, sister, daughter) but we know each
of these other ways of acting. The DID client does not always know this. It's like they
have a brick wall between the different compartments and each one holds selective
memories, usually of trauma.
There are five dissociative disorders listed in the DSM-IV-TR (American Psychiatric
Association, 2000).
1. Dissociative Amnesia:
"An inability to recall important personal information, usually of a traumatic or stressful
nature, that is too extensive to be explained by ordinary forgetfulness".
There is a retrospective gap in memory, which is usually related to traumatic, extremely
stressful events, and is more likely to occur in wartime, or as a result of a natural
disaster or other forms of severe trauma.
2. Dissociative Fugue:
"Sudden, unexpected travel away from home, or one's customary place of work,
accompanied by an inability to recall one's past and confusion about personal identity or
the assumption of a new identity". It's not very often seen.
Travel may be brief trips or complex, long term travel. There is usually no apparent
psychopathology. The person may assume a new identity, and if they do, the new
identity is usually more outgoing than their former identity. The individual may also
exhibit depression, alcohol abuse, and criminal activity, and may have a previous
history of child abuse, severe interpersonal or financial distress, substance abuse,
depression, or avoidance of responsibility (Coons, 1999).
There are two interesting schools of thought about dissociative fugue. On the one hand
some (Kihlstrom & Schacter, 1995) say that the boundaries between dissociative
amnesia and fugue are not distinct and both disorders are often put together under the
label of functional retrograde amnesia. Others (Braun, 1988), suggest that dissociative
fugue is in many ways closer to dissociative identity disorder than to dissociative
amnesia.
3. Dissociative Identity Disorder (DID):
"The presence of two or more distinct identities or personality states that recurrently
take control of the individual's behavior accompanied by an inability to recall important
personal information that is too extensive to be explained by ordinary forgetfulness. It is
a disorder characterized by identity fragmentation rather than a proliferation of separate
personalities".
4. Depersonalisation Disorder:
"A persistent or recurrent feeling of being detached from one's mental processes or
body that is accompanied by intact reality testing"
5. Dissociative Disorder Not Otherwise Specified (DDNOS):
"Disorders in which the predominant feature is a dissociative symptom, but that do not
meet the criteria for any specific Dissociative Disorder."
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Other potential Dissociative Disorders: There are those who are now saying that the
somatoform disorders are also dissociative disorders.
Somatoform Dissociation (Nijenhuis, 2000, 2004)
A wide range of somatoform (or bodily) symptoms and disturbances troubling
dissociative people may also be dissociative in nature, e.g., difficulty urinating,
numbness, pseudo seizures, difficulty swallowing, paralysis of parts of the body, speech
difficulties
e.g. Conversion disorder is a DSM-IV disorder that has many dissociative
qualities. The person may have limbs that are paralysed, or be unable to see, or
hear. The cause is thought to be psychological, and the symptoms are not
intentionally produced. The symptom causes significant distress or impairment in
occupational or social activities.
PTSD (especially complex PTSD) is also being considered for inclusion as part of the
dissociative spectrum of disorders. DID and PTSD are related constructs.
Comorbidity
Usually those with DD's have been diagnosed with multiple other disorders, eg.
depression, one or more anxiety disorders, a bipolar disorder, schizophrenia, borderline
personality disorder, to name a few. They will probably present with any one of these
others rather than a DD.
How dissociative disorders are recognised
To say for sure that there is a dissociative disorder, you need formal diagnosis by a
qualified practitioner. As you may have realised from my description and the history that
it is easy to confuse DID with other disorders. Therefore, only a Psychiatrist or
Psychologist trained in making such diagnoses should make that decision/diagnosis.
Many dissociative clients have been misdiagnosed for years and become VERY
frustrated, confused and disillusioned with the treating professions.
It is wise to work with an understanding medical practitioner when dealing with
dissociative clients. They are usually very traumatised and fragile, and have felt
misunderstood for years.
What is the cause?
Braun (1988b) argued that dissociative identity disorder is created when repeated
dissociations occur under extreme stress, usually the extreme stress of childhood
abuse. He said that the two major predisposing factors for [DID] are
(1) a natural, inborn capacity to dissociate, and
(2) Exposure to severe, overwhelming trauma such as frequent, unpredictable and
inconsistently alternating abuse and love, especially during childhood… When such
events are related by a common…adaptational theme, the dissociated elements
begin to develop a life history and behavioral style of their own, and an alternate
personality begins to develop (p.17).
Most people presenting with a dissociative disorder report that they were horribly
abused as a child. The abuse will not necessarily be sexual abuse, but could be
emotional and physical abuse and neglect as well. Also, Marlene Hunter says that
failure to attach to the caregiver satisfactorily can be a factor.
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Colin Ross agrees. He said that the core conflict in childhood-onset DID arises form
the structure of the abusive and neglectful family, and is embedded in everything we
know about attachment. Ellert Nijenhuis said these children seek closeness to abusive
and neglectful caregivers. They need acceptance, and to not feel alone, abandoned and
rejected. But when the abusive caregiver comes close to them, they react with fear and
either run away or freeze. Colin Ross calls this the problem of attachment to the
perpetrator.
The other thing that an abused child does is shift the blame for the abuse onto their own
shoulders - they are "bad", they deserved it, it's their fault. Colin Ross calls this the
locus of control shift. Part of therapy is addressing this false conception of the problem.
It wasn't their fault.
A word of warning: The False Memory debate
We can create false memories in people or have them worried sick that something may
have happened to them but they can't remember what. We can only go with what they
bring to us. We may have our suspicions, and may hear a word of knowledge from
God, but we must NEVER speak that out to try and convince them that it is true. Many
clients have taken family members to court on the suspicions planted there by wellmeaning therapists and counsellors, only to find out later that none of it was true.
We test our hypotheses in other ways that do not create more trauma.
Those who are experts in this area say to work in a non-suggestive way. The client is
the one who knows better than we do about what is happening and what is needed.
One of my clients wanted me to help her recover memories. It was not my job to do that.
Mine is to help the healing process. Some memories will never be recovered because
they were never encoded in words or anything that is recoverable by the conscious
mind. Read The Body Remembers (Babette Rothschild, 2000) for an understanding of
how memories are encoded.
What I wanted to know
How to help people who have been severely traumatised, especially as children and
then mistreated and/or misdiagnosed by the medical/psychiatric professions, sometimes
for years.
As a Ps. wife, we had a number of distressed parishioners who seemed in the too-hard
basket. Apart from listening and providing practical help - didn't know what to do with
them. The opportunity came in 1999 for me to study, and I've been doing that ever
since.
What my research shows

Trauma is one, but an important, underlying factor in development of DID. I found
that higher dissociation scores were related to higher childhood trauma scores
(emotional neglect and abuse, physical neglect and abuse, and sexual abuse). This
suggests that dissociation is at least partly caused by traumatic relationships in
childhood, and the participants' responses in the present study endorsed that view.
But that isn't the whole story.

Proneness to higher dissociation scores and DID is also personality related. Those
who were more fantasy prone (especially), neurotic, and were less agreeable, that
is, less trusting of others, were more likely to be more highly dissociative. While
Neuroticism would be a personality trait we are born with, I have yet to determine
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whether those aspects of personality, such as fantasy proneness, are present
before the trauma, or happen because of the trauma. I'm still working on that. Those
with a more vulnerable temperament are more likely to have higher dissociation
scores.

For those more likely to have DID, childhood emotional neglect and sexual abuse
were more predictive of high dissociation scores

For others, not necessarily with DID, but highly dissociative, it was more sexual
abuse and physical neglect that were the underlying factors.

For those who were more fantasy prone, it was emotional abuse that was the
strongest underlying factor.

I am now interviewing participants to ask them their experience of dissociation. The
first person I interviewed talked about the distress of blanking out and not
remembering what has happened in the preceding minutes. She also told of the
problems it causes with those around her (family, and work colleagues) as she
would not hear what they have said to her and then be expected to carry out
instructions or do things she had no idea of being asked to do. However, she also
said a benefit of dissociating is being able to blank out and rest her mind that works
overtime. Another client of mine also said the same, she liked to go home at night
and let herself dissociate in the comfort of her own home.
Treating dissociative people (probably what you came for tonight!!)
I cannot give you an AZ treatment plan tonight, but can give some vital hints to keep
you and your client safe.
First and foremost, DO NO HARM
Stay within the limits of your competence.
Get qualified supervision from someone who is competent in dealing with
dissociative clients.
Attend conferences that address dissociative disorders - it's worth the money (see the
Delphi Centre site for up-coming trauma workshops - Colin Ross in 2006)
IF… proneness to DID is personality related
IF… trauma  DID, then for those who are neurotics, anxious, and depressed, the
triggers are worse
IF… in treatment we address the trauma we increase the likelihood of making the effect
of trauma worse.
DON'T ADDRESS THE TRAUMA.
DON’T GO THERE.
Most practitioners in the trauma field today will tell you this. Teaching in the past has
been to try and remember what the trauma was in detail, and then to heal the
memories. This has only succeeded in retraumatising people and making them worse.
These people need to be treated with great care or they will be retraumatised over and
over again, becoming worse rather than better. They usually have a history of seeing
multiple doctors, psychiatrists and therapists, and of having been given multiple
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diagnoses. They have often lost hope of ever being any better and have a history of
one or more suicide attempts, as well as self-harming behaviours.
We need to first establish safety and trust with our clients. They need to experience a
constant, accepting attachment to someone who cares about them. We can be that
person for them. Then we need to strengthen the individual and their coping
mechanisms so they get stronger against the triggers.
Colin Ross (1997) says that the therapy of DID is a problem solving, practical therapy
that needs many specific interventions. He also says it is a complicated disorder and its
treatment cannot be limited to one treatment perspective only. DID also has a longterm, intensive treatment outlook
(see Ross, 1997, p.267 for the outline of treatment).
You need:
Counselling micro skills - engaging skills, empathy, open-ended questions, no "why"
questions, unconditional positive regard, clean language (Refocussing), etc.
Safety mechanisms to help put on the brakes, and reduce panic and anxiety, etc. The
Body Remembers (Rothschild, 2000).
Read and learn and have good supervision.
Refocussing (Divett, 2005) is a form of therapy that is safe to use for those trained in it.
Contact Jan Dowling at [email protected] if you are interested in doing this
course.
If I have succeeded in "putting the wind up you" that is probably good. Too much harm
has already been done to this very traumatised population and they don't need more. If
all you do is give them a safe and accepting environment, addressing their panic and
helping them feel safer, you have done much to help the healing process.
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References
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental
Disorders: DSM-IV-TR (Fourth Edition, Text Revision ed.). Washington, DC:
American Psychiatric Association.
Hunter, M. E. (2004). Understanding dissociative disorders: A guide for family
physicians and healthcare workers. Carmarthen, Wales: Crown House
Publishing, Ltd.
Nijenhuis, E. R. J. (2000). Somatoform dissociation: major symptoms of dissociative
disorders. Journal of Trauma and Dissociation, 1, 7-32.
Nijenhuis, E. R. J. (2004). Somatoform dissociation: Phenomena, measurement, and
theoretical issues. New York: W.W. Norton & Company.
Ross, C. A. (1997). Dissociative Identity Disorder: Diagnosis, Clinical features, and
Treatment of Multiple Personality. New York: John Wiley & Sons, Inc.
Rothschild, B. (2000). The body remembers: The psychophysiology of trauma and
trauma treatment. New York: W.W. Norton & company.