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1 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. 2 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. 3 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." 4 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. 5 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 6 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 AZ 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 7 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. 8 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.