#66081: Demystifying Dissociation: Principles, Best Practices, and Clinical Approaches

The word dissociation is derived from a Latin root word meaning to sever or to separate. In clinical understanding, dissociation is the inherent human tendency to separate oneself from the present moment when it becomes unpleasant or overwhelming. Dissociation can also refer to severed or separated aspects of self. In common clinical parlance, these separations may be referred to as "parts." Older terminology (e.g., "alters," "introjects") may still be used, although parts is generally seen as more normalizing and less shaming as a clinical conceptualization strategy. Just like all humans dissociate, all humans have different parts or aspects of themselves. In cases of clinically significant dissociation, the separation of parts is typically more pronounced.

The fact that dissociation encapsulates two meanings—the separation from the present moment that can manifest in a variety of ways and the separation from aspects of self—can make learning about and understanding it rather confusing. Consider, however, that the general purposes of dissociation are the same in both constructs: to protect oneself and to get one's needs met. Even the most innocuous example of a person "zoning out" or daydreaming can be seen through this lens. Individuals can go away in their minds to protect themselves from the distress of the present moment, whether that distress shows up as boredom, pain, or overwhelm. Parts, or aspects of self, will either develop over time or fail to integrate with the total self (depending on defining theory) to protect the self or to get needs met, typically needs that primary caregivers are not providing. Underlying theories of dissociation will be discussed in detail later in this course.

One of the leading psychiatric scholars in the treatment of dissociation is Dr. Elizabeth Howell. In her book The Dissociative Mind, she contends [2]:

This contention has inspired scores of clinicians. The key to better understanding dissociation truly rests in normalizing it [2,3].

When contemplating dissociation in a general sense, common expressions that come to mind include daydreaming, "zoning out," inability to make appropriate eye contact, escaping to imaginal or fantastical landscapes in the mind, or losing emotional connection to a story being told. Some people will start to yawn, fall asleep, or lose appropriate volume in their voice when distressed. It is very likely that most (if not all) people have done one or more of these things in their lives and may even do them on a regular basis, with or without a clinically significant dissociative diagnosis. Modern-day examples of dissociation include watching too much television, playing on the smartphone, or mind numbingly scrolling through social media. These activities are not dissociative in and of themselves but can be used in a dissociative manner. Even activities used in therapy for emotion regulation, including guided visualizations, can be dissociative because they remove the practitioner from their present surroundings and experiences. While the intention may be solid and indeed very helpful to many people, consider how a person could continue to use such an exercise as an escape instead of as a healthy coping strategy.

In normalizing dissociation, it is useful to look at the construct of adaptive and maladaptive in describing dissociative phenomenon. These distinctions of adaptive and maladaptive are essential to eye movement desensitization and reprocessing (EMDR) therapy [4]. As constructs, they are similar to the descriptors healthy and unhealthy but with much less of a value judgment. Furthermore, what is adaptive to one person may not be adaptive to another person. What was adaptive at one point in one's life may not be adaptive at other points in his or her life. Consider this example as it relates to dissociation: For a young child growing up in a dysfunctional home, daydreaming was adaptive because it helped him/her survive the perils of this upbringing. However, as an adult, chronic daydreaming can impede one's ability to work and support oneself, keeping one removed from certain realities that need to be faced.

Another example of commonplace dissociation is binge watching television. This practice could be dissociative in a maladaptive sense, but it could also be a needed avenue for self-care that helps a person disconnect from the rigors of work life and day-to-day responsibilities, depending on the relationship and intention with the activity. Clinicians can assist clients in making this distinction only after considering how these patterns show up in their own lives. For example, a clinician may regularly binge watch television and feel like it is a healthy outlet for rest. When the clinician is dealing with intensity in their feelings and life, it is important that they take a break. One could argue that it would be more dissociative, as an avenue to escape feelings, if the clinician dove into doing more work to keep from being present. Work can be tricky for individuals to evaluate, because while it is often an inherently positive activity, it can be taken to a maladaptively dissociative place. A later section of this course will more fully examine the intricate relationship between dissociation and addiction, but briefly, addictive behaviors generally begin as dissociative coping, usually in response to trauma or to distress.

In normalizing dissociation, it is also imperative to examine the notion of parts or aspects of self. Again, this will be more fully explored later in this course, but before starting this activity, take a moment to examine whether or not you relate to having different parts, sides, or aspects of yourself. Many use the common terminology of "inner child," vis-à-vis the more rational, presenting adult. If you have ever used this language, you are already recognizing the construct of parts. Some people, especially those who struggle with addiction, may reference having a "Dr. Jekyll and Mr. Hyde" phenomenon happening within them. Some people will even say that their sadness, anger, or other emotional experience can take on a life of their own, which can also speak to the separation of parts, or that they feel "cut off" from their bodies due to an injury, illness, or other distress. As illustrated in the passage from Dr. Howell, diagnoses like DID or other dissociative disorders refer to a more rigid separation of this very natural part of the human condition [2].

There have been many advances in better understanding trauma and dissociation through a neurobiologic lens. While this section will conclude with some of that research, it is important to obtain a basic understanding of the human brain and how unhealed trauma can impact its functioning. The simplest explanatory model that seems to work the best for clinicians to gain this understanding is the triune model of the human brain, originally developed by psychiatrist Paul MacLean [5]. Many modern scholars (e.g., Bessel van der Kolk, Daniel Siegel) continue to use it as a base of explanation.

The triune brain model espouses that the human brain operates as three separate brains, each with its own special roles—which include respective senses of time, space, and memory [5]:

Many strategies in the psychotherapeutic professions work primarily with the neocortex. For a person with unprocessed or unhealed trauma symptoms, the three brains are not optimally communicating with each other when the limbic system gets triggered or activated [6]. During periods of intense emotional disturbance, distress, or crisis, a person cannot optimally access the functions of the neocortex because the limbic, or emotional brain, is in control. In essence, a dissociative phenomenon occurs. Blood flow slows to the left prefrontal cortex when the limbic system is triggered to some degree. Thus, a person may be aware of what is happening around them, and yet that disruption or dissociation from the brain's innate totality impedes a person's capacity to process or make sense of it.

Consider these examples that may be familiar to your clinical practice: Have you ever tried to reason with someone in crisis? Have you ever asked someone who has relapsed on a drug or problematic behavior, "What were you thinking?" Have you ever tried to be logical with someone who is newly in love or lust? Attempting any of this is like trying to send an e-mail without an Internet signal. You may have awesome wisdom and cognitive strategies to impart and you can keep clicking send, but the message is not ever going to get through. Moreover, because the activated person has awareness, they may grow increasingly annoyed by persistence, which can activate the limbic responses even further.

Triggers are limbic-level activities that cannot be easily addressed using neocortical interventions alone. If a stimulus triggers a person into reaction at the limbic level, one of the quickest ways to alleviate that pain/negative reaction is to feed the pleasure potential in the limbic system. As many traumatized individuals discover, alcohol use, drug use, food, sex, or other reinforcing activities are particularly effective at killing/numbing the pain. For children growing up in the high distress of a traumatic home, dissociation can become the brain's natural and preferred way to escape the pain. Cultural commentators and scholars have referred to dissociation as a "gift" to the traumatized child for this reason [7].

Dissociation, trauma-related disorders, and addiction are inter-related because dissociation is a defense that the human brain can call upon to handle intense disturbance. People dissociate in order to escape—to sever ties with a present moment that is subjectively unpleasant or overwhelming, stemming from unhealed trauma and its impact. In referencing the triune brain model, dissociative responses—often conceptualized as similar to freeze responses—are even deeper than the limbic brain, taking place in the R-complex or brainstem [8]. This is a testament to their primary, protective quality.

Precise neurobiologic explanations of dissociative phenomenon are still being investigated, and understanding remains incomplete. In their comprehensive review, Krause-Utz, Frost, Winter, and Elzinga summarize that there is a suggested link between dissociative symptoms and alterations in brain activity associated with "emotion processing and memory (amygdala, hippocampus, parahippocampal gyrus, and middle/superior temporal gyrus), attention and interoceptive awareness (insula), filtering of sensory input (thalamus), self-referential processes (posterior cingulate cortex, precuneus, and medial prefrontal cortex), cognitive control, and arousal modulation (inferior frontal gyrus, anterior cingulate cortex, and lateral prefrontal cortices)" [9]. Electrical neuroimaging studies show a correlation between the temporoparietal junction—an area involved in sense of self, agency, perspective taking, and multimodal integration of somatosensory information—and dissociative symptoms, and specific forms of dissociation are connected with brain areas in question [10].

While the neurobiologic implications of dissociation are discussed in detail later in the course, this section has endeavored to give enough base knowledge to understand that trauma and dissociation are inter-related. Basically, dissociation can be described as an inherent mechanism of the human brain that can be called upon to manage distress. The higher the degree and the more intense the trauma, the greater the likelihood that some aspects of dissociation, whether clinically significant or not, can manifest.

Dissociative identity disorder or DID, formerly referred to as multiple personality disorder, can make for fascinating plot points and opportunities for characterization in the media. Unfortunately, these media portrayals have fed perpetuated myths and misconceptions about dissociative disorders that persist in the general public and in mental health professions. In many cases, the media only showcases the most extreme or sensationalized cases of DID [11]. Many clinicians do not realize that their clients are experiencing distress that can be described through the lens of a dissociative disorder because their clients are not presenting with symptoms that look as extreme or severe as the largely fictionalized Sybil or the highly sensationalized portrayal in the 2016 film Split. If clinicians are only using these media portrayals as their point of reference, they may be unnecessarily frightened to treat their dissociative clients, fearing violence, self-injury, or other expressions they may not feel prepared to handle.

Many individuals who dissociate express trepidation about making their condition known to the general public; this can even include fear about coming out to one's partner or one's therapist in fear of judgment. For example, I, a mental health professional active in addiction and trauma care, found "coming out" fully as a person with a dissociative disorder was much scarier than being out as someone in recovery from addiction or being out as a bisexual woman. There was a great fear that I would no longer be taken seriously, especially among professional colleagues, if I was public and open about my experiences.

In 2010, Jaime Pollack started the Healing Together Conference with the goal of providing survivors of complex trauma who identify as having a dissociative disorder a place where they could feel safe enough to share freely. Pollack and others did not feel welcome to share from personal experience as non-clinicians at professional conferences that address trauma and dissociation. Even professional clinicians have experienced a similar sense of disregard for the lived experience. Spaces like Healing Together give people with dissociative disorders from a variety of professional backgrounds a chance to be open and share freely, something that can be a rarity in this world.

There is a variety of myths and misconceptions regularly encountered from clinical professionals and from colleagues who also work as trauma trainers. The most common are the usual fears about people with dissociation acting out and causing harm to self or to others, although clinical experience and evidence suggests that there is no more risk of these behaviors than with other diagnoses [12]. The next set of myths revolves around treatment. There can be a sense that people with clinically significant dissociation, especially DID, do not respond well to treatment and cannot live full and functional lives. In many cases, professionals who hold such myths generally do not have enough grounding in trauma-informed or trauma-focused care to realize the connection between unhealed trauma and the successful treatment of maladaptive dissociation. The other major treatment myth is that for successful treatment of DID or another dissociative disorder to occur, there must be an integration of the various alters or parts into one presenting person. While this is discussed further in the section on treatment, for the time being, please know that many exist functionally and adaptively with the help of their system, and integration in the simplistic sense is never achieved—nor does it need to be.

Many individuals with DID or other dissociative disorders do not shun the word integration, but instead view integration as a healthy sense of cohesion or communication between the system. The term working wholeness may be preferred. However, when working with a client with dissociation, integration can be quite a triggering word, because previous providers may have used the term incorrectly or abusively, making them believe that they must integrate if they want to live a normal life. This can cause upheaval in the system, especially if more vulnerable parts believe they are going to be forced out. Consider this metaphorical comparison: For many years the United States was referred to a "melting pot" of sorts, suggesting the people from various backgrounds came together and blended. This metaphor has garnered criticism because a melting pot suggests that various peoples come together, melt down, and then a single, ideal alloy of an "American" emerges. While some people would like this to be so, it is neither culturally inclusive nor sensitive. An alternate metaphor refers to the United States as a salad or a bowl of stew, indicating that each ingredient brings their own unique flavor while contributing to the whole. This metaphor is also workable when referencing dissociative systems.

Many individuals with clinically significant dissociative disorders do not reach the "integration" debate stage of treatment with their providers because many mental health providers are not willing to take on their cases. Screening out for dissociation and making referrals is very common, leaving many with a message that they are "too much to handle." Often, individuals with dissociative disorders can be prematurely admitted into psychiatric facilities at the mention of self-harm or blanking out time. While clinical professionals should not go against their ethical training if there is a viable intent or a plan articulated for injury to self or others, bear in mind that suicidal ideation and self-harm can be a very normal complex trauma response and part of one's dissociative profile. In some cases, having these feelings normalized and a viable plan for addressing them developed is insufficient. Yet, many individuals who struggle with dissociative issues will not articulate struggles to their providers out of fear of being committed to an institution, which can be an unsafe place for someone with a dissociative disorder. Perhaps the biggest misconception in the mental health field is that dissociation is not real, does not exist, or, if it does, is extremely rare. Not only is this an invalidating experience for individuals, they can end up receiving a host of other diagnoses that result in excessive or improper pharmacotherapy. To understand more about the invalidation factor, please read on to the next section, which discusses historical perspectives on dissociation, how to treat it, and how to diagnose it.

The issue of dissociation and how to diagnose it has been historically shrouded in controversy in the psychological and helping professions, largely because trauma can make people uneasy. Giving people, especially children, trauma-related diagnoses can be an uncomfortable matter. When a child gets a diagnosis like attention deficit and hyperactivity disorder (ADHD) or bipolar disorder, the implication and suggestion of the medical model is that something is impaired with their brain. Medications, although often prescribed in concert with some kind of behavioral therapy, are typically emphasized as the solution. However, when a child receives a trauma-related diagnosis, generally someone is responsible—a parent or guardian who exposed them to harm, the school system, or even society at large. This meanders into uncomfortable territory for many people. Further, most medications used in the treatment of dissociative disorders focus on comorbid symptoms (e.g., depression, anxiety); psychotherapy remains the cornerstone of treatment.

Although clinically significant dissociation can develop in adulthood as a response to trauma or other distress, its etiology is usually traced to significant, complex trauma in early childhood. Often, this trauma is of a developmental nature, meaning that it happened when a child was still vulnerable and often involved betrayal by someone they loved or trusted. Useful distinctions between trauma as an incident or event (typically associated with the PTSD diagnosis as presented by the DSM) and complex or development trauma is that complex trauma experiences [13]:

Initially, even Freud seemed to be convinced of trauma's impact in his early investigation of dissociative phenomenon. As is well-established in the history of psychology, widespread pressure from his influential colleagues resulted in Freud backing down from this hypothesis and instead focusing more on repression and subconscious desires as etiology for mental and emotional disorders. The gendered label of hysteria was put into wide use, a construct that modern trauma scholars now view as a manifestation of complex trauma and dissociation [14]. Much of the early thinking in the field, especially from Pierre Janet, suggested that there is an element of dissociative phenomenon in all mental and emotional disorders, even conceptualizing what would come to be known as schizophrenia through this lens [12]. Other French colleagues of his era proposed similarly.

The dissociative disorders formally debuted in the DSM-III in 1980. The PTSD diagnosis also appeared in that edition as an anxiety disorder, but dissociative disorders were presented as a separate category. Although new to DSM-III, their discussion and inclusion were not new to the field [15]. With every iteration of the DSM since then, up to the current DSM-5, there has been intense debate and scrutiny over the dissociative disorders as being worthy of inclusion. In reality, many leaders of the field, especially those on DSM work groups, openly doubt their existence [16]. The purpose of this course is not to engage in this debate—clearly the position of this course is that dissociative disorders do exist and are potentially more widely prevalent than once thought and reported. However, major medical and psychological groups continue to report that dissociative disorders are extremely rare. This approach to dissociative disorders and resistance to their existence is borne from the same discomfort about trauma and responsibility that Freud encountered in the early days of his work. Although the general phenomenon of dissociation can show up in a wide array of clinical diagnoses, it has been established that unhealed trauma is a major etiologic factor in the development of clinically significant dissociative disorders [17].

Clinicians interested in reading more about the history and debate around dissociation, trauma, and memory are directed to Anna Holtzman's article exploring the "memory wars" in the field of psychology, written in the wake of the Harvey Weinstein trials (Resources). The memory wars refer to decades of debate in the field about the trustworthiness of memory, particularly as it relates to accusations of abuse by survivors of trauma. She discusses the history of the False Memory Syndrome Foundation, founded by the parents of Dr. Jennifer Freyd (a former president of the International Society for the Study of Trauma and Dissociation [ISSTD]). Dr. Freyd accused her parents of abuse and their response was to establish an organization to discredit survivors of abuse.

As long as unhealed trauma continues and people are threatened by its impact or made to feel responsible for it, there is a likelihood that such debate, even in scholarly settings, will continue. The general state of the evidence suggests that not only are dissociative disorders real, the prevalence is higher than previously thought [18].

While the ISSTD and mainstream advocates in the field of dissociation have promoted research and scholarship to prove that dissociation exists, there is a concern by advocates that such a focus may measure the experiences of survivors without adequately including their voices into the advocacy. In the spirit of both/and, this course acknowledges that while scholarship and research are always critical to validate constructs in the mainstream, clinicians can get overwhelmed by trying to study dissociation in this manner. Normalizing dissociation as a human phenomenon and describing how trauma and distress can impact its manifestations should also be a part of the discussion moving forward.

DID, formerly called multiple personality disorder, develops as a childhood coping mechanism. To escape pain and trauma in childhood, the mind splits off feelings, personality traits, characteristics, and memories into separate compartments which then develop into unique personality states. Each identity can have its own name and personal history. These personality states 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. DID is a spectrum disorder with varying degrees of severity. In some cases, certain parts of a person's personalities are aware of important personal information, whereas other personalities are unaware. Some personalities appear to know and interact with one another in an elaborate inner world. In other cases, a person with DID may be completely aware of all the parts of their internal system. Because the personalities often interact with each other, people with DID report hearing inner dialogue. The voices may comment on their behavior or talk directly to them. It is important to note the voices are heard on the inside versus the outside, as this is one of the main distinguishers from schizophrenia. People with DID will often lose track of time and have amnesia to life events. They may not be able to recall things they have done or account for changes in their behavior. Some may lose track of hours, while some lose track of days. They have feelings of detachment from one's self and feelings that one's surroundings are unreal. While most people cannot recall much about the first 3 to 5 years of life, people with dissociative identity disorder may have considerable amnesia for the period between 6 and 11 years of age as well. Often, people with DID will refer to themselves in the plural [20].

The most common of all dissociative disorders and usually seen in conjunction with other mental disorders, dissociative amnesia occurs when a person blocks out information, usually associated with a stressful or traumatic event, leaving him or her unable to remember important personal information. The degree of memory loss goes beyond normal forgetfulness and includes gaps in memory for long periods of time or of memories involving the traumatic event [20].

Having depersonalization has been described as being numb or in a dream or feeling as if you are watching yourself from outside your body. There is a sense of being disconnected or detached from one's body. This often occurs after a person experiences life-threatening danger, such as an accident, assault, or serious illness or injury. Symptoms may be temporary or persist or recur for many years. People with the disorder often have a great deal of difficulty describing their symptoms and may fear or believe that they are going crazy [20].

Symptoms of unspecified dissociative disorder do not meet the full criteria for any other dissociative disorder. The diagnosing clinician chooses not to specify the reason that the criteria are not met [20].

The other specified dissociative disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific dissociative disorder [20].

Many experts have expressed confusion that dissociative disorders were separately categorized instead of being included in the DSM-5-TR chapter grouping trauma- and stressor-related disorders. This may reflect some of the controversy and misunderstanding about dissociative disorders, or a lack of cohesion among the work groups that determine the categories in the DSM.

The chapter of trauma- and stressor-related disorders (which includes PTSD, acute stress disorder, adjustment disorders, reactive attachment disorder, and disinhibited social engagement) does make mention of dissociative symptomology as a potential feature of PTSD. In the DSM-5 version of the PTSD diagnosis, there is a qualifier option of PTSD with predominant dissociative symptoms. Dissociation can play out in all five symptom areas of the PTSD diagnosis, with flashbacks (under Criterion B, intrusion) specifically being described as a dissociative phenomenon. In DSM-5, depersonalization is defined as "persistent or recurrent experiences of feeling detached from, as if one were an outside observer of, one's mental process or body" (potentially an avoidance or negative mood/cognition manifestation) [19]. Derealization is defined as "persistent or recurrent experiences of unreality of surroundings" (potentially a part of the PTSD symptoms of intrusion, avoidance, or negative mood/cognitions) [19]. Although depersonalization and derealization still appear as their own diagnoses in the dissociative disorders category, those diagnoses should be ruled out if PTSD is the better explanation.

This is a gray area to navigate diagnostically, particularly because people struggling with clinically significant dissociative disorders likely meet the criteria for PTSD. With PTSD long being conceptualized as a more event-centric diagnosis that does not accurately encapsulate the depth of complex trauma, this qualifier may be more appropriate for adults who experience a traumatic event not connected to childhood or developmental trauma and develop these dissociative tendencies as a result.

According to the International Society for the Study of Trauma and Dissociation, some measures commonly used in psychological testing can provide understanding of the patient's personality structure and may yield information useful in making the differential diagnosis between disorders often confused with DID, such as borderline personality disorder and psychotic disorders.

(https://www.isst-d.org/wp-content/uploads/2019/02/GUIDELINES_REVISED2011.pdf Last Accessed: May 30, 2024)

Level of Evidence: Consensus Statement/Expert Opinion

There are a variety of psychometrics and clinical interview guides available for clinicians to help in their identification of dissociation. It is important to keep in mind, as a trauma-focused clinician, many of these devices may be too interrogatory, Use good clinical judgment about whether some of these scales or measures are a good fit for your practice and your clients. They have all played a role in research and helping to validate the existence of dissociative disorders. However, taking a test for a psychometric evaluation can be triggering in its own right and can lead to a sense of confusion in a person's system if they are not properly guided.

Theory of Structural Dissociation

While Fraser's Table is arguably one of the most popular approaches in the first wave of dissociation studies following the formal introduction of dissociative disorders into the DSM-III, the Theory of Structural Dissociation, developed by Onno van der Hart, Ellert Nijenhuis, and Kathy Steele, has become the focus of dissociation studies in the 21st century. Many trauma-focused professionals are advocates of this theory because, at its heart, it is nonpathologizing, positing that everyone is born with a fragmented or dissociative mind [25]. This is normal for infants, who get their various needs met in the absence of speech, language, or a more developed neocortex. Healthy development is defined by needs being consistently met engendering a natural integration of the personality structure. Yet, in the presence of unhealed trauma, disorganized attachment or developmental distress, a natural separation can remain.

The two main terms used in the Theory of Structural Dissociation are apparently normal personality (ANP), which is similar to Fraser's idea of the center ego state, and emotional part or personality. Emotional parts remain to protect or to meet a need, and some systems contain a more complicated interconnection of emotional parts and ANPs than others. While this is a bit of an oversimplification of how structural dissociation plays out systemically, it gives people new to this theory a good frame of reference. The model also makes use of the terms primary structural dissociation (which is more likely to be used in relation to PTSD and other trauma-related disorders), secondary dissociation (mainly related to personality disorders, dissociative disorders other than DID, and complex PTSD or developmental trauma), and tertiary dissociation (classically presented as DID). Figure 1 provides a visual presentation of how this may play out.

VISUAL PRESENTATION OF THE THEORY OF STRUCTURAL DISSOCIATION

ANP = apparently normal personality, EP = emotional part.

Figure 1

Source: Created by Author

The Theory of Structural Dissociation is certainly not without criticism. For example, psychiatric leader in the field of dissociation Dr. Colin Ross proposed an extensive modification to the theory. In his modification, Ross proposes that an emotional part does not have to be separate entities in and of themselves; instead, they can hold a fragment or experience like a thought, feeling, memory, or sensation. In this modification to the model, he expands on the Janetian idea that many disorders can be viewed through the lens of dissociation and that the idea of parts can be used as treatment conceptualization for conditions like substance use disorders and compulsive behaviors.

The theory of structural dissociation is a step in the right direction, and Ross' modifications expand the scope of what is possible and gives more permission to modify, which is essential in any facet of trauma-focused care. If rigidly interpreted, the original model is too inflexible, which is dangerous when applied to the phenomenon of systems that is fundamentally fluid and unique to the individual. Another consideration is the potentially offensive use of the adjective "normal" to describe the core self or presenting adult (ANP). This speaks to a reality of care in helping people to identify and to get to know their system; part of this is helping them to identify the terminology that best works for them and their understanding.

Some clients will develop names for their parts, some will refer to them just as numbers or ages (as in the related experience), and others will refer to them just by descriptive qualities (e.g., my angry side, my soft side, the shame part, the inner child). Before beginning work with people using Fraser's Table, mapping in the spirit of structural dissociation theory, or one of these more creative metaphors, clinicians are encouraged to first do some mapping of their own internal system. In essence, this is an important continuation of the Dissociative Profile exercise.

To do this, first spend some time brainstorming, preferably writing down, how you see the parts of yourself. Remember that if you are stuck and nothing you are reading here resonates, you can use the basic presenting adult/inner child construct. If that is the case, how do you see them inter-relating? Staying with the idea of the table, perhaps you simply imagine them sitting down to interact over a cup of tea (or maybe your adult drinks the tea and you pour lemonade for the inner child).

Using paper and whatever basic art supplies you might have on hand (or even just a pen or pencil), begin to map how you see your internal system inter-relating. Doing this exercise does not diagnose you with a dissociative disorder. We all have parts, and seeing ourselves in this way can be a useful strategy for conceptualizing.

This exercise is not about being an outstanding artist—you are not being graded or judged. Simply think of this as drawing out a rudimentary map (and for that matter—the "map" itself could be another useful, metaphorical example). Some people like to use the idea of a circle (e.g., in some cases using plain white paper plates) as the backdrop for how they map out their system.

Take as much time as you require to complete the exercise. When you are though, consider journaling/writing some impressions or sharing them with a friend or colleague. What have you learned about how the various parts of your system inter-relate? Where is there room for a greater sense of communication or understanding in your system? Are there any blocks that are apparent to communication, cohesion, or wholeness?

An exercise like this offers creative, client-centered insight into working with parts or mapping a system, and it may certainly be used with clients, especially in the early stages of working together. What you learn here can phenomenally inform your strategies for treatment planning, which is covered in a later section. Perhaps you are already beginning to understand that what works for one part of the system for resourcing and healing may be different than what other parts in the system require. This will be valuable information for moving forward with treatment.

The addiction treatment field is making steady steps toward becoming more trauma-informed, but a deficit in professionals' ability to identify signs and symptoms of dissociation persists [26]. This is a problem, especially because of the strong interplay between dissociation and addiction. Many clients will be unaware of dissociative symptoms experienced in childhood because drinking and using drugs can become their dissociative outlet in adulthood. Specific dissociative symptoms (e.g., "zoning out" at work or when emotionally overloaded) can develop in sobriety, and will require trauma-focused treatment. This phenomenon is relatively common in recovery circles, but it is often written off as "the pink cloud of recovery is passing," or "things are getting tough." When a person has a difficult time staying sober after getting sober, unhealed trauma is usually the culprit, and dissociation is a possible manifestation [6,26].

In an article on the importance of dissociation-informed treatment, several other dissociative behaviors that manifest clinically but that professionals often fail to identify were identified [26]. They included clients struggling to pay attention in group, at 12-step meetings, or during lectures; a client changing tone (e.g., "It's like I'm suddenly speaking to a 5 year old") when something distressing comes up in sessions or in group; and other manifestations of blocking or resistant client behaviors. When a client gets belligerent or angry, this may be a sign of dissociation. In some clients, these types of behaviors could be a part speaking out to protect the system or to get a need met.

The Addiction as Dissociation Model posits that addiction is a manifestation of dissociation. When children grow up in traumatizing, invalidating, or high-stress environments, the natural tendency is to dissociate in order to get needs met and protect themselves. If this happens frequently, the systems bond to this dissociative experience. At a later point in life, when chemicals or other reinforcing behaviors are introduced as possibilities, the chemical impact enhances the potency of an already familiar experience [27].

The term addiction is controversial in the modern era, because many critics feel that term is stigmatizing and not adequately trauma-informed [28]. To address this, the Addiction as Dissociation Model defines addiction as "the relationship created between unresolved trauma and the continued and unchecked progression of dissociative responses" [27]. In presentations where primary addiction treatment has failed to address trauma, dissociative experiences may produce a dissociative disorder or clinically significant symptoms of dissociation. Similarly, if dissociation in trauma has not been treated accordingly, addiction can often manifest [29]. The model contends that addiction develops in relation to trauma and dissociation, because trauma (cause) produces dissociation (effect).

According to the dissociation in trauma concept, there is a "division of an individual's personality, that is, of the dynamic, biopsychosocial system as a whole that determines his or her characteristic mental and behavioral actions" [29]. This distinction can also be seen in Waller, Putnam, and Carlson's taxometric analysis regarding nonpathologic and pathologic (e.g., adaptive and maladaptive) dissociative traits, of which "dissociation in trauma" would be represented by the latter [30]. Dissociation is what creates safety and ultimately pain relief in the moment of need. Trauma deeply impacts a person's psyche—extreme limits are pushed, and extreme reactions become necessary.

Mergler, Driessen, Ludecke, et al. examined the relationship between the PTSD dissociation subtype (PTSD-D) and other clinical presentations [31]. In a sample of 459 participants, the PTSD-D group demonstrated a statistically significantly higher need for treatment due to substance use problems, in addition to higher current use of opioids/analgesics and a higher number of lifetime drug overdoses. They ultimately concluded that PTSD-D is related to "a more severe course of substance-related problems in patients with substance use disorder, indicating that this group also has additional treatment needs" [31]. Such a connection seems like clinical common sense, but it has not been fully explored in the treatment literature.

Table 2 illustrates the tenets of the Addiction as Dissociation Model, a cohesive presentation of what exists in the literature on the inter-relation and interplay of trauma, addiction, and dissociation. While the literature clearly exists to support such a model, the model represents the first cohesive discussion of their interplay. The implications for treatment, which are summarized here and continued into the next section, are various.

Case conceptualization that respects addiction as dissociation and the related interplays between trauma, dissociation, and addiction acknowledges that addictive behavior is a dissociative response that can elicit its own continued trauma. Moreover, case conceptualization in this model defines and validates the symptoms of addiction accurately and sees the survival behavior as adaptive. This model presents how trauma and dissociation become addictive (i.e., highlights the endogenous neurochemical processes that create the dependent bond in dissociation/addictive processes), how unconscious re-enactments and feedback looping are foundational to recidivism, and provides the justification for comprehensive treatments to directly incorporate a memory reconsolidation phase.

This contention does not suggest that time-honored interventions for treating addiction should be abandoned. However, these interventions should be fortified based on the light of evolving knowledge about trauma and dissociation [6]. Solutions worth highlighting include developing the power of nonjudgmental support communities and the importance of cultivating daily practices that lead to lifestyle change. As such, the community of mutual help fellowships also benefits from an understanding of trauma and dissociation. Peer support services and fellowships like Alcoholics Anonymous, Narcotics Anonymous, Al-Anon, and Adult Children of Alcoholics can provide a safe place to discuss solutions, as long as there is a reasonable degree of trauma-informed ethics in the culture of the meeting.

Cognitive-behavioral therapy (CBT), dialectical behavioral therapy (DBT), and Seeking Safety (SS) are often used in the treatment of addiction. There is an evidence base for their use in successfully treating addiction and other substance use disorders [32]. Yet with the public health crisis of addiction continuing, it is clear that more should be done to address the root of the problem—trauma. Each of these approaches lacks a comprehensive definition of addiction, a conceptualization of where addiction fits into the psychopathology of mental health disorders, and an appreciation for how addiction is experienced as traumatic and how addiction relates to trauma and dissociation. Furthermore, they do not directly incorporate memory resolution or memory reconsolidation as an aspect of treatment.

Treatments like DBT and SS specifically offer PTSD symptom management, and they can be helpful to clients in early stages of treatment for addiction and for individuals with clinically significant dissociative disorders. However, they are not comprehensive therapies if one appreciates addiction as a manifestation of dissociation, as the memory resolution phase of the three-stage consensus model of trauma treatment is absent [33]. Clinicians who mainly practice CBT are advised to incorporate trauma-focused CBT (TF-CBT) to work with both trauma and addiction memory. While processing the narrative or explicit memories is important, having ways to process the physical aspects of trauma is necessary for adaptive resolution and to produce personal transformation [34,35,36,37].

Ultimately, incorporating trauma resolution and memory reconsolidation therapies is essential to bring about healing of the root of the problem, not just the symptoms. Memory reconsolidation is based on the belief that the brain, through a process of memory retrieval and activation, can delete unwanted emotional learning [35]. Progressive counting, emotional coherence, brainspotting, deep brain reorienting, and EMDR therapy provide more direct ways of resolving traumatic/addiction memories [4,35,37,38,39].

After treatment goals have been established in the early stages of rapport building and setting the foundation for treatment, paths for intervention can be more clearly established. Please bear in mind that treatment goals can change and evolve throughout the course of treatment, and this is especially true when working with complex trauma and dissociation. Regardless of the specific interventions a clinician is trained to use, the general recommendation in working with complex trauma and dissociation is that the three stages of treatment established by Janet in 1889 be used as a general guide for treatment planning [33]. The field of trauma study generally refers to this model as the three-stage consensus model of trauma treatment because a consensus does exist on their use as a general structure in treatment planning for anything connected to trauma or dissociation.

The stages and their tasks, as presented in modern language are [40]:

Put simply, clients work to become prepared to handle the symptoms that show up in day-today life while also preparing for a deeper level of work, if they have the intention to go there and heal trauma at its root. Treatment should also include preparing clients to adjust to the changes in their life that happen as a result of unhealed trauma being addressed and transformed. Trauma resolution is only part of treatment—it is not the entire process. Preparation and adjustment to life are also major components of treatment.

These three stages are accepted by the current academic literature reviews that guide formal treatment for dissociation in adults by the ISSTD [41]. Clinicians can access the academic papers cited by ISSTD as best practice treatment guidelines free of charge on the ISSTD website (Resources).

The three-stage consensus model is not without controversy or challenge. In a 2016 review, de Jongh, Resick, Zoellner, et al. contend that the three-stage consensus model has no clear evidence base in treatment of more complex manifestations of trauma [42]. They generally contend that survivors of trauma may not be able to achieve any semblance of stabilization until they first engage in some type of complex trauma work. This debate speaks to one of the greatest clinical puzzles that exists in working with complex trauma—when is a client ready to do the work of trauma resolution? Is taking them to the core of their traumatic memories for healing dangerous and thus focus ought to be on symptom resolution?

Unfortunately, the answer is that there is no easy answer; it must be evaluated on a case-by-case basis. When a dissociative system is involved, clinical judgment should take into account how the entire system works. In EMDR therapy, the term preparation is used instead of stabilization [4]. Perfect stabilization likely will not exist for a survivor of trauma unless they have engaged in some degree of trauma work. Stabilization, like dissociation, really can be seen as a continuum. So, the better question may be: Is the client stable enough or sufficiently prepared to take their healing to a deeper place? Preparation suggests that certain skills will need to be in place to manage life on a day-to-day basis, and widening a person's (or a system's) affective window of tolerance will be required for experiencing emotions and body sensations that are imperative in true trauma resolution work. Evaluating what a client has and what they may need to prepare themselves for meeting their treatment goals is a natural by-product of the Dissociative Profile exercise discussed previously.

Many of the approaches to treatment that exist in the mental health field make wide use of guided imagery or visualization in preparation; these techniques are exclusively cognitive. In working with trauma, especially complex trauma and dissociation, it is vitally important that clinicians have a wide variety of skills that they can offer clients for use during and between sessions. These skills should work with all of the senses and many avenues of human experience [6,43]. Grounding is the very practice of using all available senses and all available channels of human experience to remain in or return to the here and now.

Although clients will not respond favorably to all of these skills and strategies, it is important to offer choice. This choice becomes even more imperative when working with a dissociative system, because one skill may work well for one part when they are active and not another. Certain skills may work better to prevent maladaptive dissociative responses, while others are superior for helping a person (or certain parts) return to the present moment when they experience problematic dissociation.

Skills that may be used for preparation and widening affect windows of tolerance generally fall into the following categories:

Video teachings on skills in each of these categories are available online via the Trauma Made Simple website (Resources).

Some may be further ahead than others in use of such skills in clinical practice, so some clinicians may require a deeper investigation on how to use these skills personally and teach them to others. Regardless of the skills a clinician uses, it is important to trauma-inform the language and leave people plenty of options for modifying. Reading an exercise out of a book, showing a client a video, or even reading one of the skills word-for-word from this course will generally not be sufficient. If a client expresses that something is not working, it could be that they are overwhelmed; a general best practice is to modify the skill either in length or style.

In modern clinical work, many of the skills advocated for helping people to ground or widen their affective window of tolerance can be described as mindfulness practices. Mindfulness is fundamentally about remaining in or returning to the here and now. Consider that dissociation, by its nature, is the antithesis of mindfulness. Forner posits that mindfulness is fundamentally about connection (e.g., to the self, to the present moment, to others), whereas dissociation is ultimately about surviving disconnection [44]. If a person dissociates long enough or becomes bonded to this state (as proposed in the Addiction as Dissociation Model), they can become phobic of mindfulness. As with any other phobia, the answer is not to avoid teaching mindfulness strategies. Rather, clinicians should be cognizant of the idea that when mindfulness strategies are presented to people who dissociate, they are being asked to try something that can feel radical and new. Small steps are required to help people become more comfortable with being present.

While the therapeutic alliance is an important feature of any therapy and in working with any population, issues around therapeutic alliance should be attended to in a special way when working with the spectrum of dissociation. A clinician's willingness to admit that dissociation is real and that a system is not manifestation of one's imagination is a great start in building rapport. As always, clinicians should be mindful not put their own agendas or projections on to a client, even in taking a more normalizing approach to dissociation.

Navigating the particulars of the therapeutic relationship can be sensitive. For instance, some parts in the system may not like a therapist or not be a fan of therapy in general. Clinicians are encouraged to roll with this resistance and take great care not to take any insults personally. Rather, consider what that particular part may find distressing and work to explore a solution. In doing clinical work, "hearing out" a part is generally more beneficial than trying to fight it.

Another potential problem area is a tendency for therapists to over-attach to younger or more vulnerable parts. There can be a desire for younger parts to turn the therapist into a parent figure, and this can cause some enmeshment and blurring of boundaries. While it is certainly possible to validate a client's or system's desire to see one as a parent, it is important to be clear that you are not their parent. This can feel cruel, but many of clients suffer because good boundaries were not modeled for them in early childhood. So, clinicians are in a position to validate their feelings and also challenge them into action, all while modeling and offering instruction about healthy boundaries. If this type of relationship is developing, ask the client/parts what qualities are being exhibited that they may have needed in a parent. These qualities can be used when evaluating what resources need to be built or worked on for younger parts in the system.

The following meditation and resourcing strategy may prove helpful for you and your clients in this process. As always, feel free to adjust and modify if needed.

When a client (and their system) experiences an adequate sense of preparation to move forward, the system can begin heal using any number of therapeutic strategies. Before continuing, it can be helpful for clinicians to contemplate what they consider to be their primary therapeutic orientation or orientations. In many cases, professionals can use what they have already learned to help people reach their established goals by assisting them to process or modify how traumatic memories are stored in the brain.

For instance, EMDR therapy is appropriate for working with dissociation if the clinician offering the therapy is well-informed in how dissociation can play out in an individual or their system and plans their targets and strategies with respect to how the system may work. Regardless of the approach used, if a block or a resistance shows up in the work, this is likely another part trying to have their voice heard, either to meet a need or to protect the system. Clinicians should be prepared with protocols in place to address these blocks. Seeking consultation from someone who practices the specific therapeutic approach and is well-skilled in working with dissociation and dissociative parts may be warranted to help build skills and confidence.

Expressive arts therapy, which refers to using any and all available creative forms (e.g. dance/movement, writing, art, drama, music) in combination, or any of the creative arts therapies as singular strategies can be a solid adjunct to any strategy available for processing or transforming trauma's impact in the brain. In many cases, parts in a system are young in terms of chronological age or exist in a state that cannot easily be accessed by words or language. Drawing or dancing may be a way to access the material that needs to be processed. Expressive arts strategies can be used in concert other approaches to trauma-focused therapy if the clinician has a sense of adventure and a willingness to personally try these strategies [45].

Table 3 provides a list of therapeutic approaches and online resources to access additional information. All of these approaches have some form of evidence base for working with the processing of traumatic memories and a protocol for how to best handle dissociation. Some of the modalities require more training than others, and clinicians who feel unprepared to work with processing traumatic memories in a holistic way may consider pursuing additional training in one of these modalities.

In the treatment recommendations provided by the ISSTD, no one specific treatment modality is endorsed for doing stage 2 work. What is important is that clinician and client has a solid therapeutic alliance established with good boundaries, and that they understand how to work with abreaction (when material shifts from the sub-conscious into consciousness, with some type of affective release typically accompanying it). Working integration will help a client and their system be able to put the past in its proper place and allow all facets of experience to be attended to. With a system involved, this may not be an easy task; it should be handled with care and attention to the system. The client-driven An Infinite Mind organization also does not endorse any one modality in the treatment of DID. Instead, they emphasize the importance of finding a therapist who believes in dissociation and who is willing to work with it, while also giving a client/survivor of trauma options for care.

An estimated 10% of the adult population is estimated to have a dissociative disorder; the majority are living typical lives and making valuable contributions to society [46]. Prevalence rates are higher in certain populations (e.g., psychiatric inpatients). For the sake of these patients, biases or preconceived notions about the impossibility of healing and optimal functioning in people who clinically dissociate should be put aside. These clients deserve the best available care to address their traumatic memories and improve their quality of life. The third stage of the three-stage consensus model of trauma treatment is generally called reintegration, and its primary objective is to assist people to make adjustments based on healing gains in therapy, ultimately living more adaptive, fulfilling lives.

How a clinician approaches stage three work with individuals who have DID or otherwise dissociate is not unlike how one might approach this stage with any other client impacted by trauma. One should be mindful that this work should be geared toward helping the system function as optimally and as peacefully as possible. Much of the work that took place in the preparation stages has a natural carry over to the reintegration phase. A helpful strategy can be to have the client and their system do the Dissociative Profile exercise at several intervals to see if any adjustments may need made. Completing one after an initial round of some work in stage two and also re-evaluating as termination nears is recommended.

According to the International Society for the Study of Trauma and Dissociation, psychotropic medication is not a primary treatment for dissociative processes, and specific recommendations for pharmacotherapy for most dissociative symptoms await systematic research.

(https://www.isst-d.org/wp-content/uploads/2019/02/GUIDELINES_REVISED2011.pdf Last Accessed: May 30, 2024)

Level of Evidence: Consensus Statement/Expert Opinion

Another question that arises is whether or not people with DID especially will require continued treatment or care for the rest of their lives or if termination is possible. In many ways, DID and other dissociative disorders are no different than any other major mental health disorders when contemplating termination. Some people will need long-term care as they adjust to living a more adaptive life aligned with their goals and intentions; others will reach a place where regular therapeutic care is no longer necessary. Like many issues in mental health, a case-by-case approach should be taken. Pharmacotherapy is outside of the scope of this course, but clients with dissociative symptoms or DID might be prescribed medications under the care of a psychiatrist or addiction medicine specialist. If this is the case, as a therapist, it is important to have regular contact with these providers to assure continuity in care and interprofessional collaboration.

REFLECTION

Now that you are nearing the end of this course, it may be a good idea for you to go back to your original Dissociative Profile exercise and re-evaluate. Knowing what you know now, after reading and working through this course, are there any adjustments that you would make? Even if this course has inspired you to take on healthier, proactive skills in the area of grounding, do there still seem to be some places where you feel stuck? Remember that there is no shame, especially as a therapist or helping professional, to seek out your own care, especially where issues around trauma or dissociation are concerned. Not only might this care help you to live a more adaptive life, it will likely have a positive impact on your efficacy as a therapist, especially in navigating complex situations.