Why Should You Read These Articles on Dissociative Processes?

What are dissociative processes? 

Dissociation is that process in which normally related psychologic experiences and events are detached from each other and result in a distortion of experience with both subtle and profound alterations in interpretation of the meaning of personal and interpersonal events. For example, depersonalization (an out-of-body experience or feeling “unreal”) [2] is generated by a psychologic detachment for sensing being embodied, being located in “my body.” When a person cannot feel their bodily senses, then they can't feel their feelings either; they become emotionally numb, a hallmark of posttraumatic disorders. Depersonalization can be thought of as a desperate unconscious control mechanism for squelching overwhelming effects like terror, horror, utter helplessness, and so forth. A standard—and sad—report of depersonalization is having a recollection of floating on the ceiling watching “as I was raped. The person below was me, sort of, but I wasn't there. But I was. It was all very confusing. I just feel numb about it now.”

When knowledge is isolated (corollary to isolated affect, emotional numbness), a person may experience a storm of painful effect, complete with sobbing, hyperventilation, and so forth, but not have any sense of a context for why they are feeling so distressed. (“It makes me feel crazy to be taken over by all this weeping and not have a clue why I'm even crying!”) Similarly, veterans from military conflicts return home to people they have loved, know they should feel more “moved” emotionally, but simply “feel nothing”—the affect is isolated, and they have posttraumatic numbness, a dissociative symptom. Likewise, a powerfully successful businessman is rarely able to sleep when traveling. Unconsciously he experiences his hotel room, one of many on a long hallway, as too close a match for one of many hospital rooms he occupied as a child with recurrent near-fatal medical events. He spends his nights depersonalized, feeling unreal, in a panic, sleepless. A drug-addicted housewife can't remember why she snorted another round of cocaine. “I told myself I wasn't going to do it, and then I watched myself reach for that line and lift it to my face, the whole time yelling inside my mind to stop, but my arms weren't under my control!” The teenage girl in the emergency room, after cutting her upper arm, reported that “It's nothing. It stopped bleeding, so who cares? I didn't feel anything. I just got calm and felt better after I saw the blood. I don't remember cutting my arm, but I do know I didn't feel it.” The bulimic says, “My stomach was so painfully full that my whole body hurt. That's when I went to throw up, and this weird and wonderful fog filled my head like everything was just a dream. I must have fallen asleep. When I woke up I knew what I had done, but in a weird way it didn't feel like I had done it, I just knew I felt better, calm. Finally. It's what always happens. I hate throwing up, but the calm afterward is just fine with me.”

A new model of mind for the twenty-first century: states of mind 

Over 100 years ago, Sigmund Freud collaborated with Joseph Breuer to write a treatise on hysteria [3] at about the same time that Pierre Janet picked up his own pen [4]. Hysteria baffled contemporary neurologists. No wonder! With a name that meant “wandering womb,” hysteria seemed to be a disease of women that men could not understand. Janet wrote about the disaggregation of the personality, while Freud and Breuer took him on in the preface of their Studies on Hysteria, declaring that what was a so-called “double consciousness” was essentially a mistaken description of the process of repression and a weakness of the ego. Freud's disciples, including James Strachey and Joan Riviere, brought psychoanalysis to the English-speaking world at the same time that Eugene Bleuler coined the term schizophrenia (“split mind”) [5], and the work of Janet was eclipsed as the divisions in the dissociative mind became conflated with schizophrenia. It was not until the 1980s that this error began to be corrected with a new literature on what was then called multiple personality disorder [6], [7]. Now, over 100 years later, there are no good experimental models of repression, while evidence for disaggregation of mental processes—or dissociation—is a rapidly enlarging scientific and clinical literature. Contemporary psychoanalysis and psychiatry are moving far away from Freud's structural theory, id, ego, and super-ego, and embracing studies on the self and relational psychology, and an exploding literature on attachment. The study of the dissociative disorders is opening a large door into the study of mind. A confluence of work in a number of disciplines has arrived at the conclusion that a parsimonious “model of mind” is that of “states of mind” as the basic building blocks of mind [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21]. The advantages of a “states of mind” or “states of being” model, are spelled out in the articles presented in this issue. Of particular importance is that with attention to the language of the therapy (see the article by Way in this issue), patients with dissociative and other psychiatric disorders immediately understand what their therapists are saying about their minds.

Some important questions 

How do dissociative processes work? What is the neurobiology that underlies dissociative experience? What happens to an individual's subjectivity in dissociative experience? What does “I” feel like when you can't remember what your name is? Is there some kind of normal dissociative process? Wouldn't these processes, when unrecognized, skew psychiatric research through misdiagnosis? If borderline adaptations are filled with dissociative process, wouldn't it be more useful to reformulate borderline and posttraumatic processes with a knowledge of dissociative processes? How do I learn to think intuitively about these processes so that I can “get into the mindset” of my patients and use these processes to their advantage, or at least halt their destructiveness? What about intervening with the out-of-control, self-destructive patient with a full-blown dissociative disorder and altered personalities? You don't expect me to believe there are other people inside my patients, do you? (Not only is that not expected of you, it would simply be wrong to reify a subjective experience rather than call that shift in subjectivity to the patient's attention and study their experience with them.) How do I intervene to work with a potentially violent dissociative patient? How do I understand and work with alter phenomena? Is it really appropriate to agree with the patient when they tell me their name is different than their given name? Doesn't that just make things worse? Aren't I feeding a delusion? Is there something about the particular use of language, descriptive metaphor, in the treatment of the dissociative disorders that predicts or limits what we understand about a mind, or how to help someone with these problems?

What can you learn about in the pages that follow? 

The 16 articles in this issue are organized into three main sections: theory, research and evaluation, and technique. The theory section is led by Paul Dell's revisionist model of the dissociative disorders as the picture of a mind suffering from relentless intrusions of dissociated affects, knowledge, and so forth. Over a decade of work on his multidimensional inventory of dissociation has informed this view that emphasizes how individuals suffer from intrusive experience into every aspect of executive functioning. Whether you agree with him or not, he sifts dissociative experience through a very fine mesh and provides a marvelous tour of the dissociative mind. Karen Way then provides a unique vantage point from which to consider dissociative phenomena and experience by understanding how the metaphors that describe persons with dissociative disorders influence our views of mind as subject and object. She explores the notions of the self as a thing that is divided versus the self as an agent in the world that turns inwardly, away from traumatic experience and relatedness, but nevertheless cannot escape the past. She discusses her conclusion in detail: verb-based metaphors are more consistent with the goals of treatment. Lisa Butler explores the realm of normative dissociation. She combines her knowledge of dissociation and hypnosis to develop a line of inquiry that exposes the extent to which dissociative processes are part of our everyday lives. Being absorbed in reading this paragraph and having lost track of your surrounding environment is an example of everyday dissociation. Check out what she has to say. You'll learn that a dissociative process is not just something that occurs as a result of a traumatic experience—it is part of the basic operating systems in our mind. Dissociation helps us to focus and concentrate. The challenge is to not lose our bearings. Of course, paradoxically, in the face of trauma, losing one's bearings may be preferable to staying focused on unbearable trauma from which there is no escape. Lyons-Ruth and colleagues discuss how it is the specific qualities of the parent–infant dialog that are most predictive of adult dissociative disorders. The notion that traumatic experience is always at the root of dissociative adaptation seems not so sure in the face of this work. Trauma may be associated with adult and childhood dissociation, but it is the particular quality of the patterns of parent–child communication that are most predictive of dissociative coping styles. It is the “hidden trauma” of profound interpersonal emotional dysfunction that may fuel basic dissociative processes. It is within this context that Catherine Classen and colleagues responded to my invitation and wrote a reformulation of borderline and posttraumatic disorders by describing a posttraumatic personality disorder. Based on an exploration of insecure attachment that is disorganized versus organized, this article is a marvelous font toward understanding a confluence of conditions that are related to both trauma and profound relational failures. Whereas type D attachments (disorganized/disoriented pattern) are clearly consistent with the phenotype of adult dissociative disorders, the emotionally dismissive parent of the type A attachment (avoidant pattern) and the preoccupied parent of the type C attachment (anxious/ambivalent pattern) clearly show up in the behavior of borderline and posttraumatic patients. With trauma histories so prevalent in our borderline patients, isn't it time to think about reformulating the borderline construct as well as chronic posttraumatic adaptations into something that is more parsimoniously structured? You will learn a lot from their careful reformulation.

The research and evaluation section leads off with an article by clinician-scientists Frewen and Lanius. They review studies of the neural correlates of dissociative experiences, as assessed by positron emission tomography and functional MRI through the organizing principles of what some writers have called primary, secondary, and tertiary dissociation. They show how the key cortical structures involved in these processes include the medial prefrontal, anterior cingulate, somatosensory, and insular cortex, as well as the thalamus. Distinctive neural correlates of primary and secondary dissociative experiences in individuals who have posttraumatic stress disorder support state-phase models of animal defensive reaction to external threat. They speculate that disconnection of neural pathways normally linking self-awareness with body-state perception, occurring as a result of childhood trauma, may occasion the development of tertiary dissociative identities. In another article, Vedat Sar and Colin Ross discuss how the lack of attention to and knowledge about the dissociative disorders can lead to misadventure and misleading results in psychiatric research. It has always astonished me that even though the diagnosis of schizophrenia relies heavily upon hearing voices, most researchers do not screen for dissociative disorders. With psychotherapeutic interventions for schizophrenia de-emphasized, the tragedy of misdiagnosis of a dissociative disorder as a schizophrenic disorder is accentuated. Sar and Ross provide some interesting ideas to consider with regard to diagnosis and research.

Brand, Armstrong, and Loewenstein discuss how psychologic assessment can assist in the diagnosis of dissociative identity disorder (DID) as well as treatment planning for dissociative patients. They outline a battery that can assess the extent of dissociation, review the research on dissociation on various psychologic tests, and present new Rorschach data on severely dissociative patients that can be useful in planning treatment. Their work is on the frontier of the best in clinical research. As a group, their clinical skill is extraordinary. I hope you will take some time to digest their wisdom. Likewise, Frankel and Dalenberg offer a sterling review of the forensic psychology literature that is designed to be a reference guide for study by the practicing clinician. They address the role of the forensic mental health professional in the context of court-related evaluations of claims of dissociative disorders, the possible relationships between such claims and the issues to be decided by the trier of fact, research developments that may bear on the forensic evaluation of DID from biological, psychologic, and social data sources, and provide a checklist of issues about which forensic evaluators should be prepared to respond on direct and cross-examination.

For the consultation liaison clinician in you, spend some time looking at Elizabeth Bowman's comprehensive review of the relationship between pseudoseizures and dissociative processes. Bowman is one of the world's leading authorities on this topic. If you have ever treated a patient with pseudoseizures, then you know that moving the patient's understanding of what ails them from a medical model of their problem to a psychologic model requires the utmost skill. Cross-reference this with the Turkish experience in the ubiquitous presentations of conversion disorder, and you begin to see the potential for understanding a whole range of neuropsychiatric presentations based on dissociative process.

You will enjoy Eli Somer's discussion of culture-bound syndromes related to dissociative process. The expression of dissociative process is guided somewhat by culture, and Dr. Somer discusses this in detail. There is a wide range of dissociative process visible in behavioral syndromes in both sophisticated and more primitive societies. To round out this section on research and evaluation, Vedat Sar starts with the Turkish experience and adds an international roster of literature and research on the dissociative disorders. While some critics have said that dissociative disorders were a North American phenomenon, all one might need do to end the controversy is to combine the insights of Somer and Sar.

The last section will be a special treat for clinicians who are eager to learn more about the application of theory. Turkus and colleagues have put to paper many years' experience as they spell out the basics of a coherent treatment from psychoeducational approaches, through grounding techniques, to fostering inter alter communication. Their contribution is filled with clinical wisdom. Pain, Ogden, Fisher, and Ryder spell out an important element of treatment, how to integrate a knowledge of the sensorimotor neurobiologic processes into the treatment of trauma. Many clinicians focus on dissociation of affect and knowledge as the main topic of a treatment. These clinicians show how sensorimotor and even cerebellar dissociations are a powerful mode of inquiry into healing a mind filled with experience that outstripped the capacity to speak and describe overwhelming adversity with words. Somatic approaches to treatment are invaluable. While their approach may not seem immediately applicable to routine psychotherapy, read closely and you will see that even without special training, you can adapt their technique and still maintain appropriate clinical boundaries in the treatment of the traumatized person.

The last two articles in this issue are both a tour de force. Rick Kluft has written a kind of “everything you ever wanted to know about alter personalities but were afraid to ask” article. In many ways, Kluft is the father of this field. His knowledge is extraordinary. I hope you enjoy reading his work as much as I did. Rich Loewenstein's clinical wisdom comes alive in “DID 101.” Having trained under his supervision, all I can say is that he continues to delight me with his creativity and his uncommon good sense. No matter what your level of skill, you will learn something from this blow-by-blow illustrative dialog of working with two particularly challenging patients, one initially in restraints, and the other skillfully self-destructive and previously impervious to intervention.

No editor works in a vacuum. Everybody has a life. I particularly wish to thank my wife, Kathryn Chefetz, LCSW, a psychoanalyst who “gets” dissociative disorders and who has tolerated (mostly) the time that has been taken from our relationship and family for me to complete this project. I only hope to live up to the high standard she sets for intellectual honesty and compassionate involvment in doing the work of complex treatments. She is a valued colleague. Thank you for your support, Kathryn. I also want to thank my editor, Sarah Barth, for allowing me to put together 16 rather than the usual 14 papers for an issue of this type. I want to thank my authors for their hard work, and for their respectful challenges to my editorial input that made producing this publication both a pleasure and a learning experience. They are an extraordinary group of clinicians and researchers. Lastly, I wish to thank my colleagues at the International Society for the Study of Dissociation. You have provided me with many worthy challenges, but most of all with your warmth and friendship. When Rich Loewenstein edited the last issue of the Psychiatric Clinics of North America on this subject in 1991, many of the authors, and this editor, were still early on in the learning curve for understanding complex dissociative disorders and dissociative processes. The growth of this field in the last 15 years has been extraordinary. I look forward to the next 15 years, and to the advances that will lead to better treatments, faster healing, and resolution of pain for our patients. We need to assure, as best we can, that our patients can complete treatment and then go on to lead productive lives in a growth-promoting community. Fantasy? No, not at all. I believe the vast majority of our patients can do this work when their clinicians are well educated. Time to get back to work and make this belief a reality. Please join me.