Understanding Clinical Dissociation and its Treatment

Dissociation is a broad term for the defensive use of unconsciously splitting off parts of the self or one’s lived experience in order to defend against overwhelming or painful emotions, emotional conflicts, or memories. It is often a response to severe trauma, for example, repeated child abuse. It is both a a process, of splitting off, and a descriptor for a self that is split into independent parts that do not communicate or coordinate. occurs in everyone and differentiating clinical level dissociation is a matter of degree. Dissociation is a psychological defense as it protects the person from “the unthinkable, the unimaginable, and the unbearable helplessness to stop events that trigger feelings of terror, annihilation, and nonbeing” (pg. 30) so that the person may continue to function as well as they possibly can after enduring trauma.

The concept of “relational trauma” may be useful for you and your therapist, as well as the concept of clinical dissociation. Relational trauma refers to an interpersonal attachment or relationship that was continuously traumatic in some way. Often the attachment relationship evokes overwhelming and conflicting emotions that overwhelm the child or person and so they dissociate. This can apply to a primary caregiver relationship, as well as other relationships like friendships and romantic relationships. Often patients will discover that an early traumatic relationship pattern is repeated in subsequent ones throughout the lifespan.

Psychotherapy for Clinical Dissociation

A main therapeutic goal in treating trauma-related dissociation is integration of affects and self-states. This occurs over time by exploring subjective memories and emotions related to past traumas and connecting them with the patient’s current manifestations and descriptions of dissociation. It is helpful to include detailed focusing on the patient’s affect both in the session and out in the world.

A main goal of psychotherapy for dissociation is integration. Integration means that unprocessed or dissociated aspects of trauma are experienced consciously due to the psychotherapy, and then become part of the patient’s self or conscious awareness on a more regular basis. The patient may experience dissociated or independent states or “parts” that reflect the fragmented self in need of integration and strengthening in order to become more coherent, consistent, and self-aware. Difficult emotions associated with trauma are felt, ideally in degrees that the patient can tolerate, in order for integration to occur. This process is what is often referred to as the major aspect of “working through” traumatic history and can take a significant amount of time in psychotherapy. Detailed attention to the patient’s affects in psychotherapy promote the needed self-reflection and awareness that leads to greater self integration.

Another main goal of psychotherapy for dissociation is the development of effective grounding strategies for the patient. In order to be able to integrate dissociated aspects of trauma, the patient must be able to tolerate and regulate the related affects to avoid further dissociation (patients cannot integrate trauma if they are too overwhelmed). Also, the ability to self-regulate outside of sessions Is important so that the patient does not become overly destabilized by the psychotherapy and possibly engage in maladaptive coping (e.g., excessive substance use, self-injurious or suicidal behaviours).

Psychotherapy for dissociative symptoms and related trauma is typically regular (e.g., at least one session per week) and long-term. This integral trust building process of long-term psychotherapy also allows for trauma and other negative aspects of the self to come to the fore and be understood and integrated over time - this is often referred to as “working through” and is the foundation of the “Integrative Systems Perspective” (Steele, Boon, & Van Der Hart, 2107). Development of such a meaningful and trusting therapeutic relationship provide the needed opportunity for healing unlearning and revision of maladaptive relationship patterns that the patient is unconsciously seeking.

 References

Chapter 3: Symptom patterns: The subjective experience. In Lingiardi, V., & McWilliams, N. (Eds.).(2017). Psychodynamic diagnostic manual, Second Edition (PDM-2). The Guilford Press.

Howell, E. F., & Itzkowitz, S. (Eds.). (2016). The dissociative mind in psychoanalysis: Understanding and working with trauma. Routledge.

Steele, K., Boon, S., Van Der Hart, O. (2017). Treating trauma-related dissociation: A practical, integrative approach. W. W. Norton & Company, Inc.