Nature of Dissociative Symptoms
Some of the most distressing symptoms that clients report include dissociative symptoms. These symptoms include persistent daydreaming, forgetfulness and amnesia for recent events, feelings as though one’s body does not belong to oneself, feelings as though things (perhaps even the world itself) are not real, and a sense of acting so differently on occasion that it seems as though they were another person.
Often people do not report these symptoms because they may fear how others might respond. Otherwise they may assume that everyone reacts in a similar fashion. They may also sense that health professionals whom they see will not understand or believe them. Indeed, dissociative symptoms are probably the least understood symptoms by mental health professionals despite there having being much research on such reactions spanning over 100 years.
People with dissociative conditions are often diagnosed with many other conditions including depression, anxiety disorders, substance abuse, eating disorders, bipolar disorder, somatic conditions (including fibromyalgia) and borderline personality disorder. Sometimes individuals may indeed have such difficulties, but sometimes these diagnoses may result from health professionals not understanding the potential alternative of a dissociative disorder to help account (at least in part) for a person’s difficulties.
Dissociative symptoms can range considerably in their severity. For example, approximately 4 percent of psychiatric hospital in-patients would suffer from a severe dissociative condition called Dissociative Identity Disorder (whereby the person may feel or act as though they have a number of quite distinct and separate personalities). Approximately 15 per cent of psychiatric outpatients would have some form of dissociative condition.
Many highly capable individuals from many walks of life also have dissociative conditions which they may be experts in disguising. Otherwise they may assume that everyone has such reactions as extended blank spells or no memory for some significant past events (dissociative amnesia) or having difficulty recognizing oneself in a mirror or looking at oneself from a distance as though looking at another person (depersonalization).
Causes of Dissociative Symptoms
Dissociative symptoms commonly result from repeated trauma, abuse and/or neglect in early childhood years. However, it is possible for such symptoms to emerge in later years, but most commonly after severe traumatic experience. Dissociative symptoms sometimes relate to an attempt to block out painful emotions associated with overwhelming or traumatic events.
Individuals suffering from dissociative disorders may be very confused or perplexed about aspects of their behaviour such as why they might suddenly act in aggressive ways, why they might suddenly feel panicky and extremely threatened until they leave a particular situation, why they might feel helplessly immobile when they feel threatened or why they might have offered little resistance when others have treated them in an abusive way.
Such reactions typically seem to make little sense or to be very strange, but they may relate to survival mechanisms shared by humans and other animals in response to extreme threat (i.e. “fight”, “flight”, “freeze” and “submit” responses). Such responses can be triggered by reminders of earlier traumatic situations, even when individuals are not consciously aware that such memories are being triggered. This can cause people to act in an extreme way to a seemingly harmless situation and to question whether they are losing their mind. However, usually such reactions are temporary and brief and the person is functioning at a normal level at other times.
Dissociative symptoms are commonly related to hypnotisability or the potential to experience hypnosis. Hypnotic capacity is greatest when people are aged from approximately 8 to 12 years. Under hypnosis it is normal for people to experience such phenomena as amnesia for what has happened immediately beforehand or feeling as though a part of one’s body does not belong to oneself. People can even feel as though they are a different person, or can feel as though they are the same person, but at an earlier stage in their life. These reactions may seem interesting or even amusing if people are deliberately inducing them by undergoing hypnosis, but such reactions are generally much more distressing if they occur spontaneously or automatically without the person’s sense of conscious control over them.
If a young child experiences trauma and has limited available supports to comfort them at the time or to talk about their experience, that child is more likely to dissociate or use hypnosis-related strategies (including imagining that they are in a different place at the time) to help deal with their distressing experience. If this happens many times over, such as if someone is repeatedly sexually or physically abused, the person may develop an entrenched habit of responding to distressing circumstances by dissociating. If a person then experiences further trauma in later life they are far more likely to react to such circumstances with increased levels of dissociation. Such reactions themselves are so unsettling that they can add greatly to the impact of the initial trauma.
Whereas dissociative strategies or reactions may help diminish pain at the time, if such habits are over-developed this can be at great cost to the individual’s coping strategies in later life. When a person later faces distressing circumstances, they would then be less likely to learn to tolerate and adjust to the emotional pain of such circumstances, but would tend to develop indirect ways of the dealing with the difficult situation. They would more likely try to mentally remove themselves from the situation or distort their perception of that situation to neutralise it using dissociative strategies.
They therefore have much less practice at developing other more reliable coping strategies such as slowing one’s breathing, seeking to relax tension from one’s body and engaging in coping self-talk whilst developing a plan to help deal with the current situation. Other more healthy coping strategies include ensuring that one is protecting oneself in a threatening situation, seeking to communicate with others who are potentially supportive and engaging in a problem-solving process to more effectively deal with one’s current stressful circumstances.
Sometimes it is very difficult to identify earlier trauma, abuse or neglect that may have contributed to dissociative symptoms. In rare circumstances there may have been no such trauma, neglect or abuse. Sometimes people have blocked out negative experiences so strongly that they may not remember them at all. In some circumstances they may only start to remember early trauma if they come to be reminded of these experiences by other circumstances, including engaging in a therapy relationship where a person talks about what they remember of their childhood.
This is recognized by clinicians and researchers when they refer to the well-established symptom of post-traumatic amnesia, and alert therapists to the prospect of forgotten trauma memories being triggered in therapy. There has been much questioning in the popular media about the potential validity of repressed memories in the “false memory debate”. At times this commentary has questioned the existence of repressed memories, or psychogenic amnesia, and therefore the potential for “recovered memories”, which imply that such amnesia may be reversible. Few clinicians experienced in treating clients with trauma reactions would naively doubt the potential for trauma memories to be forgotten and to re-emerge at a later date, including in therapy sessions themselves.
It is no doubt important to recognize that our memory is fallible, and we may have undue confidence in our capacity to remember events exactly as they occurred. However, the aggressive questioning of the validity of repressed memories and their recoverability has led to many genuine victims of debilitating trauma to be further invalidated, compounding the negative impact of the trauma itself. It has also led to a marked past underestimate of the incidence of such trauma as childhood and church-related sexual abuse. The recent uncovering of the extent of childhood sexual abuse in the Australian Royal Commission into Institutional Responses to Child Sexual Abuse, and the Oscar-winning movie, Spotlight, have likely helped to counter this under-recognition of abuse.
Sometimes people seem to have developed dissociative conditions without past trauma if they have had a parent who suffered from marked post-traumatic stress or dissociative symptoms when they were growing up. Sometimes children can be very sensitive to the emotions and reactions of those around them. Children may pick up the unexpressed emotions of a parent and learn to block out the pain of such emotions in a similar fashion to their dissociating parent. Therefore therapists also need to be careful not to assume that people have most likely been abused even if they deny any such memory of abuse.
Treatment of Dissociative Symptoms
The treatment of dissociative conditions involves a number of steps, many of which overlap with the general treatment of trauma conditions. The first step involves psychoeducation, or learning more about dissociative experiences and their relationship to past distressing events. This may follow an initial assessment using a range of questionnaires to help establish the person’s initial level of dissociative symptoms, trauma-related thoughts, anxiety and depression. It may also involve an assessment of the person’s potential for absorption, a personality dimension related to one’s capacity to use dissociative strategies.
In the first instance the most important thing is to learn about and gain a greater understanding of dissociative symptoms and their potential protective purpose for the individual. Although this may bring up considerable distress (often associated with reminders of earlier trauma or abuse) it helps the person to start to be more accepting of themselves and their reactions. People may then be more mindful of how they are reacting to particular situations, and whether they might be using dissociative strategies. That helps to recognise the potential harm or costs that could follow from using dissociative strategies as opposed to other more reliable ways of dealing with emotionally challenging situations.
In order to limit the excessive use of dissociative strategies despite high levels of distress it is important to learn to use “grounding” techniques (such as looking at one’s shoes whilst shuffling one’s feet on the floor, standing up and looking around or briskly rubbing one’s hands together). It is particularly important for clients to develop a trusting relationship with their therapist as the person has often felt let down by others in a position of trust from whom they might have expected greatest support. It is important that the client have an opportunity to talk with their therapist about past distressing experiences, especially any past trauma, abuse and/or neglect. It is important that this is discussed only at a rate that the client feels ready and able to tolerate.
It is also important to learn anxiety management strategies such as slow breathing, relaxation techniques and coping self-statements to manage with stress. This is assisted by understanding a “graded exposure” model to deal with past trauma. This can include talking about past distressing experiences in a gradual or step-by-step fashion so that the person does not have to talk about the most distressing or overwhelming experiences right from the start.
In practice, this is what tends to happen anyway as people have a natural tendency to protect themselves from engaging in unnecessarily overwhelming experience. People also have ways of gauging the level of trust they might have in another person (including a health professional) by seeing how they respond to earlier disclosures before deciding whether to let them know about even more personal and overwhelming experiences.
Some of the most important strategies for managing with dissociative symptoms relate to developing more awareness (or mindfulness) about one’s feelings, thoughts, perceptions and impulses to act in certain ways. Individuals with dissociative tendencies can come to recognise circumstances in which they are feeling stressed and may come to find that they can stay present and grounded enough in the situation to use more reliable and adult strategies for managing their reactions.
As part of the therapy process clients will at times be going well beyond the “comfort zone” in discussing a whole range of topics. Some treatment techniques may involve a person directly re-living past traumatic experiences in some detail. Whereas such “exposure-based” techniques may be very challenging, they commonly are very effective in helping to reduce the emotional impact of past distressing experiences.
These techniques are only used when the client is well prepared and clearly understands their purpose. Individuals commonly feel uncomfortable (and may dissociate more!) prior to therapy sessions, and may feel disoriented or very distressed for some time afterward. It is good for clients to consider what they might do after a therapy session to help them manage their reactions in the hours afterwards. This may include having some time out or schedule activities that will give them a chance to come to feel more settled. A key treatment principle is that the therapist and client work together to ensure that each person can progress at their own pace.
One of the ways of gauging progress is to note how well the person is managing to establish boundaries for their own well-being and safety. This includes setting limits on ways in which others might act disrespectfully toward oneself. It can also include becoming more assertive and being more direct or open with others in expressing one’s feelings or reactions. In other circumstances it might include choosing not to have much to do with certain people. A key issue is how the person goes about observing appropriate boundaries in their own actions and noting whether others are also observing appropriate boundaries or limits in their interactions.
Although dissociative conditions can be severe in their impact individuals can commonly greatly improve their circumstances. It is typically best for people to pursue changes over a long period of time, perhaps focusing on more frequent (e.g. weekly) therapy contact in the first three or four months to develop alternative coping skills. Beyond that time it is important that individuals continue to work on the changes they seek for a period of two years or so. This is because it takes people approximately four months to establish a new habit in any aspect of their functioning, but it takes approximately two years for someone to be confident that they have truly shifted an underlying aspect of their personality functioning.
Dealing with dissociative conditions commonly means attempting to alter one’s personality functioning in a significant way, particularly with regard to mindfully and directly applying various coping strategies to manage with emotionally challenging and distressing circumstances. There may be some benefits in those with dissociative conditions meeting some others who have had to grapple with similar difficulties. For this purpose there may be benefit in an individual participating in a specific brief group therapy involvement with others who have suffered dissociative conditions to help demystify their difficulties and to appreciate that they are not alone in their reactions.
Where individuals are in established relationships it can be very helpful and important for one’s partner to be informed about dissociative symptoms and the potential causes of such symptoms. It may also help if loved ones are aware of strategies (e.g., grounding techniques) to help the person overcome the more negative effects of such conditions. Partners have typically adapted somewhat to the person’s dissociative symptoms but will commonly feel very confused as to why such reactions may occur.
Key Steps to Recovery
Even when dissociative conditions have had a severe impact on someone’s life over many years, there are usually good prospects of recovery in response to psychological therapy. In more severe cases the path to recovery can be slow and gradual over several years. In less severe cases individuals can often make significant progress within a period of several months by focusing on the following steps. In order to consolidate progress it is helpful to maintain occasional follow-up therapy sessions over a period of at least a year.
In summary, the key goals for those with dissociative conditions to pursue in therapy may include to:
- Develop a greater understanding as to how they may have developed such difficulties (usually to do with repeated childhood trauma, abuse and/or neglect)
- Develop more reliable strategies for dealing with painful emotions (and being able to feel them “from inside one’s skin”)
- Develop more appropriate ways of appropriately asserting oneself to deal with interpersonal conflict.
- Establish and maintain clearer boundaries in one’s own and others behaviour — this includes being appropriately self-protective
- Acknowledge and talk about some experiences related to past trauma, abuse and/or neglect to defuse their negative emotional impact
- Learn to better curb impulsive behaviour (or inhibit inappropriate impulses)
- Seek to act mindfully (with full conscious awareness) across a range of situations as this helps to establish and reinforce one’s sense of identity
- Focus on managing with the broad roles in one’s life (managing with one’s role functioning as a parent, friend, worker, etc)
- Where a person is a parent, appreciate one’s efforts as limiting the impact of past abuse and/or trauma on the next generation
- Appreciate the significance of one’s efforts generally. The extent of one’s efforts to rise above dissociative reactions will typically not be visible to others
Chris Mackey is a clinical psychologist and Fellow of The Australian Psychological Society with 40 years’ psychotherapy experience, including 30 years specialising in psychological trauma. He is author of The Positive Psychology of Synchronicity: Enhance Your Mental Health with the Power of Coincidence (See book website). Chris received the 2019 Australian Allied Health Impact Award for his clinical research and media work.