Dissociation

Dissociation

As interest in the field of trauma has increased over the past thirty years, so too has the study of dissociation, as the two go hand in hand. There is now a growing body of research and literature on the topic of dissociation, enhancing the ability of clinicians to understand, recognize and treat it.

Dissociation is defined as the disruption of the normal integration of experience. That is, elements of experience (behaviour, emotion, sensation, knowledge and meaning) that would normally be held together in awareness, are fragmented, or split apart in order to prevent the person from being overwhelmed. Thus, intense affects such as terror may be held out of awareness, thereby allowing the individual to continue on with their daily life.

What causes Dissociation?

Dissociation is a psychological defense that has been called "the escape when there is no escape" and is thought by some to be the human equivalent of the freeze response in animals. When used as protection from trauma, it saves the mind. However, over time, it can take on a life of its own and even when the trauma has long passed, it continues to operate as if the danger is still present, continuing to compartmentalize experience, alter sensorium and interrupt the ability to be fully present in one's life.

There are many forms of dissociation, ranging from the familiar, normal day-to-day experiences of being "lost in a good book" or not being able to remember the drive home, to the clinical types of dissociation that we see when it has been used as a defense against traumatic stress. In cases of moderate stress, dissociation is usually transient and reversible, with the events being gradually made sense of and integrated into experience. However, in cases of extreme or prolonged stress or threat, dissociation has more long-lasting and deleterious effects. This is especially true in the case of early and chronic exposure to childhood abuse and neglect or in situations where the child experiences prolonged fear states.

Symptoms of Dissociation

When used in response to trauma, dissociation is characterized by memory loss and a sense of disconnection from oneself and one's surroundings.

According to researchers, there are five core dissociative symptoms:

  1. Amnesia – the inability to account by memory for a specific and significant block of time;
  2. Depersonalization – a feeling of detachment from yourself or your body or your emotions; feeling like a robot. This is perhaps the most recognizable form of dissociation – often described as "zoning out", "checking out" or "being foggy". Some people describe feeling as if they are not in their bodies, but are observing things from a distance.
  3. Derealization – a feeling of detachment from your environment, feeling like what used to be familiar is now foreign (including people);
  4. Identity confusion – a feeling of uncertainty or conflict about who you are and how you define yourself, including your sexual identity;
  5. Identity alteration – a shift in role or identity, accompanied by changes in your behaviours that are observable to others.

It is evident then, that the means used to prevent being overwhelmed, although initially quite invaluable, can become the source and perpetuation of difficulty and distress long after the danger has passed.

Working with dissociation in therapy

There are well-documented and well-researched methods of working with dissociation, including the fragmented memory and identity that can result from early and prolonged exposure to severe trauma in childhood.

Working with dissociation in therapy involves recognition of the various forms of dissociation and awareness of the underlying trauma that drives them. It is often quite relieving for someone experiencing dissociative symptoms to understand the adaptive nature of dissociation, as there can be considerable shame connected to these symptoms. The initial stage of trauma treatment involves the acquisition of skills to increase stability in day to day functioning. By necessity, this requires the ability to recognize and deal with dissociative behaviours. For example methods of "grounding" in the present can allow an increased sense of control. Body-oriented techniques are quite invaluable in helping someone to "come back to the present" when their nervous system is responding as if they are still in the danger of the past.

Because of the high level of autonomic nervous system activation that drives dissociation, it is important to work with the trauma that underlies it in a gradual and titrated (exposing the person to small, tolerable amounts of arousal related to the trauma) manner.

A helpful metaphor is to think of a car being driven with the brakes and the gas both fully on. A gentle easing off of both pedals is what brings the car under control. In fact, the caveat for trauma treatment is "The slower you go, the faster you get there". This is key to working with trauma and dissociation; that is, understanding that accessing traumatic memories, emotions, sensations or thoughts before the person has established some degree of stability can cause more activation, thereby triggering more dissociation.

Thus, in the second stage of trauma treatment – the processing of trauma, considerable attention is paid to managing the level of distress experienced in order to not retraumatize the individual. Treatment modalities of hypnosis, EMDR and Somatic Experiencing are extremely helpful in this regard. The goal of trauma work is not memory recovery per se but rather the ability to construct a coherent narrative of one's life events, no matter how horrific past experiences may have been. As the need for dissociation lessens and elements of experience that were originally held apart can begin to come together, one is able to have context and a sense of continuity of experience and of self. In turn, the experience of a more coherent, continuous sense of self in the present creates a sense of efficacy in one's life and a newfound ability to navigate the world and relationships.

Especially in cases of childhood abuse and neglect, there is often a period of profound grief that accompanies the painful recognition of the extent of the trauma and betrayal one has survived. It is this grieving that then allows for the individual to move forward in their present life, no longer encumbered by intrusions from the past.

Later stages of treatment often consist of a consolidation of gains made and a continued building of the skills needed to be in healthy relationships and to engage the external world.

Read more about Trauma Therapy.