The Many Faces of Dissociation

Dissociation is confusing! Why? Because it is defined in several different ways in the clinical literature, and each definition requires a somewhat different treatment approach. Over time, so many symptoms have come to rest under this big umbrella term. So, it is essential we understand what we mean when we talk about ‘dissociation’.

Spacing out                                                         

The most common use of dissociation implies ‘spaciness’ or ‘checking out’. While we often associate this with trauma, it is a symptom that can occur with any mental health diagnosis. And to make it more confusing, it is something we all do when we are tired, stressed, or ill; it is normal.

But some people space out or check out for hours at a time, or during periods when they really need to be present, such as in therapy; it can be out of their control. In these cases, it is a sign of trouble with which the client needs help. The treatment for spacing out is mindfulness, grounding, and therapeutic work on learning to accept and tolerate any conflicts or emotions that trigger it.

Hypoarousal

The second way dissociation is described is as a physiological hypoarousal or shutdown. Of course, spacing out is also included in this definition, because when we shut down, we stop thinking and paying attention, and are unable to integrate experience normally. The treatment of shutdown is activation: movement, breathing, grounding, and activation of the ventral vagal system.

Depersonalisation and derealisation

The third way dissociation is defined is by symptoms of depersonalisation and derealisation. These involve time distortions; feelings of unreality (as if in a dream, acting on a stage, in a fog); and other perceptual problems such as feeling your body or a body part is larger or smaller, feeling as if you are down a tunnel, or floating out of body and watching yourself.

These symptoms are common in trauma, but any of us can experience brief, transient episodes when we are tired, stressed or ill. Very pervasive and chronic depersonalisation can result in Depersonalisation Disorder, which is challenging to treat, involving grounding, mindfulness, emotion tolerance and regulation skills, and cognitive work.

Dissociative Identity Disorder

The final way dissociation is defined actually returns us to the original and more narrow definition from over 150 years ago. This definition denotes a division, compartmentalisation, or ‘dissociation’ of the self and personality due to an inability to integrate experience, resulting in Dissociative Identity Disorder and its variations. In spaciness and shutdown, experience is not integrated because it is not encoded in memory. In dissociation of the personality, experience is encoded, but in a compartmentalised way, and thus is not accessible when the individual does not have the integrative capacity to recall it.

Dissociative personalities or identities are not people, and are not completely separate, but are parts of one person, like subsystems within a system. It is not hard to imagine a traumatised child developing very different senses of self, in response to the impossible dilemma of needing to attach to an abusive caregiver and defending against threat with the same caregiver, between trying to live everyday life and dealing with severe trauma. And it is not hard to imagine how difficult it would be to integrate those two very discrepant senses of self without a lot of help and support.

Treatment for Dissociative Identity Disorder includes all the interventions for spaciness and shutdown, plus work to support integration of these discrepant senses of self through inner conflict resolution, working through defenses, development of self-compassion, and more.

I hope this inspires you to learn more about the wide and fascinating world of dissociation!

Join Kathy Steele and Dolores Masquera at 5pm on May 14 via the PESI UK website for a free live webcast on working with traumatised and dissociative clients online during the Covid-19 pandemic.