The world of science has a bit of a problem when it comes to the word ‘dissociation’. The definition isn’t clear anymore. Different categories of experiences all get labeled as ‘dissociation’ without adding a hint about what kind of dissociation is referred to. This very blog is guilty of it too. There is no solution in sight, that is why we think it is important to at least know that there is a problem here and why it causes problems in trauma treatment.
Structural dissociation
When the word dissociation was first introduced to the field of psychology it always meant structural dissociation of the personality. It described a division between an ANP and one or more EPs, including somatoform structural dissociation. This kind of dissociation is specific to people who got traumatized. It took about 100 years before the word dissociation was used for other phenomena as well. Working with parts of the personality to integrate them is necessary to heal. There are no hints in science that ignoring these parts makes it better.
The attempts to return to that highly specific definition (van der Hart, Nijenhuis) are basically ignored because it would be too difficult. It is highly unlikely that we can turn back time, that is why we make sure to speak of ‘structural’ dissociation when we talk about a division of parts of the personality on this blog.
Alterations in the field of consciousness
I think it was around the 80s that symptoms of depersonalization and derealization were called dissociation as well. These don’t necessarily have anything to do with a division of the personality and they are not specific to trauma survivors. People with eating disorders, depression or schizophrenia experience those symptoms as well. In this category we find changes in how wide the field of consciousness is or how deep it is. Our awareness for ourselves can get limited, we feel numb, can’t sense body parts, our perceptions lose depth or we lose the sense of it being real or go into stupor. Our awareness might be so low that we don’t store any new memories and therefore experience amnesia.
It can get tricky to tell things apart here. Do we experience depersonalisation and amnesia because our field of consciousness got smaller and there really is no awareness, or are there other parts of us who do experience these things and they are just separated from our awareness? This question is unresolved and it isn’t even clear how to properly test it. Right now dp/dr and similar issues are listed as dissociative disorders but not as structural dissociation. They are considered related but not identical (paper).
So far I have seen alterations of the field of consciousness been treated with intense sensory stimulation to help people reconnect with reality and bring them back to full consciousness. There are no attempts to integrate anything, so the definition used makes a major difference in treatment.
Somatoform dissociation
Sometimes our awareness doesn’t go away, we experience more than we should. A classic example are body flashbacks. These aren’t even included in what is currently called dissociation, although they are dissociative in nature. Sometimes intense sensory stimulation is used to fix this, which often fails, because these are not changes in the field of consciousness, these are fragments of experience that were split off during traumatic experiences. Sometimes these bodily symptoms can be identified as belonging to a certain part of the personality stuck in TraumaTime, so we are back to parts work for this. Currently, being numb for pain is considered dissociation while feeling un-integrated pain is not. That is called conversion disorder, without a proper explanation how this conversion should happen except through dissociation. ‘Somatoform dissociation’ describes both phenomena and is very common in DID (study)
Tonic immobility
When people faint, collapse, lose their muscle tone, get cold and barely breathe like we see it in the animal defense mechanism that is called tonic immobility, that is also called dissociation. This is a physiological issue where our nervous system goes into a stress response and shuts down bodily functions. We usually call this Shutdown or hypoarousal on this blog. Everyone can experience this under high stress but traumatized people experience it more often because they have a smaller window of tolerance. It might or might not have something to do with structural dissociation, as sometimes parts are stuck in tonic immobility and when they switch forward, this is what we get. But it can have nothing to do with structural dissociation and neither is it limited to just a change in the field of consciousness, although tunnel vision, going numb and a shutting down of conscious awareness are a part of it. The lines get a bit blurred here.
This is usually an involuntary stress response. Some people find intense sensory stimulation helpful, for others it actually makes it worse because their body gets even more stressed. Light movement, warm drinks and mindfulness are often helpful. We need safety, orientation and grounding (see polyvagal theory). Unless this is caused by a part stuck in this stress response, then we need integration.
(We were always taught that hyperarousal is the opposite of hypoarousal, which is used as a synonym for dissociation, but if hyperarousal is the state a dissociative part is stuck in, that technically makes the experience (structurally) dissociative. Again, it is a bit hard to test this, so this is a game of thought more than a scientific fact, but it could explain why some symptoms seem to be treatment resistant.)
Avoidance strategy
It is often unclear what authors mean by defining dissociation as an avoidance or escape mechanism. Do they mean tonic immobility? That actually is the body’s mechanism to avoid life-threatening stress. It does it automatically and involuntarily, without an actual process of mentally avoiding something. That is not what is meant here most of the time. Somehow the idea came up that people can cause changes in the field of consciousness on purpose to mentally avoid difficult situations as a psychological defense. They are right and they are wrong. People can’t turn a switch and create derealization on purpose. But traumatized people have often learned the art of self-hypnosis to make themselves numb during trauma experiences. When people say that they can dissociate on purpose, that is what they mean. They don’t mean they can cause tonic immobility. But they can enter a deep trance at will and that will limit their field of consciousness and cause symptoms that can be considered depersonalisation.
Therapists who believe that dissociation is mainly this, a conscious action of avoiding problematic topics, will mistreat their patients sooner or later. Yes, they might trance out on purpose sometimes. But what will happen a lot more often is that they get intensely stressed by trauma topics and enter Shutdown. That is not a conscious decision and it cannot be controlled. Switching is very similar. It is often triggered by intense stress and trauma topics. People can’t just control that. Of course they are switching to avoid extreme stress, that is how structural dissociation works. But accusing them of avoidance is not how this is solved. Neither does the use of intense sensory stimulation help. Trancing out as an escape is best avoided by teaching better coping strategies, building a trusting therapeutic relationship and proper pacing.
So, what is dissociation? Is it a way a personality is organized? Some kind of psychological deficit? A psychological defense? A stress response and physiological defense? A symptom of a trauma disorder? Or a symptom that can show up in all kinds of disorders? Or not a disorder at all and a healthy and natural stress response? It is rarely made clear. Therefore it often remains unclear if it needs integration, sensory stimulation, pacing or safety and grounding.
There is this weird idea going around in therapeutic circles that all dissociation can be controlled (Bohus). I dare to disagree. Most of what is called dissociation or should be called dissociation cannot be controlled. It is either structurally dissociated from control, an involuntary mechanism of our body or a symptom that we can’t start on purpose. Some of what is called dissociation can be influenced willingly. People can decide not to trance out like they are used to and they can begin to use tools to influence changes in the field of consciousness after they started to show up involuntarily. It is a serious error to treat all that is called dissociation the same. It is not the same. Some things are overlapping, similar, related, but they are not the same and cannot be treated the same. Exposing an EP in a stress response to even more intense sensory stimulation is a form of mistreatment many people with DID experience. So is blaming and shaming people in tonic immobility for escaping the situation.
That is why we need to talk about the definitions we are using when we speak about dissociation. We need to make sure that we are talking about the same things. The fruit of calling all kinds of problems dissociation is serious mistreatment.
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