Dissociation means splitting up. It acts as the brain's overprotection against experiences that are so strong that they explode our capacity to handle the event in a coherent way, and where the traumatic experiences are instead received in fragments or divided parts. Dissociation can play a role in various mental disorders, and in severe cases form the basis for a comprehensive fragmentation of the personality.

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What is dissociation?

Dissociation is a broad concept and can mean different things in different contexts. We can approach the concept of dissociation through two different perspectives:

  1. Dissociation as adaptation / mastery

    Dissociation as a coping strategy / anesthesia in the face of an emotionally overwhelming situation (an adaptation strategy)
  2. Dissociation as a disease

    This may include:
    a) Dissociation as a coping strategy in the face of trauma-related memories
    b) Dissociation as division of the personality into different, separate parts (psychological pathology / disease) 

Psychologist Ellert Nijenhuis, who is a renowned trauma expert, points out that there is some conceptual confusion in relation to the use of the term dissociation, and that perhaps the most orderly understanding of dissociation is to regard it as a split of the personality into different parts, ie corresponding to point no. 2 over. 

Dissociation as numbing down to an emotionally overwhelming situation

Dissociation can be understood as a normal reaction in the face of a situation or event that exceeds our ability to relate in an integrated manner to what is happening. 

In such a context, dissociation will involve various forms of being anesthetized or distracted from a traumatic situation. Dissociation then becomes an emergency solution, a coping strategy, which helps to bring a distance between the person and what is the source of the enormous emotional discomfort. 

An example of this can be when you are exposed to an abuse, for example a sexual or physical abuse: At the same time as you are affected by an overwhelming fear, you get other emotions / feelings in parallel that give a numbing effect. It can be, for example, the feeling of numbness, of not being present, of this not really happening, or the realization that "this is not happening to me - but only to my body." 

In such a perspective, the ability to dissociate is something that has an adaptive function. It becomes a form of built-in anesthesia; a kind of overprotection against experiences that we do not feel able to withstand.

A natural analogy is to refer to electrical systems that have an overvoltage protection, and where this protection automatically "disconnects the power" when the system is overloaded.

In itself, this is an appropriate strategy, but it can also have a downside in that memories and experiences that would normally be stored in an organized way in the brain's memory systems. Due to the dissociative processes memories of the experience are stored in the brain in a fragmented way. This may help explain why the memories from the trauma may return in the form of fragmented or chaotic parts, such as flashbacks.

Nevertheless, dissociation in such a use of the term can be considered as a form of appropriate coping strategy and not necessarily as a sign of illness.

Dissociation as numbing down to trauma-related memories

Dissociation can occur in situations where there are no obvious external reasons to why one should need to anesthetize or distract oneself from what is happening here and now. However, the reason for this kind of dissociation is on a mental level. In other words: there is a "real" danger / threat that one must defend against, but this comes from within the person himself/herself, in the form of trauma-related memories.

An example could be that the child who has a history of experiencing abuse at home, reacts in the kindergarten by becoming staring, out of contact and completely unavailable for contact - and this even if the situation in the kindergarten was completely safe. The triggering factor may, for example, have been that the child got a memory of the traumatic thing that has happened / is happening at home - and a form of "disconnection" occurs where the child completely loses contact with the outside world (i.e., the child dissociates).

In such a perspective, dissociation is a form of avoidance of trauma-related material (thoughts, feelings), and can lead to a behavior that at first glance seems strange and incomprehensible.

A general research finding is that dissociation is associated with overwhelming, traumatic experiences.

In the face of feelings, emotions or thoughts that evoke or threaten to evoke traumatic memories, the reaction may be that one enters into dissociative states, which can manifest themselves through various symptoms.

Examples of dissociative symptoms

  1. The person "disappears completely" from the contact during a conversation
  2. Begins to speak in a childish voice despite the fact that he / she is an adult
  3. Gets strong physical re-experiences of something very traumatic
  4. Numbness areas in the skin that have no medical explanation
  5. Have unexplained paralysis or seizures that do not have a medical explanation
  6. Memory loss in relation to important events of recent date
  7. Dramatic mood swings
  8. Numbness and feeling of not being present; feeling of unreality
  9. Trance-like conditions with loss of normal consciousness; where this is not intentionally evoked, for example, in connection with religious rituals 
  10. Self-harm or suicidal behavior
  11. To feel that parts of the body do not belong to me
  12. To get a different type of handwriting than the one you usually have
  13. To get clear changes in one's personality that indicate that one is changing from one type to a completely different type
  14. Hearing voices in your head

In such a perspective, dissociation can be an important factor in various mental disorders, whether it is pure dissociative disorders, or other mental disorders where dissociation is part of the problem complex, for example in relation to eating disorders, self-harm or personality disorders. 

The fragmented, dissociative personality

I'm not here
This is not happening
I'm not here, I'm not here

- Radiohead

 

For people who experience prolonged, severe trauma in close relationships, the consequence may be to end up with a torn, dissociative personality. In such cases, dissociative processes become so extensive and pervasive that they must be regarded as regular structures or patterns in the person's personality. Then one lives in an invisible, but very real psychological drama - in a deep conflict with oneself, where "shadow personalities" - divided subpersonalities - live separate lives inside the person.

Onno van der Hart tells the magazine "Badeliv" at the Norwegian specialized treatment facility, Modum Bad, about this:

- The traumas destroy and shadow our personality. They do something about what we are and how we behave. By dissociation, one can experience that the patient gets a division in the personality, where some parts live the daily life, while others are carriers of the trauma. It is when one is reminded of bad events earlier in life that the symptoms are activated.

Onno van der Hart has stated to Modum Bad about this type of problem: 

In order for these patients to experience healing and recovery, all "parts" of the personality must be treated. It is also important to highlight how serious it is when adults harm children mentally, physically and sexually. They can be damaged for the rest of their lives.

 

The hidden drama behind a well-fitting facade

The following quote from people who have been exposed to various forms of trauma illustrates what happens when the personality uses dissociation as a way of organizing itself and its personality (3):

But I managed to be "good" at something in this world: I managed to carry the secret alone. What I did not understand was that this secret stopped the development of the little child I was then. The secret was that since "that day" I have carried with me the little child who never got to grow up naturally, and at his own pace. The little child took up residence in my inner life. But on the outside, completely different rules applied.

Far into my adult life, this little child has lived inside me. Quite hurt, scared, ashamed and restless it has lived inside there. While on the outside, the little child grew up and created a life for himself. A life like any other - apparently.

But sometimes the child inside makes himself known. Then it becomes difficult to be an adult, because inside me sits this child, who is no more than 8-9 years old. When the child gets enough room inside there, the fear and shame comes and penetrates into my adult life. This mixture of emotions can make everyday life difficult to cope with. " (Kronikk Bergens Tidende 2008)

 

Three parts of the personality in internal conflict

In the face of long-term trauma, abuse or neglect, the person may develop a deep division between different fragments or parts of the personality. In the Governmental Report "NOU 2012 (5): Better protection of children's development" it is pointed out that the traumatized child may have a division of the personality into the following parts:

 

  1. The seemingly well-functioning part that ignores what has happened

    A child who experiences abuse, domestic violence, sexual abuse, etc., will at the same time have a strong need to be a normal child. A child who can be with friends, play, go to school, etc. To cope with this, it is common that in a way it seems as if all the hurt does not really happen. This part pretends in a way that everything is fine, trivializes and makes the events unreal, in order to be able to cope with daily life and not have to take over what is happening or has happened. In order to cope with this, it must also push away a lot of emotions, especially negative emotions, and may therefore experience being quite emotionally flattened, and also being afraid of emotions.

  2. The vulnerable "child" part

    When the person tries to push the bad experiences away, the child who carries the bad memories of the events will exist as a "child part" in the adult. This part of the child is not emotionally flattened, but instead carries a lot of pain and emotions, such as fear, shame and self-loathing, and has a desire and goal to be taken care of and protected by a safe adult. However, this safe adult may not have been there when the person was a child, nor as part of the adult body does he experience comfort, as the seemingly well-functioning part is unable to take over what has happened, and therefore rejects the inner child . The child feels thus alone and rejected, and often also carries a lot of sadness and loneliness.

  3. The controlling part

    Feeling like a helpless victim is not perceived to be a good position to be in, especially when there is no comfort to be had. What easily arises then is that a part of the child identifies with the abuser, and becomes a "strong" controlling part. The goal of this part is to manage on your own, be independent, not be dependent on others and not show that you have a need, which is seen as a sign of weakness and also a risk of experiencing new rejections. This part thereby hates the vulnerable part, and controls it by preventing it from coming out, as well as by harassing it. If it appears, the controlling part can easily react with punitive actions such as self-harm. 

 

An inner battle with yourself

In other words, the divided, dissociative personality will be in a more or less hidden struggle against itself. In this way, the person will experience having different wills within themselves that are in deep conflict, and which can alternate between coming forward. The pattern can easily lead to an inner life that is in strong disharmony, and leads to strong loss of function. These mechanisms may sound strange, but when talking to chronically traumatized people, this is a pattern that is quite characteristic. 

Personality disorders, self-esteem and self-harm problems can be the immediate symptoms - which can both help to obscure and disclose the deep drama that unfolds in the person's psyche - and which in reality is about trying to find a way to survive.

 

Dissociative identity disorders

Modum Bad writes in its magazine Badeliv about this condition:

- People with severe dissociation disorder switch between different states of consciousness, emotions, self-understanding and perception of reality - i.e. everything that makes up a person. These conditions can become so pronounced that they each have their own patterns in how they experience, relate to and think about the world and themselves. It will then manifest itself as two or more distinct personality states in one and the same person, and we call this dissociative identity disorder (DID), formerly called multiple personality.

 

A case study: Dissociative identity disorder

In the book Dealing with Trauma-Related Dissociation by Suzette Boon, Kathy Steele, Onno van der Hart, it is written (6):

- One of the strongest symptoms of dissociation is a feeling of involuntariness. That is, the person is aware of thoughts, feelings, behaviors, memories, events, etc., but these experiences do not seem to belong to him or her. These experiences feel like "not me". Some people have the experience of being "more than one person" or have different "inner voices" or identities.

- As a result, people with dissociative disorders can be very confused about who they really are, what they think, feel, do or experience with the body. Dissociative parts of the personality are not really separate individuals or personalities in a body, but rather parts of an individual that do not yet function in a flexible, coordinated and flexible way.

 

Treatment of dissociative disorders

If it is suspected that a person has a dissociative disorder, it is important to take a thorough psychiatric examination to clarify this question. Standardized assessment tools and structured or semi-structured interviews should be used to clarify a possible suspicion. In other words, it is important to obtain the extent to which the person has difficulties related to dissociation.

Psychologist Ellert Nijenhuis that the treatment of dissociative disorders must be directed towards the "whole personality", that is, one must become acquainted with the various subpersonalities that are dissociated from each other; one must get these parts to get to know each other, each other's needs and ways of thinking; one must make the parts trust each other; and you get the dissociated parts to cooperate better with each other in everyday life.

In the example below, we see an example of such a treatment that directs the treatment towards the "whole personality" of a woman who has a dissociative disorder.

 

A case study: Treatment of a dissociative disorder

Ellert Nijenhuis talks about the following example of a dissociative disorder:

Martha (pseudonym), a married 36-year-old woman, was referred to the Trauma Center due to frequent seizures. The seizures sometimes led to incontinence, tongue biting and foaming at the mouth, and work had long been based on a theory that it was epilepsy. However, the epilepsy medicine had only a short-term effect. It was hypothesized that the seizures were due to dissociation. The referral to the Trauma Center was based on the fact that Martha had described both chronic emotional neglect and physical abuse of the parents from early childhood.

However, as the seizures continued as before, the center decided to offer her psychotherapy based on the theory of structural dissociation - because such treatment had proved successful in similar cases.

The treatment was briefly summarized as follows: The therapist got hold of how Martha perceived herself and her situation, and went on to explain the treatment: if the symptom was somatic, there was nothing the therapist could do with them - which was sad, but true . But if the seizures were either partially or totally psychologically controlled, we might be able to do something about the problem together. It was explained that psychological symptoms usually have some kind of structure. When Martha did not immediately understand what it meant, an analogy was used that might be clarifying. The therapist asked her, "Do you ever dream at night?" This is how the conversation went:

 

The conversation

  • "Yes, of course I do." 
  • "And at least sometimes your dreams have some kind of action, a story?" 
  • "Sometimes." 
  • "Nice. Is it you, so to speak, who makes that dream, or that story? ” 
  • "No, I do not think so." 
  • "But then we must ask: Who makes that dream?" 
  • "I do not know," Martha said, laughing. 
  • "There must be something inside you, then - or do you think you are haunted by a ghost or something?"
  • "No, I do not think there is any ghost." 
  • "Can I then perhaps say that there is something inside you, which for some very important reason which we do not quite understand yet, in a way gives you these seizures?" 
  • "Maybe, but how should I know?"

It was agreed to try out a method to question the part of Martha's personality that could possibly be the source of the dissociative symptoms. The method was to address this part of the personality directly and to allow him to answer the therapist's questions by allowing Martha to lift a finger if the answer to a question was yes, or to keep it calm if the answer was no. What happened next was very surprising to Martha. This is how the conversation went:

  • "Do you have a specific age?"
  • "Yes." 
  • "Are you as old as Martha?" 
  • "No." 
  • "Are you older than her?" 
  • "No". 
  • "Are you a little younger?" 
  • "No" 
  • "Are you younger than 30?" 
  • "Yes."
  • (And so on). And: 
  • "Are the seizures related to something nice?" 
  • "No." 
  • "With something unimportant?" 
  • "No." 
  • "Are they about something that is not nice?" 
  • "Yes." 
  • "Are they about something like a storm or thunder and lightning?" 
  • "No." 
  • (And so on.)

Work continued on the same methodology, where it was in a subtle way clarified what were the motives behind the seizures. The goal of working in this way was to create greater integration and coherence between Martha's divided, dissociated personality parts, and already after one hour of treatment, dramatic changes began to occur in Martha's symptoms - which she had suffered from since childhood.

Martha gained a greater understanding of the psychological drama that unfolded in and under her consciousness, and she found ways to release and appease all parts of her personality, not least the part referred to as "the vulnerable child" (see section above) . After a few more hours of treatment, the epilepsy-like cramps almost disappeared, and Martha got a whole new life. The treatment had proven to be effective - and it was thus also proven that the seizures had a psychological explanation - and thus also a psychological solution.

 

To create trust

According to Ellert Nijenhuis, another important part of the treatment of dissociative disorders is about the patient's relationship with other people. Many patients with dissociative difficulties have an ambivalence about trusting other people. There is a split between the desire to trust other people - the desire and the desire to connect with someone who can comfort me - and the widespread fear that this impossible thing can go well - it is too dangerous.

An important area of ​​therapy is therefore to build trust and collaboration with the therapist - a work that can take time.

Through therapy, one has some overriding goals, including that the patient should win until a completely new realization of himself / herself and what he / she struggles with. Many people with dissociative disorders will experience themselves as incomprehensible, and perhaps as "crazy", or as people with something fundamentally wrong. Gaining a new perspective and an understanding that one acts, thinks and feels as one does due to traumatic experiences can be important steps on the road to recovery.

Some of the insights you want the patient to gain are the following: 

 

  1. This (the traumatic) thing happened to me
  2. I'm not crazy, but I'm trying to deal with something difficult that has happened to me
  3. The pain that has happened is real.
  4. I've had a difficult life, but I can handle it

 

Three tips for better impulse control

 

In this video you get three tips for better self-control that are relevant in relation to dissociation.

  • Identify your (impulsive) parts of the self / personality
  • Learn to care for and train these parts of yourself
  • Practice recognizing what these parts of yourself need NOW. Make it a habit to ask, "What do I need? really right now? "By practicing this, instead of acting out the impulses, you can gain more control over the impulsivity. 

In mental health care, there is a constant further development of good trauma-related treatment methods, which can be read more about in this article. You will get a more detailed description of the treatment of structural dissociation of the personality here. In the films below, you will get more information about dissociation and current treatment methods / principles.

 

Dissociation is often ignored in mental health care

Dissociative disorders / dissociative identity disorder can be confused with ADHD (because dissociation also creates difficulty concentrating), bipolar disorder (because dissociation can also cause mood swings), and schizophrenia / psychosis (because dissociation can cause flashbacks). In addition, problematic substance use is commonbecause drugs are often used for or the mental pain that results from a dissociative disorder.

In a study by Ellen K. K. Jepsen who studied patients admitted to Modum Bad for a three-month trauma program for adults struggling with the late effects of sexual and other childhood abuse, the researcher found that severe degree of dissociation had a negative impact on the effect of a treatment - that did not specifically aim to include dissociation.

Badeliv writes about this:

The study concludes ... that - before starting treatment - it is important to map the patients for possible trauma and trauma-related ailments, which also includes dissociation. Patients with a severe degree of dissociation need treatment that differs in part from other trauma treatment. Treatment should focus specifically on dissociation.

According to Jepsen, it has not been a regular routine to examine early traumatized patients for dissociation when they seek help in mental health care.

The consequence can be a wrong diagnosis and wrong treatment. Patients can stay in treatment for many years without getting better.

 

Sources:

  1. What is dissociation? Svartpip.wordpress.com
  2. Patients must be examined for dissociation. Badeliv. Bad mode
  3. NOU 2012 (5): Better protection of children's development. Dissociation. Regjeringen.no
  4. Trauma, dissociation, attachment and neuroscience: A new paradigm for understanding severe mental distress. The Journal of Critical Psychology, Counseling and Psychotherapy
  5. Harvey, M. (1990). An ecological view of psychological trauma and recovery. Journal of Traumatic Stress, 9 (1), 3. – 23.
  6. Dissociation - an explanation. Svartpip.wordpress.com
  7. Trauma, dissociation, attachment and neuroscience. Dillon, Johnstone and Longden
  8. Stabilization - the most important link in trauma treatment? Journal of the Norwegian Psychological Association

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Written by

ove heradstveit

Ove Heradstveit

Psychologist, specialist in clinical community psychology. PhD.
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