A Closer Look at Dissociation

Trigger warning: this article mentions causes and consequences of psychological trauma.

You may have heard the term ‘dissociation’ being used in discussions about symptoms of psychological trauma. In this blog, psychotherapist Anya Charnaud unpacks a bit more about this important but complex internal response to situations of severe fear and helplessness, the core components of psychological trauma.

Introduction

The word ‘associate’ means to connect, and to ‘dis-associate’ (dissociate) means to disconnect, separate or split away. In the context of human responses to stress, fear and threat,

dissociation is the formal term for an amazing and powerful survival strategy where the brain ‘splits off’ or puts mental and emotional distance between our self, and the (often dangerous, hurtful or threatening) outside world. Like with many aspects of the human experience though, dissociation is on a big spectrum from mild, normal forms such as such as daydreaming or getting completely absorbed and ‘lost’ in a great book or movie,through to experiencing an accident as if you are in slow motion, dissociation as a side effect of drugs and alcohol, a choice as part of some religious or cultural practices, up to severe dissociation that prevents individuals living the lives they wish to lead.

These severe forms (which may be termed ‘dissociative disorders’) are the focus of this blog and are primarily the result of experiencing great adversity. For some people, the painful experiences of life have led their brain to take extreme, subconscious steps to ‘split off’ the traumatic event, part of it, the feelings, or even split the whole personhood into internal ‘parts’. It’s almost as if their brain knows that if the story of that person’s life was told in full it would be too overwhelming to bear, so it takes deep, subconscious measures to keep parts of the life story away from eachother in order to keep the internal overwhelm just about manageable. Some people experiencing this may have a diagnosis of dissociative identity disorder or DID (we no longer use the term ‘multiple personality disorder’) and dissociation may be linked with other mental health diagnoses too. This is a complex subject and this is just a basic introduction. I would definitely encourage all practitioners and advocates to find out more!

Dissociation as a symptom of trauma

Dissociation is a hyperarousal (high-alert threat response) symptom. The sympathetic nervous system which is engaged during the traumatic event to help us survive a form of danger (such as abuse) is left ‘switched on’ after the event has passed, making it hard to make sense of everything, calm down, recover and move forward.

With dissociation, the traumatic event is experienced in a fractured sense rather than a whole. Parts of the event are split up, and often the person feels disconnected from the experience. They may appear vague, unable to coherently recall an event or experience. They may only feel it in their body and not hold a ‘normal’ picture memory of the event. Dissociation may be experienced in many different ways at different times and in different people. In some cases somone might have an amnesiac (memory loss) dissociation to the traumatic experience and not recall anything, but know something has happened. Derealisation is where the individual struggles to feel real, in the world or connected, they zone out and have a lack of sense of being in the here and now. Depersonalisation is similar but is more around emotions and feeling. Not noticing pain, so not feeling they spilled hot coffee on their hand, or recognising normal body messages like feeling full, or hungry, hot and cold.

‘The self as a house’

Sandra Paulsen (2009) likens the ‘self’ (a person’s essential being) to a house, the different ‘rooms’ in the house hold different behaviours and responses. The room that holds ‘being a student’ differs from the room which holds ‘being a parent’ or ‘being a professional’. We can then navigate around the house and access the rooms we need when we need them, having a unified sense of identity and core being as we move between roles and demands on us.

If we experience a dissociative disorder, it’s like the rooms in the house are unknown to the navigator, there are locks on doors, and thick walls you can’t get past. The territory is unfamiliar and scary. Some rooms seem to have different people inhabiting them, and the ‘house’ doesn’t seem to have an understandable or accessible floor plan to navigate through. This can feel distressing, disorientating and confusing for people, for those who know them, and for professionals! ‘

As a psychotherapist I have worked with individuals with multiple parts (rooms) and learned the parts are all very different and all hold a specific role in the individual person. For people experiencing Dissociative Identity Disorder, within one person, I may be able to engage with those ‘rooms’ that are inaccessible and disconnected from eachother. Each ‘room’ or ‘part’ may host an identity which may have different names, ages, gender, sexuality, taste in food, music and company. They are developed by the brain to manage different, usually very difficult, experiences in a way that stops everything coming together and totally overwhelming the main person, or causing the ‘house’ to collapse.

How might health care or front-line professionals identify or be aware of dissociative presentations?

It’s important to understand dissociation is a totally normal response to adverse situations and events. However, it can move into a mental health illness or disorder when it hasn’t been integrated back into the self and memory in a safe way.

Patients or service users who seem to be zoning out, seeming far away, or detached from the here and now may be dissociating. People who say others have called them other names, or referred to events they can’t recall attending. Patients having prolonged periods of not knowing what has been happening or how they got to places. Having awareness of different personas inside them, feeling like someone else is doing things in their body. For younger patients particularly, carers or school teachers may note that they present at different times at different developmental levels and interests. Patients may also have been wrongly assigned negative labels such as being a untruthful or manipulative due to poor memory or confused stories. These may all be signs of a form of dissociation.

Some of the ways in which people with dissociative disorders cope are by using deliberate self injury. Often harming the self is about trying to feel themselves when they don’t feel real. Sometimes dissociative disorders have a part which is punishing of the individual especially if childhood abuse is present. Indicators of reduced social functioning, like self care, meeting or spending time with others, decline in other areas of their mental health like depression, anxiety, poor sleep, increased or decreased eating may be recognised through gentle, trauma-informed communication.

A basic introduction to helping people experiencing dissociation

Grounding techniques, designed to re-connect us back to the real world can be helpful for those dissociating if they are in a safe space to do so. If someone is having a dissociative response, flashback, non epileptic seizure (these are linked to dissociative reactions) then using the senses can help. Encourage someone to smell something, using scented oils or something similar. Use sound, your voice, gentle speech, remind someone it’s now, not then. Get someone to name things in the room (ensuring there are safe, neutral items to choose from not just needle, blood, bandage etc).

Create a sense of safety, gentle speech, make the person feel as safe as possible as dissociation is a threat response to trauma.

If someone is using deliberate self injury, gently enquire if they struggle to feel anything and if they feel disconnected from themselves. Avoid language that might seem critical, move away from wrong and shaming responses like’ it’s just for attention’ and try to see it as a form of communication. We all need to alert attention to our need for human help sometimes and we should never shame anyone for seeking support even if the request presents in ways that on the surface may seem challenging or hard to understand. Most of our human coping mechanisms have understandable roots and logic when we take the time to look.

We also want to make sure people are reassured that what they are experiencing is a normal response to something that should never have happened to them. They are not ‘crazy’, weird, bad or the only person to experience these difficulties. Their brain is amazing for setting up this protective system. However, getting some help to address their challenges and concerns, and to reconfigure the ‘rooms’ might be useful, and offer hope that it can be different.

Use your trauma-informed knowledge and skills to advocate for your patient or client, including against wrongful and shaming labels. Follow consent and local referral guidelines, connect your patient to local mental health support and online resources, as well as addressing any safeguarding needs that arise. We know that recovery from trauma and dissociation is possible!