The DSM describes main feature of dissociation as a disruption of memory, consciousness and identity or perception. Dissociation is a protective mechanism. Human beings have at their disposal to survive traumatic events.
Abusive painful experiences and memories are put away into isolated compartments in the mind, and separated from regular memories.
Dissociation is a way the mind organizes information
Dissociation refers to a compartmentalization of experience: elements of an experience are not integrated into a unitary whole but are stored in isolated fragments (van der Hart et.al., 1998).
Exposed to trauma, the mind splits. The part of the brain that continues with the daily functioning of life (the left brain), and the emotional part of the self that holds the traumatic memories (the right brain) and its survival impulses of the moment of trauma becomes unintegrated with each other. This leaves the person with a split sense of self.
Experiencing a split sense of self can be disturbing. To notice the phenomenon as it happens is to gain agency.
The disruption of integration of the hemispheres of the brain leads to the experience of feeling something and “not making sense” of the feelings. The feelings come in the form of emotions, perceptions or physical pain.
The experience of not making sense of what one feels, can be disturbing. As human beings we need to make meaning and understand things about ourselves to feel safe. When such splitting occurs, the trauma survivor experiences blankness and confusion. This contributes to more insecurity. Oftentimes the need to make meaning results in thoughts that are paranoid in nature, intrusive and/or obsessive.
In therapy, clients are guided to 1. first identify the feelings and sensations that make no sense, 2. accept these feelings without making meaning. 3. observe the nature of thoughts that arise from attempt to make meaning, and 4. allowing these sensations to pass (through relaxation or somatic exercises). Each of these steps are tedious and challenging, needing full attention of both therapist and client. This is also solid mindfulness work. The result is the client gaining of agency of the self.
Splitting leaves the client fragmented into parts of personality. As different times the person’s right brain may trigger experience in him/herself a part that is raging and wants to fight or take revenge, a part that is terrified, a part that is ashamed, a part that is needy and/or a part that wants to run away. When these parts are traumatized, they feel out of control.
The left brain engages the other parts of the person that wants agency. These parts manage daily function, the part that is sociable, and the part that is responsible.
Noticing split-off and traumatized parts
One can notice that splitting has occurred through phenomena like experiencing chronic inability to make decisions, continually relapsing into addictive behavior, having intrusive emotions that seem to arise out of nowhere, intrusive thoughts, shifts in mood or behavior, going numb, getting hyper-aroused, collapsing, feeling suicidal, hearing voices, loss of ability to connect with others, difficulty communicating, withdrawal from society, feelings in the body and somatic symptoms that are not based on medical logic.
There are different severity levels of dissociation
Dissociative symptoms can be severe in some people to a point of rendering them incapacitated. Many individuals, however, experience dissociative symptoms, and are still able function and be successful in life.
Treatment of dissociative symptoms with therapy in functioning individuals is a measure to keep the person healthy and functioning. While we can cope with dissociative symptoms, these symptoms do not disappear on their own. Symptoms get worse with age, and are exacerbated by crises in life. This is why and how some seemingly functioning people experience sudden psychological breakdown.
Signs to look out for in functioning individuals
It is clear that severe dissociative symptoms require professional attention. Less obvious or hidden signs of dissociation are worth noticing: 1. difficulties putting things together, not being able to remember conversations, forgetting appointments, or inability to recount coherently what happened in certain situations, 2. experience of doing things that does not seem to add up, like having sexual relationship with someone one finds unattractive, 3. having unexplained chronic pain or somatic symptoms, 4. chronic experience of stuck in life, 5. experience of identity confusion, 5. experience of self-harming or suicidal thoughts.
Therapy that focusses on mindful observation of these symptoms, its triggers and the trauma underlying lead to successful outcome in providing clients with agency over his/her life.
van der Hart, O., van der Kolk, B. A., & Boon, S. (1998). Treatment of dissociative disorders.
EMDR is a form of psychotherapy originally designed for trauma therapy. EMDR provides a here-and-now stimulus as the client recounts his/her traumatic memories. Tapping or eye movements keeps the client in the present and in the observer position. This keeps the client stable, so that he/she can remember stressful experiences without being re-traumatized.
EMDR is very much a relational-therapy application which I find very useful for integrating into my work.
EMDR is founded by Francine Shapiro. Here are 2 lectures of EMDR by Shapiro herself.
About Shapiro’s Way with EMDR
History and research history on EMDR
Commonly administered EMDR Process
EMDR process has a structure. The actual procedure administered is unique to each individual. The therapist, during the session, has to remain focus on the phenomenology of the patient. Keep in mind that simply following the steps alone is not therapy.
EMDR therapy begins with a clarification of a trauma-specific case history. The client reveals a traumatic event(s), it’s symptoms and these are to be worked on. The treatment process is also explained to the client.
The effectiveness depends on the choice of the outcome situation, and the unveiling of the cause of the traumatic situation.
Stabilization of the current situation of the client is important. The client is also prepared internally for the exercise. e.g. the client is asked to use a stop signal if he/she feels too uncomfortable. The client also gets to describe a safe place. In other words, the client is asked to consider the resources he/she has.
Estimation of the degree of severity of the experience. The client is ask to rate the degree of feeling felt at the moment about an event. The client is asked to describe and rate a negative aspect of the event (e.g. feelings of fear or guilt). The client is also asked to describe and rate a positive outcome of the event (e.g. feeling of freedom from guilt).
The client is asked to estimate how strong the feelings of stress at the moment is.
The client is asked to describe how he/she feels in the body.
Pre-processing step: to ask the client to relax and recount the event. Allowing the client to creatively enter into the scene. The therapists begins to lightly tap on the client’s wrists or knees, or guides the client with eye-movements, and encourages the client to describe the situation(s) as they arise to consciousness.
The weaving in of the here-and-now situation with past situation. The client gets to see the traumatic experience as a more mature person (as opposed to a child when he/she suffered a trauma). The client also gets to view the situation from a vantage point of a safer present.
Re-evaluation of the feelings of the traumatic events.
Anchoring: the client is asked to recite what he/she has learnt from the experience (the positive experience) as the therapists taps the client’s wrist a little more.
Body scan test: to check how the feelings in the body. And to find out what else that is stressful that is felt in the body.
Closing conversation and dialogue: something light hearted, breathing, relaying.
Next session, the previous treatment is rated again to see how the treatment is integrated. If the stress is still there, therapy can be repeated, if it is successful, anchoring work can be done.
Sometimes the client does stabilize after the therapeutic work. It is useful to be patient and listen to the patient’s current experience. The goal of the therapy is not to completely resolve every stress in one sitting, but to bring stability week to week, until the client learns to integrate the treatment.
Often the client feels permanent relief of a certain degree of stress.
Own work experience
I decided to use the tapping technique with a client who mentioned a car accident in which she was a driver that happened 20 years before. She is a successful businesswoman in her 50s, and had never mentioned this incident prior. This incident came to light as a result of a dream recollection.
The client had left a going-away party with some friends, had some drinks. It was also midnight, which was the day of her birthday. As she drove home, she collided with a drunk pedestrian, who got severely injured and died.
During the therapy, the client expressed fear and guilt which she had shut off all the years. She never had a chance to talk about her trauma to anyone and felt lonely.
The tapping allowed the client to see the event as if it were a movie. She could experience the emotions and was able (with hesitation) to vocalize the feelings. Her arms began to sweat. She began to remember more details of the night after the accident when she went home, and the morning after, how she felt like it was a nightmare, but it was for real.
At the end of the session, the client felt her loneliness, but was relieved about being able to share. Her fear level regarding the event went from a high 10 to 0. She still processes sadness and guilt about the event, which was later our work-in-progress.
Traumatic events happen in a variety of circumstances. Incidents that happen to us which suddenly shocks us, leaving us overwhelmed, and sometimes frozen, can lead us to experiencing life-long psychological and physiological effects of trauma.
Exposure to traumatic experiences affect us in very individual ways. The consequence of being traumatized, concisely explained, is the effect of our nervous system sensing the danger of the past traumatic experience as if the danger is happening in the present. Harmless situations can trigger feelings of anxiety as a result of trauma.
“The great thing then, in all education, is to make our nervous system our ally as opposed to our enemy.”
William James (1914, Habit)
Since danger and anxiety are buzzwords in trauma, healing trauma in psychotherapy requires big doses of trust. Trust that the suffering from traumatic experiences can be healed. Trust that the psychotherapeutic alliance is a working, trusting one. Trust that, whatever the outcome may be, that the work is worth doing.
This article features part of the very inspirational work of Peter Levine (1997), whose work is a guide for my professional attitude towards trauma.
Importance of Slowing Down during Trauma Work
When working with trauma, it is necessary slow down. Traumatic events and subsequent trigger reactions happen at split second duration, often out of awareness. In the treatment of trauma, the sensory events, feelings and thoughts that arise need to be witnessed with the time slowed down with guidance of the therapist.
Many trauma patients, frustrated at their symptoms, want speedy resolution. Therapists are best advised to reassure their patients, that slowing down is the safer, more effective road to healing.
Traumatic triggers happen out of awareness. The act of slowing down during therapy brings the sensations and thoughts into awareness. It is through awareness that the client gains sovereignty of his/her experiences — and ultimately nervous system.
12 Basic Concepts of Trauma Work
Levine’s work stipulates 12 basic points of trauma work and experiencing. Some clients benefit when theses points are shared with them. I use this as a map in my work, for effective tracking of the patient’s process and progress.
The phenomenon of being riveted. During an overwhelming traumatic event, the shock causes the body to stiffen up. The muscles tense up. The body can get frozen and stuck in this state. The energy is locked up in the body. The state of being riveted is experienced in each patient uniquely. In the therapeutic session, each patient displays his/her own unique symptoms of this phenomenon.
Feelings of defeat and helplessness. During a traumatic event, the sense of being overwhelmed and trapped, leads to the profound feeling that one would never escape. There is overwhelming helplessness. After the traumatic event, this feeling of defeat resides in the body of the traumatized person. People may become unable to work, play or do daily tasks as a consequence of this body memory of the traumatic experience of helplessness. It may be helpful for patients to know that this is happening to them, to allay fears or self judgment for not being able to function as society would like them to.
Tracking with Awareness. in-tunement of inner landscape. feelings, sensations, thoughts. We are not lost in the experience, or disassociated, but looking and tracking it from a close distance. Pendulate between comfortable and uncomfortable situation.
Pendulation between Polarities. To be able to move between expansion and contraction; to having feelings of past memories at one instance and then coming back to the present reality. To feel anxious at one moment, allowing the feelings to pass, taking a break from what one is doing, and slowly breathing towards calm. Pendulation is an exercise of acceptance, and allowing of oneself to move between emotional states, without hinderance.
Resourcing. The process of resourcing is to deliberately take stock of anything of value in one’s life. Resources can come in the form of relationships, material wealth, work, interests, hobbies, vocation and religion. Resources, no matter how little, add foundation to ones sense of stability.
Uncouplingfeelings of excitement with experience of fear and trauma. Take time to check in with oneself, and learn to mindfully differentiate between feeling of excitement (pleasant surprise, nervousness about a job interview or performance in public, excitement over positive events, butterfly in the stomach feelings) and fear. Take time also to differentiate between fear of actual fearful stimuli of the moment, and fear that arises out of traumatic memory.
Grounding & centering. Grounding and centering involves mindfully feeling the weight of one’s body pulling itself to the ground. .Gravity is the helper that helps the body rest and center itself. Grounding exercise is usually done by sitting comfortably on a chair and putting two feet flat on the ground. One can also lie flat on the floor and feel one’s weight on the floor. In fear and panic we loose our ground. The earth seems to disintegrate from under our feet. When we are aware of our ground, we can feel more secure.
Strength & resiliency. Building emotional, intellectual, physical strength in whatever form adds to one’s agency. Going for psychotherapy to build emotional strength, learning or studying anything to build intellectual strength, and doing muscle building exercises to gain physical strength adds to the alleviation of the dominance of the trauma symptoms.
Restoration of natural aggression. Get support from a competent therapist or an understanding friend, who is able to listen to the feelings of anger and hate that are related to the traumatic experiences. Traumatic events render the victims helpless, trapped and immobile. Coming to terms with the natural aggression that is locked up in this immobility resets the nervous system. Expressing the anger releases the aggressive energy and restores vagal tone. The body as a result feels the relief.
Running. Similar in the reasoning to restoring of aggression, running is what the body needs to do to escape from the condition of being trapped. One can experience running in the therapy session. One can also simulate running through mindfulness activity, like imagining sprinting to a safe place (even by moving arms and legs quickly while seated) every time one feels trapped. Important is for us to have a mindset that running away from the traumatic situation is actually a positive action.
Orienting. Taking the time to orientate oneself while in different situations is good practice. This sharpens one’s skills in being present in the moment. Orienting, grounding and centering enhance physical stability.
Completion of self regulation. With the support of a psychotherapist who works with emotions, one learns to experience a full repertoire of emotions, energies and perceptions. Traumatic experiences cause our senses to shut down, leaving us incapable to completing our natural self-regulatory cycles. Completing these cycles of self-regulation releases energy and brings calmness to the body.
Psychotherapists who work with trauma know that trauma is locked in the body. Being aware of, and checking into the somatic experience of the client is essential to the work. This is possible when a trusting, therapeutic alliance is already established.
Do seek professional advise if you or someone you know suffer symptoms related to trauma. It is a safer approach to healing than ignoring the symptoms or trying to treat the symptoms unprofessionally.
Levine, P. A. (1997). Waking the tiger: Healing trauma: The innate capacity to transform overwhelming experiences. North Atlantic Books.
When a person’s brain is exposed to overwhelming stressful information all at once, the phenomenon is understood as a potential traumatic situation.
Traumatic experiences are combined with extreme fear. What happens is that all the sensations (smells, noise, colors, sights, etc. ) received during the traumatic situation is locked up in long-term memory fragmented.
Non-traumatic or explicit memory, on the other hand, is contextual, conscious and to a certain extent, stable. This type of memory can be re-called or put aside almost at will, can be described, re-worked, and emotions surrounding the memory does not control the person’s here-and-now. The person is able to use this memory to make meaning, learn, make adjustments. This kind of memory is coupled with language and we can talk/write about them.
Traumatic memory, on the other hand is quite different.
Memory from traumatic occurrences can become intrusive. Sensory stimulation from sights and sounds trigger the memories. The individual becomes almost unable to put the memories aside. Emotions from the traumatic situations are felt as if the trauma is still occurring. Sometimes these memories trigger flashbacks. The person is rendered helpless against the flood of the memories.
These memories are also fragmented. The person finds it difficult to put the events into a cohesive whole. Some pieces are forgotten, and cannot be recalled.
Often the memories are decoupled from speech. The person can feel and see the memories in the mind, but finds difficulty in putting the contents of it into verbal language.
Patience, empathy and contact
Psychical trauma is injury to the psyche, and sense of the self. The consequence of trauma renders a person helpless against being overwhelmed by memories and flashbacks. Therapy with patients of trauma need time, trust and patience. Combined use of verbal and non-verbal communication makes for effective therapy. Empathic communication with the client relieves the individual of the isolation of having to live with such events.
Schubbe, O. (2004). Traumatherapie mit EMDR. Order, 22, 99.
Diane Langberg gives a lecture on Complex Trauma, or childhood trauma, which really is childhood experiences of abuse, neglect, betrayal and isolation. Complex, childhood trauma, is not usually acknowledged by the individuals affected by them. Children exposed to trauma are betrayed by the very people they are dependent on for love. They are, as Langberg describes it, marinated in trauma. As adults, these individuals come to our psychotherapy practice because of other symptoms, like depression, panic disorder or psychosomatic pain.
Langberg provides an explanation of what complex trauma is, how different it is from — and how it is related to– PTSD.
Watch this video of Langberg’s lecture.
I have sketched down notes on this lecture so for quick reviewing of the content, and against the possibility that the video becomes no longer available.
While PTSD is a typical response to a single stressor in adulthood, Complex posttraumatic Stress Disorder ( CPTSD ) is the result of childhood experience of abuse.
Complex Posttraumatic Stress Disorder CPTSD occurs in neither ICD nor DSM, but it has been proposed for over two decades (p.190). Adult victims of CPTSD suffer lifelong effects of emotional and physical instability of varying degrees of severity, making them also vulnerable in the face of stressful life situations.
Consequences of CPTSD:
Another name proposed for this disorder is “developmental trauma disorder.” CPTSD compromises an individual’s identity, self-worth, and personality; emotional regulation and self-regulation; and ability to relate to others and engage in intimacy.
Individuals can experience ongoing despair, lack of meaning, and a crisis of spirituality.
Children are Victims of CPTSD
While PTSD is an atypical response in traumatized adults, developmental trauma may be a very common (and thus the typical) response in traumatized children. Such trauma often goes unrecognized, is misunderstood or denied, or is misdiagnosed by many who assess and treat children.
Children are, due to their immaturity and helplessness, are more prone to being traumatized than adults. They are also easy targets for narcissistic abuse.
Types of Abuse in CPTSD
CPTSD is generally associated with a history of chronic neglect, trauma, and abuse over the course of childhood. Neglect in early childhood compromises secure attachment and tends to result in avoidant or resistant/ambivalent attachment—or, most severely, toward the disorganized/disoriented attachment style that leads to significant dissociative pathology.
This neglect sets the stage for trauma in early childhood, which further interferes with normal affective maturation and the verbalization of feelings, leading to anhedonia, alexithymia, and intolerance of affective expression. Children and adolescents are more prone to dissociate than are adults.
Experience of Betrayal
Dissociation is especially linked to betrayal trauma—the neglect that allows for, or passively tolerate, more active trauma.
In the face of continued betrayal trauma, dissociation is the child’s best life-saving strategy.
The Bystander Parent
Repeated trauma in childhood involves a perpetrator and victim, but also a parent who permits the trauma to occur; is uninvolved, oblivious, and neglectful; or else is paralyzed by fear into inaction. Patient and therapist may find themselves playing any of these roles and their opposites.
Psychotherapeutic Treatment of CPTSD
When a client comes to therapy, it is often not apparent that he/she suffers CPTSD. Adult clients visit therapy for an array of symptoms that include (but not exclusively) depressive, anxiety, obsessive-compulsive, posttraumatic, dissociative, somatoform, eating, sleep-wake, sexual, gender, impulse-control, substance and non-substance dependency disorders and personality disorders.
There is a danger that therapists who are not aware of CPTSD overlook childhood experiences and spend too much focus on the diagnosed symptom.
If the therapist were to treat the trauma of CPTSD itself, this treatment if successful can ameliorate all the symptoms. This requires that the childhood abuse experiences be recounted and worked through.
The Therapeutic Process
It is common that the patient who has CPTSD will not be able to recollect the events of abuse. If he/she did, he/she may not be able to experience the feelings associated with the time. This is because of the dissociation of the child who was in the situation. Freud explains that what the client does not remember, he acts out. It is important for the therapist to be observant to the repeated behavior of the client in the interaction with the therapist.
The trauma and neglect of CPTSD are essentially relational, and so the therapeutic relationship itself becomes the principal vehicle of change. How the therapist feels, thinks, and acts depends on what aspect of the neglect/trauma drama is being played out with the patient (p.191).
Dealing with childhood trauma is a complicated process in therapy. There may a degree of enactment in the transference and this can be confusing. What is really necessary is a sound therapeutic alliance based on trust. Within the transference relationship, the client a therapist experience the client’s enactments and attitudes towards the abusing parent, the bystander parent and the client as victim and perpetrator. For this reason, the therapist has to be alert to the phenomenology and the here-and-now of what unfolds in the therapy sessions.
Meanings for the term “dissociation” continue to evolve. Dissociation was originally seen as a type of hysteria, related to conversion, and distinct from depersonalization. It included amnesia, fugue, certain altered states (e.g., somnambulism), and multiple personality.
Dissociation is a criteria in DSM III for diagnosis of PTSD and ASD, as “flashback or dissociative episodes”. While flashbacks denotes sensing of something there that is not (positive symptoms), dissociative episodes denotes absence of sensing what is there –detachment, reduced awareness, derealization, depersonalization and amnesia (negative symptoms).
In Borderline Personality Disorder, dissociation in DSM-5 is described as “transient, stress-related…severe dissociative symptoms” with depersonalization as example.
3 distinct meanings of dissociative experiences (p.180):
Dissociation of some of one’s mental functions or faculties. The DSM-5 definition: “a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (p. 291). “Negative” dissociative symptoms involve the withdrawal of something, such as dissociation of memory (amnesia), sensation (conversion anesthesia), or affect (emotional blunting). “Positive” dissociative symptoms involve the intrusion of something, such as the sensory reexperiencing of a trauma (flashback), or any other intrusion of affect, knowledge, sensation (in any modality), or behavior (action, unintended vocalization, etc.). Most of these symptoms may occur within a single consciousness.
Depersonalization/derealization. These may be experienced as the withdrawal of the sense of reality. These are also considered as intrusions in the DSM.
Dissociative multiplicity. This is a plurality of consciousness, in which the first two types of dissociation commonly co-occur; thus, there is always the possibility that cases featuring the first two types of dissociation may have covert multiplicity as well. The DSM-5 definition does not really work for multiplicity because once there is more than one self occupying the center of consciousness, there is more than one center of subjective experience and consequently more than one set of symptoms.
Dissociation in Childhood Experience of Abuse
Freud and his colleague Josef Breuer (1895) identified the root of hysteria in women as child sexual abuse, specifically incest. Freud eventually reversed that emphasis to focus on a child’s fantasies of sex instead of the reality of sexual abuse. Other contemporaries—notably Pierre Janet (1889) outside the psychoanalytic movement, and Sandor Ferenczi (1949) within it—retained a focus on the trauma of childhood abuse, positing dissociation rather than repression as the main method a child (and later an adult) uses to cope. They observed that if the trauma were not worked through and resolved at some point, its residual effects would often have a lifelong (and negative) influence across various domains.
Lingiardi, Vittorio. Psychodynamic Diagnostic Manual, Second Edition (Page 182). The Guilford Press. Kindle Edition.
Dissociative effects of PTSD
Dissociation is PTSD is not psychosis. The person has a flashback — a momentary out of sync with reality, and reliving an experience in a traumatic past experience.
Dissociation is an altered state of consciousness. Unlike psychosis, the individual is functioning but loose track of time/space, etc. The persons may also have a sense of watching him/herself and not being there.
Dissociative effects from Childhood Neglect
The video above addresses dissociation from own feelings. This happens to children of child abuse from narcissistic parent. Most likely the condition of suffering is not unlike complex PTSD.
Individuals suffering PTSD display symptoms that look like that of those suffering from trauma symptoms associated with the narcissistic personality (TANS).
This article by Simon (2002) sheds clear light on distinguishing between the 2 types of patients. The table below is an extract from the article:
If we were to extract the gist of the difference between PTSD and TANS, we may be able to summarize that unlike in PTSD, patients with TANS main “damage” is that of the grandiose image of the self. There is more shame and humiliation underlying. This is manifested by anxiety about damage to a kind of grandiose self image. In PTSD symptoms, the anxiety is mainly about survival.
Knowledge of these differences facilitate the psychotherapeutic treatment of the patients, since both types of patients experience the relationship with the therapist differently. This also reflects the difference between event onset trauma in the case of PTSD, and developmental attachment related trauma in the case of complex trauma.
Simon, R. I. (2002). Distinguishing trauma-associated narcissistic symptoms from posttraumatic stress disorder: A diagnostic challenge. Harvard Review of Psychiatry, 10(1), 28-36.