It is often noted that manic individuals experience "for free" what addicted patients pay good money for. The same could be said of patients skilled in dissociation. Rather than using chemical means to disconnect from a painful or harsh reality, such "high susceptibles" have learned to do it on their own. Avoidance and alcohol are both short term solutions for anxiety and pain. Dissociation too, can easily be seen as a form of avoidance that can be used any time or any place to avoid thoughts, images, and feelings associated with traumatic events.
An example of this may be seen in dissociative identity disorder (DID), formerly known as multiple personality disorder. It is characterized by 1) the presence of two or more distinct personality states, that 2) recurrently take control of the person's behavior, and 3) leave the patient unable to recall important personal information. As stated in DSM-IV, such individuals are highly hypnotizable and quite suggestible, and can easily dissociate.
A woman arrived with a reported history of DID. During the intake evaluation, in discussing her childhood, she slouched in the chair, her voice softened, and she stated that she was confused. I addressed her by name, and asked her to identify and describe various objects in the office. Her "adult" voice and posture returned, and we discussed what had just happened. She was able to identify what occurred as a way of dealing with painful subjects. We were able to list and weigh the costs and benefits of this "safety" behavior, and later on in therapy, explore the beliefs that led her to adopt it. In her case, she believed, "If I talk about this [overwhelmingly painful subject], I'll feel vulnerable and lose control," and "If I escape, I'll be able to maintain control." By talking about 1) this safety behavior, 2) the beliefs that led to it, and 3) the feelings that triggered it, she was able to demonstrate that she could maintain control without use of such a problematic strategy.
Another therapist may be more inclined to ask, "Who are you?" when seeing such a change in posture and voice. The patient may be inclined (or subtly encouraged) to offer a name other than his or her own, and the therapist may be tempted to perform therapy on the "alter" (Fine, 1992). In doing so, the therapist may unintentionally be encouraging the very behaviors that interfere with the patient's life. And the patient may mistake a dissociative metaphor for the "reality" of separate identities.
Traditional treatment of DID often involves hypnosis and integration through the re-experiencing of early memories. Hypnosis may work insofar as it normalizes dissociation and allows patients to habituate to its fearful aspects. Re-experiencing may offer a means of exposure and habituation to the feared content of thoughts and memories. These therapeutic strategies are not without risk, though. As previously indicated, people skilled at dissociation are highly suggestible. And, as indicated by Martin Orne, hypnotic work may act to enhance belief in early memories rather than the accuracy of such memories. The patient may have great difficulty moving beyond them; therapy may come to a stand-still.
Cognitive therapy may offer another approach by examining the beliefs that lead people to adopt dissociation as a strategy. Patients might see themselves as helpless, powerless or inadequate without use of such avoidance. They might regard such memories as dangerous and fear losing control or going insane. The hypervigilance often associated with post-traumatic stress syndrome might confirm such fears. The mental residue of dissociation might confirm the fear that they are losing their minds. In summary, cognitive therapy offers two promising approaches: 1) normalizing dissociative experience, and 2) testing the beliefs that give rise to it. These techniques may yet shed some light on the very interesting behavior of dissociation.
References
Fine, C. (1992). Multiple Personality Disorder, in A. Freeman & F.M. Datillio (Eds.),
Comprehensive Casebook of Cognitive Therapy. New York: Plenum Press.
