A common question asked by visitors is: What are the limits of cognitive therapy?" A common answer is "We don't yet know. That is an empirical question." Each time a boundary is set to define the limits of cognitive therapy -- someone pushes it. Initially a treatment for depression, it has been adapted for anxiety disorders, eating disorders, personality disorders, and most recently, psychotic disorders. The next frontier may be dissociative disorders.
Very little has been written on the cognitive therapy of dissociative disorders (Fine, 1992). Yet at first sight, the disorders seem well-suited for cognitive therapy: they are disorders of "consciousness, memory, identity, or perception of the environment" (DSM-IV). They are exhibited by use of a highly powerful safety behavior -- an avoidance of thoughts and feelings. Dissociation, as a symptom, has a role in both anxiety disorders (depersonalization and derealization during panic attacks, memory loss in post-traumatic stress) and personality disorders (a response to stress in borderline personality). Like anxiety, it may even be characterized by fear of a normal internal experience. Cognitive therapy of anxiety disorders has often focused on 1) normalizing the sensations associated with anxiety, and 2) identifying beliefs that lead to safety behaviors and reducing patient's reliance on them. Treatment of dissociative disorders may benefit from a similar approach.
A natural, normal experience
Years before my training in cognitive therapy, I attended a workshop led by T.X. Barber on hypnosis. He described trance as normal dissociation which could occur while driving (highway hypnosis), watching television, reading a book, painting or drawing, or even while writing. In each case people lose time and minutes can pass like seconds. He also described "high susceptibles": people who easily entered such states, characterized as highly imaginative and likely to have imaginary playmates as children. He indicated that stage hypnotists know that such individuals are more likely to go along with the demand characteristics of the show: given suggestions, they can act in silly ways, without needing to be hypnotized. Dissociation may very well be a common occurrence, and some people are simply more skilled in applying and using it. Individuals with dissociative disorders may be high susceptibles who either mis-interpret or mis-use these states in ways that interfere with their lives. A number of posibilities have arisen in my work with patients who exhibit such symptoms.
Poetic misinterpretations of physical sensations
Some patients may merely be using poetic license in describing their physical sensations. A young man describes a feeling of unreality as "a swimming feeling in his head," some dizziness and lightheadedness -- all symptoms of anxiety. But his interpretation -- a scary, disturbing interpretation for him -- was that he was somehow "cut off from reality," "separated from the rest of the world, " "trapped in an alternate reality," and "locked in his own mind." These explanations proved terrifying to him. They added to his anxiety, and to his physical sensations. When he normalized the experience, accepted it, and drained it of such magical associations, his anxiety reduced.
Another patient had the re-occurring thought, "Nothing is real." The accompanying anxiety symptoms served to confirm this disturbing idea. Her fear of such thoughts and sensations triggered such intense internal self-focus that she felt she was losing control of her thoughts, of herself, of her grasp of reality -- and that she was in danger of never returning. Our work consisted of 1) exposure and habituation to the initially terrifying content of her thoughts, 2) psycho-education regarding the seemingly confirmatory physical sensations that accompanied them, and 3) gathering evidence to demonstrate her behavioral control in the face of such thoughts and sensations. Her symptoms improved within 20 sessions. Even after a relapse (exacerbated when a psychiatrist incorrectly suggested that she might be psychotic) she continued to make progress.
Neither of these patients had psychotic symptoms. They were just ordinary people caught in the grip of extraordinary ideas. Therapy enabled them to distance themselves from their thoughts and sensations and to test out their beliefs concerning them. In both cases, the dissociative symptoms were treated as triggers.
(... to be continued in next issue.)
