As
society has become increasingly aware of the prevalence of child abuse and its serious consequences, there has been an explosion of
information on posttraumatic and dissociative disorders resulting from abuse in childhood. Since most clinicians learned little about
childhood trauma and its aftereffects in their training, many are struggling to build their knowledge base and clinical skills to
effectively treat survivors and their families.
Understanding dissociation and its relationship to trauma is basic to
understanding the posttraumatic and dissociative disorders.
Dissociation is the disconnection from full awareness of self,
time, and/or external circumstances. It is a complex
neuropsychological process. Dissociation exists along a continuum from
normal everyday experiences to disorders that interfere with everyday
functioning. Common examples of normal dissociation are highway
hypnosis (a trance-like feeling that develops as the miles go by),
"getting lost" in a book or a movie so that one loses a sense of
passing time and surroundings, and daydreaming.
Researchers and clinicians believe that dissociation is a common,
naturally occurring defense against childhood trauma. Children tend to
dissociate more readily than adults. Faced with overwhelming abuse, it
is not surprising that children would psychologically flee
(dissociate) from full awareness of their experience. Dissociation may
become a defensive pattern that persists into adulthood and can result
in a full-fledged dissociative disorder.
The
essential feature of dissociative disorders is a disturbance or
alteration in the normally integrative functions of identity, memory,
or consciousness. If the disturbance occurs primarily in memory,
Dissociative Amnesia or Fugue (APA, 1994) results; important personal
events cannot be recalled. Dissociative Amnesia with acute loss of
memory may result from wartime trauma, a severe accident, or rape.
Dissociative Fugue is indicated by not only loss of memory, but also
travel to a new location and the assumption of a new identity.
Posttraumatic Stress Disorder (PTSD), although not officially a
dissociative disorder (it is classified as an anxiety disorder), can
be thought of as part of the dissociative spectrum. In PTSD,
recall/re-experiencing of the trauma (flashbacks) alternates with
numbing (detachment or dissociation), and avoidance. Atypical
dissociative disorders are classified as Dissociative Disorders Not
Otherwise Specified (DDNOS). If the disturbance occurs primarily in
identity with parts of the self assuming separate identities, the
resulting disorder is Dissociative Identity Disorder (DID), formerly
called Multiple Personality Disorder.
The Dissociative Spectrum
The dissociative spectrum (Braun,
1988) extends from normal dissociation to poly-fragmented DID. All of
the disorders are trauma-based, and symptoms result from the habitual
dissociation of traumatic memories. For example, a rape victim with
Dissociative Amnesia may have no conscious memory of the attack, yet
experience depression, numbness, and distress resulting from
environmental stimuli such as colors, odors, sounds, and images that
recall the traumatic experience. The dissociated memory is alive and
active--not forgotten, merely submerged (Tasman & Goldfinger, 1991).
Major studies have confirmed the traumatic origin of DID (Putnam,
1989, and Ross, 1989), which arises before the age of 12 (and often
before age 5) as a result of severe physical, sexual, and/or emotional
abuse. Poly-fragmented DID (involving over 100 personality states) may
be the result of sadistic abuse by multiple perpetrators over an
extended period of time.
Although DID is a common disorder (perhaps as common as one in 100)
(Ross, 1989), the combination of PTSD-DDNOS is the most frequent
diagnosis in survivors of childhood abuse. These survivors experience
the flashbacks and intrusion of trauma memories, sometimes not until
years after the childhood abuse, with dissociative experiences of
distancing, "trancing out", feeling unreal, the ability to ignore
pain, and feeling as if they were looking at the world through a fog.
The symptom profile of adults who were
abuse as children includes posttraumatic and dissociative disorders
combined with depression, anxiety syndromes, and addictions. These
symptoms include (1) recurrent depression; (2) anxiety, panic, and
phobias; (3) anger and rage; (4) low self-esteem, and feeling damaged
and/or worthless; (5) shame; (6) somatic pain syndromes (7)
self-destructive thoughts and/or behavior; (8) substance abuse; (9)
eating disorders: bulimia, anorexia, and compulsive overeating; (10)
relationship and intimacy difficulties; (11) sexual dysfunction,
including addictions and avoidance; (12) time loss, memory gaps, and a
sense of unreality; (13) flashbacks, intrusive thoughts and images of
trauma; (14) hypervigilance; (15) sleep disturbances: nightmares,
insomnia, and sleepwalking; and (16) alternative states of
consciousness or personalities.
Diagnosis
The diagnosis of dissociative disorders starts with an awareness of
the prevalence of childhood abuse and its relation to these clinical
disorders with their complex symptomatology. A clinical interview,
whether the client is male or female, should always include questions
about significant childhood and adult trauma. The interview should
include questions related to the above list of symptoms with a
particular focus on dissociative experiences. Pertinent questions
include those related to blackouts/time loss, disremembered behaviors,
fugues, unexplained possessions, inexplicable changes in
relationships, fluctuations in skills and knowledge, fragmentary
recall of life history, spontaneous trances, enthrallment, spontaneous
age regression, out-of-body experiences, and awareness of other parts
of self (Loewenstein, 1991).
Structured diagnostic interviews such as the Dissociative Experiences
Scale (DES) (Putnam, 1989), the Dissociative Disorders Interview
Schedule (DDIS) (Ross, 1989), and the Structured Clinical Interview
for Dissociative Disorders (SCID-D) (Steinberg, 1990) are now
available for the assessment of dissociative disorders. This can
result in more rapid and appropriate help for survivors. Dissociative
disorders can also be diagnosed by the Diagnostic Drawing Series (DDS)
(Mills & Cohen, 1993).
The diagnostic criteria for the diagnosis of DID are (1) the existence
within the person of two or more distinct personalities or personality
states, each with its own relatively enduring pattern of perceiving,
relating to, and thinking about the environment and self, (2) at least
two of these personality states recurrently take full control of the
person's behavior, (3) the inability to recall important personal
information that is to extensive to be explained by ordinary
forgetfulness, and (4) the disturbance is not due to the direct
physiological effects of a substance (blackouts due to alcohol
intoxication) or a general medical condition (APA, 1994). The
clinician must, therefore, "meet" and observe the "switch process"
between at least two personalities. The dissociative personality
system usually includes a number of personality states (alter
personalities) of varying ages (many are child alters) and of both
sexes.
In the past, individuals with dissociative disorders were often in the
mental health system for years before receiving an accurate diagnosis
and appropriate treatment. As clinicians become more skilled in the
identification and treatment dissociative disorders, there should no
longer be such delay.
Treatment
The heart of the treatment of dissociative disorders is long-term
psychodynamic/cognitive psychotherapy facilitated by hypnotherapy. It
is not uncommon for survivors to need three to five years of intensive
therapy work. Setting the frame for the trauma work is the most
important part of therapy. One cannot do trauma work without some
destabilization, so the therapy starts with assessment and
stabilization before any abreactive work (revisiting the
trauma).
A careful assessment should cover the basic issues of history (what
happened to you?), sense of self (how do you think/feel about
yourself?), symptoms (e.g., depression, anxiety, hypervigilance, rage,
flashbacks, intrusive memories, inner voices, amnesias, numbing,
nightmares, recurrent dreams), safety (of self, to and from others),
relationship difficulties, substance abuse, eating disorders, family
history (family of origin and current), social support system, and
medical status.
After gathering important information, the therapist and client should
jointly develop a plan for stabilization (Turkus, 1991). Treatment
modalities should be carefully considered. These include individual
psychotherapy, group therapy, expressive therapies (art, poetry,
movement, psychodrama, music), family therapy (current family),
psychoeducation, and pharmacotherapy. Hospital treatment may be
necessary in some cases for a comprehensive assessment and
stabilization. The Empowerment Model (Turkus, Cohen, & Courtois,
1991) for the treatment of survivors of childhood abuse--which can be
adapted to outpatient treatment--uses ego-enhancing, progressive
treatment to encourage the highest level of function ("how to keep
your life together while doing the work"). The use of sequenced
treatment using the above modalities for safe expression and
processing of painful material within the structure of a therapeutic
community of connectedness with healthy boundaries is particularly
effective. Group experiences are critical to all survivors if they are
to overcome the secrecy, shame, and isolation of survivorship.
Stabilization may include contracts to ensure physical and emotional
safety and discussion before any disclosure or confrontation related
to the abuse, and to prevent any precipitous stop in therapy.
Physician consultants should be selected for medical needs or
psychopharmacologic treatment. Antidepressant and antianxiety
medications can be helpful adjunctive treatment for survivors, but
they should be viewed as adjunctive to the psychotherapy, not
as an alternative to it.
Developing a cognitive framework is also an essential part of
stabilization. This involves sorting out how an abused child thinks
and feels, undoing damaging self-concepts, and learning about what is
"normal". Stabilization is a time to learn how to ask for help and
build support networks. The stabilization stage may take a year or
longer--as much time as is necessary for the patient to move safely
into the next phase of treatment.
If the dissociative disorder is DID, stabilization involves the
survivor's acceptance of the diagnosis and commitment to treatment.
Diagnosis is in itself a crisis, and much work must be done to reframe
DID as a creative survival tool (which it is) rather than a disease or
stigma. The treatment frame for DID includes developing acceptance and
respect for each alter as a part of the internal system. Each alter
must be treated equally, whether it presents as a delightful child or
an angry persecutor. Mapping of the dissociative personality system is
the next step, followed by the work of internal dialogue and
cooperation between alters. This is the critical stage in DID therapy,
one that must be in place before trauma work begins.
Communication and cooperation among the alters facilitates the
gathering of ego strength that stabilizes the internal system, hence
the whole person.
Revisiting and reworking the trauma is the next stage. This may
involve abreactions, which can release pain and allow dissociated
trauma back into the normal memory track. An abreaction might be
described as the vivid re-experiencing of a traumatic event
accompanied by the release of related emotion and the recovery of
repressed or dissociated aspects of that event (Steele & Colrain,
1990). The retrieval of traumatic memories should be staged with
planned abreactions. Hypnosis, when facilitated by a trained
professional, is extremely useful in abreactive work to safely contain
the abreaction and release the painful emotions more quickly. Some
survivors may only be able to do abreactive work on an inpatient basis
in a safe and supportive environment. In any setting, the work must be
paced and contained to prevent retraumatization and to give the
client a feeling of mastery. This means that the speed of the work
must be carefully monitored, and the release painful material must be
thoughtfully managed and controlled, so as not to be overwhelming. An
abreaction of a person diagnosed with DID may involve a number of
different alters, who must all participate in the work. The reworking
of the trauma involves sharing the abuse story, undoing unnecessary
shame and guilt, doing some anger work, and grieving. Grief work
pertains to both the abuse and abandonment and the damage to one's
life. Throughout this mid-level work, there is integration of memories
and, in DID, alternate personalities; the substitution of adult
methods of coping for dissociation; and the learning of new life
skills.
This leads into the final phase of the therapy work. There is
continued processing of traumatic memories and cognitive distortions,
and further letting go of shame. At the end of the grieving process,
creative energy is released. The survivor can reclaim self-worth and
personal power and rebuild life after so much focus on healing. There
are often important life choices to be made about vocation and
relationships at this time, as well as solidifying gains from
treatment.
This is challenging and satisfying work for both survivors and
therapists. The journey is painful, but the rewards are great.
Successfully working through the healing journey can significantly
impact a survivor's life and philosophy. Coming through this intense,
self-reflective process might lead one to discover a desire to
contribute to society in a variety of vital ways.
References
Braun, B. (1988). The BASK model of dissociation. DISSOCIATION, 1,
4-23. American Psychiatric Association. (1994). Diagnostic and
statistical manual of mental disorders (4th ed.). Washington, DC:
Author. Loewenstein, R.J. (1991). An office mental status examination
for complex chronic dissociative symptoms and multiple personality
disorder. Psychiatric Clinics of North America, 14(3), 567-604.
Mills, A. & Cohen, B.M. (1993). Facilitating the identification of
multiple personality disorder through art: The Diagnostic Drawing
Series. In E. Kluft (Ed.), Expressive and functional therapies in
the treatment of multiple personality disorder. Springfield:
Charles C. Thomas.
Putnam, F.W. (1989). Diagnosis and treatment of multiple
personality disorder. New York: Guilford Press.
Ross, C.A. (1989). Multiple personality disorder: Diagnosis,
clinical features, and treatment. New York: Wiley.
Steele, K., & Colrain, J. (1990). Abreactive work with sexual abuse
survivors: Concepts and techniques. In Hunter, M. (Ed.), The
sexually abused male, 2, 1-55. Lexington, MA: Lexington Books.
Steinberg, M., et al. (1990). The structured clinical interview for
DSM III-R dissociative disorders: Preliminary report on a new
diagnostic instrument. American Journal of Psychiatry, 147, 1.
Tasman, A., & Goldfinger, S. (1991). American psychiatric press
review of psychiatry. Washington, DC: American Psychiatric Press.
Turkus, J.A. (1991). Psychotherapy and case management for multiple
personality disorder: Synthesis for continuity of care. Psychiatric
Clinics of North America, 14(3), 649-660.
Turkus, J.A., Cohen, B.M., & Courtois, C.A. (1991). The empowerment
model for the treatment of post-abuse and dissociative disorders. In
B. Braun (Ed.), Proceedings of the 8th International Conference on
Multiple Personality/Dissociative States (p. 58). Skokie, IL:
International Society for the Study of Multiple Personality Disorder.
Joan A. Turkus, M.D., has extensive clinical experience in the
diagnosis and treatment of post-abuse syndromes and DID. She is the
medical director of The Center: Post-Traumatic & Dissociative
Disorders Program at The Psychiatric Institute of Washington. A
general and forensic psychiatrist in private practice, Dr. Turkus
frequently provides supervision, consultation, and teaching for
therapists on a national basis. She is co-editor of the forthcoming
book, Multiple Personality Disorder: Continuum of Care.
* This article has been adapted by Barry M. Cohen, M.A., A.T.R., for
publication in this format. It was originally published in the
May/June, 1992, issue of Moving Forward, a semi-annual
newsletter for survivors of childhood sexual abuse and those who care
about them. For subscription information, write P.O. Box 4426,
Arlington, VA, 22204, or call 703/271-4024.
