Over the last several weeks, I have had an email exchange with a young lady from Great Britain.
This young lady knows that she is dissociative. She thinks she may have developed this coping strategy as a result of the trauma of multiple deaths of those close to her in a very short time span, including one of her parents. It is entirely possible, but it is not the typical route to a dissociative pattern of survival. What has impressed me most about her is the amount of information she has acquired on her own without professional help or training. She has also taught me some about the National Health System in England as she described her efforts to obtain therapy and its response to her.
I thought that I would review some of the fundamentals of dissociative process and write about some of my thoughts on treating individuals who suffer from it. Everyone dissociates sometimes. If you have ever driven home from work and could not remember the actual drive, if you thought you were driving to the grocery store, but pulled up and parked in your ex boyfriends driveway without realizing you were going there, you have been dissociating. If you have become preoccupied with nothing, but suddenly realized a considerable amount of time had passed and you don’t know how that happened, then you have been dissociating. Dissociation is essentially an unconscious process for “losing” time and awareness. We do it when we are distracted. However, there are others who do it because being in contact and aware is so painful and so frightening that they cannot afford to be connected to their feelings, their memories or their present situation.
The dissociative continuum runs from the defense mechanism of repression, which is the selective editing of the memory or awareness to Dissociative Identity Disorder. An example of repression on the less severe end would be: I don’t like to go to the dentist, I am frightened of what will happen there, so I “forget” my dental appointment until thirty minutes after it is scheduled. That way my unconscious protects me from what I fear and resist. This is the skill we all use at one level of expertise or another. Dissociation progresses from this type of selective editing of awareness or memory, to a more orchestrated and comprehensive blockage of segments of consciousness, history or life. We may lose an entire year of our life. I have had many clients who tell me they cannot remember the year their mom died at all. None of it, not school, not work, not flash memories of parties or birthdays, or happy events, it is gone. But they remember before that year and they remember after that year in perfect sequence. This is an example of dissociation called amnesia.
Terms such as amnesia and fugue are reflective of the dissociative process. Amnesia may be caused by brain trauma from a blow to the head, or an accident of some kind that injures the brain so that the neural pathways for the memory are blocked. But without injury, amnesia is a dissociative way of protecting someone from something so onerous that they cannot afford to remember it because the fear and pain, or even self -loathing, will be too awful to endure. The most extreme example of this is what we used to call Multiple Personality Disorder, but now is called Dissociative Identity Disorder. The movie Sybil (1976 Lorimar Productions) is a good example of this. In DID there is a vertical compartmentalization of memory. There will be remembered timelines for multiple slices of reality. Each slice will have a name, an identity, a personality and a history. This history may be limited to a few years, but it will be vertical in the sense that there is a connected awareness for this individual for the entire time slot of their existence. That is different from the horizontal slice of memory loss we discussed earlier with the example of the death of the parent or the accident (that did not cause brain damage, but which the individual cannot remember.)
I found that when I worked with dissociative individuals, I gradually began to notice that they would shift or “go away somewhere.” They would disconnect from the conversation and from me. They would lose time in our sessions and they could not remember what we were talking about. This tended to occur whenever I would approach talking with them about something that was at the core of their dissociative skill. If we began to talk about a feeling they were afraid of (i.e., if they had been harshly abused about not crying and felt as if they might cry, they would just go away somewhere and not be present for those feelings.) If we began talking about an event such as the death of a parent, the pain was so strong for them they would just lose the thread of the conversation and the pain associated with it would go away, as well. Dissociation is a protective behavior. It is a complex and valued skill, and we can use it to discover what is going on. I always make the point to my clients that they should be proud of themselves for discovering a defense mechanism that allowed them to survive their traumas so that they could to get to a place where they could seek help from a therapist. I help them learn that my office is a safe place, they can stand in the presence of the pain or fear and find the memory that is hidden and be safe with it. I also gently begin to ask them to be aware of when they go away. I help identify their “tells” that identify for me that they are “going away.” As they learn to do this, they can begin to identify the triggers and we can begin to explore the feelings that are so horrific.
I constantly reassure them that they would not be able to feel or remember unless they were strong enough to handle whatever the “knowing” was. I reassure them that I approve of them and value the strength and courage they have used to protect themselves and survive no matter what the trauma was. This is especially important when dealing with horrific sexual abuse. The shame factor is so powerful and has usually been manipulated so skillfully by the perpetrator that the survivor is self-hating and shamed because they believe, or were told, that this was entirely their fault. That a six or seven year old girl can be so strongly sexual and seductive that she can override the resistance of poor old Grandpa and make him be her sexual slave is often what she was told. It was never Grandpa’s fault; it was the girl’s fault. She was bad seed in some way and she had doomed him and made him the victim. Girls who go through this internalize the propaganda from the perpetrator and come to be self-loathing. I honor their survival no matter what behaviors they had to perform in order to survive. This is a very true statement. I do honor the ability of the victim to survive and to continue to work on survival until they can find their way to my office and learn to heal. With help, they can learn how to challenge the script, to stand tall and proud of their ability to survive and to learn to call a fact a fact. What is real is real; six year old girls are not that powerfully seductive. It was grandpa all along! When the client can realize that, they can begin to cleanse themselves of the shame and self-hatred and they can begin to re-script their definition of self. They begin to learn that the adult them or the “now” them can love and honor their predecessor, the abused and victimized them. Together these disparate parts of their identity can work to meld into a strong and functioning self that is not constrained by the limits of abuse survival. They will not need to dissociate from feelings that are too powerful to behold, because they have beheld them and survived. They stop losing time and contact, and they begin to learn how to regulate their emotional process in the present moment with confidence and strength.
There are warnings that should be given about working with dissociative process if you do not have the perspective, training and skills to handle the intensity of the emotions or memories. You must remember that as a therapist, it is your job to help the survivor heal. It is not your job to track down and punish the perpetrator. Some survivors want to challenge the perpetrator and tell them the feelings they have remembered and ask for an apology or an explanation. Be extremely slow to support that step. Before they go there they must rehearse the process repeatedly. They must imagine doing it and saying it and all the possible ways that the others in their life will respond when they challenge Grandpa for the dirty old man he is. Many of their critical supporters will abandon them and shame them and side with Grandpa. They must be prepared in therapy for that possibility and learn what they will need to know in order to survive it. Many such individuals, when confronted attack. They deny and they scold and shame the client. The client needs to be strong and practiced, and they need to have a realistic appreciation of what they may get from the perpetrator and how they will incorporate whatever they get into their new definition of self with strength and peace. However, that is a topic for another day. Dissociation is an incredibly powerful defense mechanism and an extremely deft skill for the client to have. It takes an equal amount of skill, strength, and balance for the therapist. Do not go wandering randomly into the dissociative process experience. Get training first. As a therapist you must not be afraid of emotional intensity. You have to be able to be a grounded presence in the midst of the emotional firestorm. Additionally, when you get angry as you hear their story of abuse, you must tell the client that you are angry (they will have sensed this already, it is a trust and truthfulness issue) but that you are not angry with them you are angry with the perpetrator. This will have to be repeated many times before they can safely believe it. And finally, you have to tell them that you do not need them to be angry with the perpetrator. For some of them it is something they are never able to do. The challenge is to heal them, not rage at the perpetrator, or punish the perpetrator, or justify anything.