HOW COMMON IS DISASSOCIATION? Wondering who you are?
Where is the joy of life when you merely survive day to day and have lost the essence of your identity.
I have recently met with a client (not pictured) who stated he was depressed and seemed to be cognitively processing his depressive experience, in an extremely detached manner. His partner had commented he had “no empathy” and when the children hurt themselves he seemed to put a band aid on them and say they will be fine in a minute without showing any degree of concern. This client had been seeing a Therapist (psychologist) for 12 months every week and, my client said he was “no better”. Curious about his cool and totally unemotional presentation I began to read materials and research papers on the behaviour I witnessed and came to realise this “condition is called disassociation”. I had memories of lectures where severe dissociation was considered a severe mental health condition. However, I noted my client was a “functioning” person with a family. Whilst not needing to diagnose or label clients this research assisted me to better understand this behaviour. The Stranger in the Mirror (2001) by Steinberg is a fascinating book into this subject.
Dissociation is a disruption to integrated psychological functioning and apparently occurs in a range of forms and experiences. These range from `normal everyday’ (e.g. daydreaming, absorption in a task, `highway hypnosis’) to protection from being overwhelmed (i.e. a response to trauma). Manifesting in disordered, as well as healthy, expressions, dissociation appears to be not well understood within the field of mental health.
My client had been suicidal earlier in the year but when I first saw him he was more in a state of not knowing his identity, he called this a midlife crisis early. He reported seeing his life as if he was in a movie and detached. This is of course a strategy often used by Counsellors to assist clients detach from events, such as the use of the miracle question or imagine you are in a video and externalize the event. My client was living in the video.
When disassociation symptoms become severe they can disrupt people’s lives however my client was not unable to cope in fact disassociation was his main coping strategy and few people even seemed to recognize his inner struggle. His depression mood swings, and suicidal ideation seemed to fluctuate depending “how he felt when he “woke up” each morning. If he felt poorly he would return to bed until later when he may wake up in a good mental state, disrupting his ability to attend work. These symptoms were baffling to his wife and family.
My client said he felt numb emotionally and had lost his sense of taste except for very sour or very salty foods. He had seen a psychologist every week and a Psychiatrist, and said he still had no clearer idea of who he was or what he wanted to do with his life. The following case study illustrates how trauma can influence emotions.
The following case study highlights a seemingly small incident which unexpectedly causes anger and anxiety-like symptoms in later life:
"Johnny, age five, proudly riding his first bicycle, hits loose gravel and careens into a tree. He is momentarily knocked unconscious. Getting up amid a flow of tears, he feels disoriented and somehow different. His parents hug him, console him, and put him back on the bike, all the while praising his courage. They do not realise how stunned and frightened he is.
"Years after this apparently minor incident, John, driving with his wife and children, swerves to avoid an oncoming car. He freezes during the turn. Fortunately, the other driver is able to maneuvere successfully and avoid catastrophe.
"One morning several days later, John begins to feel restless while driving to work. His heart starts racing and pounding; his hands become cold and sweaty. Feeling threatened and trapped, he has a sudden impulse to jump out of the car and run. He acknowledges the 'craziness' of his feelings, realizes no one was hurt, and gradually, the symptoms subside. A vague and nagging apprehension, however, persists most of the day. Returning home that evening without incident, he feels relieved.
"The next morning, John leaves early to avoid the traffic and stays late to discuss business with some colleagues. When he arrives home, he is irritable and edgy. He argues with his wife and barks at the children. John goes to bed early. He is awakened in the middle of the night and faintly recalls a dream in which his car is running out of control. He is drenched in sweat. More fretful nights follow.
"John is experiencing a delayed reaction sensitized by the bike accident he had as a child. Incredible as it may seem, post-traumatic reactions of this type are common."
- Peter A Levine, p. 247, Waking the Tiger
After reading these books and talking with colleagues I discovered “grounding” strategies where the client feels the chair beneath them, feels the fabric of their clothing and listens to external sounds which assist with Mindfulness can help. Mindfulness has assisted my client to be curious about his feelings and more importantly contact the present consciously.
The use of questions such as;
When do you disassociate, are you able to prevent it? Do you notice when it comes on? All assisted to clarify the issues. In addition, validation of the experience as a coping strategy to help survive in a difficult time, but also questioning if it is still a coping strategy he needs and is it perhaps robbing him of a rich emotional fulfilling life.
This is an ongoing discussion hopefully enabling my client to lead a more fulfilled life of experiencing rather than merely surviving day to day.
Steinberg M, Schnall M: The Stranger in the Mirror: Dissociation-The Hidden Epidemic, HarperCollins, 2001, 2000. Translations: Spanish, Italian, Chinese
Steinberg M: Handbook for the Assessment of Dissociation: A Clinical Guide. Washington, D.C., American Psychiatric Press, 1995
Steinberg M: The Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D). Washington, D.C., American Psychiatric Press, 1994.
Steinberg M: The Interviewer’s Guide to the Structured Clinical Interview for DSM-IV Dissociative Disorders- Revised. Washington, D.C., American Psychiatric Press, 1994
Steinberg M: Advances in Diagnosing and Treating Dissociative Disorders: The SCID-D-R. Bulletin of the Menninger Clinic. 146-163, Spring 2000
Levine: Waking the Tiger. North Atlantic Books,1997