The term “dissociation” was introduced at the end of the 19th century to describe the state of mind when a complex of ideas splits off the main personality and exists independently and outside consciousness. Consequently, a group of psychogenic mental disorders resembling this pattern received the name dissociative disorders (DD). They are characterized by changes or disturbances in a number of cognitive functions – consciousness, memory, a sense of personal identity or awareness of its continuity, as well as impaired control of body movements. In contemporary psychiatry, the term DD mainly refers to three phenomena: dissociative identity disorder (DID), dissociative amnesia, and depersonalization-derealization disorder. Due to DID’s nature and debatable etiology, this topic is surrounded by a significant amount of ambiguity and uncertainty. Additionally, DID’s symptomatology in many cases closely resembles the symptomatology of other groups, which complicates the diagnostic process and produces various debates and misconceptions in professional practice. After considering the mentioned issues, it becomes plain that there is a need for a thorough discussion of possible DD treatment from the therapeutic, legal, and ethical perspectives.
Rightfully being the most controversial disorder of the DD group, DID is well known even outside the psychiatric community. It received its official name relatively recently, with the IV edition of DSM in the middle 90s. Before that, the psychiatrists lacked the proper research data to develop a specific pattern, and DID was indistinguishable from borderline personality, multiple personalities, and post-traumatic stress disorders. According to Gillig (2009), studies of that time began to recognize and acknowledge DID when the symptomatic comparison of the mentioned disorders was made. The final distinction was drawn when the emphasis moved on the changes to one’s identity and consciousness, not the personality. With its clinical acknowledgment, DID become known to the public, which led to the creation of books and later films showcasing people suffering from it. In addition, it produced the fear of a disorder’s deliberate abuse in the justice field, implying that criminals will try to put the burden of the crime on their other personalities (Loewenstein, 2018). Luckily for the anxious public and, unfortunately for therapists, it proves to be hard to diagnose DID without a proper investigation.
Despite the development of a distinctive pattern, DID still resembles various symptoms that are present in the symptomatology of other disorders. According to Sar et al. (2017), in comparison to borderline personality disorder (BPD), DID overlaps in almost ten symptoms, including lack of sleep, anxiety, mood swings, and anger issues. Another example of similarity can be found in Herman’s (2006) article, where he mentions that DID might evolve from post-traumatic stress disorder (PTSD) if the patient was continuously exposed to the trauma. However, the therapeutic community’s issues concerning DID are not limited by the laborious diagnostic process. In their research, Brand et al. (2016) highlight several misconceptions about the matter. These include DID’s iatrogenic nature in contrast to trauma-based and the treatment’s danger to the patients. Brand et al. (2016) then provide evidence of documented child abuse and eventual DID symptoms occurrence in patients whose treatment began at a later age. At the same time, little evidence of iatrogenic origin was found; on the contrary, there are confirmed cases of a positive long-term treatment, which refutes the iatrogenic nature of DID.
Concerning the DD treatment practice, developing an intimate and reliable bond between a patient and a practitioner through psychotherapy proves to be the most efficient. According to Subramanyam et al. (2020), to conduct it appropriately, a practitioner should possess solid knowledge of DD background and their clinical and psychodynamic aspects. The therapy itself consists of a therapist initiating the dialog in an attempt to uncover the inner patient’s conflicts. The patient’s deliberate cooperation is crucial in this matter; that is why it is essential to build up trust and create an atmosphere of working together to achieve a common goal. In this setting, a patient becomes more resistant to possible emotional outbreaks and gains an ability to carefully assess them, work them through, and eventually let them go. Meanwhile, a therapist can aid with a better understanding of displayed emotions by identifying which of them were primarily caused by trauma and which serve as follow-ups (Subramanyam et al., 2020). A great emphasis is put on a therapist’s skill since his failure in some cases might lead to legal issues and dire consequences.
When a patient faces emerging ideas and memories that were previously suppressed by his consciousness, his behavior becomes unpredictable to the extent of displaying homicidal intentions. Ducharme (2017) states in his article that a primary concern should always be a patient’s and a practitioner’s health. In addition, he urges practitioners to evaluate their professional competence objectively and encourages consultation and supervision if needed. Another vital concern is brought by “a duty to warn,” which was first established in California in 1974. At its core, it obligated therapists to break confidentiality and inform possible victims of a patient’s homicidal intentions (Norko, 2008). Afterward, it evolved into “a duty to protect” in 1976, allowing the involuntary commitment of a dangerous individual. This duty received mixed critique from therapists because such actions completely nullify the work done with the patients and might eliminate any possibility of future therapy. However, there are still some states where “a duty to protect” is not adopted yet. Consequently, therapists should be aware of the legal practices of the state they are working in, so they can avoid unnecessary issues.
DD, DID in particular, are intertwined with controversies and ambiguities in the public and therapeutic field, while their treatment has to face legal and ethical concerns. Being a relatively recent concept, DID was previously indistinguishable from other similar disorders due to the lack of thorough research. After its clinical acknowledgment, however, DID became widely known even outside of the therapeutic community. Its symptoms frequently overlap with the symptoms of other disorders, such as BPD or PTSD; thus, it requires a complex diagnostic process. The contemporary debate over DID etiology still remains active, although the probability of its iatrogenic nature is relatively low in contrast to the trauma-based. Despite the debate over treatment’s possible harm, psychotherapy resembles an efficient way of treating people suffering from DID. During that therapy, practitioners establish a trustful link with their patients in an attempt to invoke suppressed patients’ memories. Despite the professional help, patients might still display signs of homicidal behavior, which is addressed by specific laws in most states of the country. In the end, the term “dissociation” and disorders connected to it still prove to be problematic and, in many ways, undefined.
Brand, B. L., Sar, V., Stavropoulos, P., Krüger, C., Korzekwa, M., Martínez-Taboas, A., & Middleton, W. (2016). Separating fact from fiction: An empirical examination of six myths about dissociative identity disorder. Harvard Review of Psychiatry, 24(4), 257– 270. Web.
Ducharme, E. L. (2017). Best Practices in working with complex trauma and dissociative identity disorder. Practice Innovations, 2(3), 150–161. Web.
Gillig, P. M. (2009). Dissociative identity disorder: A controversial diagnosis. Psychiatry (Edgmont), 6(3), 24–29.
Herman J. (2006). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5(3), 377–391. Web.
Loewenstein R. J. (2018). Dissociation debates: Everything you know is wrong. Dialogues in Clinical Neuroscience, 20(3), 229–242. Web.
Norko, M. A. (2008). Duty to warn and dissociative identity disorder. AMA Journal of Ethics, 10(3), 144-149.
Sar, V. M., Alioğlu, F. M., Akyuz, G. M., Tayakısı, E., Öğülmüş, E. F., & Sönmez, D. (2017). Awareness of identity alteration and diagnostic preference between borderline personality disorder and dissociative disorders. Journal of Trauma & Dissociation, 18(5), 693–709.
Subramanyam, A. A., Somaiya, M., Shankar, S., Nasirabadi, M., Shah, H. R., Paul, I., & Ghildiyal, R. (2020). Psychological interventions for dissociative disorders. Indian Journal of Psychiatry, 62(Suppl 2), 280–289. Web.