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Controversy Regarding Dissociative Disorders

Holly Bowling

Walden University

NRNP 6665: PMHNP Care Across the Lifespan I

Dr. Pamela Mokoko

May 3, 2021

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Controversy Regarding Dissociative Disorders

Dissociative disorders (DD) are mental health disorders, such as dissociative identity

disorder (DID), dissociative amnesia, or depolarization/derealization disorder that involve the

disruption of one or more mental functions, such as memory, identity, perception, consciousness,

or motor behavior (Sadock, Sadock, & Ruiz, 2015). DD comes with many controversies, myths,

and ethical issues that the advanced practitioner must take into account when treating individuals

with such disorders. The following paper will discuss specific controversies and professional

beliefs associated with DD, as well as strategies for maintaining therapeutic alliance and legal

and ethical considerations when treating clients with DD.

Controversy Surrounding Dissociative Disorders

There is much evidence to support the relationship between dissociation disorders (DD)

and psychological trauma, especially cumulative and/or early life trauma. Some might endorse

that dissociation produces fantasies of trauma and that DD is artefactual conditions produced by

iatrogenesis and/or socio-cultural factors (Loewenstein, 2018). Other controversies are stemmed

from the anxiety evoked by unsettling clinical presentation seen with DD, which may be similar

to some clinicians’ emotional reactions to psychiatric emergency patients. There is also a dispute

over the meaning of observed symptoms of DD, and whether they are a unique and subtle set of

core symptoms and behaviors that some clinicians do not see when it is before their eyes, or as a

willful malingering cause of symptoms created by the other clinicians who think something is

there that is not (Loewenstein, 2018). A final controversy is a fear that criminals will “get off”

without being punished by a gullible justice system, which attributes behavior to another

personality and does not hold the perpetrator responsible (Loewenstein, 2018).

Professional Beliefs About Dissociative Disorders

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There are many myths and misconceptions about dissociative disorders that remain to be

settled, including that they are a fad that is dying, that they are rare, that they are iatrogenic other

than trauma-based, that they are the same entity as a borderline personality disorder, and that the

treatment is harmful to the patients (Brand et al., 2016). However, research has shown that there

is a growing evidence base for DD that exist, and that patients are consistently identified in

outpatient, inpatient, and community setting across the world (Brand et al., 2016). Studies have

also shown that Dissociative Identity Disorder alone was found in approximately 1.1%-1.5% of

representative community samples, making it inconsistent with the myth of being rare. There is

little evidence to suggest the DD are iatrogenically produced, and there have been no studies to

support a fantasy model of dissociation. However, there is much evidence to support a strong

association between trauma-dissociation and individuals with DD. Researchers have found

documented evidence of dissociative symptoms in childhood and adolescence in individuals who

were not assessed or treated for DID until later in life, as well as finding documentation of severe

child abuse in adult patients diagnosed with DID (Brand et al., 2016), therefore suggesting DD

are typically trauma-based and not iatrogenically produced. There is a close correlation between

DD and Borderline Personality Disorder (BPD), and they do commonly co-occur, and

approximately 25% of BPD patients endorse symptoms suggesting possible dissociated

personality states, and 10%–24% of patients who meet criteria for BPD also meet criteria for

DID (Brand et al., 2016). However, patients with DD showed greater self-reflective capacity,

introspection, ability to modulate emotion, social interest, accurate perception, logical thinking,

and ability to see others as potentially collaborative (Sar et al., 2017). Individuals with DD have

also shown to have more traumatic intrusions, greater internalization, and a tendency to engage

in complex contemplation about the significance of events, as well as consistently using a

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thinking-based problem-solving approach unlike those with BPD (Sar et al., 2017), therefore

showing a significant difference between DD and BPD. Along with several other studies, the

Treatment of Patients with Dissociative Disorders study reported that in over 30 months of

treatment, patients showed decreases in dissociative, posttraumatic, and depressive

symptomatology, as well as decreases in hospitalizations, self-harm, drug use, and physical pain.

It was also reported that patient functioning increased significantly over time, as did their social,

volunteer, and academic involvement, and that patients with a stronger therapeutic alliance

evidenced significantly greater decreases in dissociative, PTSD, and general distress symptoms

(Lowenstein, 2018), therefore showing inconsistency with the myth that treatments are harmful

to DD patients.

Strategies for Maintaining the Therapeutic Relationship

The standard of treatment for those with Dissociative Disorders is psychotherapy,

therefore selecting the appropriate therapist is crucial in developing a therapeutic alliance

(Subramanyam et al., 2020). There are a few other ways the therapist can maintain a therapeutic

relationship with the client. One way is to have a fund knowledge of DD, including clinical

features, psychodynamic aspects, and formal training in DD to be able to accurately diagnose the

type of DD and start an early and appropriate treatment plan (Subramanyam et al., 2020).

Cronin, Brand, & Mattanah (2014) brought out that an affective bond, agreement on goals, tasks

between the therapist and client, as well as the importance of genuineness, flexibility, and ability

to truly listen to a patient as key factors in maintaining a therapeutic relationship. They also

brought out that early patient reports of alliance strength are predictive of the strength of alliance

at the end of treatment, a finding that indicates that the alliance is relatively steady over time

(Cronin, Brand, & Mattanah, 2014).

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Legal and Ethical Considerations

There are a few legal and ethical concerns that must be taken into consideration when

treating those with dissociative disorders. The safety of both the client and practitioner must

stand as a primary concern (Ducharme, 2017). The practitioner must acquire clinical competence

in this area and remain up-to-date with the current research. Transference and

countertransference are a couple of other issues that will more than likely arise and therefore,

consultation or supervision will be an important factor when interviewing patients with DD

(Ducharme, 2017). As advanced practitioners, we must also understand the limits of our

professional competence and the need to provide services, teach and conduct research with

populations and in areas only within the boundaries of our competence (Ducharme, 2017).

Conclusion

In conclusion, dissociative disorders disrupt mental function, and if not treated quickly

and adequately, can cause prolonged suffering and disability in those with DD. Recognizing

controversies and beliefs about DD can help compound the economic cost associated with DD

due to lack of recognition and inappropriate treatment. Many strategies can be utilized in

maintaining a therapeutic relationship and maintaining an alliance over time. And the most

important aspect when considering legal and ethical issues should be the safety of not just the

patient but the practitioner as well.

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References

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. https://doi.org/10.1097/HRP.0000000000000100

Ducharme, E. L. (2017). Best Practices in Working With Complex Trauma and Dissociative

Identity Disorder. Practice Innovations, 2(3), 150–161. https://doi-

org.ezp.waldenulibrary.org/10.1037/pri0000050

Elisabeth Cronin, Bethany L. Brand, & Jonathan F. Mattanah. (2014). The impact of the

therapeutic alliance on treatment outcome in patients with dissociative

disorders. European Journal of Psychotraumatology, 5(0), 1–9. https://doi-

org.ezp.waldenulibrary.org/10.3402/ejpt.v5.22676

Gentile, J. P., Dillon, K. S., & Gillig, P. M. (2013). Psychotherapy and pharmacotherapy for

patients with dissociative identity disorder. Innovations in clinical neuroscience, 10(2),

22–29.

Loewenstein R. J. (2018). Dissociation debates: everything you know is wrong. Dialogues in

clinical neuroscience, 20(3), 229–242. https://doi-

org.ezp.waldenulibrary.org/10.31887/DCNS.2018.20.3/rloewenstein

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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 : The Official

Journal of the International Society for the Study of Dissociation (ISSD), 18(5), 693–709.

https://doi-org.ezp.waldenulibrary.org/10.1080/15299732.2016.1267684

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), S280–S289.

https://doi.org/10.4103/psychiatry.IndianJPsychiatry_777_19

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