Discussion

As seen from the findings reported in the previous section, four major themes emerged from the data (outlined below in Figure 1 as well). The findings are consistent with data reported in the literature reviewed previously, and no anomalies occurred in several major areas. Three major points will be discussed: first, dissociative mechanisms are mostly developed in childhood; second, social support networks are pivotal for DD patients’ wellbeing; and third, voluntary and/or involuntary isolation (loneliness) does facilitate the occurrence of dissociation in DD patients.
First of all, dissociation is indeed a mechanism mostly developed in childhood as stated by researchers and corroborated by participants (Schimmenti & Caretti, 2016). This is relevant to investigating a perceived impact between loneliness and dissociation for multiple reasons: first, if DD patients learn to dissociate in childhood, it means they cannot garner the social skills necessary to keep them grounded. Second, DD patients learn to dissociate early on because they lack the support they need to surpass the trauma that causes them to dissociate. In all of the cases discussed with the participants, all the patients had faced a form of trauma and had found no support to aid them; whether these traumas had occurred in childhood and the patients’ parents were the perpetrators or refused to believe them about the perpetration, or whether they occurred in adulthood, and found no one to turn to (Parry et al., 2018). Parry et al.’s (2018) study, which undertook the same design and analytical approach, looked at how DID patients feel in hospital settings. Their findings report the frustration these patients feel from their mental healthcare givers, the constant feelings of being misunderstood or at times even patronized (Parry et al., 2018). As a precursor, if patients harbor these feelings towards their mental healthcare givers, they probably model them onto other members of their lives as well, as discussed with the
participants during the interviews. In that sense, the development of this mechanism in childhood causes a vicious cycle (see Figure 2).
Furthermore, as Participant 6 (P6) had mentioned in his interview, the longer a patient co-habits with their diagnosis/illness, the more their identities tend to be built around it, and their core beliefs become harder and harder to change. The longer they live with their dissociation as a coping mechanism, the more established it is as a trigger and pattern, and the lonelier they tend to feel within crowds and when alone (Dorahy et al., 2015; Swart et al., 2020). The “existential emptiness” P7 mentioned, is basically a longstanding coping mechanism coupled with a longstanding core belief acting actively to both prove to the individual that they are not worthy of a social support network and that their dissociation from the outer world is both safe and deserved (Sar et al., 2017; van der Hart et al., 2017). This is indeed an important variable to work on when treating DD patients experiencing loneliness, and is one of the reasons that this research aimed to investigate the best therapeutic modalities and techniques for helping DD patients, which will be discussed at length below.
Second of all, social support networks play a major role in aiding patients lead healthier and happier lives (Dorahy et al., 2015; Kearney et al., 2016; Saltzman, Cross Hansel, & Bordnick, 2020). As already explained in the point above, not only do social support networks give DD patients the grounding necessary to help them find safety while trying to reconcile with early traumas, but they also help them stay grounded to their present lives (Mosquera & Steele, 2017). Mosquera and Steele (2017) discuss how Borderline Personality Disorder (BPD) patients on the dissociation spectrum are at times triggered by their relationships and abandonment issues into dissociation; the researchers explain at length how rehabilitating BPD patients and their social skills and helping them understand their triggers in terms of abandonment is pivotal for their regulation. This was also most apparent in the cases discussed with practitioners who mentioned patients with unhealthy social support networks (P2), or patients had been dependent on social support networks and lost them (P11). The impact of this loss had triggered destructive patterns of behavior including drug abuse and severer dissociation. Healthy social networks help patients lead healthier lives because they alleviate the negative core beliefs patients have about themselves and reinstate a sense of normalcy in their identities and lives (Kearney et al., 2016; Linehan, 2015; Sar et al., 2017). As all fourteen practitioners had commented, the main issue for DD patients is that they usually have very long histories of childhood abuse and they either find it difficult to believe anybody will be able to relate to them, or they find themselves within networks that really cannot show appropriate empathy, which in turn strengthens their negative core beliefs about themselves (Parry et al., 2018; van der Hart et al., 2017).
Thirdly, isolation, whether voluntary or involuntary (i.e. caused by the lack of a social support network and not because the DD patient in question chooses to be alone) does facilitate the occurrence of dissociation, as corroborated in all fourteen interviews (Dorahy et al., 2015; Mosquera & Steele, 2017). All the cases discussed showed that DD patients sought loneliness but never for the pleasure of it, rather for the familiarity of it, which goes to strengthen the two points made above about the early loss of support and how it impacts DD patients’ lifespan development in this regard. An important note here must be made: the onset of COVID-19 has worsened this for patients who depended on support groups like therapy groups, church groups, and occupational groups and interactions to feel grounded (Saltzman et al., 2020; Wild et al., 2020), as remarked by P14 and P10. The lock-down caused as a precautionary measure for the spread of COVID-19 is one of the manners in which DD patients found themselves in involuntary isolation and which has made coping significantly more difficult, according to Saltzman et al. (2020), Wild et al. (2020), and practitioners interviewed. This is an important variable worth investigating in future researches.
In terms of the theoretical framework devised for this study in the Literature Review and the results reported, further points are noteworthy: first of all, May’s (1959) claim that an inability to connect to one’s self will in turn denote an inability to bear loneliness or the lack of company, has held up indeed. Secondly, in terms of trauma reconsolidation and treatment, Alaryian’s (2019), and Kalsched’s (2017) claim that trauma must be faced and reconciled with in order for reintegration to occur, has also held up.
Addressing the first point: May (1959)’s premise in his book was meant to encourage people to understand the difference between solitude and loneliness, in an existential, philosophical sense. The ability to rejoice in solitude without feeling the emptiness of loneliness; being able to find one’s own company fulfilling (May, 1959). It is thus interesting to see the tie in between the existential psychological sense and the clinical understanding of the impact of loneliness on dissociation. What all participants in this research had agreed on was that DD patients in a sense were not missing the company of others as much as they were missing the company of their own selves. It has been mentioned repeatedly in the interviews that them missing their own selves was far more difficult to bear with than their missing members of their families or circles. An inability to connect to one’s self was a major code in the findings and usually denoted that even in the company of others this hollowness was not satisfied, which is the same conclusion May (1959) had also arrived at.
To that end, this addresses the second point: reconciliation of the trauma, which in turn strengthen sense of safety, lessens the protective layer placed on the patient’s main self-state or ego state, and lessens the dissociative cover between one’s outer experience in reality and one’s ability to be present in it (Alaryian, 2019; Kalsched, 2017; van der Hart, 2017). Reconciliation of the trauma is not always going to lead to reintegration, as all fourteen participants had concurred. At times, patients will not reconcile with traumas at all and grounding and symptom-management will be the only possible treatment plans (P6; P10; P13). In other cases, patients will reach a certain level of integration and will choose to stay at this level rather than progress further because their mechanisms are becoming adaptive rather than maladaptive and their ability to control them enables them to lead their lives freely and independently, as they choose to (P8).
While Alaryian (2019), Kalsched (2017), van der Hart et al. (2017) and the ISSTD’s (2011) guide all stress the importance of revisiting and reconciling with the trauma(s) endured in theory, practice is a different ground. As seen from the cases discussed with the participants, some patients will not be willing or able to revisit their traumas, depending on their severity and impact (P2). The point of this research, the point also made by all practitioners, is that treatment is supposed to help the patients reach and lead the lives they choose for themselves, not the lives they feel stuck with. Helping them develop social support networks, even if they never reach full reintegration, helps them regain a sense of normalcy and repairs negative core beliefs that hinder them from living the lives they would choose (Kearney et al., 2017; van der Hart et al., 2017).

Therapeutic Modalities

Lastly, in terms of the therapeutic modalities best suited to help DD patients experiencing loneliness or an inability to connect to others, the literature is at odds with what fourteen practitioners have advocated. Most research reviewed in the Literature Review (Blankenship, 2017; Cusack et al., 2016; Mosquera & Steele, 2017; van der Hart et al., 2017) has advocated for cognitive therapies (CT) in addition to the three-phase approach disseminated by the ISSTD (2011) for the treatment of DD patients. Therapy as a theme and objective of this research is relevant to the perceived impact of loneliness on dissociation because it ties into the cycle in Figure 2 above. Therapy helps patients stabilize and subsequently introduces the skills training necessary to aid them in building/maintaining social support networks to lessen their discomfort and lessen their dissociative coping mechanisms. Thus, the best modalities to aid patients in recovering was an important factor to look into in the interviews.
The ISSTD’s (2011) guide gives a strong brief on all research conducted on modalities that have shown effectiveness with DD patients. It mostly recommends psychodynamic-oriented psychotherapy, but with elements of CT to help patients recover from stress responses or ‘phobic reactions’ to certain stimuli (ISSTD, 2011). But the ISSTD (2011) does make an important distinction relevant to the findings of this research as well: it advocates the use of CTs to help patients alter negative core beliefs they develop as a result of their traumas. This claim in itself strengthens the points of discussion made above about how early trauma causes DD patients to garner core beliefs that impact their ability to connect to the world and their own selves, and is a precursor to their sense of loneliness and its impact as a trigger on their condition. In a sense, their negative core beliefs hinder them from even connecting to their own selves, because they did not have the opportunities to expose themselves to social networks that would disprove these core beliefs for them. In the same manner that CTs such as CBT and DBT (Beck & Beck, 2011; ISSTD, 2011; Linehan, 2015) advocate, these patients never expose themselves enough to the outer world to test the veracity of these core beliefs.
Participants advocated trauma-based modalities such as EMDR, Internal Family Systems (IFS), Parts Therapy, Interpersonal Neurobiology (IPNB) in addition to psychodynamic-oriented treatment and techniques for multiple reasons. First, using CTs was found to be too triggering for DD patients, and exposure in the sense of lessening phobic reactions only strengthened the dissociative mechanism at times (P1; P4; Whalen-Lipko, 2018). According to a study by Whalen-Lipko (2018), exposure therapy is sought less by PTSD victims regardless of many researches showing its effectiveness in treating PTSD. More interestingly, women with traumas of rape and sexual abuse were less likely to be willing to use exposure therapy for treatment of their PTSD (Gutner, Gallagher, Baker, Sloan, & Resick, 2016; Whalen-Lipko, 2018). Gutner et al. (2016) also conducted a study on PTSD victims and their willingness to undergo cognitive therapies in general, and found that 39 percent of patients dropped out of therapy by mid-treatment. Furthermore, since DD is based on complex trauma, patients at times were not insightful enough to know that they had faced trauma, and this is especially apparent in complex DID patients that are able to split and switch between self-states without knowing (P1; P5; P7; Parry et al., 2018; Schimmenti & Caretti, 2016). Therefore, using CTs would not be effective since they are not conscious of their disorder nor the trauma. As P4 had stated, patients tend not to be aware or ‘present’ in their frontal cortexes at times of dissociation, they are more present in lower levels of their bodies; which is why body-based and somatosensory-based techniques and modalities are more effective when grounding and stabilizing DD patients (Blankenship, 2017; Cusack et al., 2016; ISSTD, 2011).
Trauma-based modalities, for the most part, are more effective at regulating stress responses and helping patients revisit painful, complex traumas without causing them to dissociate (Bongaerts, van Minnen, & de Jongh, 2018; P4; P11), though at times, even trauma-based modalities can cause patients to become triggered (P12). The lack of comprehensive research and trials in this area is a huge limitation. It is a limitation in terms of discussing the results of this research and it is a limitation in terms of setting forth a comprehensive guide for trauma and dissociation practitioners.
Trauma-based modalities are key in the first phase of treatment for DD patients, grounding, and remain key throughout treatment in keeping them stable (Blankenship, 2017; ISSTD, 2011; P4). Trauma is regarded as being held in the body, rather than consciously in the mind (P4; P12; van der Kolk, 2014), which is why stimulating certain senses can trigger patients and why these modalities target them in treatment (P13). Furthermore, stimulating their senses, or mindfulness, is one of the most common methods practitioners use to keep patients grounded and help them remain grounded (ISSTD, 2011; Manfield, Lovett, Engel, & Manfield, 2017; P12; P14).

Limitations

Several limitations require outlining in this research. First, having more than ten out of fourteen participants discuss cases all diagnosed with DID somewhat thwarts the validity of the data in terms of looking at the full spectrum of dissociation. The data gathered mostly refers to DID dissociative mechanisms such as switching between self-states, and does not equally address other dissociative mechanisms such as derealization, depersonalization (DDD) or dissociative amnesia, or OSDD. Since the sample of participants chosen was randomized, and so were the cases chosen for discussion during the interviews, this was not a variable intended to be accounted for in this research.
Much of this section and the one before have referred to patients’ core beliefs as being pivotal in understanding the impact of loneliness on dissociation as a coping mechanism. While this is true, since it is a fact taken into consideration by any practitioner in any clinical setting about any patient they are working with, it was not an official variable that this research intended to investigate.
Lastly, while using a qualitative design for this research was intended and did yield rich data in the manner anticipated, conducting a quantitative version of this research can raise the reliability and validity of the findings. Qualitative designs are difficult to replicate because different participants will understandably have different views and approaches to the issue discussed. Furthermore, different researchers are likely to come up with different codes and analyses, which is a major challenge in thematic analysis designs and affects test-retest validity and reliability (Roberts et al., 2019).

Ethical Challenges

In terms of the research’s validity, bias must be accounted for due to this study’s design and topic. Participants were randomly recruited. Participants all had different experiences to share with different patients. Yet, when asked to choose a case of theirs to discuss, the majority of participants tended to choose DID patients over other DD patients, and thus the findings may show bias in terms of how loneliness impacts DID patients over other DD patients. This bias is present in the literature reviewed as well, and for future considerations and studies, researchers must narrow down their research focus to one dissociative disorder if they wish to explore the significance of the perceived impact on a certain type of dissociative mechanism.
A possible ethical challenge unforeseen was perhaps neglecting the fact that some mental healthcare professionals have histories of mental illness themselves. And while they have taken great steps to working on themselves and helping others in their capacities as practitioners, speaking about their own mental illness history naturally may trigger them. While they participate in this research knowing the implications, this is an ethical challenge that must be addressed in general and in future research endeavors. Ensuring appropriate resources are available to aid these practitioners should they feel triggered and need this help and/or request it is pivotal.