In reality, the issue is much more complicated with DD populations and
there are numerous variables affecting one another. Of the fourteen
participants interviewed, the majority were speaking of the DID
population primarily. Only two or three discussed Otherwise Specified
Dissociative Disorders (OSDD) or DDD diagnoses, such as derealization
and depersonalization, and whether loneliness indeed had a perceived
impact on dissociation as a coping mechanism for those patients. In
itself, this was one of this research’s limitations, since the research
was looking at dissociation as a coping mechanism and not at the
specific diagnoses of DD and their interplay in the matter. To that end
though, regardless of the type of DD patients were diagnosed with, all
the cases discussed showed that loneliness indeed was a “hallmark” of
the disorder; that there is always a sense of “lonelier in crowds,”
regardless of their type of DD, as one of the participants had termed
it.
All participants agreed that social support networks were necessary to
DD patients, because they can keep them grounded to themselves and to
their reality. Yet, most also agreed that without a sense of safety in
those networks, they found themselves only feeling lonelier amongst
those networks, and withdrawing or self-isolating more often than not,
which would in turn cause them to turn to dissociating as a means of
finding safety.
The eighth participant’s (P8) was the main interview that showed
positive anomalies in the data gathered. Through having a safe
attachment to a partner, the case study of a young woman suffering of
DID managed to make considerable steps in reintegration and finding
safety in being out in the world, which is to say, through alleviating
her sense of loneliness, she was better able to recover and lead a
healthier life. Several other case studies discussed with other
participants showed considerable positive steps when they were safely
attached, or when they were in safe, supportive close relationships with
partners, allowing them to counter long histories of abuse and
correlating negative core beliefs. On a similar note, being in abusive
relationships, especially after childhoods of abuse, were more likely to
worsen the use of dissociative coping mechanisms (see Glossary for
clarification). Part and parcel of having safety in relationships was
for patients to be able to feel understood and empathized with, for them
to feel like self-expression of themselves or their self-states was not
going to be met with hostility, lack of understanding, or bullying. In
some severer cases, practitioners interviewed discussed how their
patients’ disorders was at times used against them so close members of
their circles could take advantage of them.
In a case discussed with P6, identity was a major issue for his patient.
This was an implicit theme in all the other interviews as well, but
emerged more in the form of core beliefs that patients held about
themselves and others, rather than in the term ‘identity’ specifically.
An interesting and important part of the discourse held with P6 was as
follows:
I think young people… I think because they haven’t been in
the pathology as long and because they’re more neuroplastic, I think
they do better more quickly than somebody who’s my age[mid-forties] and has really built a life and an identity
around the struggle with the pathology. You know, there’s more
consequences to getting better… there’s always consequences to
improvement.
People with chronic illnesses tend to “coordinate” their whole lives
around their illnesses, as P6 pointed out. This ties in with their core
beliefs about themselves and their core beliefs about how the world and
others are going to perceive them and treat them. In terms of the first
theme, Social Support Networks, this is a major variable. This variable
connects to their inability to express themselves, to their inability to
believe even in genuine relationships, to feel that they deserve them
when their long histories of abuse have taught them otherwise. This also
connects to the theme of Loneliness as a Trigger, because it causes DD
individuals to seek the familiarity of being dissociated, of being
disconnected. It holds no comfort for them, but the familiarity of the
mechanism holds a maladaptive sense of safety. Because their neural
pathways have been wired to initiate an extreme response under duress,
the fastest way for DD patients to find comfort in stressful
environments or situations is to dissociate, as explained by P5 in the
following excerpt:
They’re not really equipped to deal with the trauma, so they get
overloaded; it becomes too much for them and they disconnect. And
consequently, one of the things we work with, it’s what to do when you
feel overloaded, too much stress on you, too many things happening…
And within that, their loneliness goes up, they’re disconnection from
people, and then there, what they end up doing is doing dissociative
processes such as that not feeling quite real, that not feeling like
they really connect to anybody and they aren’t really here, that they
don’t feel like they have any connections to people other than in
trauma.
The final theme, Therapy, was one of the main objectives of the
research; to identify which therapeutic modalities and techniques from
experience tend to be more effective in treating the use of dissociation
as a coping mechanism, and what are the recommendations of practitioners
specialized in treating trauma and dissociation. Therapy is a major
factor in the perceived link between loneliness and dissociation because
it mitigates the use of dissociation and enables patients through skills
training to develop social networks that subsequently keep them
grounded. While this will be discussed more at length in the Discussion
section, it is noteworthy that on the one hand, all the recent
literature in the field discussed in the Literature Review points to the
use of cognitive therapies (CT) and exposure to desensitize dissociative
patients from their stress responses. On the other hand, though, data
gathered from participants in this research seldom advocated the use of
exposure therapy or techniques with DD patients and favored other, less
cognitive in-nature techniques and modalities for treating them. When
asked why they were against exposure therapy and/or CTs in general,
there was a general consensus amongst participants that the
aforementioned modalities tend to work on a level of trauma that most DD
patients are not equipped to handle yet. Where exposure exercises were
recommended, practitioners made it a point to emphasize their use with
caution and with small issues that were not likely to trigger patients
heavily, such as having them grow more accustomed to being outdoors
through activities like having lunch at a restaurant, and riding the
bus, for example (P8).
In terms of having them reconcile their traumas, the root causes of
their DD, practitioners interviewed mainly advocated EMDR, Parts
Therapy, and psychodynamic approaches among others. Those three were
mentioned in every interview and discussion conducted on the matter. As
most of them pointed out, the traumas these individuals endure before
developing DD are immense and intricate in nature, and usually occur at
a very young age (before the age of six) when the patient has not yet
developed a stable sense of self or identity, which is a core
identification of DID. Another reason why the participants interviewed
did not recommend the use of CT is because of their belief that the
stress response wired by the trauma in these patients is not a conscious
cognitive task in nature; it happens in the body before the patient can
become aware of it at times, which is the reason why dissociative
mechanisms, once developed, are never really discarded. Using the
processes advocated by CBT for instance to attempt and break these
triggers down can be too difficult and triggering for these individuals
at times when parts of the trauma cannot be recovered or are hidden.
With recurring complex trauma and PTSD, attempting to use a cognitive
approach may cause severe somatosensory flashbacks in some severe cases.
This is why almost all participants advocated for grounding, and
following the three-phase approach advocated by the ISSTD (2011). One
participant, P14, mentioned that with DD patients, grounding is the
primary phase patients remain in and come back to, even after the other
two have taken place:
…for that first stage of grounding; which include
journaling, which can be very, very helpful for people to see what their
triggers are so they can deal; grounding and stabilization is key, at
first, and then you get into that second phase, where memories arise and
frankly a lot of mourning has to take place. Sometimes, as the woman I
was consulting with said, “You stay in phase one forever; grounding and
calming and you help people live better…”
Grounding DD patients helps them maintain a well-regulated system that
can identify and deal with stress adaptively, before the response
becomes too severe and initiates a dissociative mechanism. Grounding
them also includes enabling them with skills to lead meaningful lives
without being too hindered by their disorders; in this sense, social
support networks are one of the ways that help patients stay grounded
and fends off the trigger of loneliness. Social support networks, as
participants have discussed, can allow patients to regain a sense of
normalcy, safety, and value in their lives, when those networks are
genuine and nurturing. Participant 9 remarked that they always rejoice
when their patients are in codependent relationships that are not
abusive, because they feel safe knowing their patients are unlikely to
be abandoned and retriggered, since abandonment is usually at the base
of all childhood trauma in one form or the other, and is one of the main
triggers DD patients find difficult to defuse:
What I do like, is when they have a significant other and it turns
out the significant other is codependent. I’m like, “Yeah! ((exclaims
excitedly)) All right, that means that this person is going to stay, is
going to help me keep them safe, ‘till we get through all this.”
In fact, one of the ways DD patients tend to lose ground, so to speak,
is by self-isolating, because the lack of need or opportunity to
interact with others or with their surroundings gives them space and
enables them to dissociate back to safety. In one case discussed with
P2, she described a patient of hers who would withdraw into his room
away from his wife and children for days on end when his somatosensory
flashbacks became too severe and he could not function in the outer
world and was dissociating, or switching between self-states too
frequently. This was an example of a case that would lose their
grounding often and never managed to regain a satisfactory level of
stability while living with their disorder. This was also a case where
even having a family was not enough to help them stay grounded, mainly
because the patient’s partner was not able to empathize nor understand
his disorder, and only tended to exacerbate his inability to connect to
his own self, children, or others.
While other psychotherapeutic modalities have been mentioned by
participants and briefly included in Table 1, the methodology of these
practices and the theory behind them were not discussed during the
interviews. Modalities such as Parts Work, Internal Family Systems
(IFS), Emotional Freedom Technique (EFT), Interpersonal Neurobiology
(IPNB) (see Glossary) are all used as alternative manners of helping
patients recover and face their traumas without overloading their
systems with stimuli that can initiate a severe stress response. These
modalities are all focused on helping trauma patients recover and are
directed at mechanisms and techniques to help with trauma over other
mental illnesses or disorders. Whether or not a practitioner was likely
to use one of these modalities depended on their training and
educational background.
Lastly, the therapeutic alliance was a major topic of discussion in all
of the interviews. Every practitioner interviewed emphasized greatly the
impact of a safe therapeutic alliance on patients and their abilities to
heal and subsequently form successful relationships modeled on that
therapeutic alliance. Most of the practitioners interviewed also
emphasized that part of creating a safe therapeutic alliance for DD
patients was to be genuine with them, to be able to move away from the
traditional cold, analytical stance of the therapist and more into
becoming and showing their ‘true selves’ to the patients to help them
create trust. In part, this meant that the therapist had to be flexible
in the techniques they used with the patients and their approach to the
issue, rather than simply follow a modality to the letter blindly and
try to mold the patient into it. Furthermore, this also meant that
therapists had to respond to the patients’ needs. Several practitioners
mentioned that their patients were resisting treatment, perhaps being
only invested in venting rather than following a process, and while that
may seem counterintuitive, the practitioner had to respect and allow the
patient to do what they needed to do.
One important point made in all interviews was the importance of the
topic. All practitioners interviewed admitted that the impact of
loneliness on the use of a dissociative mechanism was indeed noteworthy
and important to consider when treating DD patients. All practitioners
also began finding patterns between how therapy was attempting to
enhance DD patients’ lives through helping them re-establish positive
and unconditionally supportive social networks, which explains how the
four major themes intertwine together to answer the research question.
Through enhancing these social support networks and helping patients
model healthy relationships in relation to their therapeutic alliances,
loneliness is alleviated and connection to one’s self can be brought
about through projection and mirroring. Consequently, connection to
others is made when these techniques can be successfully conducted with
others allowing DD patients a safe space to express themselves and their
experiences, no matter how different or difficult to relate to they may
seem. Finding safety and security in relationships is a major factor
contributing to lessening the use of dissociative mechanisms.