Literature Review
This literature review will discuss the pathology and etymology of
dissociation; the theoretical framework upon which this research is
built; and recommended treatment guidelines. Critique of the literature
reviewed will be the main focus of this chapter; the gaps in the
literature presented here are to support the research’s following
objectives: to explore if dissociative episodes or phases are triggered
in individuals as a result of loneliness; and, to identify strategies to
treat the trigger of loneliness. The gap in the literature presented
below has led to the dissertation’s main question: What is the
perceived impact of loneliness on the use of dissociation as a coping
mechanism?
Pathology and Etymology of
Dissociation
Dissociation in the shortest definition possible is the severe,
maladaptive form of avoidance a patient develops due to intense fear of
or inability to bear psychological pain (Schimmenti & Caretti, 2016).
According to research, dissociation stems back to childhood trauma
(Ducharme, 2017; Sar et al., 2017; Schimmenti & Caretti, 2016). Even if
it occurs for the first time in early adulthood, dissociation’s roots
are hypothesized by current research to have been planted since
childhood (Schimmenti & Caretti, 2016). This widely accepted theory
takes root in Bowlby’s (1973), who investigated how parental attachments
in early childhood shape a child’s lifespan resilience to environmental
pressures, or adversely, their predisposition to mental illness.
Sar et al. (2017) mention in their study that early direct
traumatization in life, such as when the child has to become the parent
to their parent(s) or for their own selves, is at times severe enough to
cause children to develop a dissociative mechanism to help them cope. To
children, lacking the stability and sense of security that comes from
having stable parental attachments is akin to feeling without safety at
all, at the mercy of their environment and acutely aware of their lack
of defenses should this environment attempt to harm them. This
anxiety-inducing sensation is capable of rewiring the child’s brain and
neurobiological markers to form mechanisms that lead to chronic lifelong
anxiety disorder, which underlies dissociative mechanisms (Kalsched,
2017). However, this is not to say that all individuals with abusive
childhoods develop a dissociative disorder or mechanism, and a factor to
be considered in this is the genetic predisposition to chronic anxiety
that plays a pivotal role in developing dissociation (Krause-Utz &
Elzinga, 2018). Environmental factors coupled with genetics can
sometimes overcome healthy parental attachments and individuals with a
genetic predisposition to chronic anxiety may foster dissociation as a
coping mechanism (Soffer-Dudek, 2014).
Theoretical Framework
The sources mentioned here as the theoretical framework amount to seven,
but only Dorahy et al. (2015) has looked at the direct link between
loneliness and dissociation. The other six sources included make
significant contributions in relevant areas that help sustain and
elaborate on the workings of such a relationship and how it can indeed
exist (Cacioppo, 2016; Kalsched, 2017; Kearney et al., 2016). May (1959)
is a part of this literature review despite it being a debatably
outdated source, and one with strong ideological underpinnings, because
it is the inspiration behind the researcher’s choice to look into this
topic, and one that posits an explanation of this perceived link between
loneliness and dissociation through an existential psychological
perspective; having made a reasonable assumption regarding loneliness,
identity, and the social interplay between both.
May (1959) predicted that at their time, the increasing technological
advances that were taking place were primary factors of the individual
neglecting the individualistic identity and by result, losing touch with
an inner part that made it possible for one to be alone but not
lonely—in other words, loss of awareness of the self-state. May (1959)
claimed that individuals could no longer stand solitude, and once they
were rejected from their social circles, were in danger of inner
fragmentation severe enough to cause a psychotic episode—depending on
how much they depended on social interaction to fill a ‘void’. From
afar, such a claim may seem existential at best and lacking sufficient
quantitative support. However, dissociation in itself, by testimony of
the literature reviewed, is just that—a loss of an ability to connect
to the ego, the perpetrator of executive function, the main judge
residing in one’s head (Alayarian, 2019; Kalsched, 2017). May (1959)
simply noted that this fragmentation became intolerable when vulnerable
individuals were left to their own devices, and this inspired the topic
of the current dissertation. The ego, when exposed to severe trauma and
in preparation of impeding death, is concealed and the individual is
left feeling like an empty shell (Cacioppo, 2016). Perhaps May (1959)
had built his reasoning on individualistic identity and its neglect in
modern society—a different cause to dissociation than the one explored
here—but his claim that loss of touch with one’s self is a terrifying
experience, at times leading to psychosis, cannot be neglected (Cernis,
Freeman, & Ehlers, 2020; Pearce et al., 2017).
Kalsched’s (2017) study makes significant contributions to the study of
ego and ego function in dissociation. Coming from a psychoanalytic
approach, Kalsched (2017) uses some emotive language and allusions to
make sense of trauma, such as his paper’s opening line: “Let your heart
break and drop the story” (Chodron, 2013, as cited by Kalsched, 2017,
p.475), which is a contradiction of traditional psychoanalytic practice
to use such humanistic language. Kalsched (2017), using psychoanalytic
theory, equates trauma to the ego hiding the ever-hurting child to
protect them from further blows, though this explanation is in general
supported by other researchers using other schools and approaches
(Alayarian, 2019; van der Hart et al., 2017). In an attempt to
demonstrate Kalsched’s (2017) theory visually surrounding the
reintegration of the self-state’s fragmented others, the researcher here
equates it to a circle; Kalsched (2017) is proposing that in order for
reintegration of self to occur, trauma must be faced and reconciled
with, which is exactly like a cycle. One must complete the circle, so to
speak, in order for one to return completely to one self-state.
The main critique the researcher has on Kalsched’s (2017) paper is that
though it is psychoanalytic in nature and terminology, Kalsched (2017)
is more or less advocating a cognitive behavioral approach of using
exposure to help the patient face the trauma and heal from it, though he
fails to specifically note that this is a cognitive behavioral approach.
In addition, many trauma clinicians and professionals actually denounce
using a cognitive behavioral approach with dissociation patients because
they firmly believe that the problem is not solely cognitive in nature,
and thus cannot be fixed through a cognitive approach, or at least notsolely , but that rather integrating the body in the process is
pivotal for recovery (van der Kolk, 2014).
Other researchers such as van der Hart et al. (2017) and Mosquera and
Steele (2017) offer more practical papers on the topic of dissociation,
where they attempt to aid clinicians by explaining the cognitive
behavioral mechanisms taking place in dissociation and proposing
treatment protocols. Though coming from different schools, all three
researches support the importance of guiding dissociation patients
towards revisiting the trauma and facing it in order to heal (Kalsched,
2017; Mosquera & Steele, 2017; van der Hart et al., 2017). The
researcher does wonder whether the three papers being published in the
same year is at all relevant to such different schools agreeing on one
approach to treating dissociation patients, or whether it is simply to
be in accordance with the International Society for the Study of Trauma
and Dissociation’s (ISSTD) protocol (2011).
It is worth mentioning here that the protocol published by the ISSTD
(2011) is focused on DID patients, and not other DD patients, unlike the
researchers discussed above, who are more focused on dissociation
ensuing trauma and relevant personality disorders. The main critique
here on both sources is that neither seem to be too concerned with what
happens if the agreed upon protocol fails; what happens if the patient
after considerable time does not show willingness to revisit their
trauma? What happens if they do revisit the trauma, become too
overwhelmed (even though stabilization has been thoroughly ensured) and
their dissociative state worsens? As discussed with participants, it
tends to fail and other protocols of treatment are usually adopted
instead to help trauma and dissociation patients, like EMDR (van der
Berg et al., 2015; see also Results and Discussion sections).
To their merit, Mosquera and Steele (2017) do well in outlining the
dissociative spectrum of BPD, which most research fails to focus on as
much as they do on DID. Even better, Mosquera and Steele (2017) do well
by outlining the different features of BPD, the dissociative versus the
non-dissociative symptoms and pathology. To newly-practicing clinicians,
this is invaluable and will go a long way in helping them better
identify what kind of issues their patients are facing, especially since
dissociative symptoms are not easily discernible. Similarly, van der
Hart et al. (2017) go to great lengths to explain the underlying
mechanisms that causes individuals to resort to dissociation, and the
significance of their contribution to the field is undeniable.
Kearney et al. (2016) attempted to identify whether trauma and
dissociation could be predictors of loneliness in a sample of college
students, and did so through a sampling of psychology major students,
surveying them online and running statistical analyses on the data
collected. While the source has been a strong part of the theoretical
framework, there are several concerns to it; firstly, the sample they
ran the assessments on was not necessarily composed of DD patients, even
though they screened for clinically significant symptoms of dissociation
and the results fell below their cutoff range. While the researchers ran
some strong assessments to screen for trauma and dissociative symptoms,
conducting a clinical interview to screen for the severity is
irreplaceable, especially since trauma does not always result in
dissociative symptoms, and having an episode of dissociation is not the
same as being a chronic DD patient (Swart, Wildschut, Draijer,
Langeland, & Smit, 2020). Thus, in terms of the data being a
determinant of anything to do with long-term DDs and the relationship it
has with loneliness, it cannot be taken into consideration in complete
faith.
However, it is important to note that through their study, trauma
patients were more likely to report feeling lonely, and that is not a
small finding to report (Kearney et al., 2016). Similarly, Dorahy et
al.’s (2015) research was one of the few that looked into a direct
relationship between loneliness and dissociation and had a significant
impact on the current dissertation. While their results corroborated
those of Kearney et al.’s (2016) and the rest of the literature reviewed
in that regard, there were some shortcomings to the sample they used as
well. First of all, their overall sample consisted of 73 participants
altogether; 36 were diagnosed with DID, 13 with chronic PTSD, and 21
with “mixed psychiatric presentations”. Furthermore, their sample
consisted of 11 males and 62 females, which furthers the issue of
unequal distribution especially since females are more likely to report
higher levels of dissociation and loneliness (Kearney et al., 2016; Şar,
2020). The small sample size coupled with unequal distribution between
diagnoses and gender causes an issue of reliability and validity of
data. Furthermore, effect size for such a sample would not be
encouraging and was not reported either.
Finally, Cacioppo (2016) focuses more on the implication of neuroscience
into the issue of dissociation and its relationship to loneliness.
Cacioppo (2016) argues that the temporo-parietal junction (TPJ) is a
pivotal brain region for sense of self, self-agency, and the ability to
integrate multisensory information to take place efficiently. Her paper
aims to introduce this neurological aspect of the brain into the
research on dissociation and loneliness and does a comprehensive job of
summarizing and evaluating all the information available on that with
neuroimaging, while giving a strong phenomenological explanation on the
matter of loneliness and what it is to be a dissociated individual; in
fact, Cacioppo’s (2016) take on loneliness for dissociated individuals
seems to corroborate May’s (1959), Kearney et al.’s (2016), and
Kalsched’s (2017) as well—to feel disconnected from self is to feel
disconnected from world because one is no longer certain there is a self
left to connect to anyone or anything else. The only shortcoming of
Cacioppo’s (2016) claim is that it does not attempt to introduce how
neuroimaging can help with the care of dissociative patients. How can it
be cost-efficient? How can clinicians rely on it to make better
judgements and follow better treatment plans? These are points that
would have added more to the practice and research on dissociation.
Recommended Guidelines for Treatment
of Dissociation
The ISSTD published a guiding paper on recommended treatments and
procedures to follow with patients diagnosed with trauma and
dissociation (ISSTD, 2011). The primary issue with the ISSTD’s (2011)
guidelines is that they mainly target DID treatment, and not the rest of
the dissociative spectrum. Though comprehensive in approach, the guide
aims more for breadth than depth—it introduces and summarizes all
practitioners need to know about DID beginning with its history and
pathology, to assessment procedures, socioeconomic factors to consider
when beginning treatment, and psychotherapeutic modalities that have
shown promise (ISSTD, 2011). The guide advocates for a phase-oriented
approach to DID, regardless of the psychotherapeutic modality chosen for
treatment. It calls on practitioners to focus on stabilization and
creating a safe environment for patients in the first phase; confronting
and helping patients integrate traumatic memories in the second; and,
working on identity reintegration in the last phase. As a guide
published by an official body aiming to regulate the study and treatment
of dissociation and trauma, this guide has influenced many researchers’
treatment guidelines in their own papers, such as Ducharme’s (2017), and
Kalsched’s (2017), who also advocate for the same phase-oriented
approach.
Mosquera and Steele (2017) produce solid guidelines on treating BPD
patients with comorbid DDs and outline the possible symptoms that could
be the underlying cause for dissociation such as triggers, affect
dysregulation, childhood traumas, Complex Traumatic Stress Disorder
(CTSD), and more. They do not outline a certain psychotherapeutic
modality, but they outline certain factors to be wary of, and how best
to tackle them with patients, which may be introductory in nature and
lacking depth, but is still one of the few sources that looks into
BPD-DD treatment plans.
Most of the literature on treating dissociation and/or trauma advocates
for CBT, cognitive therapy (CT), prolonged exposure therapy (PE), EMDR,
and/or stress inoculation therapy (SIT) (Blankenship, 2017; Cusack et
al., 2016). With the limitation outlined above taken into consideration,
Blankenship’s (2017) and Cusack et al.’s (2016) papers do make solid
contribution in reviewing trials of PTSD patients being treated with one
of the modalities outlined above, the limitations of the trial, the
effect size, and the strength of evidence in favor of the modality.
Cusack et al. (2016) report CT, CBT, and PE as being the modalities with
trials reporting the strongest evidence and effect sizes, and EMDR as
being of moderate effect size but having lower consistency and
certainty.
The primary limitation of the literature in regards to this section of
the review is the broad aspects of the dissociative spectrum, its
comorbidities, and crossing symptomology. Many researchers try comparing
and contrasting between different psychotherapies for treating a
dissociative disorder (Cusack et al., 2016; Blankenship, 2017) but the
issue here is that they are focusing on one dissociative disorder
or symptom. For example, BPD with dissociative symptoms/disorder should
follow a different treatment plan than a BPD comorbid depression
patient, than a BPD comorbid OCD patient, and so forth. Thus, to
advocate for one modality over another is probably an impossible task,
because each modality presents limitation for a certain population
exhibiting certain symptoms/comorbidities as opposed to another
(Blankenship, 2017; Cusack et al., 2016; Mosquera & Steele, 2017).