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:

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:

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:

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:

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.