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.