Controversy that Surrounds Dissociative Disorders

• Explain the controversy that surrounds dissociative disorders.
• Explain your professional beliefs about dissociative disorders, supporting your rationale with at least three scholarly references from the literature.
• Explain strategies for maintaining the therapeutic relationship with a client that may present with a dissociative disorder.
• Finally, explain ethical and legal considerations related to dissociative disorders that you need to bring to your practice and why they are important.

References x 4

 

• Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
  • Chapter 11, “Dissociative Disorders”

Dissociative Disorders: Controversy, Beliefs, Strategies, and Considerations

Dissociative disorders (DDs), encompassing dissociative identity disorder (DID), dissociative amnesia, depersonalization/derealization disorder, and other specified or unspecified dissociative disorders, are characterized by a disruption in memory, identity, or perception. These disorders often emerge as responses to traumatic experiences. However, they remain one of the most debated topics in psychiatry, with controversies surrounding their diagnosis, etiology, and treatment. This essay explores the controversies surrounding DDs, outlines professional beliefs about their validity, discusses strategies for maintaining a therapeutic relationship, and examines ethical and legal considerations for clinical practice.

Controversy Surrounding Dissociative Disorders

The controversy regarding dissociative disorders centers around their diagnosis and prevalence. Skeptics argue that DDs, particularly DID, are products of suggestibility and iatrogenesis rather than genuine conditions. The sociocognitive model posits that DID arises from cultural influences, media portrayals, or therapeutic suggestion rather than trauma (Kaplan & Sadock’s, 2022). Critics further highlight the lack of objective biomarkers, the variable prevalence across cultures, and concerns about overdiagnosis. Conversely, proponents of the trauma model argue that dissociative symptoms are adaptive mechanisms resulting from severe trauma, especially during childhood, as a defense against overwhelming experiences (van der Hart et al., 2006).

These divergent perspectives lead to challenges in identifying and managing DDs. The lack of consensus undermines research and influences the approach clinicians take toward treatment. For instance, practitioners skeptical of DDs may underdiagnose or invalidate a client’s symptoms, while overly credulous clinicians risk reinforcing pathological dissociation.

Professional Beliefs About Dissociative Disorders

From a professional standpoint, dissociative disorders are valid and complex psychiatric conditions that deserve careful evaluation and treatment. The trauma model aligns with extensive evidence linking DDs to early life trauma, such as physical, sexual, and emotional abuse (Boland et al., 2022). Neurological studies support the existence of dissociation by identifying structural and functional brain abnormalities in individuals with DDs, including alterations in the hippocampus and amygdala (Reinders et al., 2012). These findings reinforce the need to view dissociative symptoms as genuine, albeit misunderstood, manifestations of trauma.

Effective treatment requires an empathetic and trauma-informed approach that avoids pathologizing the client’s experiences. By acknowledging the lived reality of individuals with DDs and relying on robust diagnostic criteria, clinicians can foster understanding and provide effective care.

Strategies for Maintaining a Therapeutic Relationship

Establishing and maintaining a therapeutic relationship with clients presenting with DDs is critical, as these individuals often exhibit trust issues stemming from trauma. Key strategies include:

1. Building Safety and Trust: Establishing a safe and nonjudgmental environment is essential. Clinicians should validate the client’s experiences, listen actively, and demonstrate unconditional positive regard.
2. Maintaining Consistency: A predictable therapeutic structure fosters a sense of stability and trust. Consistency in session schedules and therapeutic boundaries helps counteract feelings of chaos or uncertainty.
3. Employing Trauma-Informed Care: A trauma-informed approach emphasizes understanding the impact of trauma on behavior and symptoms, thereby avoiding re-traumatization. Clinicians should remain sensitive to triggers and tailor interventions accordingly.
4. Collaborative Goal Setting: Involving clients in the treatment planning process enhances engagement and agency, empowering them to participate actively in their healing journey.

Effective communication, empathy, and flexibility are crucial when working with dissociative clients, as the therapeutic relationship often becomes the foundation for recovery.

Ethical and Legal Considerations

Ethical and legal considerations are paramount when working with clients with dissociative disorders. Key considerations include:

1. Informed Consent: Clients must fully understand their diagnosis, treatment options, and potential risks or benefits. Dissociative clients may struggle with memory or comprehension, necessitating clear, repeated explanations and opportunities for questions.
2. Confidentiality: Clinicians must ensure confidentiality, especially when working with clients who have experienced trauma, as breaches may exacerbate dissociative symptoms or erode trust.
3. Avoiding Harm and Exploitation: Therapists should remain vigilant against suggestive or leading techniques that could exacerbate symptoms or lead to false memories.
4. Competence and Continued Education: Practitioners must maintain competence by staying updated on research and best practices for treating DDs. Special training in trauma therapy and dissociation is often necessary.
5. Mandatory Reporting: Clinicians must balance confidentiality with their legal duty to report suspected abuse if clients disclose ongoing harm.

These considerations are crucial for ensuring ethical and effective care, fostering trust, and protecting the client’s well-being.

Conclusion

Dissociative disorders remain a controversial and complex aspect of psychiatric practice, with debates about their validity and origins shaping clinical approaches. Despite skepticism, substantial evidence supports their association with trauma and their impact on individuals. Clinicians must adopt empathetic and trauma-informed strategies to maintain a therapeutic relationship with clients presenting with DDs. Ethical and legal considerations, including informed consent, confidentiality, and ongoing education, further underpin responsible and effective care. By addressing these factors, clinicians can help individuals with dissociative disorders achieve greater stability and healing.

References

• Boland, R., Verdiun, M. L., & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
• Reinders, A. A., Willemsen, A. T., den Boer, J. A., & Vos, H. P. (2012). Evidence for altered neural mechanisms in dissociative identity disorder: A review. Neuroscience & Biobehavioral Reviews, 36(5), 1516-1533.
• van der Hart, O., Nijenhuis, E. R., & Steele, K. (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. W. W. Norton & Company.