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Controversy Associated With Dissociative Disorders

 

Dissociative disorders attract the most polarizing diagnosis in psychiatry due to controversies that have seen professionals take different sides on the existence of the condition. Dissociative dissociation refers to the disconnection of the integrated functioning of memory, consciousness, identity, of environmental perception (Sar, 2011). For example, dissociation in memory occurs when the mind compartmentalizes parts of the memory from normal consciousness. Thus, dissociative disorders are a class of conditions that have clinical syndromes that cause disturbance associated with the domains of dissociation (Sar, 2011). The categories include dissociative identity disorder, dissociative amnesia, dissociative fatigue, and depersonalization disorder. The condition is serious and causes significant impairment in a person’s life, limiting his/her capacity to hold employment or normal social life. Moreover, dissociative disorders occur alongside, as well as closely resemble other psychiatric disorders such as post-traumatic stress, schizophrenia, and others making it difficult to diagnose. Nevertheless, an accurate diagnosis is necessary to initiate an effective treatment to restore integrated consciousness.

Controversies on Dissociative Disorders

The first controversy with DD arises from the DSM-V diagnostic criteria, which some professionals do not agree with noting that it elicits overdiagnosis. Thus, clinicians must rely on a structured clinical interview to support diagnosis because the diagnostic criteria are inadequate. For instance, the most severe form of DD, dissociative identity disorder initially referred to as multiple personality disorder is considered by some critics as hysteria. Moreover, some professionals believe that the diagnosis of DID is iatrogenic influences (Lynn et al., 2012). This refers to a misdiagnosis of some sort based on the psychiatrist’s construction of the problem. For example, critics argue that the symptoms of DID become visible only after diagnosis meaning that they become existent only after the psychiatrist introduces the idea. Another controversy about the DID is lack of its existence in children. Yet the basis of the disease is traumatic childhood experiences. Moreover, some professionals argue that the earlier research purported to have been done on the condition turned out to be fictitious (Lynn et al., 2012). Finally, the connection of the disease with memory experiences also raises controversy. Critiques dispute the existence of repressed memories in patients who had a traumatic experience, for example, those who encountered sexual abuse. The argument about such existence is linked to the possibility of false memories created in laboratories to support the existence of the condition (Peters & Treisman, 2017).

My Professional Beliefs

In response to the controversies, researchers have been conducting studies to prove the existence and viability of DD, especially the most controversial DID. Thus, I believe there is overwhelming evidence to support DD as a condition as opposed to a hypnotic suggestion, social contagion, or misdiagnosis. A study examining empirical evidence on DID found out that it exists across a range of markers, but is rather complex to understand (Dorahy, et al., 2014). The researchers also evidenced that the condition is distinct from other psychological disorders. According to Dorahy, et al. (2014), the etiology of the disease is complex involving a mix of cultural factors, childhood trauma, and developmental issues. Similarly, Subramanyam et al. (2020) research confirms the existence of split-off mental compartments in people with DD and suggests psychological interventions that effectively help is restoring consciousness. Further, empirical evidence presented by links DID to cognitive, neurological, and interpersonal non-integration that arise from stressful childhood events. Thus, traumatic childhood-related abuse, attachment issues, neglect, and boundary violations explain DID.

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Strategies for Maintaining Therapeutic Relationship with a Client

According to Subramanyam, et al. (2020) the first strategy in working with clients that have DD is to understand the condition well. Being cognizant of the condition is essential during the assessment so that the diagnostic interview questions directly relate to the inquiry about the features of dissociation. This knowledge is critical because the training does not cover mental examination and diagnostic interviews relevant to the condition. Secondly, the therapist needs to establish a healthy relationship with the client to promote communication and cooperation, which is essential in psychotherapy involving DD (Subramanyam, et al., 2020). Thus, the mental health practitioner must apply empathy and other skills needed to build trust and rapport to promote a therapeutic relationship with the client. Another important strategy is to ensure the personal and emotional stability of the mental health practitioner. The treatment process in DD especially for patients with DID requires significant transference and patience because of the snail-paced progress (Subramanyam, et al., 2020). Transference can be quite demanding and wearing for the therapist thus needs the development of boundaries, but at the same time maintaining the element of care, which keeps the therapeutic relationship positive to enhance treatment success.

Ethical and Legal Considerations

In ethical considerations, the first objective is to facilitate client safety. Safety is a critical requirement when working with clients with DD because of the complex trauma experienced by these individuals. Secondly, when choosing a psychotherapeutic model, the practitioner must ensure that the option chosen is effective in integrating functioning (Ducharme, 2017). The core elements of the therapy model should be consistent with research findings regarding the neurobiology of attachment. Thus, the choice of model is important and individualized considering the diversity of clinical manifestations of DD characteristics in patients. Similarly, the possibility of psychotic breakdown during treatment is high in DD patients. thus, the therapist must be able to identify and address this to enhance effective treatment and safety of the patient. A complex occurrence in patients with DID is that one of the personality/identity presentations might be dangerous and capable of criminal activity (Ducharme, 2017). When the therapist learns of this, they need to inform the authorities especially when the identity threatens to harm a third party. The situation also presents an ethical dilemma for the therapist who will be torn between reporting the intended crime or protecting the other innocent identity(s). The ethical and legal issues include assessment of suicidal risk, confidentiality, privacy, and informed consent.

 

References

Dorahy, M. J., Brand, B., Şar, V., Krüger, C., Stavropoulos, P., & Martínez-Taboas, A. (2014). Dissociative identity disorder: An empirical overview. Australian and New Zealand Journal of Psychiatry, https://doi.org/10.1177/0004867414527523.

Ducharme, E. L. (2017). Best practices in working with complex trauma and dissociative identity disorder. Practice Innovations, 2(3), 150–161. https://doi.org/10.1037/pri0000050.

Lynn, S. J., Lilienfeld, S., Merckelbach, H., Giesbrecht, T., & der Kloet, D. (2012). Dissociation and Dissociative Disorders: Challenging Conventional Wisdom. Current Directions in Psychological Science, 21(1), 8-53. https://www.jstor.org/stable/23213120.

Peters, M. E., & Treisman, G. (2017). Dissociative Identity Disorder. Treisman, M.D., Ph.D., https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Psychiatry_Guide/787069/all/Dissociative_Identity_Disorder.

Sar, V. (2011). Epidemiology of Dissociative Disorders: An Overview. Epidemiology Research International, https://doi.org/10.1155/2011/404538.

Subramanyam, A. A., Somaiya, M., Shankar, S., Nasirabadi, M., Shah, H., & Paul, I. (2020). Psychological Interventions for Dissociative disorders. Indian J Psychiatry, 62(Suppl 2): S280–S289. doi: 10.4103/psychiatry.IndianJPsychiatry_777_19.

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