Dear NESTTD Members and Supporters:

There is almost always some serendipity in the timing of the columns for this newsletter: Today, I am writing the President’s Column while simultaneously preparing a workshop entitled "Dealing with Dissociative Phenomena in the Everyday Therapy of Traumatized Patients" to be given at the Psychological Trauma Conference in Boston on March 22-24. This is a subject near and dear to my heart, and, as I was writing this, I began to ask myself WHY I feel so passionate about teaching therapists that dissociation is not a freak, low-incidence disorder, that it is not always pathological, that it can a significant feature in the psychological landscape of many high-functioning patients and even many patients who come in the door without clear-cut histories of trauma. On the other hand, it is also true that children and adults do not learn to rely on dissociation as a defense except under abnormal circumstances. It is just that, when abnormal circumstances are part and parcel of every day experience, dissociation is the healthy alternative to unbearable states of hyperarousal and to the knowledge of unbearable truths. It may also prove true that dissociation is the best vehicle for avoiding or titrating connection to frightened or frightening caregivers, as Liotti and Main have observed in their attachment research. I teach my dissociative patients that dissociation acts like a circuit breaker system in the brain: whenever they reach stimulus overload or are in states of stimulus deprivation, they will dissociate as a way of self-regulating—with better and worse consequences depending on the situation. For example, I plan to depend upon dissociation when I present my workshop in March! How else could I detach from my anxiety and quivering knees to focus intently on the message I want to convey?

I ask myself again, "Why does it feel so important to teach therapists about the subtle, everyday manifestations of dissociation in patients who do not have diagnosable disorders?" Because the "soft signs" of dissociation are very difficult to recognize without training, because most therapists are not educated about dissociation as either a mental ability or a defense, and because dissociation has been so pathologized that clinicians are reluctant to recognize and name it unless they are absolutely certain that the patient has a dissociative disorder. But there is more to it even than that. Without therapist and patient recognizing the impact of dissociative symptoms or dissociative defenses, the resulting problems become pejoratively labeled as "resistance" or "procrastination" or "difficulty making decisions" or "poor memory" or "borderline splitting" or "bad temper." One patient who came this week for a consultation described her failure to succeed in an Anger Management class to which she was sent by her therapist. She was so relieved when I laughed and said, "Of course, no wonder it didn’t work! What part of you went to the class? I’ll bet it wasn’t the part of you that has the angry outbursts!"

One of the values inherent in dissociative disorders work that I treasure most is the emphasis on finding the adaptive value in every symptom, in every aspect of self, no matter how apparently self-destructive or maladaptive. When dissociative symptoms are not recognized as such and instead are given generic labels, the opportunity to understand their adaptive value is diminished or lost. We tend not to ask about what was once or is now the adaptive value of procrastination or chronic problems with decision-making or memory lapses. But working in a dissociation model even with patients who have dissociative symptoms, not disorders, allows a much more creative approach. Having identified the stuck issue with my consultee as undiagnosed DDNOS or Complex PTSD with significant dissociative features, she and her therapist can begin to explore with more curiosity and mindfulness what those anger states are all about. Strictly speaking, they are not about anger management; they are about angry states in response to other feeling states in response to dissociated past traumas. Together, the consultee and I identified a "domino effect" in which being treated in an angry or critical way at work or at home triggers fear states followed almost instantaneously by anger states which are hidden behind compliant behavior at work but emerge explosively at home. (I do not need to tell you anything about her trauma history: you "know" some of what happened to her just from this one vignette.)

So, thank you for giving me this opportunity to clarify what I want to say next week. It really is a message about how an understanding of dissociation helps us to appreciate what is "right" in our patients, rather than focusing on what is "wrong." It helps us to be mindful about looking for hidden strengths as well as hidden vulnerabilities. And it opens up new possibilities for growth and change inherent in being able to see old things in new ways.

president@nesttd.org