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To Prepare

  • Review this week’s Learning Resources on dissociative disorders.
  • Use the Walden Library to investigate the controversy regarding dissociative disorders. Locate at least three scholarly articles that you can use to support your Assignment. 

The Assignment (2–3 pages)

  • 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.

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Controversy Regarding Dissociative Disorders

Holly Bowling

Walden University

NRNP 6665: PMHNP Care Across the Lifespan I

Dr. Pamela Mokoko

May 3, 2021

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Controversy Regarding Dissociative Disorders

Dissociative disorders (DD) are mental health disorders, such as dissociative identity

disorder (DID), dissociative amnesia, or depolarization/derealization disorder that involve the

disruption of one or more mental functions, such as memory, identity, perception, consciousness,

or motor behavior (Sadock, Sadock, & Ruiz, 2015). DD comes with many controversies, myths,

and ethical issues that the advanced practitioner must take into account when treating individuals

with such disorders. The following paper will discuss specific controversies and professional

beliefs associated with DD, as well as strategies for maintaining therapeutic alliance and legal

and ethical considerations when treating clients with DD.

Controversy Surrounding Dissociative Disorders

There is much evidence to support the relationship between dissociation disorders (DD)

and psychological trauma, especially cumulative and/or early life trauma. Some might endorse

that dissociation produces fantasies of trauma and that DD is artefactual conditions produced by

iatrogenesis and/or socio-cultural factors (Loewenstein, 2018). Other controversies are stemmed

from the anxiety evoked by unsettling clinical presentation seen with DD, which may be similar

to some clinicians’ emotional reactions to psychiatric emergency patients. There is also a dispute

over the meaning of observed symptoms of DD, and whether they are a unique and subtle set of

core symptoms and behaviors that some clinicians do not see when it is before their eyes, or as a

willful malingering cause of symptoms created by the other clinicians who think something is

there that is not (Loewenstein, 2018). A final controversy is a fear that criminals will “get off”

without being punished by a gullible justice system, which attributes behavior to another

personality and does not hold the perpetrator responsible (Loewenstein, 2018).

Professional Beliefs About Dissociative Disorders

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There are many myths and misconceptions about dissociative disorders that remain to be

settled, including that they are a fad that is dying, that they are rare, that they are iatrogenic other

than trauma-based, that they are the same entity as a borderline personality disorder, and that the

treatment is harmful to the patients (Brand et al., 2016). However, research has shown that there

is a growing evidence base for DD that exist, and that patients are consistently identified in

outpatient, inpatient, and community setting across the world (Brand et al., 2016). Studies have

also shown that Dissociative Identity Disorder alone was found in approximately 1.1%-1.5% of

representative community samples, making it inconsistent with the myth of being rare. There is

little evidence to suggest the DD are iatrogenically produced, and there have been no studies to

support a fantasy model of dissociation. However, there is much evidence to support a strong

association between trauma-dissociation and individuals with DD. Researchers have found

documented evidence of dissociative symptoms in childhood and adolescence in individuals who

were not assessed or treated for DID until later in life, as well as finding documentation of severe

child abuse in adult patients diagnosed with DID (Brand et al., 2016), therefore suggesting DD

are typically trauma-based and not iatrogenically produced. There is a close correlation between

DD and Borderline Personality Disorder (BPD), and they do commonly co-occur, and

approximately 25% of BPD patients endorse symptoms suggesting possible dissociated

personality states, and 10%–24% of patients who meet criteria for BPD also meet criteria for

DID (Brand et al., 2016). However, patients with DD showed greater self-reflective capacity,

introspection, ability to modulate emotion, social interest, accurate perception, logical thinking,

and ability to see others as potentially collaborative (Sar et al., 2017). Individuals with DD have

also shown to have more traumatic intrusions, greater internalization, and a tendency to engage

in complex contemplation about the significance of events, as well as consistently using a

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thinking-based problem-solving approach unlike those with BPD (Sar et al., 2017), therefore

showing a significant difference between DD and BPD. Along with several other studies, the

Treatment of Patients with Dissociative Disorders study reported that in over 30 months of

treatment, patients showed decreases in dissociative, posttraumatic, and depressive

symptomatology, as well as decreases in hospitalizations, self-harm, drug use, and physical pain.

It was also reported that patient functioning increased significantly over time, as did their social,

volunteer, and academic involvement, and that patients with a stronger therapeutic alliance

evidenced significantly greater decreases in dissociative, PTSD, and general distress symptoms

(Lowenstein, 2018), therefore showing inconsistency with the myth that treatments are harmful

to DD patients.

Strategies for Maintaining the Therapeutic Relationship

The standard of treatment for those with Dissociative Disorders is psychotherapy,

therefore selecting the appropriate therapist is crucial in developing a therapeutic alliance

(Subramanyam et al., 2020). There are a few other ways the therapist can maintain a therapeutic

relationship with the client. One way is to have a fund knowledge of DD, including clinical

features, psychodynamic aspects, and formal training in DD to be able to accurately diagnose the

type of DD and start an early and appropriate treatment plan (Subramanyam et al., 2020).

Cronin, Brand, & Mattanah (2014) brought out that an affective bond, agreement on goals, tasks

between the therapist and client, as well as the importance of genuineness, flexibility, and ability

to truly listen to a patient as key factors in maintaining a therapeutic relationship. They also

brought out that early patient reports of alliance strength are predictive of the strength of alliance

at the end of treatment, a finding that indicates that the alliance is relatively steady over time

(Cronin, Brand, & Mattanah, 2014).

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Legal and Ethical Considerations

There are a few legal and ethical concerns that must be taken into consideration when

treating those with dissociative disorders. The safety of both the client and practitioner must

stand as a primary concern (Ducharme, 2017). The practitioner must acquire clinical competence

in this area and remain up-to-date with the current research. Transference and

countertransference are a couple of other issues that will more than likely arise and therefore,

consultation or supervision will be an important factor when interviewing patients with DD

(Ducharme, 2017). As advanced practitioners, we must also understand the limits of our

professional competence and the need to provide services, teach and conduct research with

populations and in areas only within the boundaries of our competence (Ducharme, 2017).

Conclusion

In conclusion, dissociative disorders disrupt mental function, and if not treated quickly

and adequately, can cause prolonged suffering and disability in those with DD. Recognizing

controversies and beliefs about DD can help compound the economic cost associated with DD

due to lack of recognition and inappropriate treatment. Many strategies can be utilized in

maintaining a therapeutic relationship and maintaining an alliance over time. And the most

important aspect when considering legal and ethical issues should be the safety of not just the

patient but the practitioner as well.

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References

Brand, B. L., Sar, V., Stavropoulos, P., Krüger, C., Korzekwa, M., Martínez-Taboas, A., &

Middleton, W. (2016). Separating Fact from Fiction: An Empirical Examination of Six

Myths About Dissociative Identity Disorder. Harvard review of psychiatry, 24(4), 257–

270. https://doi.org/10.1097/HRP.0000000000000100

Ducharme, E. L. (2017). Best Practices in Working With Complex Trauma and Dissociative

Identity Disorder. Practice Innovations, 2(3), 150–161. https://doi-

org.ezp.waldenulibrary.org/10.1037/pri0000050

Elisabeth Cronin, Bethany L. Brand, & Jonathan F. Mattanah. (2014). The impact of the

therapeutic alliance on treatment outcome in patients with dissociative

disorders. European Journal of Psychotraumatology, 5(0), 1–9. https://doi-

org.ezp.waldenulibrary.org/10.3402/ejpt.v5.22676

Gentile, J. P., Dillon, K. S., & Gillig, P. M. (2013). Psychotherapy and pharmacotherapy for

patients with dissociative identity disorder. Innovations in clinical neuroscience, 10(2),

22–29.

Loewenstein R. J. (2018). Dissociation debates: everything you know is wrong. Dialogues in

clinical neuroscience, 20(3), 229–242. https://doi-

org.ezp.waldenulibrary.org/10.31887/DCNS.2018.20.3/rloewenstein

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Sar, V. M., Alioğlu, F. M., Akyuz, G. M., Tayakısı, E., Öğülmüş, E. F., & Sönmez, D. (2017).

Awareness of identity alteration and diagnostic preference between borderline personality

disorder and dissociative disorders. Journal of Trauma & Dissociation : The Official

Journal of the International Society for the Study of Dissociation (ISSD), 18(5), 693–709.

https://doi-org.ezp.waldenulibrary.org/10.1080/15299732.2016.1267684

Subramanyam, A. A., Somaiya, M., Shankar, S., Nasirabadi, M., Shah, H. R., Paul, I., &

Ghildiyal, R. (2020). Psychological Interventions for Dissociative disorders. Indian

journal of psychiatry, 62(Suppl 2), S280–S289.

https://doi.org/10.4103/psychiatry.IndianJPsychiatry_777_19

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5

Dissociative Disorder

Monica Castelao

Walden University Dr Hopkins

Aug 1, 2022

Dissociative Disorder

Controversies that Surrounds the Disorder There are three primary controversies that are often attached to dissociative disorder. First, dissociative identity disorder (DID) attracts debate on whether it has iatrogenic influences. 1
 However, the existing body of empirical evidences does not support such a conclusion, though iatrogenic influences may play a significant role in the presentation and manifestation of this mental health problem. The second controversy related to how sufficient its diagnostic criteria are. Many psychiatrists and psychologists hold the view that DSM-IV and V may elicit over diagnosis. As a consequence, there is a need for health care professionals to perform diagnoses using clinical interviews and assessments. 1
 The third controversy emanates from the memory processes of DID patients. 
In that respect, controversies over whether psychogenic amnesia for sexual abuse patients exist, or are the repressed memories of sexual abuse resent false memories that are unintentionally induced by an overzealous therapist. 
2
 More specifically, clinical data and experimental laboratory findings do not often cover this problem (Bailey et al., 2019). 
1
 The massive amnesia for traumatic events that are clinically reported in dissociative disorders have not yet been replicated in empirical and laboratory studies, while memory research indicate that false memories can be established in the laboratory.

My Professional Beliefs about the Disorder There are various professional beliefs that I hold about dissociative disorders. First, the problem occurs when people feel detached from themselves and the world around them. For instance, they may feel separated from their body as though the world around them is unreal (Bailey et al., 2019). 3
 Dissociation is one of the ways in which the mind copes with too much stress, including the outcomes of a traumatic event, such as war or death of a loved one (Martinez et al., 2020). People who detach themselves from the real world for a long time may develop dissociative disorders. (Ganslev et al., 2020) Rather than the problem being something that one experiences for a short time, it may escalate into a far more common issue, and as such, is normally becomes the main way that people respond to stressful experiences.

Strategies of Maintaining Therapeutic Relationship with Patients The strategies of maintaining therapeutic relationship should be aimed at building a therapeutic alliance with patients. First, the therapist should develop an affective bond, which incorporates an agreement on the goals and tasks that should be accomplished between the therapist and the client (Ganslev et al., 2020). Additionally, it is important to show genuineness, flexibility, and capacity to truly listen to the patient. In that respect, such a process should strengthen alliance strength and be predictive of the strength of alliance at the end of the treatment. Individuals who undergo different forms of abuses are likely to have challenges in developing trusting relationships later in their lives. Thus, building trust should be the focus of a therapist since it goes a long way in alleviating symptoms as the patient’s state of the mind may not be easy to explore. As the treatment progresses, the therapist should examine the client’s unconscious conflicts that may be a cause of maladaptive functioning. This can help to reduce resistance, which emerges during the therapeutic procedure.

Ethical and Legal Considerations DID patients may pose many ethical and legal challenges to health professionals These problems stem from the capacity for medical decision-making. Since the patients present with different personality states, it would not be easy to determine their suitability to adhere to medications and the clarity of their judgment (Rocchio, 2020). In such a case, the ethical concept of patient self-determination should be weighed against their ability to make sound treatment decisions. Moreover, the patient may have shifting views, beliefs, and moral principles based on the changes in their mental states as they detach themselves from the real world (Rocchio, 2020). These problems can result in conflicting choices as to the appropriateness of the pharmacological interventions to be used.

References

Bailey, T. 4
 D., Boyer, S. 
M., & Brand, B. L. (2019). Dissociative disorders. In Diagnostic interviewing (pp. 401-424). 5
 Springer, New York, NY.

Ganslev, C. 6
 A., Storebø, O. 
J., Callesen, H. 
E., Ruddy, R., & Søgaard, U. (2020). 6
 Psychosocial interventions for conversion and dissociative disorders in adults. 
Cochrane Database of Systematic Reviews, (7).

Martinez, A. 7
 P., Dorahy, M. 
J., Nesbit, A., Palmer, R., & Middleton, W. (2020). 7
 Delusional beliefs and their characteristics: 
A comparative study
between dissociative identity disorder and schizophrenia spectrum disorders. 
Journal of Psychiatric Research, 131, 263-268.

Rocchio, L. M. (2020). 8
 Ethical and professional considerations in the forensic assessment of complex trauma and dissociation. 
9
 Psychological injury and law, 13(2), 124-134.

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