CSAR

What Are We Talking About When We Talk About Dissociation?

by Daniel Hill

Confused about what people mean when they use the word ‘dissociation’? You’re not alone. Dell (2009) notes that the definition of dissociation “has never suffered from clarity.” Clinicians use the same term to refer to a bewildering array of disparate phenomena. Researchers and theoreticians bemoan the lack of an agreed- upon definition. The good news is that there is now considerable consensus among traumatologists that there are two fundamental types of dissociative phenomena: compartmentalization and altered states of consciousness[1]. (Cardena, 1994, Putman 1997, Allen, 2001, Holmes et al, 2005, Meares, 2014, Spitzer et al, 2006). I found this definition, and distinction, enormously clarifying.

Compartmentalization involves the isolation of psychological structures. Dissociated self states, for example, are compartmentalized structures and have been extensively theorized — personality subsystems that are defensively kept at bay, until they’re not. Amnesia, for example, involves a compartmentalized psychological structure; specific memories are quarantined and inaccessible unless triggered.

Altered states of consciousness, on the other hand, are relatively neglected.   Although it is commonplace for psychotherapists to use the term “dissociated” to refer to moments in which they or their patients were “not themselves,” or “checked out,” or were not taking in reality normally, such altered states of consciousness have not received the same degree of attention in the psychotherapy literature. These states tend to be mentioned only in passing, often referring to periods of time in which we’re unable to process what is happening coherently.

The topic of pathologically altered states of consciousness is actually an old one, but much of our understanding of this subject seems to have been lost; a shame given how important it is. Such states are the subjective experience of our patients. We need to understand them in order to respond empathically. If we don’t attend to these experiences, therapeutic progress will be impeded.

Janet was the first to observe pathologically altered, trauma-related states of consciousness. He described them as “narrowed” and understood that they are the result of “vehement emotion,” which is to say they are the result of dysregulation. You can get a sense of the constriction he refers to if you think of your own state of consciousness when you’re dysregulated; e.g. while being defensive in a spat with your spouse. Consider the limited the range of your thinking and memories, and how tight the state feels. Perhaps most importantly, there is at such times a lack of the reflective functioning that goes along with a sense of a larger, more expansive state of consciousness; a state in which you can roam around. Think also of the degree of automation that takes over; you become relatively scripted, as if running some kind of algorithm.   Janet appreciated that automaticity accompanied narrowed states of consciousness; that without reflective consciousness we lose voluntariness.

Affect regulation theory adds to this. Along with being constricted, altered states of consciousness due to dysregulation may be hyper- or hypo-aroused. Each has profoundly different effects on subjective experience. For example, flashbacks and depersonalization-derealization are altered states of consciousness. The former occur in states of extreme hyper-arousal that generate full immersion — reliving experiences. The latter occur in states of extreme hypo-arousal that generate full detachment from experience. Such immersed or detached states come in moderate forms that generate partial immersion and detachment and that we encounter daily in our patients and ourselves. (I addressed moderately dysregulated states of consciousness in Affect Regulation Theory: A Clinical Model.)

The distinction between compartmentalization and altered states of consciousness is crucial as each of these forms of dissociation has different mechanisms requiring different therapeutic actions. Compartmentalization involves defensive processes (avoidance, denial, disavowal, etc) that isolate psychological structures as a bulwark against dysregulation. Amnesia, for example, involves the isolation of a memory which, if activated, would intrude into consciousness and dysregulate its owner.   Similarly, dissociated self states involve the sequestration of entire personality subsystems which, if activated, would expose dysregulating aspects of the self –usually shameful ones. Compartmentalization is thus the sequestration of psychological structures by psychological defenses aimed at averting dysregulation.

An altered state of consciousness, on the other hand, is the subjective experience of being dysregulated. It is generally understood that such states of consciousness are the result of dissociation at the neurological level; i.e. they occur when the neural systems subserving consciousness become disorganized/dissociated as a result of dysregulation. Due to the diminished neural integration, one enters a lower, less complex, constricted state of consciousness.

Thus, compartmentalization is a defense against dysregulation involving dissociation of psychological structures, whereas an altered state of consciousness is a symptom of dysregulation resulting from dissociation of neurological structures.

I vote that we use the term “dysregulation-dissociation” to refer to disorganization/dissociation at the neural level that manifests as altered states of consciousness, and that we use the term “compartmentalization” to refer to psychological structures that are isolated/un-integrated and kept out of consciousness as a defense against dysregulation.

With regard to the relationship between compartmentalization and altered states of consciousness, we can say this. When compartmentalization is working, well quarantined content is kept at bay; we remain regulated and experience a normal waking state of consciousness. When compartmentalization fails and a compartmentalized structure is activated, we become dysregulated, enter an altered/constricted state of consciousness and become automated.

 

Dan Hill, Ph.D.  is a psychoanalyst, educator and a leading proponent of the paradigm shift to affect regulation. In addition to his private practice he has taught courses for over 30 years at psychoanalytic and psychotherapy institutes. Dr. Hill is the author of the book  Affect Regulation Theory: a Clinical Model (Norton); other publications and presentations address topics ranging from the erotic transference and the clinical use of multiple models to the influence of the internet on psychoanalysis and the possibilities and limitations of video-mediated therapy. His most recent article addresses religious fundamentalism understood through the lens of affect regulation.  In 1996 he founded PsyBC, which in 2015 became the Center for the Study of Affect Regulation.   Dr. Hill is on the faculties of the National Institute of the Psychotherapies and the New York University Postdoctoral Program in Psychoanalysis and Psychotherapy. 

 

 

[1] See Steele et al (2009) for a dissenting argument.

 

References

Allen J.G. (2001) Traumatic Relationships and Serious Mental Disorders. 
New York: Wiley.

Cardena E. The domain of dissociation. In: Lynn SJ, Rhue RW (eds). Dissociation: Theoretical, Clinical, and Research Perspectives. New York: Guilford, 1994:15-31.

Dell, P. (2009) Understanding Dissociation. In Dell, P. and O’Neil, J. (Eds), Dissociation and the Dissociative Disorders: DSM-V and Beyond. New York, Routledge.

Holmes, E.A., Brown, R.J., Mansell, W., Mansell, W., Pasco Fearon, R., Hunter, E., Frasquilho, F., Oakley, D.A.. (2005) Are there two qualitatively distinct forms of dissociation? A review and some clinical implications. Clinical Psychological Review. 25, 1-23. New York. Routledge.

Meares, R. (2012) A Dissociation Model of Borderline Personality Disorder. New York, Norton.

Putnam, F.W. (1997) Dissociation in Children and Adolescents: A Developmental Perspective. New York, The Guilford Press.

Spitzer, C., Barnow, S., Freyberger, H.J. Grabe, H.J. (2006) Recent developments in the theory of dissociation. World Psychiatry 5, 82-86.

Steele, K., Dorahy, M., van der Hart, O., and Nijenhuis, E. (2009). Dissociation versus Alterations in Consciousness: Related but Different Concepts. In Dell, P. and O’Neil, J. (Eds), Dissociation and the Dissociative Disorders: DSM-V and Beyond. New York, Routledge.

 

 

 

 

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