Recent research underscores the critical importance of addressing both trauma and dissociation in treatment, particularly when dissociative symptoms are clinically significant. Meta-analyses reveal that while therapy-as-usual and non-trauma-focused therapies e.g. cognitive-behavioral therapy (CBT) can be beneficial, targeted approaches yield significantly better outcomes in the presence of dissociation.
Therapy-as-usual is effective, but if it does not directly work on these areas, it will not help sufficiently - and these areas often are barriers to therapeutic growth beyond a certain level - as is the case with untreated depresion, anxiety and other conditions.
Key findings from systematic reviews:
- Trauma-focused therapies: Cognitive Processing Therapy (CPT), Eye Movement Desensitization and Reprocessing (EMDR), and Prolonged Exposure (PE) demonstrate larger effect sizes compared to therapy-as-usual.
- Dialectical Behavior Therapy for PTSD (DBT-PTSD): Shows particular benefit for complex PTSD with borderline personality disorder (BPD) features.
- STAIR (Skills Training in Affective and Interpersonal Regulation): Effectively addresses emotion dysregulation and interpersonal challenges.
- Multicomponent approaches: Improve retention and engagement in treatment.
Clinical indicators that may benefit from specialized approaches:
- Significant dissociative symptoms
- Emotion dysregulation
- Interpersonal difficulties
- Comorbid BPD features
- History of childhood trauma
An important insight from recent research is that dissociation functions as a critical mediator between trauma and treatment outcomes. Without addressing dissociation, trauma symptoms may persist or worsen.
Detection and treatment of dissociation can lead to significant reductions in healthcare utilization, improved quality of life, and shorter treatment durations. Persistent dissociation at two weeks independently predicts worse three-month PTSD outcomes, beyond childhood trauma and current symptoms. Dissociation is also linked to impaired neurobehavioral decision systems affecting anxiety, depression, and stress regulation.
These findings suggest the necessity of early assessment and direct treatment of dissociation, positioning it as a gateway to effective trauma processing.
- Integrating fragmented "parts of the self"* is essential for healing from dissociation and achieving a cohesive identity. Key strategies include:
- Establishing Safety and Trust: Creating a secure environment allows individuals to explore and acknowledge different aspects of themselves without fear.
- Recognizing Internal Parts: Identifying and understanding the distinct subpersonalities or ego states, each with unique emotions and roles, is crucial.
- Facilitating Internal Communication: Encouraging dialogue among these parts fosters cooperation and reduces internal conflicts.
- Processing Traumatic Memories: Addressing unresolved trauma linked to dissociated parts helps alleviate their burdens, aiding integration.
- Promoting Self-Leadership: Cultivating a compassionate core self to guide and harmonize internal parts leads to unity.
- Harmonizing the Self System: Gradually integrating these parts into a cohesive whole acknowledges each part's positive attributes, resulting in a balanced identity.
- Incorporating these strategies can significantly aid in reducing dissociative symptoms and improving overall well-being.
* It is very important clinically and ethically not to over-reify the idea of "parts of the self". The individual is one person, in one body - without invalidating personal experience or foreclosing on therapeutic opportunities. The clinician is careful to avoid imposing one's own pre-conceived notions about how self is constructed and experienced, which attending to the best data we have. Iatrogenic harm is a real issue with misdiagnosis, overdiagnosis, and overpathologizing.
#TraumaInformedCare #Dissociation #ComplexPTSD #EMDR #DBTPTSD #ClinicalPsychology #MentalHealthTreatment #EvidenceBasedPractice #TraumaTherapy
References:
Karatzias, T., et al. (2019). Psychological interventions for ICD-11 complex PTSD symptoms. Psychological Medicine, 49(11), 1761-1775.
Coventry, P. A., et al. (2020). Interventions for PTSD and comorbid problems following complex trauma. PLoS Medicine, 17(8), e1003262.
Schnurr, P. P., et al. (2024). Management of PTSD and acute stress disorder: 2023 VA/DOD guidelines. Annals of Internal Medicine, 177(3), 363-374.
Hoppen, T. H., et al. (2023). Efficacy and acceptability of psychological interventions for adult PTSD. Journal of Consulting and Clinical Psychology, 91(8), 445-461.
Bohus, M., et al. (2020). DBT-PTSD compared with CPT in complex presentations. JAMA Psychiatry, 77(12), 1235-1245.
Kleindienst, N., et al. (2021). Treating dual diagnosis BPD and PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology, 89(11), 925-936.
Cloitre, M., et al. (2024). Home-based STAIR for women veterans with MST. Journal of Consulting and Clinical Psychology, 92(5), 261-274.
Maercker, A., et al. (2022). Complex post-traumatic stress disorder. The Lancet, 400(10345), 60-72.
Sele, P., et al. (2023). Comparing phase-based treatment, PE, and skills-training for CPTSD. Journal of Anxiety Disorders, 100, 102786.
Langeland, W., et al. (2020). The economic burden of dissociative disorders. Psychological Trauma, 12, 730-738.
Lebois, L. A. M., et al. (2022). Persistent dissociation and its neural correlates predict outcomes. American Journal of Psychiatry, 179(9), 661-672.
Basso, J. C., et al. (2024). Dissociation and trauma symptomatology linked to CNDS imbalance. Frontiers in Psychology, 14, 1317088.
Rüfenacht, E., et al. (2023). Addressing dissociation with trauma-focused mentalization-based treatment. Psychoanalytic Psychotherapy, 37(4), 467-491.
#Dissociation #MentalHealth #TraumaRecovery #CPTSD #PTSD #Anxiety #Depression #Healing #SelfCare #Mindfulness #EmotionalRegulation #SelfIntegration #TraumaHealing #MentalHealthAwareness #Therapy #SelfLove #Recovery #MentalIllness #ComplexPTSD #TraumaInformedCare