A Call for a Holistic View of Dissociation in Psychiatry
Text by Lea Rebecca Minow (Freie Universität Berlin)
© Rebecca Eisele
She constantly looked at the floor. Sometimes closing her eyes while talking. Even though we were already sitting together for some time she didn't look into my eyes. I knew it wasn't about me. The atmosphere was tense. Darkness outside. The constant sound of cars passing by. The sometimes-recognisable vibration of the neon tube light. I had done my best to make this office a nice, welcoming place where people would feel comfortable to talk. But as we were sitting there, both of us not knowing what to look at, this seemed ridiculous. No nice room could ever make it easy to talk about living a life with trauma. My project was challenging her and me. Talking about how it feels, what living with trauma means. Talking about the unspeakable. To a stranger.
“You know … when I’m away, and then come back, that hurts. And I can’t tell anyone about that. People would just look at me. […].” Pause. She looked at me hesitantly. “I know the feeling. I know what you’re talking about.” I said slowly. Silence. A feeling of relief spread in the room.
While doing research on the sensory worlds of traumatised female bodies in Berlin, dissociation often became a topic. This was almost always an important moment. It happened in different ways. Some people sped up in their narration to get through it faster, some hesitated. It was not the centrality of dissociation to my research that lent these moments their significance. I had not even planned to focus on dissociation. It was more about the change of atmosphere that occurred. A little moment of ease. Release, once dissociation was on the table, no longer hidden. And at the same time, there was no necessity to explain oneself once it became clear that I knew what we were talking about – through experience. As soon as I made clear that we were sharing this experience, a big step was made. This was not only because talking about alternative states of consciousness is difficult, vocabulary-wise. I came to realise that it was because of stigma. The stigma was present in the room because of mental illness, because of trauma and, very explicitly, when it came to dissociation. Stigma sat in on our conversation. Making it heavier than it already was. And stigma was sent out of the room when it became clear that we were sharing this experience of dissociative states. And even though it often knocked, again and again, moments without it came up - precious and important moments.
Starting from experiences - experiences from my fieldwork as well as my personal experiences - in this essay I want to refer back to existing research on the phenomenon of dissociation. Subsequently, I will discuss these findings in the face of the lived realities. The contrasting findings will lead me to a critical view on dissociation and an outlook on dealing with dissociative states in Euro-US-American society.
An Alternative State of Mind and its Very Different Conceptualisations
While talking about dissociation in Euro-US-American contexts mostly means talking about mental illness, dissociation is a cross-cultural phenomenon, found in different forms and contexts around the world. Experiences of dissociation range from often unrecognised short periods of absorption in everyday life - like highway hypnosis or daydreaming - through more intense and longer-lasting experiences of depersonalisation or derealisation - for example in the context of mediumship or trauma - to even deeper experiences that may cause profound shifts in identity - e.g. Dissociative Identity Disorder or spiritual breakthrough. The Anthropologist Christopher D. Lynn (2005) attempts to visualise this range. Even though Lynn emphasises that his visualisation is "very indiscrete" and highly "oversimplified" (ibid. 39), the figure “The Dissociation Continuum” gives an idea about the wide range and the complexity of the phenomenon and ways to experience it.
Figure 1. The Dissociation Continuum (Lynn 2005, 17)
Dissociative states are shifted states of consciousness (Seligman & Kirmayer 2008, 33) or alternative states of consciousness (Lynn 2005, 20). Light versions of dissociation have been described as "absorption-intense focal concentration and cognitive involvement in one or more aspects of consciousness" (Butler 2006, 46). In this state, phenomenological content other than the attentional object may not be experienced and therefore the whole context of the situation may be experienced differently. Let's take the example of daydreaming. Even though you are in a certain context and maybe even performing an action, you may forget about what surrounds you and focus on your imagination. Sometimes your memory of the situation may be absent or altered: for example, your perception of time may be different for that situation. In other words, such states of alternative perception in lighter or more intense versions share traits such as difficulty recalling the time period or experience (Seligman & Kirmayer 2008, 41).
To access this phenomenon, Transcultural Psychiatry and Psychological Anthropology take into account social, psychological, psychobiological and neurobiological factors. Dissociation here is defined as:
“… the product of normal processes that regulate flow of attention and information related to things such as social role performance and discursive practices related to the self. [D]issociation is a type of cognitive resource-management strategy that is sometimes socially marked and sometimes not. Thus, dissociative experiences may be highly socially scripted, yet have a neurobiological substrate that is not ‘merely’ socially scripted, and can occur in forms that are independent of, contradict, or subvert social scripts” (Seligman & Kirmayer 2008, 33).
While different cultures vary in how or if they frame dissociative states, the ability of individuals to become absorbed also varies within one culture (Luhrmann et. al 2010, 74). Dissociation is found mainly in response to acute stress or trauma, in rituals and healing practices and as an everyday experience that mostly happens spontaneously and without being recognised - unless it is in line with local systems of meaning (Kirmayer & Seligman 2008, 32). It is assumed that the psychophysiology of dissociation is the same, no matter in which context and in which intensity dissociation occurs (ibid.). To approach the complex phenomenon of dissociation we must also take a look at how different factors work together. The complex interaction between emotion, cognition and the behavioural environment can be seen as the ongoing process of self-regulation (Damasio 1994). This process coordinates the distribution of attention, as well as cognitive and information processing resources. To make sense of our world, we interpret and attribute meaning to what happens around and inside of us. We do this through the cognitive and discursive capacities our social-cultural surrounding provides (Seligman & Kirmayer 2008, 49-50). There are then constant and mutually reinforcing links between meaning, practice and experience - biological processes included (Seligman 2018, 423).
“Hence, dissociative experiences of all kinds are likely to be the product of a ‘bio-looping’ process in which patterns of attention and information processing create experiences that must be explained by cultural scripts, and cultural scripts and social imperatives, in turn, influence the allocation of attention and information processing resources” (Seligman & Kirmayer 2008, 50).
“[These bio-loopings or feed-forwards are] process[es] in which the mechanics of bodies are affected by learning and experience, and the characteristics of particular bodies in turn shape the ways in which they come to learn from and embody experience.” (Seligman 2018, 421-23).
There are mainly two disciplines working on the phenomena of dissociation: Psychiatry and Anthropology. Although it has been proven that there are normative states of dissociation in everyday life that most people do or did experience (Butler 2006), both disciplines generally have focused, and still do focus, on extreme forms of dissociation (Lynn 2005). Psychiatry looks at dissociation with a focus on mental illness and its clinically significant forms – currently particularly in the context of trauma – and concentrates on its psychological functions and neurobiological mechanisms. The experience of dissociation is presumed to be a product of the functional triggering of underlying neurological mechanisms. Dissociation in this context is mostly a phenomenon of pathology. This perspective tends not to take into account the social dimension of dissociative experience, which has consequences for the subjective perception of an individual experiencing dissociative states (Seligman & Kirmayer 2008, 39-42). Even though it has been found that how the experience is culturally categorised has a huge effect on the individual (Lynn 2005, Seligman 2005).
In anthropology, the dissociation phenomenon has mainly been worked on under questions of social meaning and discursive function in special cultural settings focusing on trance, healing or possession (Ong 1988, Boddy 1988 et al). While these approaches tended to ignore knowledge from psychiatry (i.e. the emotional dimension) and neuropsychology, more recent works from the (psychological) anthropological field and the interface of anthropology and psychiatry develop and work with more holistic and so-called integrative approaches to dissociation (see above), trying to integrate knowledge from different fields (Luhrman 2010, Seligman & Kirmayer 2008, Lynn 2005, Seligman 2005).
Experiencing Dissociative Realities or What it Means to Have Extreme Dissociative Experience in the Euro-US-American Context
Reading about the integrative view on dissociation we must not forget about the fact that there is a huge difference between the experience of dissociation causing deep distress in a person and the experience of this state as positive. No matter what the distress causes, it often defines the experience as hurtful. In the Euro-US-American psychiatry discourse, dissociation is commonly a pathologised experience. Even if cross-cultural research might have attributed a more differentiated view and practice (e.g. DSM V (American Psychiatric Association 2013a, b)), my argument goes further. Resulting from my experience, I now know that I dissociated from a very young age. A phenomenon which at that time was often helpful, sometimes pleasurable, and most of the time unrecognised. Only later, when I had to deal with severe trauma again in adult life, did dissociative episodes become hurtful. They started to frighten me. The feeling of losing control brought on by episodes of amnesia, and this unusual perception of my life was almost unbearable. Add to that, the shame raised when I realised that no one around me could explain what was happening. I remember feeling a sense of release when it happened that a trauma specialised psychologist was present once when I dissociated, and she did recognise the situation. Usually, no one would know what was going on, and would be irritated by my lack of reaction or inability to recall things that just happened. So, I felt a huge release when she explained to me that there was a concept for what happened to me and that she knew strategies to handle such situations or to even reduce them. I learned about dissociation as an adaptive behaviour in traumatic situations, which later became maladaptive because my system was "falling back" into the past event due to triggers, and not because of "truly" being in danger. So, what I was experiencing was in the eyes of a professional "not normal", even very unhealthy (but explainable through the psychiatric concept of trauma) - had to get rid of it. The message was clear, and I accepted it. In other words, I accepted the psychiatric-adaptive view and the accompanying valuation of what happened to me. So did the women I worked with during my research. Dissociation often became a topic. The vocabulary of pathology, distress, and shame ruled the conversation. This was because we all experienced huge distress in the context of dissociation. The cause of distress cannot be reduced to the experience of an alternative state of consciousness but is entangled with the experience of behaving in a way that is not socially accepted, not socially scripted, or scripted as mental illness. Within this essay, I do not want to relativise any experienced distress or pain. My point is that in a society where the dissociative phenomenon is seldom scripted out of psychiatry, the psychiatric discourse and praxis becomes a very powerful and dominant narrative. Being confronted with this powerful narrative during my research, I had the opportunity to question this well-established “truth”. An opportunity that was out of my reach at the time I first had to face this narrative.
When I say the psychiatric discourse is powerful, I mean that it is not simply the only accessible framework for dissociative phenomena, but the psychiatric explanation also becomes reality for affected persons - and it is a stigmatised one. This hurts even more.
We know that less extreme forms of dissociation are ordinary (Butler 2006). We also know that if a person perceives their own situation as negative, the chances to heal reduce. From cross-cultural research we learned, that extreme dissociative states have very different meanings for, and effects on, people, depending on the cultural context. For example, the Anthropologist Rebecca Seligman found that in Candomblé in Northern Brazil, dissociative states may contribute to turning a life full of distress and loss into a more positive one: when people are initiated in the healing practice, experiencing dissociative states which are highly socially scripted (Seligman 2005, 2018). Seligman found that this engagement may increase people’s capacity to effectively regulate their state of arousal (e.g. state regulation) (Seligman 2018, 429) which means that this contributes to healing and (mental) health (Seligman 2018, 432). In addition, her findings show that the meaning assigned to dissociation may change the experience of dissociation itself (Seligman 2018, 28-32). Hence, the context and effects of this cross-cultural phenomenon are extremely diverse.
Even though it is very difficult to change a culturally shaped discourse like the psychiatric-adaptive narrative concerning dissociation, which underlie profound cultural convictions like for example a self-discourse which does not allow gaps of recall (Kirmayer & Seligman 2008, 41), or the belief that dissociation is intertwined with trauma (ibid, 35-36), it is possible. Looking at the dynamic nature of how sickness is perceived and how diagnosis is practised (Thesing 2017), and at the same time recognising, that in this globalised world steps towards holistic and transcultural understandings of sickness and wellbeing (e.g. Transcultural Psychiatry) have been made, I argue that if we would start to talk differently about dissociation in the psychiatric context, we can change the societal and individual perception and therefore the experience of dissociative states. Again, this is not about the relativism of distress. This is about how completely and in which words dissociative states are explained to those who are most affected by them, which are the patients. Firstly, I believe that knowing the phenomenon of dissociation is similar to daydreaming or other ordinary states people without trauma experience in everyday life, which are in these forms often perceived as a positive capacity, is very important. This knowledge simply moves dissociation from the category of inherently "abnormal" to potentially "normal", with more or less extreme forms. Thus, dissociation can be discussed not only in the context of illness but also in the context of the ordinary and even in the context of well-being. Hence, dissociation is positioned inside societies, which means the phenomenon is seen as a part of a dynamic and interacting network and is not placed outside of a society and its narratives (as illness or the abnormal often is). I do not argue that the whole psychiatric discourse around dissociation is about abnormality, however I argue that this is often what reaches patients through psychiatric practice.
I deeply believe that changing this discourse would help to calm down the negative spirals in patients’ realities, which begin with, “I am not normal” or “I am about to go crazy”, which - in the context of sickness - turn out to have negative consequences. A practised integrative view on dissociation would create a non-pathological vocabulary, words with which we, in the Euro-US-American context (including psychiatrists, psychologists, patients, and other people), can talk about dissociation. This act of transforming dissociation from a very severe psychiatric sickness into, first of all, a human capacity, and a phenomenon that may be everything from helpful, pleasurable, or fascinating to hurtful and unendurable - depending on severity and context - has the potential to change how dissociation is perceived and experienced. When we have the possibility to talk about this alternative state of mind in neutral words, more research can be done about the experience of dissociation, since the possibility to neutrally talk about it before it is pathologised becomes an option. Instead of only having access to concepts of pathology as explanatory models, dissociation and experiencing dissociation can be discussed in a more detailed and differentiated way.
Conclusion & Outlook
If talking in terms of disciplines we can conclude that the self-image and tools of anthropology tend to consider dynamics of a society and looks at ambivalent events or experiences but also at (positively) scripted forms of dissociation and its societally relevant functions and motivations, whereas psychiatry focusses on the individual and a definition of illness. The benefit of the holistic view I’m arguing for is to take into account the socio-cultural dimension of dissociation and to question the ascribed meanings of the phenomenon, which would lead us to a less pathologised account from the outset on. A holistic view also takes into account the individual experiences of such ascriptions and meanings as neurobiological processes. This account has the potential to be of great benefit for individuals experiencing dissociative states, which is in my opinion one of the main purposes for research on dissociation. The integrative view is therefore a fruitful one, which holds the possibility to positively influence the experience of extreme states of dissociation. Hence, access to this approach must be taken into psychiatric practice.
This claim fits into the ongoing debate about the dimensional diagnostic model in psychology and psychiatry which is being discussed for its suitability to replace the present categorical diagnostic (Boateng & Schalast 2011, Hopwood et al 2018).
American Psychiatric Association. 2013a. Highlights of Changes from DSM-IV-TR to DSM-5. Accessed December 2, 2019. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Changes_from_DSM-IV-TR_-to_DSM-5.pdf.
American Psychiatric Association. 2013b. Diagnostic and statistical manual of mental disorders fifth edition: DSM-5. Washington: American Psychiatric Publishing.
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Butler, Lisa. 2006. “Normative Dissociation.” Psychiatric Clinics of North America 29:45-62.
Hopwood, Christopher et al. 2018. “Commentary. The time has come for dimensional personality disorder diagnosis.” Personality and Mental Health 12:82–86.
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 Translation from German to English.
 The term “Euro-US-American society” is to be viewed critically as there is no homogenous Euro-US-American society. I do refer to the dominant cultural discourse in Europe and the U.S. and especially to the reach of psychiatry as it developed in Europe. And do so as most of the literature I refer to does also apply the term.  “The continuum of dissociation is very indiscrete. This representation is purely to provide visual reinforcement to the idea of a continuum but is grossly oversimplified. There are many problems with such a model: all forms of dissociative behavior vary in intensity and frequency from person to person and therefore vary in their position on this continuum; there is much overlap among dissociative behaviors which is not represented here; and the order here is subjectively determined. I have little to no expertise with any of these behaviors personally and have positioned them based on impressions from the literature cited. “Alzheimer’s disease and schizophrenia involve an organic disintegration of self- awareness (Gallup et al. 2003) that may involve the same or related mechanisms in the right prefrontal cortex as dissociation. These are, however, irrevocable changes in neural pathways, as opposed to all other forms of dissociation. Allisonian MPD involves such severe trauma and marked dissociation that the victim cannot func- tion. Allison (1996, 2005) does not recognize the DSM-IV-TR (American Psychiatric Association 2000) definition of DID. He recognizes truly multiple personalities, rather than mere dissociated identities, but only in circumstances of severe develop- mental trauma before the age of seven. The trauma was such that the victim had a real, immediate, and terrifying fear of being killed in the course of physical and/or sexual abuse. DID can be as severe as Allisonian MPD but can also be diagnosed in functional people who suffered trauma though not necessarily abuse. Amok, Pissu, Zar, falling-out/black out, Hsieh-ping, Uqamairineq, Latah, and Nangiarpok (kayak anxiety) are just a few examples of culture-bound syndromes involving dissociation. (Hughes 1985b). Soul journeys is a generic term for shamanic trances, which vary cross-culturally and in intensity. Glossalalia is the “speaking in tongues” of Penta- costalism (e.g., Goodman 1972, 1988). Hypnosis, shock/post-traumatic stress disorder, self-deceit, and meditation vary in their forms and intensity. Phosphene Eye-Pressing is the technique utilized in the Central Highlands of Irian Jaya (now Papua), Indonesia to achieve a meditative state during shamanic activities (Hampton 2005, personal communication). Creative expression is another generic term to describe meditative, trance, or absorption experiences encountered through dance, music, painting, and other creative or artistic pursuits. Selective attention and retention is unconsciously filtering information so only acceptable information consciously received and recalled. Absorption is focused attention, as when engrossed with tele- vision, music, a book, driving, etc. to the exclusion of other stimuli. Daydreaming is essentially the opposite of absorption; it is attention focused inward instead of out- ward based not on interest in one external stimulus but disinterest or excess of exter- nal stimuli. Anxiety and depression are an inability to partition internal information or detrimentally thorough and accurate self-awareness” (Lynn 2005, 39-40).  I do mainly refer to dissociation in the context of trauma as personal experience as research experiences were often framed in this context. Still my argument also speaks to other forms and contexts of dissociation as diagnostic is dynamic and experiences often cannot be categorized by diagnostic manuals.