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
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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