Understanding Dissociation: A Comprehensive Guide
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Introduction to Dissociation
Dissociation is a psychological experience of feeling disconnected from oneself or reality. Historically Janet, who studied hysteria and dissociative states using hypnosis, defined dissociation as a way that the mind compartmentalizes trauma (1889, as cited in Van Der Hart & Horst, 1989). Dissociation protects survival in cases of caregiver abuse by enabling "betrayal blindness”, where victims suppress awareness of the abuse to maintain attachment and safety (Freyd, 1996). Modern understandings of dissociation see it as a possible response to trauma, where fragmented memories or states emerge in addition to other mental and behavioural symptoms as adaptive survival mechanisms (Van der Hart, 2021).
Some therapists use a broad definition of dissociation, seeing it as a normal response to trauma rather than a sign of something “wrong.” This view, called the Trauma Model, sees dissociation on a spectrum—from everyday reactions to more severe forms—which many clients find less pathologizing (Loewenstein, 2018). However, this can clash with psychiatry’s more rigid model, which treats dissociation as a set of distinct, diagnosable conditions like the dissociative subtype of PTSD (PTSD-DS) or dissociative identity disorder (DID) (Loewenstein, 2018). In North America, our main diagnostic manual, the DSM-5-TR, uses terms like PTSD-DS to describe people who experience symptoms such as feeling detached from themselves or the world, on top of standard PTSD symptoms (APA, 2022). Because of these different models, a person’s understanding of their symptoms often depends on whether they seek help through medical professionals like psychiatrists or through therapists in the counselling field. The addiction field tends to align more with the medical system, but it may not always offer the same level of diagnostic depth or the consistent therapeutic support often available through private-practice mental health therapists (Marsh & Fair, 2006).
There is a huge lack of knowledge about dissociation, and those with these experiences may feel confused and not feel comfortable describing these experiences. This post aims to provide clear, accessible knowledge to those affected or interested in mental health.
Complex Trauma: A Missing Link
To make things even more confusing, North America doesn’t have an official diagnosis that clearly points to long-term childhood trauma as the source of a person’s difficulties. In Europe, there is a diagnosis called complex PTSD (C-PTSD), which many people feel describes childhood trauma more accurately than regular PTSD, because complex trauma refers to trauma that was ongoing, repeated, or long-lasting. Another issue is that some types of childhood abuse or neglect don’t meet the strict requirements for a PTSD diagnosis in North America, even though they can have serious lifelong effects. C-PTSD includes symptoms like trouble managing emotions, relationship difficulties, and a deeply negative sense of self—symptoms that aren’t part of standard PTSD. Research also shows that people with C-PTSD are more likely to experience dissociation than those with PTSD, suggesting that dissociation is an important thing to pay attention to when treating C-PTSD.
Our Strategies for Treating Dissociation
Catching the dissociative subtype of PTSD (PTSD-DS) early can help therapists create treatment plans that address both the trauma and the dissociation that comes with it. Trauma-focused therapies that use exposure—where clients safely revisit traumatic memories in a controlled way—have been shown to reduce PTSD symptoms even in people with PTSD-DS. Newer research also suggests that more intensive approaches, like a week-long version of Prolonged Exposure therapy, can be safe and helpful for people with complex trauma and dissociation. Still, no single treatment works for everyone, and responses vary from person to person.
Many clinicians lack training in dissociative disorders, leading to under recognition and underdiagnosis (Kumar et al., 2022). Practitioners may avoid trauma-focused interventions for fear of destabilizing clients or exacerbating dissociative symptoms (Zoellner et al., 2011). In a survey of PE training, many clinicians expressed concern that this treatment method would increase patient distress. Clinicians with a specialization in PTSD expressed less concern about using PE (Ruzek et al., 2014).
Treatments that focus on revisiting and processing traumatic memories, such as EMDR and Prolonged Exposure (PE), have been shown to be effective for PTSD and complex PTSD (Karatzias et al., 2019; Deacon & Abramowitz, 2004). Some research indicates that combining EMDR with exposure therapy is effective for people with the dissociative subtype of PTSD (PTSD-DS) (Van Toorenburg et al., 2020; Zepeda Méndez et al., 2024; Zoet et al., 2018). EMDR, when paired with grounding techniques to help clients stay present, can also reduce dissociation, including feelings of depersonalization and derealization (Bae et al., 2016). Reviews of PE suggest it can be safely used with people experiencing dissociation, substance use disorders, borderline personality traits, depression, and suicidal behaviour (Van Minnen et al., 2012). There is also some qualitative evidence that EMDR may help reduce alcohol and substance use in clients with PTSD and substance use disorders (Kullack & Laugharne, 2016).
Dispelling Myths and Reducing Stigma
Importance of Awareness: At Oceans Counselling, we emphasize education’s role in fostering empathy and informed support within communities. We promote sharing experiences to normalize dissociation and encourage help-seeking behaviors. Dissociation is not a sign of weakness or ‘faking it’. We promote evidence based treatment for trauma, complex trauma, and dissociation.
