Psychiatric Annals

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Stabilizing Patients With Dissociative Disorders: Practical approaches to acute management and treatment.

Victor Welzant, PsyD

Abstract

The treatment of patients with dissociative disorders and complex posttraumatic stress disorder (CPTSD) has advanced greatly in the past 2 decades. These syndromes typically are co-occurring and frequently lead to states of acute crisis naturalistically. Research, clinical consensus, and pragmatism have resulted in an understanding of the pathways by which healing may occur.

Innovations in psychotherapeutic technique also have provided a wider range of treatment options. Outcome data suggest that both clinical improvement and cost reduction may be accomplished by a phase oriented treatment, focused on dissociative symptoms, with an overarching goal of integrated functioning.1 This article focuses on the stabilization of acute presentations of both dissociative disorders and CPTSD.

Initial presentation of a dissociative disorder may include a wide range of concerns and symptoms that overwhelm both the patient and the clinician. It is not uncommon to encounter suicidality, affective disorders, self mutilation, eating disorders, and substance abuse as comorbid conditions, in addition to the dissociative and posttraumatic symptoms that are core diagnostic criteria for these conditions (Kluft, see page 633). Patients often present in crisis, which requires resolution before more definitive work on underlying conditions can be attempted.

The case of Ms. B is illustrative. A 29-year-old woman who received psychiatric treatment with several clinicians during a 6-year period, she has accumulated multiple Axis I and II diagnoses, including major depression, bipolar II disorder, borderline personality disorder, and alcohol dependence. She is seeking treatment with a new clinician due to increasing difficulty in managing her depressive symptoms and inability to function in her role as a high school math teacher.

In her intake session, Ms. B reports insomnia, depressed mood, chronic dysphoria, periods of amnesia for her behavior, and a 2-month history of self mutilation by cutting and superficially burning her arms when she is emotionally overwhelmed. She acknowledges periods of depersonalization that are aversive to her and during which she is uncertain if she is “alive or not.” She reports that self mutilation typically terminates these dissociative episodes. She also acknowledges periods of being overwhelmed by intrusive recollections of childhood sexual abuse, which have been occurring with greater frequency during the previous 2 months. Because colleagues have noticed a change in her usual high level of performance, she was encouraged to seek assistance.

Clinicians faced with such complexity often struggle to prioritize treatment goals and to maximize relief. A trauma-focused and informed treatment plan offers a common sense treatment sequence and prioritizes safety and functioning. It also may offer a patient with this constellation of symptoms a feeling of being understood and instill hope for healing.

Modern standards of care for the treatment of psychological trauma advise a “phasic” model of treatment in which the initial treatment goals involve stabilizing acute symptoms and establishing safety for the patient. The treatment of these more complex forms of PTSD and dissociative disorders has been addressed, most notably by Herman.2 As the degree of complexity of the posttraumatic response increases, it is recommended that a more structured and stage-oriented approach to treatment be used.

Herman's treatment model includes phases of establishing safety, remembering, processing, and mourning losses associated with traumatic events, and reconnection with one's social network and engagement with life's activities. A variety of therapeutic techniques and strategies are used to address the differing treatment foci of each stage, with an overall eclectic approach to the stage-oriented goals, grounded in a relational psychodynamic orientation. This model is based on the establishment of a therapeutic alliance that allows treatment to progress in a planned way, with collaborative goals at each stage. The stages are not discrete and do not proceed…

The treatment of patients with dissociative disorders and complex posttraumatic stress disorder (CPTSD) has advanced greatly in the past 2 decades. These syndromes typically are co-occurring and frequently lead to states of acute crisis naturalistically. Research, clinical consensus, and pragmatism have resulted in an understanding of the pathways by which healing may occur.

Innovations in psychotherapeutic technique also have provided a wider range of treatment options. Outcome data suggest that both clinical improvement and cost reduction may be accomplished by a phase oriented treatment, focused on dissociative symptoms, with an overarching goal of integrated functioning.1 This article focuses on the stabilization of acute presentations of both dissociative disorders and CPTSD.

Case Presentations

Initial presentation of a dissociative disorder may include a wide range of concerns and symptoms that overwhelm both the patient and the clinician. It is not uncommon to encounter suicidality, affective disorders, self mutilation, eating disorders, and substance abuse as comorbid conditions, in addition to the dissociative and posttraumatic symptoms that are core diagnostic criteria for these conditions (Kluft, see page 633). Patients often present in crisis, which requires resolution before more definitive work on underlying conditions can be attempted.

The case of Ms. B is illustrative. A 29-year-old woman who received psychiatric treatment with several clinicians during a 6-year period, she has accumulated multiple Axis I and II diagnoses, including major depression, bipolar II disorder, borderline personality disorder, and alcohol dependence. She is seeking treatment with a new clinician due to increasing difficulty in managing her depressive symptoms and inability to function in her role as a high school math teacher.

In her intake session, Ms. B reports insomnia, depressed mood, chronic dysphoria, periods of amnesia for her behavior, and a 2-month history of self mutilation by cutting and superficially burning her arms when she is emotionally overwhelmed. She acknowledges periods of depersonalization that are aversive to her and during which she is uncertain if she is “alive or not.” She reports that self mutilation typically terminates these dissociative episodes. She also acknowledges periods of being overwhelmed by intrusive recollections of childhood sexual abuse, which have been occurring with greater frequency during the previous 2 months. Because colleagues have noticed a change in her usual high level of performance, she was encouraged to seek assistance.

Clinicians faced with such complexity often struggle to prioritize treatment goals and to maximize relief. A trauma-focused and informed treatment plan offers a common sense treatment sequence and prioritizes safety and functioning. It also may offer a patient with this constellation of symptoms a feeling of being understood and instill hope for healing.

Basic Principles of Stabilization

Modern standards of care for the treatment of psychological trauma advise a “phasic” model of treatment in which the initial treatment goals involve stabilizing acute symptoms and establishing safety for the patient. The treatment of these more complex forms of PTSD and dissociative disorders has been addressed, most notably by Herman.2 As the degree of complexity of the posttraumatic response increases, it is recommended that a more structured and stage-oriented approach to treatment be used.

Herman's treatment model includes phases of establishing safety, remembering, processing, and mourning losses associated with traumatic events, and reconnection with one's social network and engagement with life's activities. A variety of therapeutic techniques and strategies are used to address the differing treatment foci of each stage, with an overall eclectic approach to the stage-oriented goals, grounded in a relational psychodynamic orientation. This model is based on the establishment of a therapeutic alliance that allows treatment to progress in a planned way, with collaborative goals at each stage. The stages are not discrete and do not proceed in a linear way; however, the conceptualization of treatment as occurring in stages does allow for more effective stabilization before more exploratory work can occur.

More recently, Courtois3 described an evolving consensus model for the treatment of post-traumatic conditions, including dissociative disorders. It is based on the tri-phasic treatment model and is a stage-specific model with goals, tasks, and outcome criteria for each stage. It represents a trend in the field toward integrating research in memory and forensic considerations into the treatment of posttraumatic stress and dissociative disorders.

This model builds on the work of Kluft, a pioneer in the treatment of dissociative disorders. He outlined the treatment of dissociative identity disorder as occurring in stages that prioritize establishing psychotherapy, preliminary interventions that stabilize dysfunctional behaviors and provide symptomatic relief, followed later by more direct work with exploration of the traumatic origins of the condition.4

Courtois' model is divided into early, middle, and late phase interventions and goals. Early phase work involves establishing the treatment frame, developing the therapeutic alliance, providing informed consent, and identifying initial tasks and goals. There is an overarching focus on the establishment of safety, as well as the enhancement of self-care. This is accomplished by developing skills and self functions such as affect tolerance, affect modulation, and personal stress management. The patient's support systems are assessed and enhanced as necessary. The criteria for resolution of the tasks of this stage include restraint from self-injury as well as symptom stabilization. The transition from this stage is marked by a renegotiation of the therapeutic contract to do more exploratory work in the middle phase, if indicated.

The following vignette illustrates early phase goals. A client with dissociative identity disorder (DID) presented in the fourth session of psychotherapy with multiple lacerations bilaterally to both arms. When asked to discuss the injuries, the client reported a period of amnesia the previous evening and “waking up” to find the injuries the following morning. The therapist empathically responded to her distress while also emphasizing that safety from self-inflicted injury is a primary treatment goal. The patient's current suicidality and impulsivity was assessed, a list of strategies to express distress without harm was developed, and the client's plan for contacting the therapist in an emergency prior to self-injury was reviewed. The client was then engaged in a process of behavioral contracting to reduce the likelihood of further self-injury.

Middle-phase interventions focus on reconstruction of the narrative of traumatic experience, resolution of post-traumatic triggers and cues, mourning of losses associated with the traumas, and integration and resolution of the traumatic experiences through integration into the person's own view of self and life. Courtois notes that this stage follows only after careful assessment of the goals and client variables to determine suitability for this more intense form of psychotherapeutic exploration.

As the goals of this stage are progressively met, the work shifts into what is termed “the late phase.” This is marked by the focus on establishment and continuance of secure social relationships, continued development of self-efficacy, and re-consolidation and restructuring of daily patterns of living toward the goal of developing of a nontrauma-focused lifestyle. This may be thought of as a stage of consolidation of therapeutic gains and a shift and emphasis from a self-identity as a traumatized person to a focus on reconnecting with life goals, pursuits and relationships (living in community).

Regardless of the thoughtfulness of these theoretical principles, in practice, they represent guidelines and goals rather than the likely trajectory of a therapy. For example, some presentations of acute mutilation and self-harm may require a limited working through of middle-phase material. In this situation, a concerted effort to provide as many early-phase coping skills and supports as possible is woven into ongoing work. Keeping in mind the principles of the phasic model, clinicians would be wise to verbalize the need to resolve the current crisis and then go back to do the rest of the stabilization work waiting to be completed. This is necessary to build enough self-confidence, and self-efficacy in the patient to tolerate more middle-phase work and “have a life” in the meantime.

Skill-Focused Symptom Management

Stabilization may be accomplished by a number of strategies, including the use of skill-focused and psychoeducational approaches, trauma-specific partial hospital programs, psychopharmacologic interventions, and inpatient hospitalization (Sidebar 1, see page 680). The use of skill-focused symptom management and psychoeducation is always in the context of an ongoing psychotherapeutic relationship of sufficient intensity to support the goals of stabilization.

Sidebar 1.

Stabilization Phase Treatment Goals

Establish the treatment frame and alliance

  • Assess dangerousness, symptoms, level of functioning, and coping resources
  • Provide psychoeducation about dissociative and posttraumatic symptoms
  • Secure informed consent
  • Provide symptomatic relief
  • Teach symptom management strategies and coping techniques
  • Encourage self-care and self-soothing strategies
  • Create a safety plan
  • Secure a behavioral contract
  • Correct cognitive distortions
  • Address high-risk behaviors (eg, substance use, violence, unsafe relationships)

Central to this is the clinician's ability to tolerate the intense affects that appear in countertransference responses to the profound disorganization, distress, and needs of the acutely distressed patient. Traditional clinical tasks of “holding and containment” take on new meaning in this kind of clinical venue. The establishment of a therapeutic alliance that conveys hope for recovery and counters demoralization5 is a requirement for successful work. Peer support, supervision, or both for novice (and sometimes also experienced) therapists may be essential.

The treatment alliance is an essential component of the efficacy of any efforts to stabilize patients with dissociative disorders. Whether a patient's trauma is more emotional, physical, or sexual, it is always interpersonal. The clinician's relationship with the patient must be cultivated scrupulously. Relationships are at the source of the patient's problems, as well as the centerpiece of the solutions. A clinician knowledgeable about the trauma response is much more effective.

Initial interventions often involve efforts to educate patients regarding the trauma response. Psychoeducation may enhance mastery and empowerment, as well as normalize and destigmatize current symptoms. Emphasis typically is placed on the adaptive value of dissociative symptoms, while empathizing with the need to use such extreme measures. For example, patients will not abandon old strategies for self-soothing through paradoxical self-harm before they have learned new, reliable techniques for self-soothing. Amnesia for the reasons dissociative adaptations are activated often leaves a person knowledgeable about failure to function but bereft of understanding what happened to cause that lapse of function. Consciousness for the psychological motivation to activate the dissociative adaptation is crucial in making eventual changes in behavior. The following vignette demonstrates how this may be accomplished in the context of individual psychotherapy.

Mrs. A began a psychotherapy session with a series of berating, self-deprecating remarks about her memory, after failing a test in a college course she was taking. Exploration of the situation revealed that the content of the test was related to state laws for nurses regarding mandatory reporting of child abuse. Mrs. A noted that she started to read the questions on the exam and began to “space out.” She described regaining awareness several hours later, with no memory of finishing the exam.

When her therapist inquired about her need to dissociate, the patient reported being aware of memories of her own childhood physical abuse prior to the onset of the amnestic episode. The therapist empathically suggested that the dissociative episode might be best understood as an understandable attempt to avoid painful recollections of her own traumatic history, rather than a sign of her poor memory. Mrs. A reported that this way of understanding her symptom helped to “make sense of it” in a new way that led to some reduction in self-criticism. It provided her with a sense that her mind was not against her, but that childhood strategies of coping with adversity could be counterproductive in her adult life.

Psychoeducation may occur in the context of individual or group therapy. Models of psychoeducational groups have been developed and may be organized around trauma related themes or topics for each session (Sidebar 2, see page 680). Many patients find that knowledge of common posttraumatic reactions allows for more effective self-monitoring of levels of distress and a greater sense of mastery over what may have felt uncontrollable but was simply an unmonitored (unconscious) effort to avoid distress. Not making an effort to periodically track or assess emotional states leaves people vulnerable to emotional surprise and impulsive reaction.

Sidebar 2.

Psychoeducation Topics

  • Dissociation and dissociative symptoms
  • Posttraumatic stress disorder symptoms
  • Treatment goals
  • Symptom management techniques (eg, imagery, reframing, self talk)
  • Self-soothing techniques
  • Interpersonal safety skills
  • Relaxation techniques
  • Setting interpersonal boundaries
  • Stress management skills
  • Sensory awareness and grounding techniques (focusing on present environment)
  • Journal-writing techniques
  • Identifying and correcting cognitive distortions

Psychoeducation Topics

Symptom relief is the central goal of the stabilization phase. Therapeutic efforts to demonstrate that the symptoms can be managed are a key aspect of the treatment. Strategies such as grounding and sensory awareness may be taught in sessions and practiced as “homework.” The patient may benefit from identifying cues (both internal and environmental) that are associated with an increase in symptoms and coached to use techniques that can help contain distress. The use of imagery and hypnotherapeutic techniques (such as the development of a “safe place” image) may be especially useful in the management of acute distress. Patients may be taught relaxation, stress management, and self-care/self-soothing techniques to use during times of acute distress.

Clients also may benefit from skill-oriented modalities such as dialectical behavior therapy (DBT).6 This model of treatment emphasizes the development of distress tolerance, mindfulness, and interpersonal effectiveness skills, which may be especially useful for traumatized clients. DBT principles move some patients from their own view of the world as consisting of apparently simple, black-and-white situations toward gaining both cognitive and affective complexity. This allows the development of alternative behaviors that could not be conceived in a more simple formulation of experience.

Another strategy useful for stabilization is symptom monitoring. Self-monitoring of symptoms often leads to greater awareness of the level of dissociation that may be occurring but that rarely is reported spontaneously by the patient. Developing thoughtful consciousness for what is otherwise experienced as involuntary is the first step in acquiring a sense of personal agency, a quality of mind typically lost when detachment from feeling alive occurs — in depersonalization, for example. Homework assignments to track levels of dissociative symptoms and awareness every 15 to 30 minutes for several days may highlight issues that affect the patient's daily functioning but would not have been assessed by interview alone.

Cognitive-behavior methods also can be used to work with trauma-based cognitive distortions. These techniques counter the disruptions in memory and information processing frequently seen in patients with dissociative and post-traumatic disorders.7 Identifying and challenging trauma-based cognitions serves as a path to reducing distress. It also allows clients to differentiate between past and present interpretations of events that may become blurred when dissociative symptoms increase. Having the client write out cognitions, as well as more adaptive ways of interpreting events, facilitates learning and can represent effective therapeutic assignments between treatment sessions.

The following case illustrates the use of cognitive-behavior strategies to address trauma-based cognitive distortions. Ms. M, a 25-year-old patient with a history of dissociative amnesia, remarked that she frequently felt unable to respond to her employer's verbal attacks in the workplace when she made procedural errors. She reported feeling “like a child” and was terrified at those times. This led her to withdrawal and silence in the workplace.

Her therapist asked her to write out the sequence of precipitating events — thoughts, associated emotional reactions, and related behavioral action tendencies — to further clarify her experience. As she reflected on the assignment, she identified cognitive patterns of viewing herself as a “bad” child, and then as incapable of responding. She was then asked to identify an alternative response, using self-talk to add thoughts regarding her actual adulthood and related skills or allowing herself to use adult thoughts and feelings to “take care” of these child-oriented thoughts and feelings. She was asked to consider the likely consequences of using this strategy the next time her employer was verbally abusive. The therapist helped her to differentiate her current reaction from its posttraumatic determinants through a role-playing exercise where she rehearsed new, assertive responses for this situation.

Posttraumatic reactivity in patients with dissociative disorders leads to destabilization and may be addressed by attention to these cognitive processes, along with specific techniques to modify them. Dissociative processes may make the retention, internalization, and consolidation of cognitive therapy interventions more difficult, requiring frequent repetition and persistence for optimal effectiveness. One alter may learn the information, but not all may “get” the information. Exploration of the reasons this kind of information block occurs may be particularly useful. Lack of internalization of what is learned in one session and forgotten by the next may signal both shifts in the patient's state of mind and intolerance of the affects associated with the cognitions. Careful inquiry into these lapses may prove especially valuable.

Stabilization Specific to Dissociative Disorders

Interventions focus on the development of awareness of dissociative self-states and the development of an empathic and collaborative relationship with all aspects of the patient. Self-states may be worked with effectively by directly addressing concerns, understanding the adaptive function of the dissociative process, and inviting participation in the treatment. It is a common misconception that addressing the specific self-states serves to iatrogenically reinforce the condition (Gleaves, see page 648). It is especially important to validate the patient's experiences to facilitate stabilization.

Behavioral contracting strategies are useful for addressing self-destructive behaviors, as well as behaviors that interfere with the progress of the psychotherapy. Contracting should be seen as a tool and a therapeutic alliance-building strategy, rather than a substitute for careful evaluation of the patient's potential for self-harm. Relying on a contract to guarantee the safety of a patient is a misguided clinical stance.

Typical behaviors targeting by contracting might include suicidal acts, self-mutilation, substance abuse, medication noncompliance, and eating disorder behaviors such as binging and purging. Initially attempting to contract for as many of these behaviors as possible may serve to stabilize acute reactions and build the therapeutic alliance.

For example, Ms. C presented for treatment with a 6-year history of self-mutilation, depersonalization, amnestic episodes, and fugue experiences. She was diagnosed with DID by her psychiatrist based on clinical interview and a structured diagnostic instrument (eg, SCIDD; Kluft, see page 633). Her presenting symptoms included weekly self-mutilation when overly distressed, a history of abrupt termination of treatment relationships, and a history of binge drinking.

After reviewing treatment options and obtaining informed consent, the clinician engaged the patient in a process of psychoeducation regarding dissociative disorders. She was asked to contract to maintain safety and to abstain from all substance use. As her treatment progressed, Ms. C learned a series of coping strategies for managing distress, including relaxation and breathing techniques, calming imagery, and cognitive-behavior techniques for challenging trauma based interpretations of current reality. As she had successful experiences of mastering her symptoms, her ability to address her self-mutilation improved significantly. She was able to identify alternative coping strategies and incorporate these into a safety plan, for use when distressed. This clinical progress significantly reduced the number of both emergency department visits and acute inpatient hospitalizations in the following year of her treatment.

Stabilization may be an ongoing task throughout the course of the treatment for some patients who have clinical courses that do not fit a triphasic model of treatment. The use of inpatient or partial hospital programs is indicated for acute periods of risk for harm to self and acute symptomatic destabilization that impairs function. Specialized treatment programs that address dissociative disorders specifically have proven useful in stabilization phase work with dissociative patients requiring that level of treatment intensity.

Summary

For some patients, the goals of stabilization require consistent intervention over a long period of time. Clinicians who focus skilled attention on the goals of stabilization may assist patients in enhancing mastery over a painful and demoralizing condition, thus enhancing treatment outcome and reducing suffering. Careful attention to stabilization and the development of coping and self management skills early in treatment are necessary aspects of the process of recovery.8 Although dissociative disorders are associated with significant human pain, careful attention to approaches that stabilize can prevent excessive decompensation and empower patients to be active participants in their recovery.

References

  1. Loewenstein RJ, Putnam FW. Dissociative disorders. In: Kaplan J, Sadock A, eds. Comprehensive Textbook of Psychiatry, Vol. 1. 8th Edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2004: 1844–1901.
  2. Herman JL. Trauma and Recovery. New York, NY: Basic Books; 1992
  3. Courtois CA. Recollections of Sexual Abuse: Treatment Principles and Guidelines. New York, NY: W.W. Norton & Company; 1999.
  4. Kluft RP. Dissociative identity disorder. In: Gabbard GO, ed. Treatment of Psychiatric Disorders, Vol. 2. 3rd ed. Washington, DC: American Psychiatric Publishing; 2001:1653–1693.
  5. Kluft RP. Initial stages of psychotherapy in the treatment of multiple personality disorder. Dissociation. 1993; 6(1):145–161.
  6. Linehan M. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, NY: The Guilford Press; 1993.
  7. Fine CG. Treatment stabilization and crisis prevention. Pacing the therapy of the multiple personality disorder patient. Psychiatr Clin North Am. 1991;14(3):661–675. doi:10.1016/S0193-953X(18)30294-6 [CrossRef]1946029
  8. Baranowsky AB, Gentry JE, Schultz DF. Trauma Practice: Tools for Stabilization and Recovery. Cambridge, MA. Hogrefe & Huber; 2005.

Sidebar 1.

Stabilization Phase Treatment Goals

Establish the treatment frame and alliance

  • Assess dangerousness, symptoms, level of functioning, and coping resources
  • Provide psychoeducation about dissociative and posttraumatic symptoms
  • Secure informed consent
  • Provide symptomatic relief
  • Teach symptom management strategies and coping techniques
  • Encourage self-care and self-soothing strategies
  • Create a safety plan
  • Secure a behavioral contract
  • Correct cognitive distortions
  • Address high-risk behaviors (eg, substance use, violence, unsafe relationships)

Sidebar 2.

Psychoeducation Topics

  • Dissociation and dissociative symptoms
  • Posttraumatic stress disorder symptoms
  • Treatment goals
  • Symptom management techniques (eg, imagery, reframing, self talk)
  • Self-soothing techniques
  • Interpersonal safety skills
  • Relaxation techniques
  • Setting interpersonal boundaries
  • Stress management skills
  • Sensory awareness and grounding techniques (focusing on present environment)
  • Journal-writing techniques
  • Identifying and correcting cognitive distortions

Psychoeducation Topics

Sidebar 3.

Creating a Plan for Safety in the Outpatient Setting

  • Enlist cooperative alliance around safety issues
  • Educate patient about the need to remain safe during psychotherapy
  • Use behavioral contracting for specific behaviors
  • Teach self-monitoring of cognitive, emotional, physical, interpersonal, and behavioral cues and precipitants predicting unsafe behaviors
  • Create a written plan of alternative behaviors to cope with strong affect, such as:
    • Diaphragmatic breathing
    • Relaxation techniques
    • Journal writing when distressed
    • Imagery focusing on a “safe” or “peaceful” place to provide respite
    • Calling a friend for support
    • Listening to soothing music
  • Teach physical grounding techniques (to cope with dissociative reactions), such as:
    • Placing both feet on the floor
    • Keeping one's eyes open and focused on current environment
    • Grasping a familiar object and focusing on the sensation to maintain present moment awareness
  • Assess the function of unsafe behavior from the patient's perspective
  • Challenge cognitive distortions that are maintaining unsafe behavior
  • Process episodes of unsafe behavior thoroughly with a focus on learning
  • Use higher levels of care when indicated clinically

Creating a Plan for Safety in the Outpatient Setting

Authors

Dr. Welzant is director of acute trauma services, Sheppard Pratt Health System, Towson, MD.

Address reprint requests to: Victor Welzant, PsyD, Sheppard Pratt Health Systesms, 6525 N. Charles St., Ste. 135, Towson, MD, 21204; or e-mail vwelzant@aol.com

10.3928/00485713-20050801-09

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