Contextualizing Dissociation and Dissociative Disorders
Multicultural Considerations for the Past, Present, & Future of our Field
Nicholas A. Pierorazio, Christina M. Dardis, & Bethany L. Brand
Section Editor: Claire J. Starrs
Dissociation is presently understood as a disconnection and/or disintegration in consciousness, memory, identity, emotion, perception, somatic experience, motor functioning, and/or behavior (American Psychiatric Association, 2022). Dissociation may range from being normative (e.g., absorption) to complex (e.g., dissociative identities). Complex dissociation is posited as traumagenic (Dalenberg et al., 2012), with dissociative disorders (DDs) arising from complex trauma in childhood (Chu & Dill, 1990). Complex dissociation is prevalent; up to 4% of the United States’ general population report it (Simeon & Putnam, 2023).
Understanding the role of culture within the study of trauma, dissociation, and DDs is difficult (Krüger, 2020b). Many studies define culture as one dimension of identity, such as nationality. However, culture is multidimensional and often nested below the surface of an individual’s experience. Specifically, individuals hold layers of identities (e.g., Black, woman, mother, writer) and exist within layers of systems that influence their meaning-making about trauma, its sequelae, and related healing processes (Brown, 2008). Research exploring the intersection between culture and dissociation has been nebulous, as is the history of defining and understanding dissociation itself.
A History of Dissociation Enveloped in Stigma
Just as psychological trauma is part of the human lived experience, dissociation is also intertwined with human history. While the first documented experiences of dissociation were noted before the 18th century, descriptions and conceptualizations of dissociation began to proliferate in the late 19th and early 20th centuries with the rise of psychoanalytic personality theories (van der Hart et al., 1989). Specifically, dissociation was theorized as a protective mechanism enabling the fragmentation of traumatic events from conscious awareness to reduce internal threat (van der Hart et al., 1989). Trauma and dissociation experts have continued to view trauma as an important etiological factor in the development of complex dissociation (e.g., dissociative identity disorder [DID]). This trauma model (TM) of dissociation has received empirical support (Dalenberg et al., 2012).
By the mid-20th century, dissociation was understood as occurring on a continuum from normative to complex, with individuals possessing an innate dissociative capacity (Spiegel, 1963). DDs were later integrated into the Diagnostic and Statistical Manual of Mental Disorders in DSM-III in 1980, including multiple personality disorder, renamed DID in DSM-IV, capturing the most complex form of dissociation: identity fragmentation (APA, 1980; 1994). The idea of dissociation on a continuum has persisted in the field, and professionals have begun to consider dissociation as encompassing a wide range of experiences and presentations (Şar, 2022).
However, despite strong theoretical and cross-cultural (e.g., Ross et al., 2008) empirical support for the TM of dissociation, some theorists strongly dispute it, in favor of the fantasy model of dissociation (FM; Dalenberg et al., 2012). The FM posits that individuals who are suggestible and fantasy-prone are susceptible to dissociating, which in turn heightens the likelihood of developing false trauma memories due to social influences. Proponents of this model further argue that therapists implant false trauma memories and DID in these vulnerable individuals (Dalenberg, 2012; Lynn et al., 2014). They also claim that dissociative individuals are prone to over-reporting symptoms (e.g., Merckelbach et al., 2015). Thus, FM theorists posit that DID is an iatrogenic condition, rather than a genuine disorder. In the 1990s, parents who had been accused of child sexual abuse and their supporters, formed the False Memory Syndrome Foundation, an advocacy group that vocally supported the FM (Olio, 2004). No studies in clinical populations strongly support this etiological model. Additionally, research has consistently found people with DID are not highly suggestible, nor prone to false memories or symptom over-reporting (Merckelbach et al., 2015; Vissia et al., 2016). However, FM theorists continue to deny the validity of the TM and the DD diagnoses.
The FM has greatly contributed to stigma regarding dissociation, especially DID, which is surrounded by myths and is misunderstood (Brand et al., 2016). People who experience complex dissociation are subject to re-traumatization by the same mental health systems that purport to serve them. People who dissociate face additional dissociation-related mental health treatment barriers. For example, a study by Nester and colleagues (2022) identified multiple significant treatment barriers, including providers’ limited understanding of trauma and dissociation, the fear of having their dissociation disbelieved, as well as more frequent treatment ruptures due to providers responding poorly to dissociation. Moreover, many of the participants also endorsed treatment barriers related to their minoritized identities, such as being unable to receive adequate dissociation-informed treatment due to racism.
Stigmatization also occurs in the media (Brand & Pasko, 2017). The media frequently engages in damaging misportrayals of dissociation, especially DID. Films such as Sybil (1976) have foregone clinical accuracy to make a spectacle of dissociation and DID. Even more recently, Hollywood productions like Split (2016) have sensationalized DID and portrayed the condition as inherently violent, contrary to the research literature. This historical stigma surrounding dissociation and DDs may represent a cultural dimension that compounds dissociative individuals’ trauma and dissociation, as many professionals continue to approach dissociation and the DDs through this stigmatized lens.
Dissociation as Cultural Context
The history of clinical conceptualizations of dissociation and the stigma around it provide context for how it has been studied. Quantitative approaches have allowed experts to obtain evidence about etiological factors and related treatment that has consistently supported the TM (see Dalenberg, 2012). However, academic debate has persisted in the field, despite strong empirical support for the TM. This dynamic of debate has been relatively exclusionary of those with lived experience, often leaving these individuals out of conversations regarding their own experiences, meaning-making, and treatment goals (Christensen, 2022). Furthermore, research has mostly been in Western contexts (Krüger, 2020b); although, there has been some cross-cultural research, highlighting cultural complexities around dissociation.
Myriad dissociative presentations are observed across cultures (Şar, 2022), indicating multicultural nuance for dissociation. For example, dissociative possession phenomena may be experienced more often in Eastern contexts than in the West. Dissociation may present as functional neurological symptom disorder, possession phenomena, and chronic mood disorders in Eastern cultures such as Turkey, Africa, and Asia respectively, as well as acute reactions to stress (e.g., ataques de nervios) in Latin American cultures, and as mass trauma (Şar, 2022). A greater cultural understanding of dissociation may be dependent on culture-specific clinical training and conceptualizations. For instance, episodes of psychosis are often characterized as dissociative in Turkey, whereas the dissociative nature of these same episodes may be overlooked in traditional Western conceptualizations (Lewis-Fernández et al., 2007). In one quantitative study, Douglas (2009) found that Black and Asian American students who reported higher dissociation experienced less distress. The author suggested dissociation may be more protective for Black and Asian American students than it is for White students. It may be that dissociation is a traumagenic reaction to cultural traumas, such as colonial violence (Dupuis-Rossi & Reynolds, 2018), institutional betrayal (Smith & Freyd, 2017), cultural betrayal (Gómez, 2019), and racial discrimination (Polanco-Roman et al., 2016).
In the greater mental health culture, discourse has historically marginalized contextual approaches to understanding psychological experiences (Ratts & Greenleaf, 2018), including trauma and dissociation. However, these processes are inextricably contextually situated. The few published qualitative studies have often aligned with post-positivist values, sacrificing important nuance to quantify experience. Professionals are beginning to call for more qualitative research in the study of trauma and dissociation, in particular to understand the ways in which culture and dissociation interact. Qualitative methodologies may be the strongest way to open doors for the exploration of such under-researched phenomena, and this research could broaden our understanding of dissociation and illuminate the sociological processes involved.
Trauma specialists have more recently begun investigating culture in relation to trauma and dissociation. Pierorazio and colleagues (2023) explored meaning-making about culture, dissociation, and the treatment of dissociative individuals in a reflexive thematic analysis study. Participants with lived experience of dissociation understood their dissociative and treatment-related experiences in the context of sociocultural processes, including through cultural aspects such as queer identity, race, stigma, and systemic oppression, among others. They conceptualized their dissociation as either catalyzed or buffered by their intersectional identities; that is, participants often understood their dissociation as worsened by the ways in which they are oppressed, and countered by how they held privilege. Some participants also decontextualized themselves from their culture (e.g., explaining they have no culture), which may itself be a dissociative disconnection from cultural identity.
Dissociation may even be cultural for those who experience it. Christensen (2022) suggested online spaces (e.g., dissociation support forums) for those who identify as Plural are cultural spaces with their origins in dissociation-related lived experiences. The author identified that in these online spaces, there is also some intersectionality with transgender and autistic populations. Many members indicate being Plural due to trauma (e.g., DID). However, there are also Plural people who identify as endogenic (i.e., Plural before birth and not due to trauma), and exogenic (i.e., Plural since some time after birth yet not due to known trauma). There has not yet been any empirical research specifically related to these online cultural spaces.
Contextual Dissociation in Mental Health Treatment
Evidence-informed treatment guidelines for complex dissociation include dissociation-informed phasic psychotherapy that emphasizes safety and stabilization (International Society for the Study of Trauma and Dissociation, 2011). This psychotherapeutic treatment for complex dissociation can be empowering within a multicultural framework; yet there remain calls to include those with lived experiences of complex dissociation in the revision of these guidelines (Christensen, 2022). There is also a call for the integration of social action, such as advocating against the societal denial of dissociation and changing social policies, alongside trauma- and dissociation-informed treatment (Pierorazio et al., 2023). Social action could address treatment barriers for people who dissociate. Considering the contextual nature of dissociation, mental health professionals working with people who dissociate should consider using culturally-responsive, trauma-informed, and social justice-oriented interventions (Dupuis-Rossi & Reynolds, 2018). For example, community-based, culturally-consistent healing methods may be most beneficial for possession experiences (e.g., Indigenous healing; Kirmayer et al., 2003). It is important for researchers, clinicians, and activists to understand that treatments should acknowledge the systems in which we live, validate clients’ lived experiences, and be culturally-relevant.
Future Directions for the Field of Trauma and Dissociation
Consistent with the calls for researchers and clinicians to hold a more contextualized understanding of dissociation, professionals in the field must learn to acknowledge the layers of identity, culture, and systems that can affect dissociation in complex ways. Stigma has complicated our progress in understanding dissociation from a multicultural perspective. A more contextualized understanding of dissociation may be reached by moving away from medical model conceptualizations. In particular, the assumption of universality regarding the pathological nature of dissociation may be harmful to the nuance of how dissociation is experienced.
There is a lack of research regarding dissociation-adjacent cultural identities, including being Plural. Research with multicultural approaches is necessary when considering these shifting cultures. Further, qualitative research may provide valuable insight into their implications for the budding understanding of plurality as a cultural identity. These methods would allow us to gain understanding from people with lived experiences of dissociation and/or plurality, voices that have historically been silenced. In the meantime, clinicians should consider empowering these voices by validating these cultural identities (Christensen, 2022).
Cultural traumas may precede complex dissociation; however, research regarding dissociation as a response to historical-cultural trauma is scarce. Further research should explore dissociation as a response to these traumas, such as institutional betrayals, cultural betrayals, intergenerational trauma, and other forms of insidious trauma such as microaggressions. To do so, exploration may begin with interdisciplinary and qualitative research through an intersectional, multicultural framework (Krüger, 2020a). Creativity and subjectivity may be essential resources to integrate into these approaches (Braun & Clarke, 2022), as well as in clinical practice. Truly addressing dissociation may require mental health professionals to push the bounds of what is generally accepted in psychology. Professionals in the field must explore the traumatic nature of oppression and its interaction with dissociative processes to fully understand dissociation and related healing.
NICHOLAS PIERORAZIO is a Research Assistant for the Treatment of Patients with Dissociative Disorders (TOP DD) Lab at Towson University. His research interests are trauma, dissociation, psychotherapy, and qualitative methodologies. He has worked on several studies in the TOP DD Lab and has spearheaded research examining multicultural considerations surrounding trauma and dissociation. His clinical experience includes working as a Mental Health Worker on a trauma disorders inpatient psychiatric unit.
CHRISTINA M. DARDIS, PhD, is an Assistant Professor of Psychology and Director of the Laboratory for Interpersonal Violence and Traumatic Stress Studies at Towson University. Her research interests include predictors and correlates of stalking and cyberstalking victimization and perpetration, the role of social support in interpersonal violence, empowerment self-defense, and intersections between gender and violence.
BETHANY BRAND, PhD, is a Professor at Towson University in Maryland and an expert in trauma disorders. Dr. Brand conducts research in five areas: treatment of dissociative disorders (TOP DD studies); methods for distinguishing dissociative disorders from malingering; the impact of training clinicians about trauma; investigating the trauma versus fantasy model of dissociation; and assessing the accuracy of textbooks’ information about trauma. In her private practice, she treats complex trauma patients and serves as an expert witness in trauma-related cases.