Journal of Trauma & Dissociation
ISSN: 1529-9732 (Print) 1529-9740 (Online) Journal homepage: http://www.tandfonline.com/loi/wjtd20
Considering Psychoeducation on Structural Dissociation for Dialectical Behavior Therapy Patients Experiencing High-Risk Dissociative Behaviors Olivia Shabb Psy.D. To cite this article: Olivia Shabb Psy.D. (2015): Considering Psychoeducation on Structural Dissociation for Dialectical Behavior Therapy Patients Experiencing High-Risk Dissociative Behaviors, Journal of Trauma & Dissociation, DOI: 10.1080/15299732.2015.1053657 To link to this article: http://dx.doi.org/10.1080/15299732.2015.1053657
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Considering psychoeducation on Structural Dissociation for Dialectical Behavior Therapy patients experiencing high-risk dissociative behaviors
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Author is currently affiliated with New York University; however this work is not associated with an institution and should not be associated with New York University. 11 W 8th St #2A, New York, New York 10011
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(650) 868-8214
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[email protected] No fax number
Key words: Posttraumatic stress disorder, Dialectical Behavioral Therapy, Dissociation, Structural Dissociation, Self-harm
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This content has not been previously presented nor published. No grant nor commercial support was received for this paper. Abstract
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Dialectical Behavioral Therapy (DBT) programs, particularly for low functioning individuals at
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the safety and stabilization phase of therapy, work with a variety of high-risk and often complex cases, with a curriculum consisting primarily of concrete skill-acquisition and application. A significant subset of individuals in DBT programs, however, may suffer high-risk dissociative
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Olivia Shabb, Psy.D.
episodes in which skill application may be less available to them, contributing to further destabilization, demoralization, and thoughts of self-inefficacy in treatment. This paper evaluates the potential benefits of complementing traditional DBT with psychoeducation on Structural
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Dissociation for such patients, acknowledging and addressing some of the concerns that might accompany such a consideration. Key words: Posttraumatic stress disorder, Dialectical Behavioral Therapy, Dissociation,
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Dialectical Behavioral Therapy (Linehan, 1993) is a well-validated (Linehan, Armstrong, Suarez,
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Allmon, & Heard, 1991; Panos, Jackson, Hasan, & Panos, 2014; Stepp, Epler, Jahng, & Trull, 2008), widespread, skills-based treatment for borderline personality disorder (BPD), though it
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also enjoys successful application and adaptation beyond this diagnosis to additional populations with emotion dysregulation (Chugani, Ghali, & Brunner, 2013; Frazier & Vela, 2014; Neacsiu, Eberle, Kramer, Wiesmann, & Linehan, 2014) or high-risk behaviors such as self-harm and suicidality (Booth, Keogh, Doyle, & Owens, 2014; Denckla, Bailey, Jackson, Tatarakis, & Chen,
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C. K, 2014; Ward-Ciesielski, 2013).
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The four modules of DBT, mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness, provide patients with tools to improve self-attunement and more effectively
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navigate emotions, situations, and relationships. However, the application of these skills requires conscious awareness. Many individuals with BPD traits and high-risk behaviors who may benefit from DBT, however, experience dissociation, especially where a significant trauma history is
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Structural Dissociation, Self-harm
present. Sack, Sachsse and Overkamp (2013) conducted a multisite study revealing that the overwhelming majority (96%) of patients with BPD reported at least one traumatic experience in their lifetime, with most of them reporting several such experiences. This study estimated that 79% of patients BPD had comorbid PTSD. As dissociative disorders are common in trauma
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patients, they are also likely common in individuals with borderline traits or borderline functioning. Indeed, Sack et al’s multisite study (2013) found that 41% of BPD patients had comorbid severe dissociative disorders. Korzekwa, Dell, Links, Thabane, and Fougere (2009)
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further highlight the elevated frequency of dissociative disorders in individuals with Borderline
quarter reported no dissociative symptoms, and over three quarters qualified for dissociative
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disorders ranging from relatively mild (dissociative amnesia and depersonalization, 29%) to most severe (dissociative identity disorder, 24%).
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It has been observed clinically that certain DBT patients with severe dissociation may engage in self-harm or suicidal behaviors while in dissociative states, with little to no awareness or recollection of these behaviors. These patients may pose a particular challenge to DBT programs,
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as the behavior that would typically be targeted for change (self-harm) appears to be outside of the patients’ control or awareness. Bolstering skills that DBT teaches, particularly in the Distress
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Tolerance and Mindfulness modules, can help patients monitor awareness and decrease risk factors for dissociation. While harm reduction through skill use is essential, its impact on
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dissociative patients may be limited as the more functional, overregulated part of their personality mat attend group and learn skills, while under-regulated parts that are fixed in trauma are absent, do not reap the benefits of this learning, and their ongoing dissociation may in fact
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Personality Disorder. Out of a sample of 21 such patients in outpatient treatment, less than a
continue to threaten the efficacy of the part that functions in daily life. This paper therefore explores the question of whether DBT patients who exhibit high-risk behavior in dissociative states may uniquely benefit, even in a Phase 1 Safety and Stabilization program (Herman, 1992),
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from supplementing DBT skills training with psychoeducation providing insight into the nature and function of structural dissociation (Van der Haart, Nijenhuis, & Steele, 2006).
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Structural Dissociation
adapt to trauma, particularly if the trauma is intense and repeated, by a dissociative process that
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involves splitting into two parts. The first is the part that functions in daily life or “business as
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usual” part, which typically occupies the majority of consciousness. The second is the part that is fixated in trauma. The part that functions in daily life is driven by the desire to do what needs to be done in order to get by and therefore includes a drive for attachment and engagement with the world and others. To do so it is invested in suppressing awareness of the trauma, which is thus
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relegated to the shadow part that is fixated in trauma. The part that functions in daily life may only acknowledge trauma in a superficial and cursory manner, if at all, but the part that is fixated
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in trauma remembers trauma vividly. It is stuck in a traumatized mindset and constantly feels threatened as when trauma was experienced. Its drive is primarily defensive and self-protective,
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directly at odds with the drive of the part that functions in daily lifeto connect and get by in the world.
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Structural Dissociation of the personality (Van der Haart et al, 2006) posits that personality can
The long-term incompatibility of these drives, along with the phobic relationship trauma survivors often have to experiencing strong emotions, results in and accentuates the schism
between these two parts over time, preventing their integration into a cohesive whole that is able to acknowledge trauma without overwhelm. Thus a trauma survivor may rely primarily on the
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part of their personality that functions in daily life, but when triggered, they may reflexively respond from a part that is fixated in trauma. The nature of this response depends on each individual’s particular traumatized parts, as the part that is fixated in trauma can further be
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divided into parts that assume different self-defensive modes: fight, flight, freeze, submit, and
the time of the original trauma. For example, an individual whose fight part is activated may
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respond to a trigger with aggression towards others or him or herself. In cases of severe trauma, the dissociation between the part that functions in daily life and the part that is fixated in trauma
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may be extreme to the point that a traumatized part may take over without awareness on the part that functions in daily life; when the individual reverts to the latter part, they may thus be surprised, alarmed, and confused regarding their situation. Indeed, the part of individuals with trauma that functions in daily life is often unaware of chunks of these individuals’ experience
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(for example, inability to account for lapses of time), suggesting dissociation to an alternative part that is stuck in trauma. These episodes can include a range of behaviors depending on the
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traumatized part that was activated, and can include self-harm (typically a fight part response, as
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previously indicated).
Based on the above, a psychoeducational module addressing structural dissociation might:
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attach. A triggered individual may revert to one or several parts that helped the individual cope at
•
Introduce patients to the part that functions in daily life, the part that is fixated in trauma,
and their respective functions •
Discuss the incompatibility of these parts
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•
Explain how this incompatibility obstructs integration and promotes dissociation and
dissociative behaviors Understand dissociation as a trauma-based, self-protective response to triggering
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•
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•
Validate this trauma response and nurture compassion and motivation to use DBT skills
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to head off dissociation and develop more effective coping
Such education provides context and a vocabulary for understanding and naming the
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behaviorally and emotionally challenging phenomenon of dissociative experiences. It can help normalize and elucidate for patients the otherwise perplexing, unsettling experience of finding themselves having destroyed property, assaulted another person, self-harmed, or engaged in
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other unconscious behaviors. It can decrease disorientation, shame, and self-defeating judgments, increase self-compassion, and mitigate the additional emotional dysregulation that such
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experiences cause.
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Concerns
There are several important and valid concerns when considering adding a psychoeducational
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situations or distressing emotions
component to a DBT program or track, particularly for a Phase 1 (Safety and Stabilization) program. Some of these concerns are outlined and addressed below:
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1. DBT, particularly in a strictly adherent track, is skills-based because the priority for individuals
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behavioral control, rather than insight-oriented work. While DBT intends to focus on practical skills training rather than delving into explanations of
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the origins of behaviors that are targeted for change, dissociation presents a challenge for both identifying and addressing target behaviors. Peri-dissociative high-risk behaviors often seem less predictable and controllable to patients than behaviors that are typically targeted for change and that occur with their full awareness. While behaviors collaboratively targeted for change by DBT
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patients and their therapists are often used by patients in a control-seeking, if ineffective, manner, severe dissociation is usually a reflexive response to stress in which the part that
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functions in daily life is overwhelmed and relinquishes control, with the part that is fixated in
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trauma taking over without direction or even consciousness from the part that functions in daily life. Thus destructive behaviors can happen in dissociative states without planning or memory. In these cases, since the targeted high-risk behaviors are secondary to dissociation, the problem of
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assigned to such a track is risk reduction and
dissociation becomes more prominent and vital to treatment. While disagreement exists over whether insight is essential for change in psychotherapy, insight into the origins and functions of dissociation appears critical to beginning the work of integration of the self, or at least reconciliation of the split manifestations of consciousness – a primary
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treatment goal for patients with severe dissociative disorders according to the International Society for the Study of Dissociation (2011). Research indicates that dissociation and related symptomatology predict poor response to DBT (Kleindienst, Limberger, Ebner-Priemer, Keibel-
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Mauchnik, Dyer, Berger, … & Bohus, 2011), perhaps due to the potentially obstructive or
Spitzer, Grabe, Freyberger, & Hamm, 2012), a primary goal and area of competency in DBT.
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Therefore, for traumatized patients with borderline traits as well as high-risk dissociation, behavioral stabilization and safety appear to be difficult to achieve without concurrently
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targeting integration of personality and experience. Contextualizing DBT skills and behavioral control in the larger framework of integration may resonate more effectively with individuals on the severe end of the dissociative spectrum, providing further motivation for the use of DBT
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skills that promote mindfulness and preventive, adaptive coping.
These data further suggest that Phase 1 DBT programs stand to boost positive engagement and from
complementing
skill-based
interventions
with
integration-promoting
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response
psychoeducation for the high number of dissociative patients they are likely to treat. The effort to
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address dissociative disorders in increasingly skills-based psychotherapy programs remains new, yet it speaks to the insufficiency of skills training alone, and to the need to target dissociation more specifically and effectively. This viewpoint is often echoed by practitioners and researchers
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mitigating effect dissociation may have on emotion regulation (Barnow, Limberg, Stopsack,
working with dissociative patients (Kleindienst et al, 2011; Korzekwa, Dell, & Pain, 2009; Lanius, Vermetten, Loewenstein, Brand, Schmahl, Bremner, & Spiegel, 2010).
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Boon, Van der Hart and Steele (2011) provide a precedent for combining skills work with psychoeducation on dissociation in the workbook Coping with Trauma-Related Dissociation: Skills Training for Patients and Therapists. This manual was developed in response to the
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observation that available Phase 1 treatments tend to neglect the realities and needs of patients
dissociation at this phase of treatment, either undermining the central relevance of dissociative & Steele, 2005) or crafting
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symptoms in traumatized patients (Van der Hart, Nijenhuis
experimental approaches and hoping for the best. The workbook thus addresses this clinical gap.
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The bulk of the text consists of an eclectic skill set and strategies for grounding and coping, yet the very first section of the workbook, Understanding Dissociation and Trauma-Related Disorders, explains the concepts and processes of integration and structural dissociation in accessible language, including the ways in which they are shaped by trauma (as is related in the
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above section on Structural Dissociation). The skills are thus couched in psychoeducation about
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their relevance to the treatment of dissociative symptoms. Working specifically from a DBT approach, protocols have begun to emerge concurrently
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targeting borderline traits as well as trauma, helping to address the research gap on treating comorbid borderline personality disorder and PTSD. A combined DBT + Prolonged Exposure (PE) treatment module (Harned, Korslund, Foa, & Linehan, 2012) is one such promising
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suffering from severe dissociation, and that clinicians themselves appear to struggle with treating
treatment, whereby patients with borderline personality disorder as well as PTSD who received DBT + PE demonstrated greater therapeutic gains than those who received solely DBT (Harned, Korslund, & Linehan, 2014). However, the effectiveness of this protocol may not be generalizable to high-risk dissociators at Phase 1 of treatment. Exposure-based therapies may be
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uniquely risky for such patients given their use of dissociative self-harm as a coping response to stress, and may be best reserved for Phase 2 interventions once stabilization and alternative coping have been acquired. In any case, intent to address PTSD may not result in effective
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targeting of dissociation, as increasing evidence points to the heterogeneity and fluctuation of
et al., 2010) that requires severe dissociation to be addressed specifically and deliberately
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(Kleindienst et al, 2011; Lanius et al, 2010), not only under the general umbrella of PTSD.
Thus treatment solutions for patients with borderline personality traits who experience
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pervasive, high-risk dissociation remain under-researched, and clinical interventions underappreciative of the obstructive effect of dissociation. Coupling skills-based DBT training with psychoeducation on structural dissociation, perhaps with inspiration from Boon et al’s approach
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(2011), is one way to reverse this clinical trend, and to inform and inspire relevant future research. These authors’ work has been adapted for skills training in the current web-based
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Treatment of Patients with Dissociative Disorders (TOP DD; Towson University), which will
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further elucidate the effectiveness of their model.
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posttraumatic symptoms and syndromes, including a uniquely dissociative presentation (Lanius
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2. Patients assigned to DBT treatment may not be able to tolerate discussing and processing trauma-related
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Any process work related to trauma is typically contraindicated for a Safety and
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Stabilization phase treatment (Herman, 1992), particularly for individuals whose coping style and emotion regulation ability are impaired and risky enough that DBT treatment is indicated.
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However, the addition under review is of a psychoeducational nature, focusing on providing insight regarding the impact of trauma on the development and maintenance of a maladaptive coping style, and aiming to normalize dissociation in light of a history of trauma. This differs
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greatly from processing the trauma itself. Acknowledging the impact of trauma on the present is in line with Safety and Stabilization phase goals, especially since many of these goals – for
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example, increasing social support and developing adaptive coping skills – are obstructed by maladaptive, trauma-related coping such as isolation and self-harm (Herman, 1992). The better
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one understands the impact of trauma, the easier it is to develop the compassion, rationale, and courage to make the kinds of change that Safety and Stabilization requires.
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information.
Recent research suggests that individuals with BPD and extensive trauma histories are indeed able to tolerate insight-oriented psychoeducation about trauma. Mental health providers often
and understandably worry about the fragility of traumatized patients with borderline functioning. However, research is optimistic on this matter. Recent research (Barnicot & Priebe, 2013)
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suggests that patients presenting with comorbid BPD and PTSD are more likely to benefit from treatment that concurrently addresses trauma while building coping skills, rather than focusing exclusively on skill building. A study (Van Minnen, Harned, Zoellner, & Mills, 2012)
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investigating potential contraindications for Prolonged Exposure (Foa, Hembree, & Rothbaum,
common attributes of patients in DBT programs – did not constitute contraindications for such
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intense a treatment. Harned et al’s combined DBT & PE program (2012), found the combination of skills training and trauma work safe and effective, although the limitations of assuming that
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PTSD work targets dissociation and of applying process-based trauma interventions for high-risk dissociators at Phase 1 has been raised. Together these findings suggest that a much milder, shorter, and non-process oriented intervention such as a session of psychoeducation is likely to be tolerated by patients, if not actively beneficial. Indeed, individual work addressing
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& Gutheil, 2013).
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dissociation in conjunction with skills training has yielded promising results (Biswas, Chu, Perez,
As with any presentation and any course of therapy, psychoeducation about symptoms and a
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collaborative approach to treatment (for example, explaining why dysregulation and dissociation occur and the relevance of targeting them both as part of the treatment plan), are important for restoring a sense of cohesion, agency, and control to the patient. This is particularly important
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2007) found that Borderline Personality Disorder, dissociation, and suicidal ideation – all
with traumatized patients as trauma and related dissociation tend to corrode these vital areas of
intra- and interpersonal functioning (Herman, 1992). If, through psychoeducation, clinician and
patient can agree on an explanatory model of symptoms and on a collaborative, logical treatment plan, the patient is more likely to feel validated and motivated (Horvath & Luborsky, 1993).
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Further validation can come from understanding dissociation as an originally adaptive response to trauma, and from reassurance that the patient will not be stripped of such defenses without
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support and concurrent development of more presently effective coping strategies.
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research as a skills-based intervention; adding an insight-oriented
component
would
entail
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compromising adherence to the treatment as it was validated.
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DBT, especially at Phase 1, is indeed a skill-based treatment approach with cohesive theoretical and philosophical underpinnings and strong empirical support. The addition of a structural
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dissociation trauma education component, no matter how small this addition relative to the
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course of treatment, does constitute a deviation from the original program. Naturally, such an addition would call into question the empirical validity of the modified treatment now being delivered. With this acknowledgement, the addition of a structural dissociation psychoeducation
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3. DBT group treatment has been validated by
component does not contradict, and may very well in fact be very compatible with the principles and goals of DBT. Wagner and Linehan (2006) posit that DBT is principle rather than protocol-driven, suggesting that DBT can be adapted to fit the needs of traumatized patients both ideographically and as a
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subpopulation (Wagner, Rizvi, & Harned, 2007) particularly if the approach to treatment is consistent with the theoretical underpinnings of DBT (Wagner & Linehan, 2006) and complements the goals of DBT.
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The biosocial model at the core of DBT can be wed to structural dissociation to reflect and
model subsumes trauma as part of an invalidating environment. The biological aspect of the
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explanatory model includes neuroregulatory dyscontrol, particularly of the limbic and paralimbic systems, with under-regulation leading to hyperarousal, and overregulation leading to
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hypoarousal (Frewen & Lanius, 2006; Lanius et al, 2010). Hypoarousal may or not be triggered by intolerance of hyperarousal and for individuals with severe trauma, it can manifest as switching to a dissociated, fixated in trauma personality state that in and of itself can have over-
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or under-reactive qualities depending on the unconscious or overly-learned coping strategies that developed as a response to trauma.
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Moreover, for individuals exhibiting high risk dissociation, complementing DBT skills work
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with integration-promoting psychoeducation and interventions is also likely to improve resolution of dialectical dilemmas such as self-invalidation versus emotional vulnerability, as patients better understand and support themselves through disorienting and uncomfortable
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explain the experiences of high-risk dissociators. The social or experiential component of the
experiences and emotions. The purpose of such education is also closely aligned with the principle of validation that is so central to DBT (Linehan, 2013). The incorporation of psychoeducation regarding structural dissociation necessarily results in a non-Empirically Supported Treatment (Herbert, 2003) because this particular combination of
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therapy components does not appear to have been systematically studied. However, if this combination is clinically indicated, then its delivery is very much in keeping with EvidenceBased Practice (Lilienfeld, Ritschel, Lynn, Cautin, & Latzman, 2013), which advocates for
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mental health providers to flexibly and mindfully combine empirically supported techniques with
In the context of a DBT-adherent group-based program where there is concern for the integrity
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of the DBT curriculum, or if concern exists about the relevance of psychoeducation regarding structural dissociation to certain group members or its potential impact on them, this component
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may be provided in adjunct individual sessions, which patients in DBT skills groups are typically concurrently receiving anyway, to ensure its relevance to the patient. In DBT programs or groups where members all share trauma histories and exhibit dissociative behaviors, such education
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might be provided in a group format with attention to limited processing to avoid unnecessary triggering.
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When contemplating the addition of this component to a DBT curriculum, the question naturally
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arises of where it might fit in. Individual therapy allows for some degree of flexibility in terms of when to integrate psychoeducation about structural dissociation into treatment. In terms of group therapy, if and when appropriate, it may be a natural supplement to the distress tolerance module,
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patients’ unique characteristics and needs.
if dissociation is understood as a nearly-automatic response to overwhelming emotions such as anxiety, anger, or sadness.
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Conclusion It is important to stress that the addition of the adjunct intervention reviewed in this paper
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remains experimental and constitutes a deviation from the standard DBT treatment model that
based groups is conceptually and therapeutically justified for borderline personality disorder
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patients with trauma histories and a pattern of potentially destructive dissociative behavior, there are also strong clinical and theoretical reasons to consider complementing skills-based
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interventions with psychoeducation about dissociation – a combination that will hopefully be further examined going forth, through the symbiotic and complementary relationship of clinical practice and psychological research. With regards to practice, given that so many borderline personality disorder patients present with co-occurring dissociation, it is essential that
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dissociative disorders be actively screened for and accurately diagnosed, and that DBT and other clinicians working with individuals with borderline personality disorder remain abreast of the
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developing literature on addressing co-morbid dissociation. Alternatively, or as a complement,
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future literature might also provide more explicit clarification regarding ways of competently addressing co-morbid dissociation from within the DBT model if such ways exist, for example, the application and effectiveness of chain and solution analysis to dissociation.
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has been studied and substantiated by research (Linehan, 1993). While adherence to DBT skills-
Finally, in reviewing the pros and cons of such a combination given current data, it is helpful to
remain mindful of the principles of Evidence-Based Practice (Lilienfeld et al, 2013), which seeks to complement rigorously and scientifically validated treatment modules with an approach that honors the unique needs of different patient populations’ characteristics and needs,
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understanding that successful therapeutic outcomes rely not only on the implementation of specific interventions, but also on variables such as complexity of patient characteristics, patient stage of change (Prochaska & Norcross, 2001), and most importantly, a strong, client-centered
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therapeutic rapport (Lambert & Barley, 2001).
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Barnicot, K. & Priebe, S. (2013). Post-traumatic stress disorder and the outcome of dialectical behaviour therapy for borderline personality disorder. Personality and Mental Health, 7(3), 181-
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190.
Barnow, S., Limberg, A., Stopsack, M., Spitzer, C., Grabe, H., Freyberger, H., & Hamm, A. (2012). Dissociation and Emotion Regulation in Borderline Personality Disorder. Psychological Medicine, 42(4), 783-794.
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Biswas, J., Chu, J., Perez, D., & Gutheil, T. (2013). From the neuropsychiatric to the analytic:
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Three perspectives on dissociative identity disorder. Harvard Review of Psychiatry, 21(1), 41-51. Boon, S., Van der Hart., K, & Steele., O. (2011). Coping with Trauma-Related Dissociation:
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Skills Training for Patients and Therapists. W. W. Norton & Company: New York. Booth, R. Keogh, K., Doyle, J., & Owens, T. (2014). Living through distress: A skills training
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borderline personality disorders. Results of a multicenter study. Der Nervenarzt, 84(5), 608-614.
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Stepp, S. D., Epler, A. J., Jahng, S., & Trull, T. J. (2008). The effect of dialectical behavior therapy skills use on borderline personality disorder features. Journal of Personality Disorders, 22(6), 549-563.
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DD) Study. Retrieved from: www.towson.edu/topddstudy/.
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Towson University. (2015, April 4). Treatment of Patients with Dissociative Disorders (TOP
Vol.43(3), 324-335.
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ISSN: 1529-9732 (Print) 1529-9740 (Online) Journal homepage: http://www.tandfonline.com/loi/wjtd20
Considering Psychoeducation on Structural Dissociation for Dialectical Behavior Therapy Patients Experiencing High-Risk Dissociative Behaviors Olivia Shabb Psy.D. To cite this article: Olivia Shabb Psy.D. (2015): Considering Psychoeducation on Structural Dissociation for Dialectical Behavior Therapy Patients Experiencing High-Risk Dissociative Behaviors, Journal of Trauma & Dissociation, DOI: 10.1080/15299732.2015.1053657 To link to this article: http://dx.doi.org/10.1080/15299732.2015.1053657
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Considering psychoeducation on Structural Dissociation for Dialectical Behavior Therapy patients experiencing high-risk dissociative behaviors
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Author is currently affiliated with New York University; however this work is not associated with an institution and should not be associated with New York University. 11 W 8th St #2A, New York, New York 10011
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(650) 868-8214
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[email protected] No fax number
Key words: Posttraumatic stress disorder, Dialectical Behavioral Therapy, Dissociation, Structural Dissociation, Self-harm
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This content has not been previously presented nor published. No grant nor commercial support was received for this paper. Abstract
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Dialectical Behavioral Therapy (DBT) programs, particularly for low functioning individuals at
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the safety and stabilization phase of therapy, work with a variety of high-risk and often complex cases, with a curriculum consisting primarily of concrete skill-acquisition and application. A significant subset of individuals in DBT programs, however, may suffer high-risk dissociative
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Olivia Shabb, Psy.D.
episodes in which skill application may be less available to them, contributing to further destabilization, demoralization, and thoughts of self-inefficacy in treatment. This paper evaluates the potential benefits of complementing traditional DBT with psychoeducation on Structural
1
Dissociation for such patients, acknowledging and addressing some of the concerns that might accompany such a consideration. Key words: Posttraumatic stress disorder, Dialectical Behavioral Therapy, Dissociation,
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Dialectical Behavioral Therapy (Linehan, 1993) is a well-validated (Linehan, Armstrong, Suarez,
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Allmon, & Heard, 1991; Panos, Jackson, Hasan, & Panos, 2014; Stepp, Epler, Jahng, & Trull, 2008), widespread, skills-based treatment for borderline personality disorder (BPD), though it
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also enjoys successful application and adaptation beyond this diagnosis to additional populations with emotion dysregulation (Chugani, Ghali, & Brunner, 2013; Frazier & Vela, 2014; Neacsiu, Eberle, Kramer, Wiesmann, & Linehan, 2014) or high-risk behaviors such as self-harm and suicidality (Booth, Keogh, Doyle, & Owens, 2014; Denckla, Bailey, Jackson, Tatarakis, & Chen,
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C. K, 2014; Ward-Ciesielski, 2013).
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The four modules of DBT, mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness, provide patients with tools to improve self-attunement and more effectively
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navigate emotions, situations, and relationships. However, the application of these skills requires conscious awareness. Many individuals with BPD traits and high-risk behaviors who may benefit from DBT, however, experience dissociation, especially where a significant trauma history is
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Structural Dissociation, Self-harm
present. Sack, Sachsse and Overkamp (2013) conducted a multisite study revealing that the overwhelming majority (96%) of patients with BPD reported at least one traumatic experience in their lifetime, with most of them reporting several such experiences. This study estimated that 79% of patients BPD had comorbid PTSD. As dissociative disorders are common in trauma
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patients, they are also likely common in individuals with borderline traits or borderline functioning. Indeed, Sack et al’s multisite study (2013) found that 41% of BPD patients had comorbid severe dissociative disorders. Korzekwa, Dell, Links, Thabane, and Fougere (2009)
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further highlight the elevated frequency of dissociative disorders in individuals with Borderline
quarter reported no dissociative symptoms, and over three quarters qualified for dissociative
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disorders ranging from relatively mild (dissociative amnesia and depersonalization, 29%) to most severe (dissociative identity disorder, 24%).
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It has been observed clinically that certain DBT patients with severe dissociation may engage in self-harm or suicidal behaviors while in dissociative states, with little to no awareness or recollection of these behaviors. These patients may pose a particular challenge to DBT programs,
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as the behavior that would typically be targeted for change (self-harm) appears to be outside of the patients’ control or awareness. Bolstering skills that DBT teaches, particularly in the Distress
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Tolerance and Mindfulness modules, can help patients monitor awareness and decrease risk factors for dissociation. While harm reduction through skill use is essential, its impact on
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dissociative patients may be limited as the more functional, overregulated part of their personality mat attend group and learn skills, while under-regulated parts that are fixed in trauma are absent, do not reap the benefits of this learning, and their ongoing dissociation may in fact
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Personality Disorder. Out of a sample of 21 such patients in outpatient treatment, less than a
continue to threaten the efficacy of the part that functions in daily life. This paper therefore explores the question of whether DBT patients who exhibit high-risk behavior in dissociative states may uniquely benefit, even in a Phase 1 Safety and Stabilization program (Herman, 1992),
3
from supplementing DBT skills training with psychoeducation providing insight into the nature and function of structural dissociation (Van der Haart, Nijenhuis, & Steele, 2006).
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Structural Dissociation
adapt to trauma, particularly if the trauma is intense and repeated, by a dissociative process that
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involves splitting into two parts. The first is the part that functions in daily life or “business as
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usual” part, which typically occupies the majority of consciousness. The second is the part that is fixated in trauma. The part that functions in daily life is driven by the desire to do what needs to be done in order to get by and therefore includes a drive for attachment and engagement with the world and others. To do so it is invested in suppressing awareness of the trauma, which is thus
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relegated to the shadow part that is fixated in trauma. The part that functions in daily life may only acknowledge trauma in a superficial and cursory manner, if at all, but the part that is fixated
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in trauma remembers trauma vividly. It is stuck in a traumatized mindset and constantly feels threatened as when trauma was experienced. Its drive is primarily defensive and self-protective,
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directly at odds with the drive of the part that functions in daily lifeto connect and get by in the world.
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Structural Dissociation of the personality (Van der Haart et al, 2006) posits that personality can
The long-term incompatibility of these drives, along with the phobic relationship trauma survivors often have to experiencing strong emotions, results in and accentuates the schism
between these two parts over time, preventing their integration into a cohesive whole that is able to acknowledge trauma without overwhelm. Thus a trauma survivor may rely primarily on the
4
part of their personality that functions in daily life, but when triggered, they may reflexively respond from a part that is fixated in trauma. The nature of this response depends on each individual’s particular traumatized parts, as the part that is fixated in trauma can further be
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divided into parts that assume different self-defensive modes: fight, flight, freeze, submit, and
the time of the original trauma. For example, an individual whose fight part is activated may
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respond to a trigger with aggression towards others or him or herself. In cases of severe trauma, the dissociation between the part that functions in daily life and the part that is fixated in trauma
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may be extreme to the point that a traumatized part may take over without awareness on the part that functions in daily life; when the individual reverts to the latter part, they may thus be surprised, alarmed, and confused regarding their situation. Indeed, the part of individuals with trauma that functions in daily life is often unaware of chunks of these individuals’ experience
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(for example, inability to account for lapses of time), suggesting dissociation to an alternative part that is stuck in trauma. These episodes can include a range of behaviors depending on the
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traumatized part that was activated, and can include self-harm (typically a fight part response, as
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previously indicated).
Based on the above, a psychoeducational module addressing structural dissociation might:
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attach. A triggered individual may revert to one or several parts that helped the individual cope at
•
Introduce patients to the part that functions in daily life, the part that is fixated in trauma,
and their respective functions •
Discuss the incompatibility of these parts
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•
Explain how this incompatibility obstructs integration and promotes dissociation and
dissociative behaviors Understand dissociation as a trauma-based, self-protective response to triggering
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•
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•
Validate this trauma response and nurture compassion and motivation to use DBT skills
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to head off dissociation and develop more effective coping
Such education provides context and a vocabulary for understanding and naming the
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behaviorally and emotionally challenging phenomenon of dissociative experiences. It can help normalize and elucidate for patients the otherwise perplexing, unsettling experience of finding themselves having destroyed property, assaulted another person, self-harmed, or engaged in
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other unconscious behaviors. It can decrease disorientation, shame, and self-defeating judgments, increase self-compassion, and mitigate the additional emotional dysregulation that such
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experiences cause.
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Concerns
There are several important and valid concerns when considering adding a psychoeducational
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situations or distressing emotions
component to a DBT program or track, particularly for a Phase 1 (Safety and Stabilization) program. Some of these concerns are outlined and addressed below:
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1. DBT, particularly in a strictly adherent track, is skills-based because the priority for individuals
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behavioral control, rather than insight-oriented work. While DBT intends to focus on practical skills training rather than delving into explanations of
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the origins of behaviors that are targeted for change, dissociation presents a challenge for both identifying and addressing target behaviors. Peri-dissociative high-risk behaviors often seem less predictable and controllable to patients than behaviors that are typically targeted for change and that occur with their full awareness. While behaviors collaboratively targeted for change by DBT
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patients and their therapists are often used by patients in a control-seeking, if ineffective, manner, severe dissociation is usually a reflexive response to stress in which the part that
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functions in daily life is overwhelmed and relinquishes control, with the part that is fixated in
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trauma taking over without direction or even consciousness from the part that functions in daily life. Thus destructive behaviors can happen in dissociative states without planning or memory. In these cases, since the targeted high-risk behaviors are secondary to dissociation, the problem of
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assigned to such a track is risk reduction and
dissociation becomes more prominent and vital to treatment. While disagreement exists over whether insight is essential for change in psychotherapy, insight into the origins and functions of dissociation appears critical to beginning the work of integration of the self, or at least reconciliation of the split manifestations of consciousness – a primary
7
treatment goal for patients with severe dissociative disorders according to the International Society for the Study of Dissociation (2011). Research indicates that dissociation and related symptomatology predict poor response to DBT (Kleindienst, Limberger, Ebner-Priemer, Keibel-
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Mauchnik, Dyer, Berger, … & Bohus, 2011), perhaps due to the potentially obstructive or
Spitzer, Grabe, Freyberger, & Hamm, 2012), a primary goal and area of competency in DBT.
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Therefore, for traumatized patients with borderline traits as well as high-risk dissociation, behavioral stabilization and safety appear to be difficult to achieve without concurrently
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targeting integration of personality and experience. Contextualizing DBT skills and behavioral control in the larger framework of integration may resonate more effectively with individuals on the severe end of the dissociative spectrum, providing further motivation for the use of DBT
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skills that promote mindfulness and preventive, adaptive coping.
These data further suggest that Phase 1 DBT programs stand to boost positive engagement and from
complementing
skill-based
interventions
with
integration-promoting
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response
psychoeducation for the high number of dissociative patients they are likely to treat. The effort to
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address dissociative disorders in increasingly skills-based psychotherapy programs remains new, yet it speaks to the insufficiency of skills training alone, and to the need to target dissociation more specifically and effectively. This viewpoint is often echoed by practitioners and researchers
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mitigating effect dissociation may have on emotion regulation (Barnow, Limberg, Stopsack,
working with dissociative patients (Kleindienst et al, 2011; Korzekwa, Dell, & Pain, 2009; Lanius, Vermetten, Loewenstein, Brand, Schmahl, Bremner, & Spiegel, 2010).
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Boon, Van der Hart and Steele (2011) provide a precedent for combining skills work with psychoeducation on dissociation in the workbook Coping with Trauma-Related Dissociation: Skills Training for Patients and Therapists. This manual was developed in response to the
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observation that available Phase 1 treatments tend to neglect the realities and needs of patients
dissociation at this phase of treatment, either undermining the central relevance of dissociative & Steele, 2005) or crafting
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symptoms in traumatized patients (Van der Hart, Nijenhuis
experimental approaches and hoping for the best. The workbook thus addresses this clinical gap.
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The bulk of the text consists of an eclectic skill set and strategies for grounding and coping, yet the very first section of the workbook, Understanding Dissociation and Trauma-Related Disorders, explains the concepts and processes of integration and structural dissociation in accessible language, including the ways in which they are shaped by trauma (as is related in the
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above section on Structural Dissociation). The skills are thus couched in psychoeducation about
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their relevance to the treatment of dissociative symptoms. Working specifically from a DBT approach, protocols have begun to emerge concurrently
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targeting borderline traits as well as trauma, helping to address the research gap on treating comorbid borderline personality disorder and PTSD. A combined DBT + Prolonged Exposure (PE) treatment module (Harned, Korslund, Foa, & Linehan, 2012) is one such promising
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suffering from severe dissociation, and that clinicians themselves appear to struggle with treating
treatment, whereby patients with borderline personality disorder as well as PTSD who received DBT + PE demonstrated greater therapeutic gains than those who received solely DBT (Harned, Korslund, & Linehan, 2014). However, the effectiveness of this protocol may not be generalizable to high-risk dissociators at Phase 1 of treatment. Exposure-based therapies may be
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uniquely risky for such patients given their use of dissociative self-harm as a coping response to stress, and may be best reserved for Phase 2 interventions once stabilization and alternative coping have been acquired. In any case, intent to address PTSD may not result in effective
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targeting of dissociation, as increasing evidence points to the heterogeneity and fluctuation of
et al., 2010) that requires severe dissociation to be addressed specifically and deliberately
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(Kleindienst et al, 2011; Lanius et al, 2010), not only under the general umbrella of PTSD.
Thus treatment solutions for patients with borderline personality traits who experience
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pervasive, high-risk dissociation remain under-researched, and clinical interventions underappreciative of the obstructive effect of dissociation. Coupling skills-based DBT training with psychoeducation on structural dissociation, perhaps with inspiration from Boon et al’s approach
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(2011), is one way to reverse this clinical trend, and to inform and inspire relevant future research. These authors’ work has been adapted for skills training in the current web-based
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Treatment of Patients with Dissociative Disorders (TOP DD; Towson University), which will
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further elucidate the effectiveness of their model.
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posttraumatic symptoms and syndromes, including a uniquely dissociative presentation (Lanius
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2. Patients assigned to DBT treatment may not be able to tolerate discussing and processing trauma-related
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Any process work related to trauma is typically contraindicated for a Safety and
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Stabilization phase treatment (Herman, 1992), particularly for individuals whose coping style and emotion regulation ability are impaired and risky enough that DBT treatment is indicated.
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However, the addition under review is of a psychoeducational nature, focusing on providing insight regarding the impact of trauma on the development and maintenance of a maladaptive coping style, and aiming to normalize dissociation in light of a history of trauma. This differs
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greatly from processing the trauma itself. Acknowledging the impact of trauma on the present is in line with Safety and Stabilization phase goals, especially since many of these goals – for
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example, increasing social support and developing adaptive coping skills – are obstructed by maladaptive, trauma-related coping such as isolation and self-harm (Herman, 1992). The better
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one understands the impact of trauma, the easier it is to develop the compassion, rationale, and courage to make the kinds of change that Safety and Stabilization requires.
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information.
Recent research suggests that individuals with BPD and extensive trauma histories are indeed able to tolerate insight-oriented psychoeducation about trauma. Mental health providers often
and understandably worry about the fragility of traumatized patients with borderline functioning. However, research is optimistic on this matter. Recent research (Barnicot & Priebe, 2013)
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suggests that patients presenting with comorbid BPD and PTSD are more likely to benefit from treatment that concurrently addresses trauma while building coping skills, rather than focusing exclusively on skill building. A study (Van Minnen, Harned, Zoellner, & Mills, 2012)
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investigating potential contraindications for Prolonged Exposure (Foa, Hembree, & Rothbaum,
common attributes of patients in DBT programs – did not constitute contraindications for such
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intense a treatment. Harned et al’s combined DBT & PE program (2012), found the combination of skills training and trauma work safe and effective, although the limitations of assuming that
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PTSD work targets dissociation and of applying process-based trauma interventions for high-risk dissociators at Phase 1 has been raised. Together these findings suggest that a much milder, shorter, and non-process oriented intervention such as a session of psychoeducation is likely to be tolerated by patients, if not actively beneficial. Indeed, individual work addressing
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& Gutheil, 2013).
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dissociation in conjunction with skills training has yielded promising results (Biswas, Chu, Perez,
As with any presentation and any course of therapy, psychoeducation about symptoms and a
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collaborative approach to treatment (for example, explaining why dysregulation and dissociation occur and the relevance of targeting them both as part of the treatment plan), are important for restoring a sense of cohesion, agency, and control to the patient. This is particularly important
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2007) found that Borderline Personality Disorder, dissociation, and suicidal ideation – all
with traumatized patients as trauma and related dissociation tend to corrode these vital areas of
intra- and interpersonal functioning (Herman, 1992). If, through psychoeducation, clinician and
patient can agree on an explanatory model of symptoms and on a collaborative, logical treatment plan, the patient is more likely to feel validated and motivated (Horvath & Luborsky, 1993).
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Further validation can come from understanding dissociation as an originally adaptive response to trauma, and from reassurance that the patient will not be stripped of such defenses without
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support and concurrent development of more presently effective coping strategies.
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research as a skills-based intervention; adding an insight-oriented
component
would
entail
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compromising adherence to the treatment as it was validated.
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DBT, especially at Phase 1, is indeed a skill-based treatment approach with cohesive theoretical and philosophical underpinnings and strong empirical support. The addition of a structural
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dissociation trauma education component, no matter how small this addition relative to the
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course of treatment, does constitute a deviation from the original program. Naturally, such an addition would call into question the empirical validity of the modified treatment now being delivered. With this acknowledgement, the addition of a structural dissociation psychoeducation
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3. DBT group treatment has been validated by
component does not contradict, and may very well in fact be very compatible with the principles and goals of DBT. Wagner and Linehan (2006) posit that DBT is principle rather than protocol-driven, suggesting that DBT can be adapted to fit the needs of traumatized patients both ideographically and as a
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subpopulation (Wagner, Rizvi, & Harned, 2007) particularly if the approach to treatment is consistent with the theoretical underpinnings of DBT (Wagner & Linehan, 2006) and complements the goals of DBT.
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The biosocial model at the core of DBT can be wed to structural dissociation to reflect and
model subsumes trauma as part of an invalidating environment. The biological aspect of the
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explanatory model includes neuroregulatory dyscontrol, particularly of the limbic and paralimbic systems, with under-regulation leading to hyperarousal, and overregulation leading to
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hypoarousal (Frewen & Lanius, 2006; Lanius et al, 2010). Hypoarousal may or not be triggered by intolerance of hyperarousal and for individuals with severe trauma, it can manifest as switching to a dissociated, fixated in trauma personality state that in and of itself can have over-
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or under-reactive qualities depending on the unconscious or overly-learned coping strategies that developed as a response to trauma.
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Moreover, for individuals exhibiting high risk dissociation, complementing DBT skills work
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with integration-promoting psychoeducation and interventions is also likely to improve resolution of dialectical dilemmas such as self-invalidation versus emotional vulnerability, as patients better understand and support themselves through disorienting and uncomfortable
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explain the experiences of high-risk dissociators. The social or experiential component of the
experiences and emotions. The purpose of such education is also closely aligned with the principle of validation that is so central to DBT (Linehan, 2013). The incorporation of psychoeducation regarding structural dissociation necessarily results in a non-Empirically Supported Treatment (Herbert, 2003) because this particular combination of
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therapy components does not appear to have been systematically studied. However, if this combination is clinically indicated, then its delivery is very much in keeping with EvidenceBased Practice (Lilienfeld, Ritschel, Lynn, Cautin, & Latzman, 2013), which advocates for
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mental health providers to flexibly and mindfully combine empirically supported techniques with
In the context of a DBT-adherent group-based program where there is concern for the integrity
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of the DBT curriculum, or if concern exists about the relevance of psychoeducation regarding structural dissociation to certain group members or its potential impact on them, this component
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may be provided in adjunct individual sessions, which patients in DBT skills groups are typically concurrently receiving anyway, to ensure its relevance to the patient. In DBT programs or groups where members all share trauma histories and exhibit dissociative behaviors, such education
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might be provided in a group format with attention to limited processing to avoid unnecessary triggering.
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When contemplating the addition of this component to a DBT curriculum, the question naturally
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arises of where it might fit in. Individual therapy allows for some degree of flexibility in terms of when to integrate psychoeducation about structural dissociation into treatment. In terms of group therapy, if and when appropriate, it may be a natural supplement to the distress tolerance module,
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patients’ unique characteristics and needs.
if dissociation is understood as a nearly-automatic response to overwhelming emotions such as anxiety, anger, or sadness.
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Conclusion It is important to stress that the addition of the adjunct intervention reviewed in this paper
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remains experimental and constitutes a deviation from the standard DBT treatment model that
based groups is conceptually and therapeutically justified for borderline personality disorder
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patients with trauma histories and a pattern of potentially destructive dissociative behavior, there are also strong clinical and theoretical reasons to consider complementing skills-based
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interventions with psychoeducation about dissociation – a combination that will hopefully be further examined going forth, through the symbiotic and complementary relationship of clinical practice and psychological research. With regards to practice, given that so many borderline personality disorder patients present with co-occurring dissociation, it is essential that
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dissociative disorders be actively screened for and accurately diagnosed, and that DBT and other clinicians working with individuals with borderline personality disorder remain abreast of the
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developing literature on addressing co-morbid dissociation. Alternatively, or as a complement,
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future literature might also provide more explicit clarification regarding ways of competently addressing co-morbid dissociation from within the DBT model if such ways exist, for example, the application and effectiveness of chain and solution analysis to dissociation.
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has been studied and substantiated by research (Linehan, 1993). While adherence to DBT skills-
Finally, in reviewing the pros and cons of such a combination given current data, it is helpful to
remain mindful of the principles of Evidence-Based Practice (Lilienfeld et al, 2013), which seeks to complement rigorously and scientifically validated treatment modules with an approach that honors the unique needs of different patient populations’ characteristics and needs,
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understanding that successful therapeutic outcomes rely not only on the implementation of specific interventions, but also on variables such as complexity of patient characteristics, patient stage of change (Prochaska & Norcross, 2001), and most importantly, a strong, client-centered
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therapeutic rapport (Lambert & Barley, 2001).
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Barnicot, K. & Priebe, S. (2013). Post-traumatic stress disorder and the outcome of dialectical behaviour therapy for borderline personality disorder. Personality and Mental Health, 7(3), 181-
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190.
Barnow, S., Limberg, A., Stopsack, M., Spitzer, C., Grabe, H., Freyberger, H., & Hamm, A. (2012). Dissociation and Emotion Regulation in Borderline Personality Disorder. Psychological Medicine, 42(4), 783-794.
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Biswas, J., Chu, J., Perez, D., & Gutheil, T. (2013). From the neuropsychiatric to the analytic:
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Three perspectives on dissociative identity disorder. Harvard Review of Psychiatry, 21(1), 41-51. Boon, S., Van der Hart., K, & Steele., O. (2011). Coping with Trauma-Related Dissociation:
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Skills Training for Patients and Therapists. W. W. Norton & Company: New York. Booth, R. Keogh, K., Doyle, J., & Owens, T. (2014). Living through distress: A skills training
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