Assignment: Controversy Associated With Dissociative Disorders To Prepare Review this week’s Learning Resources on dissociative disorders.Use the Walden Library to investigate the controversy regard

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Week 9: Controversies with Dissociative Disorders

Lori Sfakios

College of Nursing-PMHNP, Walden University

PRAC 6665: PMHNP Care Across the Lifespan I

Dr. Trace Yule

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Dissociative Disorders

Dissociative disorders (DD) are a group of disorders that often result from stressful

situations, trauma, childhood trauma, or abuse. The disorders include dissociative amnesia,

dissociative identity disorder, depersonalization or derealization disorder, and dissociative fugue

(Mad Medicine, 2019). These disorders involve a disruption in mental functions such as memory,

awareness, perception, consciousness, motor control, and identity, leading to feelings of being

disconnected from oneself or disconnected from their environment (Sadock et al., 2015).

Dissociating is the body’s physiological and psychological coping response to overwhelming,

distressing, and painful trauma (Temple, 2019). There is a great deal of controversy, and ethical

conflict regarding DD is due to the lack of scientific literature to support this group of disorders.

The following paper will address the controversies with DD and my professional beliefs,

strategies to maintain a therapeutic alliance with clients, and legal and ethical considerations.

Controversy Associated with Dissociative Disorders

Controversy with DD stems from the lack of scientific literature despite the evidence

supporting a strong relationship between DD and trauma (Lowenstein, 2018). Lowenstein (2018)

and Grande (2018) explain that the controversial debate focuses on whether dissociations result

from psychological trauma or something a person has made up with their confabulated trauma

memories or is it iatrogenic. Theorists such as Pierre Janet have studied dissociation. Janet

described dissociation as an instinctive and adaptive process universal to everyone in traumatic

situations (Temple, 2019). His theory was disregarded because of the shift to the psychoanalytic

theory in the early 1900s. Many have disputed DD and the concept of dissociation through the

years because of the lack of empirical evidence or the lack of ability to replicate previous

findings (Lowenstein, 2018; Temple, 2019). Unfortunately, the controversies continue to lead to This study source was downloaded by 100000794395091 from CourseHero.com on 10-24-2022 10:58:11 GMT -05:00

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a lack of knowledge and understanding essential to treat clients with DD. Evidence shows a

strong prevalence of DD in those with post-traumatic stress disorder (PTSD), obsessive-

compulsive disorder, and borderline personality disorder (Grande, 2018; Temple, 2019). Despite

DD being one of the oldest groups of psychiatric disorders, skeptics remain. Dissociative identity

disorder (DID)is the most controversial of the four primary DD. The media has portrayed very

dramatic characteristics in people with DID, leading to a great misunderstanding. Professional

beliefs must come from the evidence that does exist.

Professional Beliefs of Dissociative Disorders

The controversy of whether DD is caused by trauma or iatrogenic causes is irrelevant at

this time in history. Those suffering from DD are highly underserved, leading to a large cost

burden to the healthcare system and society (Lowenstein, 2018). Professionals need to put aside

negative beliefs about DD and utilize the latest literature and clinical guidelines to treat it.

DD has been listed in the Diagnostic and statistical manual of mental. My experience is limited,

and I have only encountered one child, age 12, who has reported dissociative symptoms after

witnessing her mother experience significant trauma. I believe that clients who have dissociative

symptoms often have underlying co-occurring disorders. The reality is that clients with DD exist

and dismissing them could lead to their demise. DD leads to severe symptoms, high utilization of

psychiatric services, increased comorbidity, and increased suicidality (Lanius et al., 2018;

Temple, 2019). It is paramount that providers develop strategies to maintain a therapeutic

alliance with clients diagnosed with a DD.

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Treating clients diagnosed with DD is challenging as these clients often struggle with

trust issues. The first step in caring for clients with DD is to develop professional competence

with these disorders (Lawson et al., 2017). The first-line treatment is for clients with DD is

psychotherapy. Psychotherapy modalities recommended for those who have experienced trauma

are trauma-focused cognitive behavioral therapy (TF-CBT) (Lawson et al., 2017). Clinicians

who take on clients with DD must be knowledgeable of DD and treatments. The client and the

clinician should mutually agree upon case formulation and treatment plans. Selecting a treatment

modality is just one piece of the puzzle. The clinicians must first develop a therapeutic alliance

with the client, and secondly, the clinician must maintain that alliance with the client. Clinicians

should avoid trying to dive right into a client’s troubling memories as this is anxiety-inducing

and may cause the client to shut down (Ducharme, 2017). The clinicians must understand the

client’s culture, which may impact the treatment and potential outcomes. The therapeutic alliance

is a vital indicator of treatment outcomes. Victims of abuse and trauma often face challenges

with interpersonal relationships because they are often abused by someone they trust.

Victims of abuse develop feelings of mistrust and insecurities that they then apply to the

general population, not just their assailants (Lawson et al., 2017). According to Lawson et al.

(2017), clients who have dissociative symptoms are emotionally dysregulated, require long-term

treatment, and often have less than optimal outcomes, which makes building a therapeutic

alliance an even more significant challenge. Clinicians must have self-awareness, be mindful of

their judgments and biases and avoid countertransference. It is important to continuously assess

the therapeutic alliance, monitor for subtle changes in the client, and be aware of their own

emotions when reacting to client changes (Lawson et al., 2017).

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The treatment of DD comes with certain legal and ethical considerations. The treatment

of clients with dissociative disorders is very complex and lengthy. Clinicians who take on clients

with these disorders must be committed. Clinicians have an ethical obligation to remain

knowledgeable of the disorders and competent to provide appropriate treatment to facilitate a

positive outcome. Competency with this unique population often requires post-graduate work

such as coursework, workshops, and supervisory guidance (Ducharme, 2017). Legal issues can

arise when treating DD clients. Often those with dissociative identity disorder have two or more

alters. Acquiring informed consent may be a challenge if the alter presents itself to the clinician.

There may be concerns that the client may not fully understand the treatment they have

consented to. Often, clinicians will facilitate a no-harm contract with the client; however, this is

not legally binding and does not prevent suicide (Ducharme, 2017). DD clients often engage in

self-injurious behaviors which makes them an even greater safety risk (Parry et al., 2017).

Caring for clients who engage in self-injurious behaviors requires a safety assessment at each

treatment session.

Conclusion

Treatment of clients with DD is a specialty. Only clinicians who have been appropriately

trained should take on this unique population. Controversial beliefs continue to linger about DD.

Clinicians must utilize the latest evidence-based treatment to help clients with DD. One of the

most important aspects of caring for a client with DD is the therapeutic alliance. If there is no

therapeutic alliance, there will be no positive outcomes. Positive relationships between clinicians

and their clients can positively influence recovery from their past trauma and improve social

connections, resilience, and safety (Parry et al., 2017).

References This study source was downloaded by 100000794395091 from CourseHero.com on 10-24-2022 10:58:11 GMT -05:00

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Ducharme, E. L. (2017). Best practices in working with complex trauma and dissociative identity

disorder. Practice Innovations, 2 (3), 150–161. https://doi.org/10.1037/pri0000050

Lanius, R. A., Boyd, J. E., McKinnon, M. C., Nicholson, A. A., Frewen, P., Vermetten, E., Jetly,

R., & Spiegel, D. (2018). A review of the neurobiological basis of trauma-related

dissociation and Its relation to cannabinoid- and opioid-mediated stress response: A

transdiagnostic, translational approach. Current Psychiatry Reports, 20( 12), 118.

https://doi.org/10.1007/s11920-018-0983-y

Lawson, D. M., Stulmaker, H., & Tinsley, K. (2017). Therapeutic Alliance, Interpersonal

Relations, and Trauma Symptoms: Examining a Mediation Model of Women With

Childhood Abuse Histories . Journal of Aggression, Maltreatment & Trauma , 26 (8), 861–

878. https://doi.org/10.1080/10926771.2017.1331941

Loewenstein, R. J. (2018). Dissociation debates: everything you know is wrong. Dialogues in

Clinical Neuroscience , 20 (3), 229–242.

O’Mahony, B., Milne, B., & Smith, K. (2018). Investigative interviewing, dissociative identity

disorder and the role of the registered intermediary. Journal of Forensic Practice, 20 (1),

10-19. doi:http://dx.doi.org/10.1108/JFP-05-2017-0018

Parry, S., Lloyd, M., & Simpson, J. (2017). Experiences of therapeutic relationships on hospital

wards, dissociation, and making connections. Journal of Trauma & Dissociation : The

Official Journal of the International Society for the Study of Dissociation (ISSD), 18 (4),

544–558. https://doi.org/10.1080/15299732.2016.1241852

Temple, M. J. (2019). Understanding, identifying, and managing severe dissociative disorders in

general psychiatric settings. BJPsych Advances, 25 (1), 14–25. This study source was downloaded by 100000794395091 from CourseHero.com on 10-24-2022 10:58:11 GMT -05:00

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