Dissociation: Defense or Result of Cognitive/Perceptual Disruption?

The term dissociation has been used to describe so many things it at times appears to mean nothing at all. For instance, it has been used to refer to describe a continuum of experiences of detaching from reality that can range from daydreaming and boredom to the fragmentation of the self into separate streams of consciousness such as we see in dissociative identity disorder.

In ISTDP we make several distinctions when dealing with this class of defenses. First of all, detaching and daydreaming are viewed as tactical or repressive defenses when the patient’s anxiety is in the striated muscles. In this case, we point out how the patient detaches from her feelings (repressive defense or character defense) or detaches from the therapist (tactical defense or transference resistance). We point out the defense, help the patient see its price, and invite her to let go of her defense to have deeper contact with her inner life and to have a deeper connection with others.

However, when we address more pathological forms of dissociation (blanking out, derealization, amnesia, or fragmentation of self experience), the anxiety is discharged into cognitive/perceptual disruption. When anxiety is channeled into cognitive/perceptual disruption, we regulate anxiety before addressing the defense of dissociation. We have to restore proper functioning of the brain. In this case, as soon as a severe form of dissociation occurs, we point out the anxiety and regulate it until the patient’s anxiety returns to the striated muscles. Then we will explore feelings again, building the patient’s capacity step by step so that he can tolerate higher levels of feeling without resorting to the defense of dissociation. Once the patient’s anxiety has been completely restructured into the striated muscles, the dissociation will no longer be necessary as a defense.

ISTDP differs in two ways from many other models of working with dissociation. First, when dissociation results from anxiety in cognitive/perceptual disruption, anxiety regulation takes precedence over defense work. Often, anxiety regulation leads to a drop in the defense of dissociation in the moment. Second, ISTDP does not work with the integration of the “multiple” selves. Why? These multiple selves are the results of the defense of splitting. We regulate anxiety until the defense is not necessary. Then we help the patient face and integrate his complex mixed feelings internally without splitting, so those feelings and experiences do not have to be split apart and represented as “multiple” selves. You can read an interesting case of ISTDP with a dissociative man on our resources page, “The Man Who Awoke from a Coma.”








8 responses to “Dissociation: Defense or Result of Cognitive/Perceptual Disruption?”

  1. Karen Fisher Avatar

    Hi Dr. Frederickson. I recently started ISTDP for C-PTSD. During the 4th counselling session I split into at least 8 “selves” or “parts” that I was previously unaware of. 3 are young children who now want to be heard and rescued from a well, a jail cell, and a critical part towering over her. One of the “parts” actually took control over me and I had facial and body gestures and an accent of a part that called himself “the Sherrif”. Correct me if I’m wrong, but according to what I’ve read splitting is something that is to be potentially prevented. My therapist told me she will not address the “parts”; however, the “parts” want to be. My dilemma now is I can’t just put them back and pretend it never happened. My question is two-fold: How should my ISTDP therapist proceed and can ISTDP still help me? I have chronic pain and many “somatic” symptoms that I am desperate to improve.
    Thank you for considering my comments and questions.

  2. Jon Frederickson Avatar
    Jon Frederickson

    Of course, without seeing the video, all I can do is speculate. If there was this kind of splitting, that would ordinarily indicate that anxiety was getting too high. ISTDP can help this situation, but attention to anxiety is essential, then invitation to experience the split apart feelings, and also addressing feelings toward others that may be coming back upon you in the form of chronic pain and somatic symptoms. Other with these symptoms have recovered with ISTDP. But it may be that your therapist and you are finding the right level of feeling to work at that will be integrative.

    1. Karen Fisher Avatar

      Thank you for your very prompt reply Dr. Frederickson.
      The first time I became aware of a part, I saw (an image that seemed to be inside my chest area) of a little girl in a well reaching up with her right arm pleading for help. This was an internal vision not a hallucination. The therapist ignored my sharing of this and later I had thoughts inside of the little girl being angry that the therapist didn’t show the part empathy or acknowledge her distress.

      Just so I uderstand correctly, what if my anxiety isn’t regulated, goes over my anxiety threshold and results in cognitive/perceptual disruption again; for example: the “Sherrif” emerges.
      How is this addressed in therapy? Do you have any examples of this type of “splitting” and how to work with this in your book?

      Again thank you for your time and consideration of my questions.


  3. Jon Frederickson Avatar
    Jon Frederickson

    I have examples of how to work with dissociation in my most recent book. However, what you describe and how you describe it suggests that your capacity is higher. And that might be a reason your therapist is working differently. Seeing an internal image is not necessarily dissociation and there are other ways to work with that kind of imagery.

  4. Nana Avatar

    Sorry. But as an istdp-client with severe problems that both relates to bpd and c-ptsd. I would suggest that the client and therapist work on that anger, the client shows when her inner child wounds are overheard. This is kind of basic knowledge for real trauma survivors that we were never heard. So… this is an opportunity to get pissed at your therapist and let the therapist own it and deal with the damage. And then… this is the good stuff. The client both work with emotions, boundaries, attachment and gets to speak out for him/her self.
    No trauma-healing should include shaming and overhearing the client. Not even istdp. Maybe you get “well-sorted-out”-clients in the end. Or maybe you get clients who learn to be quiet. And not speak up. Like they were taught in childhood.
    Of course misaliance can also be a beautiful goal for some trauma therapists. Just be aware of if it is healing or building up a bad alliance with a client. No therapist is omnipotent. If they feel that, they should reconsider if they are doing Stone-therapy or doing the soul-healing.

    1. Jon J Frederickson Avatar
      Jon J Frederickson

      Of course, we need to address and integrate any feelings that have been split off. But when anxiety is in cognitive/perceptual disruption, we need to regulate anxiety first. And then we can help the patient bear the rage, bit by bit.

      1. Karen Fisher Avatar

        I respectfully disagree. And I’d appreciate if my experience is not questioned. Speaking from personal experience as one who dissociates/splits, when my feelings/experiences/parts were not acknowledged, validated and/or addressed I felt as I did when I was a child i.e. that I was again not heard, dismissed by the therapist and this made me feel angry at her and became a constant barrier to developing trust or a therapeutic alliance. I never knew that as a survivor of complex trauma that I had developed the coping strategy of developing “parts” or splitting until I entered therapy with an ISTDP therapist early 2021. A child part finally thought they were safe to expose themselves to the therapist and me and this was NOT even acknowledged by the therapist! I reported to the therapist that there was a child inside me reaching her arm up asking over and over for help. No help came. She said nothing about it. Other splitting continued to occur over the course of the next sessions and lots of anger and challenging directed at the therapist. I couldn’t stay present to get anywhere and she did not know how to ground me. I discontinued our relationship. I tried another counsellor; however, parts did not feel safe to share. The ISTDP therapist was only concerned with getting me try to think of a memory and get angry at the person and get in touch with shame whether I had same or not. This had a really destabilizing effect on me. The only positive is that I now know that I have these survivor coping methods; however, I don’t know how to find healing.

  5. Jon J Frederickson Avatar
    Jon J Frederickson

    I said nothing about your experience. I only pointed out the importance, in general, of regulating anxiety. I am very sorry that your therapist failed to address splitting and instead pursued a strategy that made you worse. This, alas, is a not uncommon problem for many therapists who are not taught systematically how to identify and work with splitting in ways that lead to healing. Splitting can manifest in many ways, and fortunately there are many ways to help such patients. However, the vast majority of therapists I find do not have those skills.

Leave a Reply

Your email address will not be published. Required fields are marked *