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.”