Time to (re-)integrate dissociation into psychoanalytic psychotherapy? An introduction to the special issue on dissociative disorders and psychoanalytic psychotherapy

Whilst writing this introduction (14 October 2023), an entire nation – the State of Israel – is being traumatized and evidences signs of collective dissociative symptoms. An orchestrated, carefully planned attack from Gaza, by the Hamas Organization, has culminated in more than 1300 Israelis (mostly civilians) being brutally murdered and about 200 hundred Israelis kidnapped to Gaza. The consensus consolidating among Israelis these days is that the Israeli Defense Forces (IDF), arguably one of the most formidable armies worldwide, has never before been surprised and overwhelmed as it was on the Saturday of 7 October 2023, when the attack commenced. Golan Shahar, the editor of this special issue, currently providing psychological first-aid with both civilians and members of the security forces, is awed by one recurring theme reverberating in the words of virtually all the survivors with whom he works: a theme of surrealism. ‘This is not happening’, ‘I barely sleep and when I wake up it is with the hope that it didn’t happen’ are merely some of the utterances he repeatedly hears, and they echoed his own experiences.

Psychological dissociation is The Surreal. It is an amalgamation of thoughts, emotions, and behaviors that share the common denominator of challenging the way we experience self and world. Dissociation is not merely altered consciousness, it is an attack on consciousness: on memory, identity, and goal-directed action. Freud (1919) titled it ‘Unheimlich’, improperly translated as ‘The Uncanny’ (see also Sullivan, 1953, on uncanny emotions), and for Bion (1959), it was the outcome of attacks on linking. The attempt, metaphoric as it was, by these psychoanalytic theorists to grapple with this clinical entity is marred by the very same frustration evinced by descriptive psychopathologists in the face of understanding the similarities and differences between dissociative symptoms and disorders and other types of psychopathology (Sar & Ross, 2006). Decades of theory, followed by further decades of empirical research, have advanced our understanding of experiences such as depersonalization, derealization, dissociative amnesia, self-compartmentalization, and other dissociative manifestations, but they are far from settling gnawing questions in psychopathology – with clear implications for psychotherapy – such as ‘what is the difference between dissociation and psychosis?’, ‘is there dissociation without prior trauma?’, ‘can people really be dissociatively split into multiple identities?’, ‘what are the adaptive and maladaptive ways in which people cope with dissociative manifestations?’, ‘how should pathological dissociation be treated?’, and more (see Chefetz, 2015; Sar & Ross, 2006).

These are the questions that serve as an impetus for developing this special issue, which brings together contributions from leading authors in the field of dissociation. The DSM-V and ICD-11 categorise a number of dissociative disorders: Depersonalisation-Derealization; Dissociative amnesia (with or without dissociative fugue); Partial Dissociative Identity disorder; Dissociative Identity disorder (DID); Dissociative neurological symptom disorder; Trance disorder; and Possession trance disorder. Some of these diagnoses have provoked controversy and skepticism. Whilst many, if not most, clinicians will have encountered various forms of dissociative psychopathology, DID remains an elusive and contested presentation. Perhaps in a parallel to the disorder itself, it continues to be challenging for theorists and clinicians to view the field as a whole and contain the disagreements, contradictions, and paradoxes. We hope and believe that this special issue will serve as an important facilitator of the pursuit of integrative clinical scholarship connecting psychoanalytic thinking and practice with dissociation research and treatment.

The special issue begins with a commentary by Richard Chefetz entitled ‘The curious reader’ in which he offers an overview of this complex subject and guides readers, both new and experienced, through the articles.

The next article, by Richard Chefetz, Nirit Soffer-Dudek, and Eli Somer, describes these authors’ fascinating and innovative research program focusing on maladaptive daydreaming (MD). Pertaining to an excessive employment of immersive daydreaming characterized by highly absorbing fantasy, daydreaming becomes maladaptive when it is executed at the expense of living in the real world. MD appears to be incredibly prevalent and confers considerable damage to functioning and well-being and is involved in a wide array of psychiatric comorbidities. In their article, the authors locate research on MD within the psychoanalytic literature focusing on fragmentation and multiple self-states (Chefetz & Bromberg, 2004), and Winnicott’s (1971) notions concerning adaptive and maladaptive imagination. Case illustrations are provided, and clinical implications are briefly discussed.

The third article, by Richard Loewenstein and Bethany Brand, provides an introduction to DID and its links to psychoanalytic theory and clinical practice. The authors propose that psychodynamically informed psychotherapy is necessary for the successful treatment of DID. They illustrate how psychoanalytic concepts such as the therapeutic alliance, the frame, conflict, defense, transference and countertransference, intersubjectivity, observing ego, projective identification, negative therapeutic reaction, regression in the service of the ego, etc. are central to successful treatment of DID. However, they also describe multiple clinical and theoretical ambiguities, paradoxes, and even apparent contradictions, which must be held in mind in order to make sense of DID. For example, in order to accurately conceptualize and work effectively with DID, psychoanalytic practitioners must incorporate domains of knowledge from other modalities, such as non-psycho-analytic views of the mind, hypnosis/hypnotherapy, developmental traumatology, as well as approaches to the therapy that may feel alien, uncomfortable, and even heterodox. The authors highlight the limited focus on this subject in mental health training programmes. This is despite the burgeoning interest in ‘trauma’ in the mainstream media. They present a case for increased training in the diagnosis and treatment of trauma-and-stressor-related disorders, including DID, in the context of both international prevalence data and also the proliferation of unregulated treatments lacking any theoretical basis or research evidence of efficacy.

The fourth article in this special issue, by Vedat Sar, presents a comprehensive theory of dissociative depression, a construct he himself termed. Espousing his absolute command of the psychopathology literature, Sar construes dissociative depression as a chronic and complex mood disorder characterized by both persistent depressive symptoms, intermittent major depressive episodes, and dissociative symptoms such as depersonalization, derealization, and amnesia. The importance of dissociative depression as a clinical construct lies in its ability to shed light on the complexity of depression (see Shahar, 2024), and to pave new grounds in intervention with patients manifesting treatment-resistant depression (TRD, Cuijpers, 2023). Sar locates the origins of dissociative depression in disturbances of sense of self and agency formed around developmental difficulties in separation-individuation, juxtaposed against a serious developmental traumatization. The author amasses an impressive list of continental thinkers, within and outside psychoanalysis, to substantiate his etiological theory of dissociative depression.

We continue with an article by Dana Amir, who presents an intriguing psychoanalytic and literary theory of somatoform dissociation. Drawing from her previous work integrating literary scholarship, psychoanalytic theory, and psychopathology (e.g., Amir, 2014, 2016, 2019), as well as on empirical research on somatoform dissociation (Nijenhuis et al., 1996), Amir distinguishes between three forms of somatic dissociation, each of which conforms to different literary-symbolic configurations: The metaphorical, in which there is a symbolic connection between the somatoform phenomenon and the traumatic content, the metonymic, which constitutes a revival of the traumatic experience without the ability to reflect on it, and the psychotic, in which the somatoform phenomenon is experienced as ego-syntonic, thus neither causes distress nor evokes thinking. Clinical vignettes illustrating each of the three forms of somatic dissociation are presented, and a fourth vignette illustrates the role of therapist’s countertransference in the treatment of these conditions.

The next paper, by Antonino Costanzo, Gianluca Santoro, and Adriano Schimmenti, describes the role of self-medication in maintaining dissociative states. Using the clinical example of ‘Charles’, an anonymised patient with characteristics that many readers will recognise, the article explores the relationship between developmental trauma, dissociation, and substance abuse within the framework of the self-medication hypothesis. The authors describe how substance abuse can serve as a maladaptive coping strategy for attempting to regulate the overwhelming emotions that can arise from traumatic impingements on the development of attachment relationships. People who have experienced this type of developmental trauma may dissociate negative attachment memories and their accompanying emotions, with consequent compartmentalization of their internal states and impaired self-regulation abilities. In these scenarios, substance abuse can be used as an external regulator of distressing emotions, enabling the person to distance themselves from their traumatic memories and facilitating an omnipotent and self-reliant attitude. The authors assert the paramount importance for clinicians to accurately identify and address the needs of these individuals in order to develop their capacity to acknowledge, explore, and integrate their trauma memories as intrinsic elements of their identity, thereby fostering the development of a unified and cohesive self-concept.

The following article, authored by Eva Rüfenacht, Lisa Shaverin, Jo Stubley, Maaike Smits, Anthony Bateman, Peter Fonagy, and Patrick Luyten, describes their experience of adapting Mentalization-Based Treatment (MBT) for use with people with complex post-traumatic stress disorder (C-PTSD). The article introduces a novel conceptualisation and treatment approach for complex post-traumatic stress symptoms, including dissociation, derived from attachment and mentalization theories. The authors provide an overview of the different expressions of dissociation and the prevailing understanding of their links with diverse clinical manifestations and their role in trauma. They go on to reinterpret these clinical symptoms through an attachment and mentalization lens, before elaborating on their new trauma-focused mentalization-based treatment and its therapeutic objectives. The article concludes with clinical material to illustrate the application of this approach in a treatment setting.

This special issue concludes with a contribution from Golan Shahar, Morgan Robison and Thomas Joiner. Their ambitious article offers a conceptualization that integrates three bodies of literature: Joiner’s Interpersonal-Psychological Theory of Suicide (IPTS), dissociation theory and research, and psychoanalytic object-relations theory, with a particular focus on social-cognitive reformulations of this theory. A case example of an adult psychotherapy patient’s serious, near-lethal suicide attempt is used to illustrate this theoretical viewpoint.

The authors use the Reformulated Object Relations Theory, including a reformulation of Melanie Klein’s depressive position, to propose a bridge between IPTS and dissociation theory and research. By contrasting the pathological depressive position with Ogden’s concept of the historical position, and introducing a temporal axis, the authors describe how depressed individuals project their hoped-for self-with-other representations onto the future only to be met with interpersonal stress and a dearth of social support and positive events. They go on to suggest that, for the reformulated depressive position to spiral into suicidality, dissociative mechanisms must make it the only available position. A diagram is provided to illustrate the role of basic level and advanced level dissociative processes in the progression of the depressive position into suicidality.

Disclosure statement

No potential conflict of interest was reported by the author(s).