What Mindfulness can learn about Dissociation and what Dissociation can learn from Mindfulness

ABSTRACT

Mindfulness based psychotherapeutic interventions have shown to be an effective intervention for quite some time now. These intervention, however, have not been that successful with individuals who experience dissociative disorders. There is a very clear disconnect between these two fields. In an attempt to close the gap, reviewing what mindfulness might be from an attachment and human developed lens, one can learn that there is a lot more occurring in a mindful state other than relaxation. There is a level of human development achievement that comes from a regular mindfulness practice that seems to play a role in raising our young and being part of a complex social group. Evidence suggests that the end product of mindfulness is likely deeply connected human relationships and balanced care-giving abilities. In knowing the benefits from a relational perspective of mindfulness those in the dissociative world can utilize adaptations of mindfulness so that their clients can eventually learn to developed mindfulness and, in turn, have the same deeply connected relationship that they often missed. Conversely those in the mindfulness based therapeutic world can learn a lot about dissociation and harmed people by understanding the real difficulties that individuals with dissociative disorders have in experiencing a mindful state. They can learn to understand the need to adapt mindfulness based practices to accommodate individuals who have a system that is phobic of awareness, terrified of being calm and who have no concept of what non-judgement means. Both fields would benefit greatly by knowing more about the other.

KEYWORDS:

• Dissociation
• mindfulness
• attachment
• childhood trauma

The “world” of dissociation and the “world” of mindfulness do not often mix. As stated in a 2013 article, “there is a paucity of literature regarding the use of mindfulness in the treatment for dissociation” (Zerubavel & Messman-Moore, 2015, p. 307). Mindfulness Meditations have been examined as a therapeutic intervention since the 1960’s and yet there are only a few articles that deal with dissociation and mindfulness (Zerubavel & Messman-Moore, 2015). Mindfulness Mediation, and all of its therapeutic forms, such as Dialectical Behavior Therapy (DBT; Linehan, 1993a), Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 1990), Mindfulness-Based Cognitive Therapy (MBCT; Segal, Williams, & Teasdale, 2002) and Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999) have all demonstrated that there is efficacy in these interventions and a real benefit to practicing mindfulness. So why is it that there are several excellent therapeutic modalities related to mindfulness and little to almost no research regarding dissociation and mindfulness? In particular, there is no body of literature regarding Dissociative Identity Disorder and Psychotherapeutic Mindfulness. There is obviously a rather large disconnection between these worlds. Perhaps if the field of dissociation knew more about the field of mindfulness and if the mindfulness field knew more about dissociation this gap could be bridged in the future.

Traditional Mindfulness can best be described as “a deep state of relaxation in which one in engaged in an active mental state requiring great attention” (Lazar et al., 2000). It is often a family of self-regulation practices that involve training, attention, and awareness (Forner, 2009). The most classic definition of Mindfulness is that it involves the development of awareness of present-moment experience with a compassionate, non-judgmental stance (Kabat-Zinn, 1990). Mindfulness mediation, when used as an agent of change, has three main components to the psychological process “(1) awareness, (2) of present experience, (3) with acceptance” (Germer, 2006, p. 13). There is a great variety of meditation practices that induce the state of mindfulness. The most common types of meditations are concentration meditations, mindfulness meditations, and goal-oriented meditations (Brach, 2003; Shapiro & Walsh, 2006).

Mindfulness and mindfulness meditation are two different things that are often are assumed to be the same thing. There is a difference in mindfulness practices, for example, mindfulness from a Sensorimotor Psychotherpay perspective differer from a mindfulness-based practice. Ogden, Minton, and Pain (2006) offer a great definition of mindfulness as:

[o]rienting and attending to the ebb and flow of the present internal experiences. Awareness and attention are directed towards the building blocks of present experiences: thoughts, feelings, sensory perceptions, inner body sensations, muscular changes, and movement impulses as they occur in the here and now.

(Ogden et al., 2006, p. 193)

Regardless of the technical definition, this thing called mindfulness is proving to be deep, rich, and vitally important in gaining further understanding of who we perhaps could be, as homo sapiens. This editorial is not about the spiritual practices or mindfulness-based practices that many might assume are being referred to when one is discussing mindfulness. In this discussion, we can learn from our experience in the dissociation field: not all trauma responses are the same, and not all mindfulness practices are the same as well. There is a distinct and important difference when we are discussing the more active stuck defenses of flight or fight, and the more inactive stuck defense of tonic immobility and feigned death. The effects of trauma, as we know, are much more than what is commonly known or understood. The same can be said of mindfulness; there is so much more to mindfulness than what is commonly understood. This article is a conversation on what mindfulness really might be, seen through an attachment and relational lens. This essay will provide a glimpse of what mindfulness might actually be, viewed from a very different lens to help the clinical population we work with. It is also intended to be another resource that we can have to sustain our own self-care.

Mindfulness, from the onset, can be understood from a much broader perspective than meditation alone. Mindfulness, examined from a human development and neurobiological perspective is an altered state and a state that can become a trait (Cahn & Polich, 2013; Perry, Pollard, Blanicley, Baker, & Vigilante, 1995). Mindfulness involves interconnected activity in brain networks that facilitate self-awareness and emotion regulation (Doll, Holzel, Boucard, Wohlschlager, & Sorg, 2015; Farb, Segal, & Anderson, 2012; Young et al., 2018). These prominently include the medial prefrontal cortex (mPFC) and the posterior parietal cortex in the Default Mode Network, as well as the amygdala and insula in the Stress/Salience Network (Farb et al., 2012; Holzel et al., 2007; Hölzel, Carmody, et al., 2011; Hölzel, Lazar, et al., 2011; Kang et al., 2013; Lazar et al., 2000, 2005; Luders, Toga, Lepore, & Gaser, 2009; Siegel, 2007, 2010). In many ways, mindfulness can be best understood as a combination of awareness of one’s own body and emotions and from a one step removed objective, non-judgmental perspective (Young et al., 2018). It just so happens that when one meditates, key areas in the brain’s cortical gray matter become denser and thicker (Hölzel, Carmody, et al., 2011; Kang et al., 2013; Lazar et al., 2000, 2005; Luders et al., 2009). In other words, the intentional activity of mindful awareness from a place of curiosity and acceptance rather than ordinary consciousness may enable key areas in the brain to become stronger and more predominant in our daily lives. When one investigates what these areas in the brain are responsible for, the greater understanding of our human design, a picture that we may not usually focus on, begins to unfold. The world of mindfulness research and practice have offered some insights into what our potential can be. Adding in a lens of attachment and dissociation, one can see other deep layers and other tasks we can do, to assist in the therapeutic process. Looking into what the mPFC and other brain structures that seem to be in charge of mindfulness reveal significant possibilities. The areas of the brain associated with mindfulness are responsible for nine basic functions that are quite sophisticated:

1) Body regulation, 2) Attuned communication, 3) Emotional balancing, 4) Response flexibility, 5) Empathy, 6) Insight, 7) Conditioned fear modulation 8) Intuition, and 9) Morality

(Badenoch, 2008; Marks-Tarlow, 2012; Panksepp, 1998, 2002; Perry & Szalavitz, 2010; Porges, 1998, 2003, 2011; Schore, 1994, 2003a, 2003b; Siegel, 1999, 2007, 2010; 2012; Siegel & Bryson, 2007; pp. 42–44; 2011).

Examining each of these processes, piece by piece, a new possibility in our human potential emerges; a potential that can be found within us and that can be a goal for our clients. These nine different functions can be viewed from the bottom to the top and from developmental milestones. In looking at each point in greater detail, one can conceive of ways to access these capacities, and when we can do so, to enhance our lives in ways that perhaps we are not utilizing as much as we could.

Body Regulation can help us to regulate our fear. This includes being able to put words, meaning, and context to our fear. It also includes down regulating or up regulating us after we have been frightened or overwhelmed. Instead of just mindlessly reacting, mindfulness provides us with greater awareness of and objectivity about a sequence of facts: (a) we feel scared, (b​) we can become aware of the true source of our fear, so that, (c) we can address the problem that our fear is communicating, and/or (d) process the fearful thing or event so that we can learn more about our environment and move on safely (Diorioi, Viau, & Meaney, 1993; Kalischa & Gerlichera, 2014; Motzkin, Philippi, Wolf, & Baskaya, 2015; Panksepp, 2002).

Emotional Balance: The brain’s Default Mode Network and Stress/Salience Network are active and interconnected (Doll et al., 2016) when we are regulating, articulating and expressing our emotions with intelligence. This is the ability to ask, “What important issues are my emotions trying to communicate?” Mindfulness, or non-judgmental awareness of our emotional language, helps us understand our emotions and helps us feel them and express them with, objectivity (Ogden, 2009). It is the life-affirming aspect of emotions, including feeling pain, suffering, confusion, fear, grief, attachment pain, love, and heartache, which we can feel and express with intelligence and perhaps even with compassion. When we have learned the skill of affect tolerance in the form of developing mindfulness we can grow the ability to know why we are feeling what we are feeling with validity, and without shame (Hyejeen, Heller, Van Reekum, Nelson, & Davidon, 2012; Kellogg, 2013; Kolb & Whishaw, 2004; Martelli, Chester, Brown, Eisenberger, & DeWall, 2018). This is the ability to feel what we feel and know what we know, and then live with, in peace, what has happened that resulted in the original feeling and sensation (Alexander & Brown, 2011; Motzkin et al., 2015; Van Der Kolk, 2006).

Response Flexibility: When we are in a mindful state, we can promote response flexibility or the ability to take a mental pause (Siegel, 2007). Mindfulness helps you cultivate the ability to pause what is happening inside of you and ask questions or gather information before reacting. This is valuable in raising our young and not getting “dragged under” by another’s dysregulation (Alexander & Brown, 2011; Cahn & Polich, 2013; Diorioi et al., 1993; Farb et al., 2007; Hyejeen et al., 2012; Siegel, 1999).

Regulating the Conditioned Fear Response: With mindfulness, we have the ability to regulate our conditioned fear responses or procedurally learned experiences. In other words, this involves “updating our files” as we grow. Two feet of water is very scary and a life threat to a toddler, but not to an adult. Mindfulness enables us to differentiate and distinguish that this fear was valid as a small child, and facilitate the realization that we are grown now and the fear is no longer valid. The underlying brain structures, when well developed, enable us to put our fears into perspective as well as regulate these fears and express them with balance and in proportion to the present context (Alexander & Brown, 2011; Cahn & Polich, 2013; Diorioi et al., 1993; Farb et al., 2007; Hyejeen et al., 2012; Siegel, 1999).

Attuned Communication: This term is defined in two different ways: 1) is the ability to make inferences and close enough guesses as to what others are feeling; 2) it is the ability to transmit and communicate information that is less obvious than spoken words (Montgomery, 2013; Ogden, 2012; Ogden & Fisher, 2015; Ogden et al., 2006; Schore, 1994, 2003a, 2003b). This enables us to be one step removed from others’ emotions, because we can take a step away and think or intuit what others are communicating and experiencing. This ability helps us understand what our offspring need to communicate when they lack the ability to use verbal language. It is also the capacity to be curious and able to understand that emotions are a form of vital communication from others. This is true especially for understanding our young, whose primary and first language is emotion and sensations rather than words. It is the brain structure that will feel others’ feelings, but add in “this is their emotional state, not mine” (Alexander & Brown, 2011; Cahn & Polich, 2013; Diorioi et al., 1993; Farb et al., 2007; Hyejeen et al., 2012; Siegel, 1999).

Empathy: The brain networks involved in mindfulness also can make us capable of an impressive level of empathy (Farb et al., 2007, 2012). Mindfulness can result in a sense of compassion and understanding of others’ feelings and perspectives. It is an intimate experience to feel what others are feeling in order to communicate our experience in a non-verbal way. It is a grand skill to know that what you are empathizing with is not your own feelings but someone else’s (Perry & Szalavitz, 2010; Tronick & Beeghly, 2011). This is very important when our offspring are born without the ability to verbally communicate, and when their experiential communication is vital to their survival. This is also the ability to feel “felt” in the world; that we are felt by others and that we feel their presence, as well. It is the anti-lonely experience that combats aloneness and the fear that we, as children, feel when we feel that we are alone.

Insight: Mindfulness involves insight (Farb et al., 2007, 2012) and introspection (Porges, 2003, 2011). The underlying brain structures are responsible for being able to feel curiosity about why we are reacting from a physical place in our bodies, like our gut or heart. This allows us to gather information about the past, present, and possible future, in a non-reactive, but informative manner. It is a reflective process that can ask oneself, “Am I creating this problem or can I solve this problem?” With mindfulness, we can analyze information as to what the source of the somatic or body response is; and then gather the information and act accordingly, with action or an emotional response.

Intuition: Mindfulness also involves putting instincts and intuition into the correct words, meaning and proper context (Marks-Tarlow, 2012). It will give meaning to our more primitive reactions so that these reactions make sense and/or so we can learn about what the instinct is communicating, both within ourselves and in terms of information coming from others.

Morality: When you put all of these functions together and you have someone who engages their full capacities for mindfulness, one can see that the end result is a more compassionate and empathic, tolerant and regulated individual (Brenner & Homonoff, 2004; Martelli et al., 2018). In other words, if you exercise the above-mentioned brain structures with whatever means you prefer to get to a mindful state so it can turn into a trait, you will have a human who is able to understand, regulate, articulate, and be at one with their reptilian and mammalian brains and reactions. You will have a mature adult who can regulate and communicate what is happing with their bodies and their emotions. You will find that this person is calm, empathic, and not driven by fear, anger, sadness, terror, suffering or pain. This person will be objective about both their inner world and the inner and external worlds of others. You will have someone who has a very large window of tolerance, and who is curious, compassionate, understanding, wise, grounded and steady. This adult is potentially there in all of us; it can become our basic neurobiological expression of ourselves or in other words, a mindful person could be our baseline of everyday functioning. This is also the state that our infants’ little bodies and primitive brains are expecting from us (Alexander & Brown, 2011; Brach, 2006; Doidge, 2007; Farb, Segal, & Anderson, 2012; Finger et al., 2008; Hölzel, Carmody, et al., 2011; Luders et al., 2009; Milutinovic, Zhuang, Niveleau, & Szyf, 2003).

When you consider all that the mindful brain can do, you can see that its tasks are not at all just about paying attention; it is also part of our human attachment system. It is the foundation for healthy human attachment, growth, and development (Austin, 1998; Brenner & Homonoff, 2004). Therefore, when you examine the side benefits of a regular meditation practice or regular mindfulness experiences and the benefits of a secure attachment system, they are much the same (Siegel, 2007); an adult who is calm, regulated, wise, insightful, patient, compassionate, empathic, welcoming of human intimacy, capable of life-enhancing grief, moral, and loving. This could be a developmental milestone within all of us and part of a healthy baseline, which all structures inside of us gravitate towards. From this perspective, mindfulness is far more about human attachment systems than it is about meditating. The well-working mindful brain is likely a successfully achieved developmental milestone and a relational achievement. It is also something that many of our dissociative clients crave within themselves and from others:

The mindful brain seems to be more about connection and dissociation seems to be more about how to survive disconnection. This is where the field of mindfulness can be enhanced by what we have learned in the field of dissociation. We know that when someone is dissociating the brain works very different than during ordinary consciousness or especially mindfulness (Lanius, Lanius, Fisher, & Ogden, 2006; Lanius, Bluhm, & Lanius, 2007; Lazar et al., 2000, 2005). Dissociation is about preserving life and mindfulness seems to be about enhancing our life. The purpose of mindfulness is not to help us survive life-threatening events, rather it is to help us raise our young and support our communities in the safest and secure way (Bögels, Hellemans, Van Deursen, Römer, & Van Der Meulen, 2014). Mindfulness very well could be about living with other complex beings, in peace and prosperity. Mindfulness, if you view it from an attachment perspective would be there in part helps us raise our young, but it also helps us live with other emotional, reactive, wise beings, whose major evolutionary defense is to be with others, rather than be alone. The very real challenge in all of this is that it takes a human who has a well-working brain to assist and help develop a well-working brain in its young. It takes roughly 25 years for us to grow our brains to their full potential, and this growth is heavily dependent on safety (Schore, 1994, 2003a, 2003b; Van Der Kolk, 2003, 2005, 2014). This is so because the developing brain is extremely sensitive to stress and life-threatening experiences. This is common sense; in times of life-threatening danger, all of the functions of the brain that are impacted by mindfulness are put on hold while the active defense system or inactive defense system takes over. The mindful functioning of the brain in times of crisis is actually very dangerous and will put a human at risk of further harm, rather than closer to the possibility of escape. For example, if you a running or fighting (active defense) a saber tooth tiger, being emphatic, compassionate, aware is not needed or if you are in the tiger's mouth (inactive defense) being aware is not good at all. The functions of mindfulness and the brain that uses the above mentioned 9 functions as a baseline is very useful for relating to others, feeling our emotions with intelligence, being part of intimate adult relationships, caring for our young and being one step removed from other’s primary reactive responses. It is not good at all when you are dealing with a human to human harm.

Dissociation, on the other hand, is a grand master of survival, especially when humans are not available to keep us safe. This is a bold statement, yet there is plenty of support to suggest that dissociation is a rival brain activity to mindfulness and it seems to be phobic of mindfulness and it also seems to be based on a phobia of mindfulness. This can be seen when we compare and contrast a brain that is dissociating with a brain that has a lot of mindfulness training (Lanius et al., 2006; 2007; Lazar et al., 2000, 2005). Mindfulness is about knowing, and awareness and dissociation are about not knowing and being unaware, to save your life. These two brains, the one that dissociates and the one that is in a mindful state are very different brains.

People who over-utilize dissociation clearly have a great deal of difficulty regulating their fear. They also have an extremely contentious relationship with their emotions. They certainly have little insight into what and why they feel what they feel. These folks have difficulty with updating old files; the pain and suffering from the past is their present. Empathy, for them, is difficult to achieve or it can send them into a traumatic re-enactment. Often empathy is unavailable to them. These folks really feel unfelt by others; their terrifying aloneness is tangible. Often their instinctual knowing and introspection are not on line. They cannot be objective, and they do not understand the insight and the wisdom of their intuition. Their traumatic dissociation has cut off or shut off the vital structures that send information from their body to their cerebral cortex. They are often not fully aware of all that they feel and know. In fact the opposite is true; simply by the nature of dissociation, they often do not know, fully, what happened (Brand et al., 2009; Brand, Loewenstein, & Spiegel, 2014; Brand et al., 2016; Bremner, 2003; Cromer, Stevens, DePrince, & Pears, 2006; De Ruiter, Elzinga, & Phaf, 2006; De Ruiter, Phaf, Elzinga, & Van Dyke, 2004; Elzinga et al., 2007; Elzinga, De Beaurs, Sergent, Van Dyke, & Phaf, 2000; Frewen & Lanius, 2006; Lanius et al., 2007; Lanius, Bluhm, Lanius, & Pain, 2005; Lanius et al., 2005; Lanius, 2014; Lanius, Paulsen & Corrigan, 2014a; Perry, 1999, 2001; Perry & Pollard, 1998; Reinders et al., 2003, 2006; Ross, 1991; Schauer & Elbert, 2010; Schlumpf et al., 2014; Teicher, 2002).

In many ways, dissociation is a state of missing mindfulness. In order to survive the incidents that resulted in dissociation, the human body and brain will cut off or shut off the threatening information off in order to play dead or dissociate (Frewen & Lanius, 2006; Lanius et al., 2007; Lanius et al., 2005, 2005; Lanius, 2014; Lanius, Paulsen & Corrigan, 2014b) If someone dissociates often enough, they will become a human being who is phobic of mindfulness. Knowing terrifying or brutal things, when you are on the brink of death or in the jaws of a predator, is not a good survival strategy. Feeling the intense feelings that go with an enhanced awareness of the present moment is often too much and when the person is approaching anything resembling mindfulness, they will reject the mindfulness. The brain structures, such as the Insula and medial prefrontal cortex that can help us intellectually and physically manage the pain and suffering are cut off and therefore unable to do what they are supposed to do, or, in severely abused children, it never got the chance to develop normally in the first place.

This makes sense when you examine it from the perspective of our reptilian and mammalian brains. It is as if the brain says, “Feeling these feelings, knowing this fear and these circumstances, these abuses, connecting to the perpetrator, empathizing with yourself and the predator, knowing the full true reality of my life, being hopeful, moral, attuned, and connected to myself when I am in life and death survival mode is not a great idea.” Being too mindful, whilst in life and death danger, may decrease your chances of survival.

So, the body makes the logical reaction to cut off mindfulness while it introduces dissociation as the primary survival strategy. However, once the danger is over, it is mindfulness that helps us heal and move beyond the terror of surviving into the land of thriving. But often, in highly traumatized people, their social engagement is off line and their mindful brains are not readily available. This leaves them with a great deficit in mindfulness. There is no objective observer with some of the most severely abused people, that there is no comprehension to the notion of paying attention to anything, because it is all hurtful, and that any type of suggestion to go inward is tantamount to blowing up all of the dissociative barriers and blowing everything wide open is too much for these individuals when you go straight into mindfulness.

Our challenge as therapists in working with this population is to be aware of what mindfulness does and can do. The relationship between mindfulness and dissociation is a rather large missing topic in the literature, likely because the more common teachings about mindfulness do not include the power of dissociation. As well, dissociation and mindfulness are like oil and water; they just do not mix. Often mindfulness is brought into a therapy without the therapist understanding the power and importance of dissociation. This can result in mindfulness exercises that will be too much for the person. When this happens, the client will have to use dissociation again to escape the intense nature of their experiences and feelings. Attempts at mindfulness training will then inadvertently reinforce dissociation (Ogden, 2009) as we introduce things that can and will blow them out of their windows of tolerance.

By using frameworks like the window of tolerance (Ogden et al., 2006; Siegel, 1999) and the International Society for the Study of Trauma and Dissociation Treatment Guidelines (Chu et al., 2011, 2005), mindfulness, and with it the mindful brain, can grow. We can, with care, teach our clients to achieve fully the developmental milestone of mindfulness. Likely this will happen more quickly if we exercise, expand and grow our own mindful brains. This will take a lot of patience, time, and, yes, mindfulness.

I encourage all therapists to think more about mindfulness, as this will enhance their practices. I also encourage those who study mindfulness to learn more about dissociation and the unique challenges that this population has. It is also important to understand if we look at both issues from an attachment lens we can learn that our clients who dissociate desperately need your mindfulness.