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Make sure to read Part 1 of the answer.
I would like to continue the discussion begun in the last column of how to overcome denial that gets in the way of addressing important problems in one’s life, focusing on the particular problem of having a dissociative disorder. In the first part of this column, I began by talking about Diane’s denial of some of her psychological problems and stresses, and discussed denial as one of many defense mechanisms that our minds automatically use to decrease our sense of subjective distress, even if this is at the expense of our ability to solve the problems that contribute to this distress. I will continue that discussion by talking about denial as the first phase of a process of grief or acceptance, and then discussing the other steps of that process.
The five-step process of grieving for the impending loss of oneself through death was articulated by Elizabeth Kubler-Ross in her landmark book On Death and Dying (1969). Dr. Kubler-Ross identified that people facing their own death went through a process that included steps of denial, anger, bargaining, depression, and (finally) acceptance. These steps do not always occur as five separate and discrete steps, but may occur in mixtures or in a different order. Nevertheless, these five steps with their accompanying emotions usually can be seen in a person who knows they are dying, and a person must make it through the earlier stages in order to get to the stage of acceptance, where they can again feel some peace. To put this another way, acceptance is not the result of suppressing anger and depression, but of allowing these feelings to be present and to be worked through as necessary stages of the process.
Subsequently, other writers and clinicians (such as Melody Beattie, well-known author of the books Codependent No More and Denial, among others) have observed that these same five stages are seen when people must face a variety of other kinds of losses. These losses include the loss of others through death, the breakup of relationships (including divorce), or the change in relationships that happens as people grow older. People also experience loss when they lose aspects or qualities of their life that supported their sense of self. For example, having someone become dependant upon you (child, significant other, aging parent, etc.) can result in some loss of the feeling of autonomy or independence, since taking care of the other person requires giving up some of the freedom to come and go as one pleases. This is often more of a loss than people bargained for when they accepted the commitment of a relationship or of having a child. Conversely, when someone who was dependant upon you no longer needs you in that way (e.g., children growing up) this can result in the loss of the feeling of being needed, which may also be an important aspect of one’s sense of self.
People also confront losses when they must give up various wishes or fantasies about themselves or others, or when they have to acknowledge that they (or someone) do not have a certain ability or potential. People have to grieve for their wished-for futures when they realize that these futures will not occur. When a person loses a job they also lose some aspects of self that were attached to the job in the form of self-esteem, the sense of competency/ability implied by the job, and the image of themselves as working reflected by others. When a person loses a job or a place they were living, they also lose some of their feeling of basic security. Even if some of what is lost was an illusion, it is still experienced as loss and must be grieved.
People also have to grieve for their wished-for parents or partners (or others) when they realize that the other people in their life are not who they hoped they would be. This is very difficult, as people will go to great lengths (both consciously and unconsciously) to preserve the fantasy that an important other is the “good” person that they want. In fact, the defense of “splitting” can be considered an effort to preserve the image of and wish for the “good” parent or other by keeping the image and evidence of the “bad” parent or other separate from the “good” one, so that the “good” one will not be contaminated by the “badness.”
This is by no means a comprehensive list of losses that can be important to people, and I am not sure that such a catalogue is possible. My point is to expand the concept of loss to include situations in which the “loss” might not be intuitively obvious. However, if we can find a “loss” in situations where a person is using denial to a significant extent, then we may be able to reframe that denial as the first step in the process of grieving, leading toward acceptance.
Let’s return to the example posed in Diane’s question – how does a person get out of denial of having a psychiatric disorder, in particular a dissociative disorder. In my experience, there are several losses that must be acknowledged in order for a person to accept that they have a dissociative disorder. These losses include loss of the belief of total control of one’s mental processes, loss of the belief of total control over what happens in one’s life, loss of the fantasy that the trauma really wasn’t that bad (or that one’s childhood and/or one’s abuser was really OK), and loss of the fantasy that one could have been rescued.
At the risk of sounding simplistic, in order for a person to accept that they have a dissociative disorder, the person has to accept that they dissociate – which means that they experience “a disruption of the integrated functions of consciousness, memory, identity, or perception of the environment” according to the DSM IV. Such an experience implies that the person doesn’t have complete control of their mental processes. This issue is by no means unique to dissociative disorders! There are many situations and conditions in which people find that they have done things motivated by forces outside of their awareness, or by impulses they could not resist. There are also disorders that affect a person’s ability to tell what perceptions are real, and what thoughts are based in reality. All of these situations indicate that the consciously experiencing self is not in full control. Periods of dissociation, of being in an altered state of consciousness (feeling unreal or not yourself) or not there at all (e.g. lost time), very powerfully show the limits of one’s control of mental phenomena. And the various experiences of people with true alters (hearing their thoughts inside your own head; finding their writings, drawings and clothes; being told by others about their presence; observing the consequences of their behavior when they are “out;” etc.) go even further to show the limits of one’s control. Thus, accepting that one has a dissociative disorder requires grieving for the loss of a sense of control of one’s own mind that most people take for granted. In addition, this sense of loss of control may be especially poignant for patients with dissociative disorders because during the traumas/abuse that led to their illness, they may have consoled themselves with the idea that although they could not stop what people were doing to their bodies, they could at least stop the abuser from affecting them mentally. How painful, then, to realize that they were, in fact, affected mentally in such an enduring way!
For people with Dissociative Identity Disorder, there is the related feeling of loss of control over what happens in their life. By definition, this diagnosis requires that at least one other identity (alter) or personality state recurrently takes control of the person’s behavior. This means that the alter(s) or other personality state(s) can interact with the other people in your life, start their own relationships, spend money, get or lose jobs, and do all kinds of things that have an impact on a person’s life. The sense of loss of control is heightened in some people with DID because they grew up in situations where boundaries were not safe and events were unpredictable, and therefore as adults tried very hard to make sure that there is much more safety and predictability in their lives than there was when they were children. For such people, finding the evidence of their alters being out is initially experienced as both dangerous and as a failure.
A third major kind of loss that must sometimes be acknowledged and then grieved for in order to accept the existence of a dissociative disorder is loss of a person’s wished-for (or fantasized) childhood, and the loss of the wished-for parental figures or protectors that go with that desired childhood. This wish may be held ambivalently – while on the one hand a person may seek validation for their experiences and feelings, on the other hand they may harbor a fantasy that “maybe it wasn’t really so bad“, the hope being that if it wasn’t so bad, then the present distress will magically vanish. Another aspect of this wish for some people is often the persistent desire to believe that they were loved as a child, and therefore are lovable, which they may cling to if they have difficulty feeling lovable in the present. A potential complication to grieving for the wished-for parents or protectors is that a person with DID may have child alters who still actively hold on to this wish, which can lead to internal conflict as a person tries to grieve for their childhood.
Connecting denial with the kinds of losses described in the foregoing, or other losses that are more specific for a given individual, then allows a person to begin the difficult process of grief work, which although very painful, allows for the possibility of moving from denial to acceptance. This process will require working through the intermediate steps of anger, bargaining, and depression, although not necessarily in a particular order. The most difficult aspects of this “working through,” in my experience, are tolerating the feelings of anger and depression. It may be that the process will proceed according to which feeling the person is better able to tolerate first. Not infrequently, the early traumatic experiences and family situation that give rise to dissociative disorders create the expectation that anger is extremely dangerous, particularly if any expressions of anger during childhood were met with punitive and/or abusive responses, as was often the case. Also, experiencing anger may evoke great anxiety if being angry is equated with being like the person who was the abuser. For these reasons, and because of a fear of further loss of control when angry, abuse survivors may find anger harder to tolerate than depression, and may not be able to work through this feeling until after first dealing with feelings of sadness and mourning. But it will be important for the person and whoever is working with them to keep in mind that both of these feelings and their different mixtures are part of the grief process and one indicates the (eventual) presence of the other. Further, the person may require reminders that these feelings are entirely normal in the context of the grief process.
Depression is also difficult for abuse survivors to tolerate. They have often experienced many insults to their self-esteem over the years, usually starting in childhood when they were treated as objects, not as people, and when their distress was not recognized. These experiences make them susceptible to hopelessness and helplessness when they become depressed. Also, they may experience depression as weakness that makes them more vulnerable, or they may have been punished for showing sadness (e.g., crying) when they were younger (or in subsequent relationships). Thus, the process of grieving is inherently difficult for abuse survivors, and can feel endless, rather than feel like steps toward a goal. Reminders of the steps and of the goal will be very necessary, whether the person can continually remind themselves in one way or another, and/or can get reminders from others.
In this light, it may be helpful for the person or others in their life (particularly therapists) to be alert to evidence of bargaining. Bargaining behavior may show up with regard to accepting diagnoses and/or treatment, but may also show up in the context of relationships with family members, friends, and/or doctors and therapists. Sometimes, bargaining will show up in derivative form, such as in other negotiations about relationships or therapy. My point here is to recognize bargaining as a step in the process of grieving and acceptance in addition to a desire to want to have a say about one’s life, which is quite normal.
Acceptance is the goal of this process, but in the case of accepting a psychiatric diagnosis or other problems, acceptance may only be an intermediate goal if there is work to be done (such as therapy) that can meaningfully help the person to cope with their problems and pursue their other life goals. Although it may not always be possible to “cure” a psychiatric illness, it is often very possible to lessen the suffering that a person experiences as a result of the illness, and to enable a person to be more effective in creating a life that feels worth living. Teasing apart what are the things that must be accepted as likely to remain as they are, and what things must be accepted as prelude to working to change them is an ongoing challenge for all of us. In the well known words attributed to the theologian Reinhold Niebuhr:
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