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What We Know and What We Need

to Learn About the Treatment of
Dissociative Disorders
a
Bethany L. Brand PhD
a
Psychology Department, Towson University, Towson, Maryland, USA
Accepted author version posted online: 16 Mar 2012.Published
online: 31 May 2012.

To cite this article: Bethany L. Brand PhD (2012): What We Know and What We Need to Learn About
the Treatment of Dissociative Disorders, Journal of Trauma & Dissociation, 13:4, 387-396

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 Journal of Trauma & Dissociation, 13:387–396, 2012
Copyright © Taylor & Francis Group, LLC
ISSN: 1529-9732 print/1529-9740 online
DOI: 10.1080/15299732.2012.672550

EDITORIAL

What We Know and What We Need to Learn

About the Treatment of Dissociative Disorders

BETHANY L. BRAND, PhD

Psychology Department, Towson University, Towson, Maryland, USA
Downloaded by [Universite De Paris 1] at 00:25 27 June 2013

In this editorial, I briefly review research design issues and the

current treatment research for dissociative disorders (DD), discuss
the limitations and challenges of conducting treatment studies for
patients with DD, and conclude by describing what I see as the
first wave and second wave in the field of dissociation. Insurers
and federally funded programs are increasingly requiring that
treatment be empirically supported in order for treatment to be
reimbursed. For example, psychoanalysis will no longer be reim-
bursed in The Netherlands because of what is perceived as a lack
of empirical support. Other countries have also established stan-
dards about the treatments that have sufficient empirical support
to merit government payment. I believe it is only a matter of time
before it is common for patients with DD to be required to seek out
empirically supported treatment if they want treatment to be reim-
bursed. We need to financially support treatment studies in order
to develop a more solid empirical basis for the treatment of DD.

KEYWORDS dissociation, dissociative disorders, dissociative

identity disorder, psychotherapy, treatment

I begin this overview of dissociative disorders (DD) treatment research by

reviewing research design issues. Treatments must be validated by research,
the design of which dictates what conclusions can be made. For exam-
ple, a researcher can conclude that a treatment for dissociation “causes”

Received 25 January 2012.

Address correspondence to Bethany L. Brand, PhD, Psychology Department, Towson
University, Liberal Arts Building, 8000 York Road, Towson, MD 21252. E-mail: bbrand@
towson.edu

387
 388 B. L. Brand

patients’ symptoms to improve only if the researcher found that the level of
dissociative symptoms was statistically lower after the treatment than before
the treatment and that a control group of similar patients, monitored for
the same length of time without treatment, did not show a reduction in
symptoms. This controlled trial type of study provides compelling empir-
ical support for a treatment. The control group can receive a different
form of psychotherapy or be waitlisted, meaning that their symptoms are
monitored for the duration of the time the treatment group receives the
active treatment to rule out the possibility that the mere passage of time,
maturation, or other factors unrelated to the treatment cause symptoms
to improve. The most rigorous of the controlled trials, randomized clin-
ical trials (RCTs), requires the random assignment of patients to groups,
thereby reducing the chance for bias that could alter the results, such as if
the most symptomatic patients were placed in or preferred to sign up for
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one type of treatment. One common definition of empirical support stipu-

lates that at least two RCTs have been conducted by different researchers.
Uncontrolled trials assess patients who are receiving treatment but do not
utilize a control group, so definitive conclusions cannot be drawn that
the treatment caused any change in symptoms. A naturalistic or observa-
tional study observes how patients’ symptoms vary over time, whether in
response to treatment or other factors. In naturalistic studies, the researcher
does not provide a specific type of treatment; rather, the researcher gathers
data about symptom change over time without altering treatment, which is
often provided by community therapists. Although they are the most cost-
effective type of treatment study, naturalistic designs rely on treatments that
cannot be readily replicated because they are not standardized in manu-
als. Because it is difficult to determine the precise interventions used, it
is unclear which interventions are responsible for reductions in symptoms.
Researchers using any type of design other than the RCT should be cautious
about making causal statements such as “The treatment caused the patients’
dissociation to improve.” Instead, they should make correlational rather than
causal conclusions, such as “The treatment is associated with reductions in
dissociation.”
What type of treatment outcome research do we have at this time
for DD? The answer is not what we would like it to be. Although there
are several controlled trials for adult survivors of child abuse, there are
no controlled trials for DD, although arguably one of the case stud-
ies is sufficiently rigorous to be considered controlled. A single study of
dissociative seizures utilized a “manualized” treatment (Goldstein, Deale,
Mitchell-O’Malley, Toone, & Mellers, 2004). In other words, almost all of our
treatment studies to date have been uncontrolled trials of treatment, typically
using only a single inpatient unit or a single or a few outpatient therapists
collecting data on their own patients over time, or naturalistic studies of
treatment outcome among DD patients treated by community therapists.
 Journal of Trauma & Dissociation, 13:387–396, 2012 389

For a thorough review of DD treatment research through 2009, see Brand,

Classen, McNary, and Zaveri (2009).
This paucity of research is largely due to a lack of funding and the
high level of complexity of DD patients. RCT studies that involve collecting
data from multiple sites cost many hundreds of thousands or even sev-
eral million dollars. The National Institute of Mental Health, the source of
funding for the majority of large treatment outcome studies in the United
States, has not funded a single treatment outcome study of dissociative
identity disorder (DID) or dissociative disorder not otherwise specified
(DDNOS) and has funded only a handful of studies that have even looked
at dissociation in general. Nel Draijer summed up this Catch-22: “The prob-
lem with policy makers is that they often say: no RCTs, no evidence, no
money. At the same time, the same policy makers prevent evidence from
developing by not providing funding” (personal communication, January 2,
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2012). Patients suffering from DID and severe DDNOS have many psychi-
atric disorders, self-injurious behaviors and suicide attempts, dysfunctional
relationships, numerous psychosocial and medical stressors, and heteroge-
neous presentations with unique sets of dissociated self-states. They do not
typically respond rapidly to treatment, and it is almost impossible to create a
design that ethically enrolls them in a waitlist group for months while being
deprived of individual treatment. Designing a treatment that can be used for
such a challenging and variable group of patients is difficult at best.
Because of these challenges, almost all trauma researchers have stud-
ied simple rather than complex posttraumatic stress disorder (PTSD) or DD.
After all, academics are required to get funded and published in order to
retain their jobs. Journals are reluctant to publish studies with insignifi-
cant findings. It is much easier to obtain improvement in a homogenous,
high-functioning, and moderately symptomatic group than in a severely
symptomatic group with chronic comorbid conditions that require individu-
alized rather than standardized treatments. It is infinitely more manageable
to fund and conduct short-term treatments with patients with just one
psychiatric disorder than studies of patients who take years to improve.
Furthermore, the longer the study, the higher the dropout rate; attrition jeop-
ardizes the conclusions that can be drawn because the final sample is often
less ill than the initially recruited sample. In a meta-analysis of RCTs for
PTSD, researchers concluded that more studies need to focus on complex
trauma patients because research has typically overlooked polysymptomatic
patients (Bradley, Greene, Russ, Dutra, & Westen, 2005). For example, these
researchers discovered that 62% of the studies in their review excluded
participants with current alcohol or alcohol use, whereas 46% excluded
individuals with suicidal ideation. Such exclusion criteria mean that few if
any DD patients would be permitted to participate. DD patients are often
directly excluded even from studies investigating treatment for survivors of
childhood abuse.
 390 B. L. Brand

Despite the challenges of designing and conducting research with DD

patients, there is a critical need for it because of the high costs and suffering
associated with DD. DID patients have the highest inpatient psychiatric costs
among patients receiving psychiatric disability payments in Massachusetts
(van der Kolk, 2008). DD patients required more therapy sessions than any
other patients in a study of treatment utilization among spouses of men serv-
ing in the military (Mansfield et al., 2010). These studies suggest that there
are compelling economic incentives for developing effective treatments for
those with DD. Preliminary studies indicate that specialized treatment of DD
appears to be associated with cost savings. Furthermore, recent research
shows that individuals with high levels of dissociative symptoms may drop
out of current cognitive–behavioral treatments and are generally less respon-
sive to treatment; therefore, standard cognitive–behavioral treatments may
not be as effective for, or as well tolerated by, these patients (Brand, Lanius,
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Loewenstein, Vermetten, & Spiegel, 2012).

CASE STUDIES AND INPATIENT STUDIES

There have been many case studies and studies of inpatient treatment of
DD with follow-up ranging from several months to 10 years following
treatment (see Brand, Classen, McNary, et al., 2009, for a review). These
studies document that treatment is effective at reducing a variety of symp-
toms, including depression, Axis I and Axis II diagnoses, PTSD, anxiety, and
dissociative symptoms. Compared to unintegrated patients, those who inte-
grate their self-states show greater improvement across a range of symptoms,
although it is less common for patients to no longer meet criteria for DD.
Early estimates of integration were higher (i.e., 50%–73% of DID patients),
although the longest follow-up data to date found that only 33% of patients
had achieved integration. The case series have methodological weaknesses,
including the potential for experimenter bias, lack of standardized mea-
sures, and demand characteristics (i.e., patients feel compelled to accentuate
improvement). Despite methodological limitations, these studies suggest that
many DD patients appear to improve when provided with DD treatment.
Although some of the case studies utilized standardized assessment
tools, they were not controlled. Therefore, conclusions about treatment
causing the improvements cannot be made, with the exception of Kellett’s
(2005) rigorous cognitive analytic therapy DID case study. The design illus-
trated that the patient’s depression and dissociation were stable at a high
level before treatment and decreased only after targeted interventions were
applied, allowing Kellett to conclude that improvements in the patient’s
symptoms were caused by treatment techniques. Many would consider
this to be a controlled case study, although some would not because
the treatment was not removed and then reinstituted to show that the
symptoms waxed and waned as treatment was applied and removed. More
 Journal of Trauma & Dissociation, 13:387–396, 2012 391

well-designed case studies are needed that show the specific interventions
that are useful in treating DD.
A recent DD treatment review included a small meta-analysis of eight
nonrandomized, uncontrolled treatment studies examining treatment for DD
(Brand, Classen, McNary, et al., 2009). Sufficient outcome data were avail-
able from eight studies to create effect sizes (ESs). The overall ES using
within-patient analyses was 0.71, with improvements in the large range
for symptoms of dissociation (ES = 0.70), anxiety (ES = 0.94), somato-
form disorder (ES = 0.83), depression (ES = 1.12), general distress (ES =
1.09), and drug/alcohol use (ES = 0.78). (Note that within-patient analyses
generally yield higher ESs than do between-group comparisons.) Although
these data are encouraging, these studies’ design limitations included no
control groups. Patients were not randomly selected, and often they were
not systematically selected, although in some studies inclusion was based on
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consecutive admissions. (Systematic selection reduces bias.) Dropout rates

were typically high or not reported. Small samples size also limited some
of these studies; larger samples are generally less prone to the influence of
outliers who are not representative of typical patients.

RECENT TREATMENT STUDIES AND EXPERT SURVEYS

The International Society for the Study of Trauma and Dissociation (ISSTD;
2011) has just published the third edition of its treatment guidelines for DID.
Treatment guidelines for DID established by expert consensus have been in
place since 1994. Such guidelines are a crucial step in establishing treatments
for complex disorders. Several studies related to DD treatment have also
been published in recent years, including two surveys of experts. A study
of 36 international DD experts (Brand, McNary, et al., 2012) found that a
core set of treatment techniques emerged as consistently recommended for
individuals with DID and DDNOS. The experts uniformly advised the use
of a staged treatment, with the first stage emphasizing grounding, emotion
regulation, impulse control, interpersonal effectiveness, and containment of
intrusive material. Experts recommended that in the second stage, modi-
fied exposure/abreaction techniques should be used some of the time but
only in combination with core, foundational interventions. The last stage
of treatment is more individualized, and a consistent pattern of techniques
was not found. Consistent with the longest follow-up case study, the experts
reported that unification of self-states occurred among a small subset of DID
patients.
Another recent development is the development of a model intended
to predict the treatment outcome for Stage 1 stabilization therapy for DID
patients (Baars et al., 2011). Experts from around the world were asked
to list patient characteristics that they believed predict a negative response
to treatment. A set of 46 items was developed that the experts believe
 392 B. L. Brand

predict negative outcomes for DID patients. This prognostic list needs to
be empirically tested. These two expert consensus studies set the stage for
the development of a manualized, empirically based investigation of DID
treatment outcome. The prognostic checklist (Baars et al., 2011) could be
used to predict patient outcomes in a manualized Stage 1 treatment that
is based on the interventions recommended by experts in the Brand et al.
study (Brand, McNary, et al., 2012). Such a study is urgently needed and
could be the precursor to developing an RCT for DID.
A prospective observational study using the longest follow-up and
the largest sample to date is yielding important findings about DD treat-
ment outcome. This study, the Treatment of Patients with Dissociative
Disorders (TOP DD; Brand, Classen, Lanius, et al., 2009), had a sample
of 280 DID or DDNOS patients and 292 therapists who participated from
19 countries. The cross-sectional results indicated that patients in the later
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stages of treatment had fewer symptoms of dissociation, PTSD, and gen-

eral distress; fewer recent hospitalizations; and better adaptive functioning
(e.g., Global Assessment of Functioning (GAF) score, increased socializ-
ing) than patients in the early stages of treatment. The longitudinal results
demonstrated that patients showed less dissociation, PTSD, general dis-
tress, depression, suicide attempts, self-harm, dangerous behaviors, drug
use, physical pain, and hospitalizations as well as improved functioning,
including an increase in GAF scores over 30 months of treatment (Brand,
McNary, et al., 2012). Participants were more frequently involved in volun-
teer jobs and/or attending school and socializing, and reported feeling good,
as treatment progressed. Furthermore, therapists reported that more patients
progressed from an early stage of treatment to a more advanced stage than
regressed from an advanced to an earlier stage. As uniformly encouraging as
these results are, most patients still suffered from a broad range of symptoms
after 30 months of treatment, many despite being in treatment for years. The
authors concluded that the field needs to continue developing better, empir-
ically supported ways to effectively treat DD. The TOP DD study offers a
methodological advantage in that both therapists and patients reported on
patients’ symptoms and adaptive functioning. The consistency of the reports
by therapists and patients strengthens the conclusion that treatment was
associated with a wide range of improvements. Nonetheless, the study did
not use a control group or random selection, so we cannot be certain that
the treatment caused these improvements, although the direction and unifor-
mity of the improvements across two sources of observations are consistent
with the treatment causing these important changes.

OUR FUTURE: THE SECOND WAVE IN THE FIELD OF DD

The current case studies and uncontrolled outcome studies provide

encouraging evidence that treatment for DD is beneficial. Treatments are
 Journal of Trauma & Dissociation, 13:387–396, 2012 393

associated with improvement in a wide range of associated symptoms as

well as improved adaptive functioning. Writers from within the insurance
industry have warned that DID patients are among the most expensive psy-
chiatric patients to treat and have a high risk for early mortality (Galbraith
& Neubauer, 2000). In view of the high cost associated with DD patients,
it is particularly noteworthy that treatment is associated with improved
social and occupational functioning as well as decreases in self-destructive
behaviors and suicide attempts. Given that current evidence is derived
from uncontrolled studies, other than the case study by Kellett (2005), it
is possible these improvements would have occurred without treatment.
Although this possibility is unlikely, more controlled trials—particularly
those that use systematic recruitment and, when possible, randomization to
groups—are needed to refute this possibility as well as to establish that DD
treatment is empirically supported. Studies should use large samples with
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multiple sites and/or therapists and standardized measures. Well-described

treatments are crucial to make it clear what techniques are beneficial and
to make replication possible. Additional rigorous, single-case experimental
studies using standardized measures administered repeatedly before, during,
and after treatment and clearly described interventions are a particularly
cost-effective way to provide controlled evidence of the impact of treatment.
Researchers recruiting community therapists and their patients as par-
ticipants may be able to conduct systematic treatment for the stabilization
phase of DID/DDNOS treatment using the recently developed expert prog-
nostic model and recommended interventions (Baars et al., 2011; Brand,
McNary, et al., 2012). This type of cost-effective collaboration between
researchers, community therapists, and patients, such as occurred in the
TOP DD study, can generate much-needed information about treatment
outcomes using real-world, complex DD patients. Because there are few
exclusion criteria, the results are more generalizable to patients encountered
in practice than are those developed in most RCTs. The TOP DD research
team is developing a psychoeducational intervention that will be an adjunc-
tive Web-based intervention for early-stage DID/DDNOS patients who are
already participating in individual therapy. If the pilot study is successful,
this intervention could be developed into an RCT trial if funding is available.
Given the number of DD patients and the lack of therapists trained in treat-
ing DD around the globe, a Web-based intervention could make accessible
urgently needed education globally to therapists and patients about under-
standing and managing dissociation and other trauma symptoms. Another
feasible design could involve community clinicians recruiting a predeter-
mined number of consecutive DD patients seen in treatment in a given week
(thereby avoiding selection bias) to provide assessments of their patients
over the course of treatment. It is hoped that creative research designs such
as these can eventually lead to the development of RCTs that will establish
empirically supported treatments for DD.
 394 B. L. Brand

The development of funding is critical. Most DD researchers, including

those who conduct treatment studies, depend on donations to conduct their
studies because federal funding for DD treatment studies is not yet available.
I strongly urge readers to consider supporting the future of the DD field by
contacting researchers and offering financial support. Unless we develop
a stronger empirical basis for our treatments, we may soon see the day
when clinicians cannot expect reimbursement for treating DD. Researchers
have uniformly told me how much they appreciate and rely on even small
gifts. One touched his wallet as he said, “Here’s the source of my research
funding.” By recognizing our potential power, and by joining together as a
field of researchers, clinicians, patients, and supportive others, we can effect
change at a broad scale for DD patients, even globally in some studies, if
we financially support it.
In the early 1980s, what is now the ISSTD began when a handful of
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prescient, dedicated clinicians saw the need for an association to provide

collegial education and support for those treating and studying DD. That
could be seen as the first wave of the DD field, characterized by defining
dissociation and laying the foundation of knowledge about assessing and
treating DD. This first wave resulted in the development of increased aware-
ness about dissociation; assessment measures of dissociation; early treatment
studies of DD; a professional network that eventually led to the develop-
ment of the journal Dissociation, the precursor to the Journal of Trauma
& Dissociation; and the annual conference hosted by the ISSTD. I believe
we are now in the beginning of the second wave of the dissociation field,
supported by hundreds, perhaps thousands, of studies that have researched
various facets of dissociation conducted by mainstream researchers as well
as dissociation experts around the world using a vast array of nonclinical and
clinical samples that include patients with schizophrenia, anxiety and mood
disorders, personality disorders, eating disorders, as well as DD. Prevalence
studies now show that DD are found globally, even in China, where DD
have yet to be added to the psychiatric diagnostic manual (Junhan et al.,
2010). There are more than a dozen measures of dissociation, translated
into as many languages, including a new dissociation measure that includes
validity scales (Dell, 2006) and another that is normed on the U.S. gen-
eral population (Briere, 2002). Frank Putnam is in the top 10% of most
frequently cited researchers to have worked at the National Institutes of
Health (P. Azoulay, personal communication, January 24, 2012; Azoulay,
Ganguli, & Graff Zivin, 2012), indicating how frequently references are made
to Dr. Putnam’s pioneering work in dissociation and trauma and how often
researchers use the Dissociative Experiences Scale. Exciting strides have
begun to reveal the neurobiology of dissociation, resulting in a review arti-
cle about the dissociative subtype of PTSD being the recent cover story of
the American Journal of Psychiatry (Lanius et al., 2010). The neurobiolog-
ical research is particularly important because it illustrates that dissociation
 Journal of Trauma & Dissociation, 13:387–396, 2012 395

is accompanied by altered activation of brain structures that are involved in

regulating awareness of bodily states, arousal, and emotions. For those skep-
tical about the existence of dissociation, the neuroimaging studies provide
concrete, theoretically consistent evidence that dissociation exists. A group
of researchers have suggested the addition of a dissociative subtype of PTSD,
and a forthcoming special edition of the journal Depression and Anxiety
focuses on the dissociative subtype (Lanius, Brand, Vermetten, Frewen,
& Spiegel, 2012). It includes treatment studies that provide support for a
dissociative subtype of PTSD in that individuals high in dissociation show
a different response to treatment than do those low in dissociation. For
example, women high in baseline dissociation showed greater reductions
in dissociation if they received affective regulation and interpersonal skills
training prior to engaging in modified exposure therapy; furthermore, if
women high in dissociation received either of the two comparative treat-
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ments (i.e., supportive counseling with either skills training or exposure

therapy), their PTSD escalated after treatment (Cloitre, Petkova, & Wang,
in press). The Journal of Trauma & Dissociation is now readily accessible
and widely indexed, thereby exerting a global influence on researchers and
clinicians. This cursory overview of recent developments shows that this
second wave in the field of dissociation is characterized by rigorous, more
broadly based empirical investigation. If funding becomes available, the
field is poised to launch groundbreaking and critically needed research on
the treatment of DD as part of this important second wave.

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