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Letters to the Editor: Response to “Reforming Mental Health Care”: Page 4 of 4

Letters to the Editor: Response to “Reforming Mental Health Care”: Page 4 of 4

Denying Dissociation and Attacking Mental Health Care

Diagnosing dissociation does not make it happen, and denying it does not make it go away. Dr Barden has a vested interest in advocating for a certain point of view in suing psychotherapists. But he has not always prevailed. When he took the Susan Greene case to a North Carolina jury in 1998, the jury found for all defendant mental health professionals, and not for Barden’s client.

It seems that Barden is not well informed about dissociative identity disorder (DID) research and treatment. Contrary to his claims, the literature has shown for decades that DID patients improve during treatment. Research on DID treatment includes 10 publications based on an international treatment outcome study involving 280 therapists and their patients (Treatment of Patients with Dissociative Disorders [TOP DD] study).1-4 The TOP DD study showed that consistent treatment based on DID expert consensus guidelines is associated with decreased dissociation, PTSD, depression, distress, self-harm, suicide attempts, physical pain, and hospitalizations as well as improved functioning—including increased socializing and better school attendance.5

Jepsen and colleagues4 found that symptoms of DID (eg, amnesia) failed to improve when clinicians did not focus on DID symptoms, although other symptoms improved. A meta-analysis of 8 dissociative disorders treatment studies found moderate to large pre- and post-effect sizes across 7 types of symptoms (mean = 0.71).6 In our recent review we concluded:

The claims that DID treatment is harmful are based on anecdotal cases, opinion pieces, reports of damage that are not substantiated in the scientific literature, misrepresentations of the data, and misunderstandings about DID treatment and the phenomenology of DID. Given the severe symptomatology and disability associated with DID, iatrogenic harm is far more likely to come from depriving DID patients of treatment that is consistent with expert consensus, treatment guidelines, and current research.7

Dr Barden wrongly assumes that memory “recovery” is the primary focus of treatment. A survey of DID experts found that at no stage in treatment was the processing of trauma memories one of the most frequently recommended treatment interventions, not even during the middle phase when DID patients occasionally discuss trauma in detail.8 The experts preferentially advocated teaching of symptom management techniques and practicing containment of traumatic memories. Containment techniques are the opposite of exploring trauma memories and assist patients in achieving greater distance from, and mastery over, intrusive flashbacks of traumatic memories; that actually permits the successful resolution of traumatic memories in treatment.

Barden seems oddly uninformed about research involving the empirically established link between trauma and dissociation published in numerous scientific journals.9-13 This type of research is the reason why DID and a new dissociative subtype of PTSD are included in DSM-5.14,15

Dissociation existed long before psychiatry did. We didn’t create it. Treating it well is the least we can do.

Bethany L. Brand, PhD
Clinical Professor, Dept of Psychology
Towson University
Towson, Md

Richard J. Loewenstein, MD
Clinical Professor, Dept of Psychiatry
University of Maryland School of Medicine, and Sheppard Pratt Health System

David Spiegel, MD
Willson Professor and Associate Chair
Dept of Psychiatry and Behavioral Sciences
Stanford University School of Medicine
Stanford, Calif


1. Brand B, Classen C, Lanius R. A naturalistic study of dissociative identity disorder and dissociative disorder not otherwise specified patients treated by community clinicians. Psychol Trauma. 2009;1:153-171.

2. Brand B, Loewenstein RJ. Does phasic trauma treatment make patients with dissociative identity disorder treatment more dissociative? J Trauma Dissociation. 2014;15:52-65.

3. Brand BL, Lanius R, Vermetten E, et al. Where are we going? An update on assessment, treatment, and neurobiological research in dissociative disorders as we move toward the DSM-5. J Trauma Dissociation. 2012;13:9-31.

4. Jepsen EK, Langeland W, Heir T. Impact of dissociation and interpersonal functioning on inpatient treatment for early sexually abused adults. Eur J Psychotraumatol. 2013;4.

5. Brand BL, McNary SW, Myrick AC, et al. A longitudinal, naturalistic study of dissociative disorder patients treated by community clinicians. Psychol Trauma. 2013;5:301-308.

6. Brand BL, Classen CC, McNary SW, Zaveri P. A review of dissociative disorders treatment studies. J Nerv Ment Dis. 2009;197:646-654.

7. Brand BL, Loewenstein RJ, Spiegel D. Dispelling myths about dissociative identity disorder treatment: an empirically based approach. Psychiatry. 2014;77:169-189.

8. Brand BL, Myrick AC, Loewenstein RJ, et al. A survey of practices and recommended treatment interventions among expert therapists treating patients with dissociative identity disorder and dissociative disorder not otherwise specified. Psychol Trauma. 2012;4:490-500.

9. Dalenberg CJ, Brand BL, Loewenstein RJ, et al. Reality versus fantasy: reply to Lynn et al. Psychol Bull. 2014;140:911-920.

10. Dalenberg CJ, Brand BL, Gleaves DH, et al. Evaluation of the evidence for the trauma and fantasy models of dissociation. Psychol Bull. 2012;138:550-588.

11. Lanius RA, Vermetten E, Loewenstein RJ, et al. Emotion modulation in PTSD: clinical and neurobiological evidence for a dissociative subtype. Am J Psychiatry. 2010;167:640-647.

12. Stein DJ, Koenen KC, Friedman MJ, et al. Dissociation in posttraumatic stress disorder: evidence from the world mental health surveys. Biol Psychiatry. 2013;73:302-312.

13. Dorahy MJ, Brand BL, Sar V, et al. Dissociative identity disorder: an empirical overview. Aust N Z J Psychiatry. 2014;48:402-417.

14. Spiegel D, Loewenstein RJ, Lewis-Fernández R, et al. Dissociative disorders in DSM-5. Depress Anxiety. 2011;28:E17-E45.

15. Spiegel D, Lewis-Fernández R, Lanius R, et al. Dissociative disorders in DSM-5. Annu Rev Clin Psychol. 2013;9:299-326.


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