Dissociation reduction in body therapy during sexual abuse recovery

Summary

The study purpose was to examine dissociation in body therapy for women receiving psychotherapy for childhood sexual abuse. An initial intervention study provided an opportunity to examine dissociation; the sample of 24 women received eight, 1-h body therapy sessions. The Dissociative Experiences Scale served as the predictor variable, and the outcome measures reflected psychological and physical health, and body connection. Repeated measures analysis of variance was used to examine dissociation reduction across time. Pearson correlations were used to describe associations between the relative change in dissociation and outcomes. The results demonstrated that the greatest change was the reduction of dissociation; there was an incremental effect across time and a strong association between change in dissociation and health outcomes. High dissociation at baseline (moderate levels) predicted positive outcomes. The results demonstrated the importance of moderate dissociation as an indicator of distress, and the central role of dissociation reduction in health and healing.

Introduction

Dissociation can be a useful protection from the pain of inescapable childhood abuse, however it may become a liability later in life—it is associated with the psychological and physical distress in post-traumatic stress disorder (PTSD),¹ affect dysregulation and somatization,² problems with gastrointestinal health,³ and appears to predict future dissociative experiences⁴ (for definitions see Table 1). A primary characteristic of dissociation is the fragmentation of consciousness; thus the experience of dissociation involves a sense of separation from self. Sexual symptoms and dysfunction, also common sequels of sexual abuse,⁵ are thought to be related to dissociation from the body.⁶ Clinical experts in the field emphasize the importance of reconnection with the self in healing from child sexual abuse—this involves recognizing, understanding and reducing dissociation.7, 8, 9

To date there have been few intervention studies that either measure or examine the changes in dissociation associated with psychological care for childhood sexual abuse. The role of dissociation reduction on health outcomes in sexual abuse recovery in adults has rarely been explored. The lack of study in this area is surprising given that research demonstrates that dissociation serves as a mediator of psychological health in children with sexual abuse histories,¹⁰ that dissociation is prevalent among adult sexual abuse survivors,11, 12 and that dissociation is recognized as a mental health problem in psychotherapeutic recovery from childhood sexual abuse.7, 8, 13

This is a study of dissociation in body therapy during sexual abuse recovery. The analysis originated from an intervention study examining two body therapy approaches, massage and a body-oriented therapy, as an adjunctive treatment for women in psychotherapy. Massage is a form of bodywork that involves manipulation of muscle and soft tissue to facilitate tension release. Body-oriented therapy is a form of body-psychotherapy that involves the combination of hands-on bodywork with a focus on body awareness and the emotional processing of psychotherapy. The primary aim of the original study was to examine the efficacy of body-oriented therapy with massage therapy as the comparison control. The hypothesis that body-oriented therapy would result in greater reduction in health outcomes compared to the control was not substantiated. Rather, the results indicated that both groups experienced significant change on all outcomes across time; the findings are reported in a previous publication.¹⁴ The purpose of the present study was to describe dissociation with respect to body therapy in sexual abuse recovery, specifically a study of non-pathological dissociation (i.e., among participants without dissociation disorders). There were two hypotheses. The first hypothesis predicted that there would be an incremental decrease in dissociation over the course of the body therapy interventions. The second hypothesis posited that dissociation reduction would be positively associated with change in psychological well-being, physical well-being, and body connection across time.

The measurement of dissociation in research typically involves quantifying the frequency of dissociative experiences using the Dissociative Experiences Scale (DES).¹⁵ Designed to measure dissociation on a continuum, the DES includes items associated with the full range of dissociative experiences from normal to pathological. Factor analysis indicates that the items represent three sets of dissociative experiences: absorption (normal range), depersonalization/derealization (moderate range), and amnesia (severe range) (for definitions see Table 1). The DES score, however, is a sum of all possible dissociation experiences representing the frequency of overall dissociative experiences.

The need for increased specificity to identify the prevalence of particular aspects of dissociative experiences and their mental health correlates has led to the use of item subsets from the DES to examine, for example, depersonalization among clinical populations ¹⁶ (16) and severe dissociation in the general population.¹⁷ A newer instrument, the DES-T, was developed to include only items from the DES that are characteristic of dissociative disorders, thereby distinguishing pathological types of dissociation (i.e. taxon membership—for definition see Table 1) from non-pathological dissociation¹⁸; contributing to a typological model for conceptualizing dissociation as an alternative to the continuum model.¹⁹ Increased specificity in dissociation research, from the perspectives of both conceptual models, has clarified the importance of distinguishing among dissociative symptoms as well as the need for better understanding of the health implications of dissociative experience. For example, in a study of taxon membership representing pathological dissociation, taxon membership was found in only 3.3% of the general population.¹⁷ In contrast, a study of depersonalization in the general population $(N=1008)$ found 23% of the respondents reporting symptoms of depersonalization in the preceding year.²⁰ Importantly, research findings suggest that symptoms of moderate dissociation, specifically depersonalization, may be linked to emotional stress and associated with physical symptoms of chronic pain in the general population,²⁰ and emotional maltreatment in childhood—including sexual abuse—among a clinical population.¹⁶

Dissociation as a sequela of childhood sexual abuse has been primarily studied among a psychiatric population. There is substantial evidence that sexual abuse is associated with “dissociation identity disorder,” the least common and most extreme dissociative experience.19, 21 Dissociative experiences that include “moderate” symptomatology such as symptoms of depersonalization are common in many clinical populations, however we know little about the association between moderate dissociation and psychological and physical health among sexual abuse survivors. A recent study, however, found that both pathological (taxon membership) dissociation and moderate (non-taxon membership) dissociation were associated with comparable levels of psychological distress among women with a childhood sexual abuse history. Although there were distinctly different patterns of psychological distress between the severe and moderate dissociators, both groups had significantly greater psychological distress compared to normal (low) dissociators.²² That is, elevated dissociation—whether in the moderate or severe range of dissociative experiences—was associated with significant psychological distress in this population.

The reduction of dissociation is considered integral to sexual abuse recovery among clinicians working with adult sexual abuse survivors within the combined areas of bodywork and body-psychotherapy.9, 23, 24, 25 The emphasis on dissociation reduction among therapists who work with the body in trauma recovery is most likely due to the focus on body awareness in these approaches. The focus on body awareness in conjunction with touch (i.e., bodywork) provides a unique perspective on dissociation that highlights the experience of dissociation in the body as a barrier to emotional awareness and integration of aspects of the self—and is, therefore, particularly useful as a complement to psychotherapy for adults in trauma recovery.

The lack of sensory and emotional awareness—and the underlying processes of inner connection to the self—are common among women with a history of severe trauma⁸; and is referred to in this paper as a lack of “body connection.” Women typically seek body therapy in sexual abuse recovery to increase their sense of body connection—in other words, to increase the sense of continuity and integration between self and bodily experience.14, 26 For example, women who seek body therapy in trauma recovery often report minimal purposeful attention to bodily experience, which appears to be associated with a lack of sensory (physical) and emotional awareness. A common self-description includes being “cut off from the neck down” or “a walking head,” indicating that sense-of-self does not incorporate bodily experience. The feeling of being ‘cut-off’ from the body can be a distressing experience in daily life that is typically associated with the trigger of unresolved and negative emotional experiences stemming from abuse; the experience of being ‘cut-off,’ or separated, is a symptom of depersonalization.²⁷ Examples of bodywork and body-psychotherapy therapy techniques used to increase body connection and reduce dissociation include: increasing the capacity to be present (i.e., maintaining awareness of inner experience without dissociating) during bodywork; developing body literacy—the ability to identify and articulate bodily experience; teaching inner body awareness approaches to facilitate access to somatic and emotional awareness; and verbal processing of session experiences to facilitate cognitive understanding, acceptance and insight. Thus, these techniques are thought to facilitate increased body awareness as a primary strategy for dissociation reduction, involving the connection between sensory, emotional, and cognitive awareness.9, 14, 23, 24, 25, 28, 29, 30

Anecdotal9, 23, 31 and experimental evidence¹⁴ suggests that body therapy (therapy that specifically involves hands-on bodywork) is associated with reductions in dissociation among adult survivors of childhood sexual abuse. However, with the exception of the author's two prior studies,14, 32 measures of dissociation have not been included in body therapy research. Thus we know little about the effect of body therapy on dissociation, and nothing about the relationship between dissociation reduction and health outcomes in body therapy. This study is designed to examine dissociation in body therapy during sexual abuse recovery, a first step in this area of inquiry.