Vis sammendrag
This study explores experiences of change related to treatment among individuals with complex dissociative disorders (CDD). Their first-person accounts shed light on their experiences with a psychoeducative skills-training group, the impressions it left, and their broader sense of recovery over time.
CDD is a severe condition associated with wide variability in functioning and intense internal symptom pressure (Diagnostic and Statistical Manual of Mental Disorders [DSM-5 TR], American Psychiatric Association [APA], 2022; International Society for the Study of Trauma and Dissociation [ISSTD], 2011). Individuals may struggle with memory for current situations, altered time perception, and significant internal conflict (Marais et al., 2023; Parry et al., 2018). CDD typically present with multiple comorbid disorders (Rodewald et al., 2011) and elevated risk of self-harm and suicidality (Leonard et al., 2005; Webermann et al., 2017). Studies suggest that many receive other diagnoses first and that CDD diagnosis often is delayed (Spiegel et al., 2011). Relative to its prevalence and clinical significance, CDD has received little empirical attention, and key determinants of effective treatment remain unclear.
The field is marked by conceptual debates (e.g., the definition and scope of dissociation; Dorahy & Gold, 2023; Nijenhuis & van der Hart, 2011), etiological disagreements (e.g., trauma versus sociocognitive models; Dalenberg et al., 2012; Lynn et al., 2012), and treatment controversies (e.g., phase-oriented vs. exposure-based approaches; De Jongh et al., 2016; Stavropoulos & Elliott, 2023; van Vliet et al., 2018). This thesis is shaped by all of these debates, in which participants’ experiences of change relate to how dissociation is defined, how its origins are understood, and, consequently, what may constitute effective treatment.
In this contested field, the treatment debate is especially relevant to the present study. Despite ongoing disagreements, international guidelines currently recommend a phase oriented, dissociation-specific approach (ISSTD, 2011; Brand et al., 2012). Such treatment is not yet strictly operationalized, and empirical studies of its effectiveness remain limited. Although a recent randomized controlled trial (RCT) of a psychoeducative intervention and a systematic review indicate some support for phase-oriented treatment (Brand et al., 2025; Griffiths et al., 2025), there are no comparative studies of different types of interventions. And we still know little about how treatment works, how it is experienced, which interventions are perceived as helpful, what individuals with CDD long for, and how to assess change when dissociation complicates self-report.
To address some of the knowledge gaps related to first-person perspectives on change and treatment, we conducted a qualitative, longitudinal study at a Norwegian trauma outpatient clinic in Oslo. Participants also took part in an RCT examining the effects of a 20 week psychoeducative group-intervention. The longitudinal sample comprised 26 adults with CDD who had extensive histories of childhood trauma, high comorbidity, and long treatment trajectories. They were interviewed six months (Paper I) and two years (Paper II) after the group intervention. A smaller subsample, also interviewed at pre-treatment, contributed to Paper III. Across papers, we examined participants’ accounts of change using hermeneutic phenomenological qualitative analyses.
In Paper I we aimed to explore participants’ experience and perceived impact of the group intervention with interviews conducted six months post-intervention. The key findings were movement toward a more coherent sense of self and an increased sense of agency. Psychoeducation provided non-stigmatizing language and skills such as grounding and dual attention helped reestablish presence and the capacity to notice and engage with internal conflicts. Recovery was experienced as coordinating parts of the personality, not eliminating them. Being with others in the group had a substantial impact, normalizing experiences that had often set them apart, fostering belonging, and reducing detachment.
Paper II aimed to identify long-term patterns and variations of change two years after the intervention. The main finding was movement along three pathways of change: (1) increased ability to stay present in life, (2) approaching and negotiating internal conflicts among parts of the personality, and (3) increased ownership (“mineness”) of past and present. The majority of participants used coping strategies that helped them tolerate and relate to their internal conflicts. They reported greater ownership of their reactions and their histories. A smaller group relied on regulation strategies to maintain functioning and prevent breakdowns. They experienced less change in their ability to engage in negotiating internal conflicts.
Paper III followed six participants longitudinally from pre-treatment through six months and two years post-intervention. We explored trajectories of change in relation to what they longed for before treatment. These longings clustered around identity, self-trust, safety, relational authenticity, and contributing to society. Over time, change consolidated into restoring the self, restoring safety, and restoring connectedness. These changes culminated in an overarching theme: “restoring the sense of next,” understood as a renewed capacity to imagine and take the next step in life. Validation from the therapist, careful pacing, and regulating rest and activity were described as important.
The findings across Papers I–III are discussed in terms of what changed, how treatment affected those changes, and how we can measure whether change has occurred. Methodological limitations are also addressed. Across the three papers, this thesis offers lived-experience insights that may have implications for other individuals with CDD:
• A patient-centered, longitudinal map of change. These studies highlight the importance of discerning patients’ longings, building capacities to stay present, maintaining dual attention, and tolerate internal states. Negotiating internal conflicts appeared to support ownership and integration of past and present experiences into a more coherent narrative.
• Practical guidance on what facilitates change. Psychoeducation explaining why dissociation occurs and what internal conflicts express, was experienced as helpful. Skills that increased capacity to relate to mental content seemed to contribute to a stronger sense of agency. A helpful therapeutic alliance included careful pacing and validation of experiences. Meeting others in similar situations normalized experiences and reduced shame.
• An assessment frame aligned with different phases of treatment. Early perceived changes can be meaningful even if they do not immediately produce significant shifts on symptom scales. Changes in the dissociative structure seem often to emerge later in treatment or when directly targeted. Combining symptoms and functioning measures with process sensitive markers, and using measures suitable for longer-term follow-up, better captures what patients experience as meaningful progress.
• A hopeful, mechanism-informed view of change in CDD. The findings suggest that substantial structural and existential changes may be possible when treatment aligns with longings and capacities, helping individuals “gather themselves” into a more coherent, agentic self with a renewed sense of next.
