Letter From The President

Cultural Differences in Dissociative Disorder Presentations

March 5 is DID Awareness Day and we will be having articles on the topic in this month’s ISSTD Newsletter, as well as a webinar being held for the public on March 4 (March 5 in Australia/New Zealand). Please join us!

It is only fitting that this month we attend to the Cultural differences in dissociative disorder presentations in our communities and discuss significant treatment elements with three of our International therapists.  

Universal cultural and linguistic clinical sensitivity and awareness guarantees services relevance and accessibility. Providing a physical, intellectual, emotional, sensory sensitive milieu that is warm, accessible and inclusive to clients from of all ages and diverse backgrounds promote participation, healing and resilience.

Below is what Adithy a psychologist from India has so generously agreed to share with us.

“I work as a counselling psychologist and psychotherapist in private practice in the city of Pune, Maharashtra State, in India.

I work with urban adults, coming from various regional/religious/family sub-cultures, mostly having grown up in families with traditional collectivistic cultural values, with strong patriarchal beliefs and hierarchical structure, but now exposed to and exploring more values of freedom and individualism.

A typical context in the background of someone presenting with a dissociative disorder could be as follows: A man and a woman in their late teens or early twenties had their ‘arranged marriage’ within their caste/community/religion/region of origin; the woman living in the joint household of or in close proximity of the husband’s family, where she is expected to respect and obey all the elders, sometimes even hand over the income from any job she does outside, to the head of the household, with little freedom for choosing for own family sub-system. A child is born to the couple. The mother is the primary caregiver of the child while she is expected to continue her duties to the elders. The father is busy with work and does not have much emotional connection with the child and might also be feeling powerless in the joint household. Going against the wishes or demands of the elders (including attempts at individuation) is considered bad (bad karma for some) and is expected to bring a malady of physical, mental, financial, or relational nature, if not in this life, then in the next, for oneself or for the descendants.

As the child is growing up, the mother might be feeling frustrated in the marriage. The mother might hyper-focus on the child, she might release her frustration by severely punishing the child physically or verbally (often to make the child study better), or she might be neglectful of the child, while struggling to live up to the external expectations. In addition, the child could be the person a parent pours out their woes to, as there is hardly any adult they can trust, given the loveless relation with the spouse. The child is likely to be a target for sexual abuse, including incest, not knowing what healthy boundaries are. The child is expected to respect the parent and follow what is suggested by the elders in the stream of education, work and the choice of marital partner, and excel in these areas, to make the parents and family proud. Sex is considered a taboo subject in the society in general. The child grows up in an environment of oppression and neglect, with hardly any education about own needs (including sexual) or emotions or their healthy expressions, struggling to be a ‘good child’ in the eyes of the family but having hardly any psychological tools. This child, might have suffered discrimination based on many factors, namely gender, skin color, caste, religion, region of origin, financial status, etc., on the way to reaching adulthood. Remnants of oppression carried down through educational, administrative, or judicial systems that were established by the foreigners that occupied the region years ago, or the state of political and civic affairs in the recent times, could also contribute to lowered sense of self-worth, safety or control.

Even though there are many avenues now available for moving forward in life, the person struggles with inner conflicts and unhealthy ways of coping, and accesses help reluctantly. Help for many mental health difficulties are sought initially from an astrologer, religious advisor, faith healer, etc., who treat the malady as a bad phase in the lifeline, or external energy (‘possession’) and advise prayers or rituals for absolution. Stigma of accessing mental health services is a big barrier to cross.

Given this context, dissociative disorder presentations come in many forms, and dissociative structure can be found underneath many mental health diagnoses that adult clients come with. Anger in a dissociated/dis-owned form is quite common. Shame states holding belief that one is not good enough or normal enough, not having lived up to the family expectation, or for having traits like a disliked parent, or having sexual needs, especially as a woman or homosexual man, have been common. Persons with ‘possession’ states have been documented in the media but are not commonly seen in urban mental health practices, probably because the persons are revered when the possessions are seen to be that of a goddess or other powerful spirit. Perpetrator introjects seen are often imitating abusive parents. People who are highly talented and functioning in their chosen fields have presented with dissociative sub-structure. Presentations such as phobia and panic, maladaptive daydreaming, uncontrollable sexualized behavior, repetitive dreams, compulsive behaviors including cleaning, shopping, helping someone, over-working, binge-watching television shows, internet-surfing, gaming, prayer or spiritual rituals have been seen. Many people have difficulty navigating romantic, family or work relationships, struggling with boundaries. Depression, suicidal and self-harm behaviors, zoning out and time loss are common presentations. Pain and physical difficulties such as gynaecological problems and related emotional difficulties are some of the ‘permissible’ expressions of dissociated states. Voice-hearing is a condition that quickly gets diagnosed as psychosis by the mental health system. The presentations of dissociative disorders or the backgrounds may not be unique in this region of vast cultural diversity, yet they seem to carry own cultural nuances from a variety of sub-cultures”.

Sandra Baita, a psychologist from Argentina and a long standing ISSTD Spanish Trainer, also shared her thoughts about the impact of cultural-societal attitudes on dissociative disorder presentations below.

“I live and work in private practice in the city of Buenos Aires, Argentina, which is the largest and richest city of the country. I am not sure I can describe a unique dissociative cultural-clinical presentation, because knowledge and research and writings about dissociation are still developing in all the Latinamerican region. But I can name a practice that certainly contributes to deepen my clients´ dissociation. 

It is sadly usual that Family Courts involved in situations of domestic violence and/or intrafamilial sexual abuse, at some point, act as if the abuse -either physical or sexual or both- had never happened. Sometimes they are fast and firm in providing protective measures for the kids involved in these cases, while the case is still under investigation by the Criminal Court. However, after a while we find it hard to explain to Judges why, from a psychological point of view, it is not recommended for the child´s sake to resume contact with the alleged perpetrator. Is the alleged perpetrator under treatment? No. Did the alleged perpetrator acknowledge the damage caused to the child? If the case is still under investigation, you can´t expect this question to be answered, because every citizen is protected by law to make any statements against himself. Do we know whether the abusive patterns of the alleged perpetrator´s behavior have changed in order to ensure that further contacts with the child are not going to be harmful? Silence is the usual answer to this question. And yet, some Family Judges start pushing for a reunification to happen. Cases in which the Family Court orders unsupervised visits of a child with an abusive father who is under investigation for having sexually abused her, are not a rare exception. Societal responses to trauma can promote as much dissociation as the sexual or the physical abuse itself. A mother who tells her girl that she is lying about the sexual abuse of her father, a father who tells the girl that what he is doing is something she likes, no matter how terrified the girl is, those family responses contribute to create different realities for this girl that need to be separated for the child to survive every single day.

But if you turn to someone outside of your home that you think could help you, someone bigger and more powerful, and at some point you are believed, only for your experience to be dismissed later, only for being told that your fear is exaggerated, or that your father made a mistake and you should forgive him, or that this is the father life gave to you and so you must learn to live with that… isn´t that the same dynamic the girl has faced inside her home?” 

Noula Diamantopoulos is an Australian clinical psychotherapist, author, and artist.  About her psychotherapy work and culture Noula stated, “I work in Sydney, Australia and my DID clients range in cultural background. Australia has grown from a strong immigration pool that began with her first English settlers and then post WW2 with immigrant from Europe, and more recently immigrants from Asia as the 3rd wave of cultural influence, over and above our original indigenous people of Australia, our aboriginal brothers and sisters.

I cannot speak directly to any specific cultural-clinical presentation in my practice except to say that it is diverse and broad given the diversity of cultural backgrounds that inhabit Australia at large and Sydney being the biggest city in Australia is populated a large variety of cultures. And as I reflect on this, I realise how I have become diverse in my relationship with my DID clients through learning and appreciating their family of origin sensitivities and understanding their spiritual lens on life (including the absence of one). This diverse cultural background of DID clients has inspired me to reflect on my own cultural influences and how my cultural background values, rituals, practices, support me and ground me and that this has become a source for me to explore with my clients as an approach to supporting my clients to ground (beyond the mindfulness, creating techniques and other somatic grounding tools)”. 

Thank you Adithy, Sandra and Noula for taking the time to share with us such important areas of cultural interest, as well as your clinical dilemmas.  

Much gratitude to all the readers for your significant community work and contributions!

Rosita Cortizo, PsyD, LMFT, MA
ISSTD 2021 President

Spanish Corner:

“Nosotros no sanamos aisladamente, sino en comunidad” ― S. Kelley Harrell


“We don’t heal in isolation, but in community.” ― S. Kelley Harrell