Working with dissociative fugue in a general psychotherapy practice: A cautionary tale

American Journal of Clinical Hypnosis, Apr 2003 by Jasper, Frank J

Pitfalls and Lessons Learned

1. Dissociative Disorders Are Not Rare. Saxe, van der Kolk, Berkowitz, Chinman, et al. (1994) found that 15 % of the psychiatric inpatient population they studied scored within the dissociative disorder range on the Dissociative Experiences Scale. They concluded that the incidence of dissociative disorders in the general psychiatric inpatient population is much higher than generally thought and that these disorders are generally unrecognized. Others (Horen, Leichner, & Lawson, 1995; Modestin, Ebner, Junghan, & Erni, 1996) have reported similar findings.

2. Dissociative Fugue State Can Exist Co-Morbidly with Other Psychiatric Disorders

Including Other Dissociative Disorders. Joe's history revealed that he had had dissociative symptoms long before the fugue state occurred. His life style was a dissociated one in which his wife and family knew nothing of his family of origin or childhood. He had also displayed poor impulse control in the form outbursts of anger and a threat of bodily harm. During ideomotor exploration Joe displayed behavior suggestive of divided consciousness. In his interactions with me he displayed significant guardedness in his refusal to take psychological tests, and his refusal to have me speak with his employer appeared to be a way of keeping me from discovering that it was he, not his boss, who was limiting his availability for therapy and further diagnostic exploration. It is quite possible that Joe suffered from Dissociative Identity Disorder (DID).

3. Fugue Is A Very Complex Disorder to Treat. Even with more than 25 years of clinical experience, I found I was rapidly in "over my head" with this case. My general knowledge of this area was insufficient to allow me to proceed with my usual confidence. Even though everyone wanted a short-term solution to this problem, that approach may not have been in Joe's best interest. I focused so intently on removing the symptom of memory loss that I missed the larger role that the dissociative disorder played in Joe's life.

4. Diagnosis Should Precede Treatment. Joe refused psychological testing. I would not have known exactly what to look for in the standard personality test battery, and such tests are generally unhelpful when diagnosing dissociative disorders (Putnam, 1989). Indeed, in reviewing the literature on psychological testing, I found little useful information for a general psychotherapist. The Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D; Steinberg, 1994a, 1994b) however, provides very useful questions that can be used easily in an informal way to cast more light on the scope and nature of dissociative symptoms or tendencies. I would recommend a familiarity with this instrument, even for those who never use it in a formal assessment.

5. A Phase-Oriented Treatment Approach Is Required. Even though I was able to use hypnosis for symptom removal and stabilize Joe sufficiently for him to get back to work and his "usual routine," I was unable to address the underlying dissociative disorder that seemed to have its roots in his forgotten childhood. I proceeded too quickly to address the symptom of memory loss and would have benefited from a phase-oriented approach (Herman, 1992; Phillips & Frederick, 1995) to build a sound therapeutic alliance and working relationship. This approach may have engaged Joe so that we could have worked together to discover what his treatment needs really were and to address some of his immediate fears and underlying issues. The major ego-strengthener would have been the therapeutic alliance as opposed to symptom removal.