In the last edition of the ESTD Newsletter, Camille Tarquinio had the kindness to present a summary of the thesis that I defended last March 2021 at the University of Lorraine, Department of Psychology, in Metz, France (Piedfort-Marin, 2021). Onno van der Hart asked me to share, in an article intended for the ESTD Newsletter, my experiences and recommendations regarding working on a thesis on the topic of dissociative disorders, so as to be a source of inspiration for other clinicians with an interest in research in our field.
How it started
It all started with an apparently “beside” comment from Prof Cyril Tarquinio after he read a paper that I, as a clinician specialized in the treatment of trauma-related disorders, including dissociative disorders, had written in French in 2017. “You should give your work more visibility”, he said. I did not know what he meant until he explained to me that I should do a thesis under his direction. Cyril Tarquinio is Professor of Psychology at the University in Metz; he has set up a Master degree in psychotraumatology, University diplomas in EMDR, and he is the director of the Centre Pierre Janet, a center integrated within the university, providing therapy to patients, training to professionals, and researching in the field of trauma. I was surprised at first by his suggestion, and I did not really know what to think of this proposition. It did not fit in the way I imagined my life. Back then I was at a moment of my career where I had in mind to share things that I had learned by writing clinical articles. I had also embarked in a validity study of the French version of the SCID-D. After a period of doubt, I thought why not have the bonus of a Ph.D. title after the work that I want to do anyhow?! Of course, I learned in the meantime that a Ph.D. is not simply a bonus… In France, at least, and in some other countries as well, experienced clinicians can do a thesis based on a series of articles they have published in selected peer-reviewed journals. The articles must then be integrated in the text of the thesis. I decided early on that my thesis would have a mixed content: an empirical study (the SCID-D research) but also theoretical and clinical articles. I wanted my thesis to be helpful for clinicians and researchers as well, as there is a need for a rapprochement between the two. Experienced clinicians have now the possibility to link a conceptual reflection with their clinical practice in a doctoral thesis. This was a great opportunity that I decided to take.
What would be the theme of my thesis? This was the first question I needed to address., I wanted to fit the ten articles needed for my thesis in a well-structured document that was coherent and with clear, specific aims. I reflected on my years of clinical work since I first heard of dissociation, and I realized that I should give tribute to dissociative disorders. We know that, around the globe, these disorders receive little interest from the scientific community. We know that there is very little money for research in this field. And we know that there are many misconceptions about dissociative disorders. In fact, as I started to prepare the validity study of the French version of the SCID-D back in 2014, my intention was to respond to the needs of colleagues to properly assess dissociative disorders, and the need of dissociative patients to be recognized in their very specific pain and symptoms, for which they should receive the appropriate treatment that they deserve. Another aim was to provide the French-speaking countries with the basic tool for future research in the field, namely a recognized diagnostic instrument. I understood – perhaps incorrectly – that I would not find support from a psychiatric hospital. This is why I decided to monitor this research by myself, with the help of several colleagues who helped with the translation, with the study itself, and with finding some (very limited) funds.
Writing a thesis on the dissociative disorders would mean that these disorders would enter the university. This also meant that the invited members of the jury – some of whom are not specialized in this field – would have to read the thesis and debate it with me. In the context of French psychology and psychiatry, and the dominance of Freudian and Lacanian psychoanalysis in France (an exception which it shares, worldwide, with Argentina, it seems), this was quite a challenge to bring back to France the ideas of Pierre Janet! Colleagues from other countries may not know that Janet has been largely forgotten in his native France. His work hardly appears in the Bachelor’s or Master’s programs of universities of psychology across this country. While most of Janet’s books have been re-published in France, they are even difficult to find in French bookshops! Other countries may be more advanced than France in the rediscovery of Janet and his brilliant work.
Acknowledging, assessing, and treating dissociative disorders
Writing a thesis as an experienced clinician asks you to look back at your career, what you have learned, achieved, missed, what you have failed at, and what you want to learn in the years to come. I hesitated on the subject and the title of my thesis for more than a year. This was not a problem, as you can change the focus of your work in the course of the thesis, but one should be careful not to lose too much time in procrastination. This is actually the process of the thesis: thinking, thinking and reflecting. Trauma and dissociation are my specialties, but this was much too broad for a thesis. Looking back at the last 15 years of my professional path, I realized that the core of my work had not just been to fight for the recognition of the traumatic origins of mental disorders. I had fought hard and constantly for the recognition of dissociative disorders in my region and beyond, which often led to a feeling of solitude. I have even been called “dissident” in the CBT field at some point … and this was true! Therefore, I decided to use this thesis as an opportunity to give recognition to the dissociative disorders and to the individuals suffering from these conditions. Suddenly, this made complete sense. This implied that I would leave aside articles that I had already published but that would not fit so well in this thesis. This resulted in the need to write more articles than originally planned. But work is not a problem, it is the solution. I had the subject of my thesis and the plan as well. “Acknowledging, Assessing, and Treating Dissociative Disorders”: this would be the title of my thesis.
Acknowledging dissociative disorders is a difficult task, not only for psychiatry and psychology in general, but also often for colleagues already interested in trauma-related disorders. The differences with psychosis and schizophrenia, but also with borderline personality disorder, are subjects of battles between researchers and clinicians. Colleagues starting a training in dissociative disorders may become troubled because learning about dissociative disorders obliges them to take a critical look at what they have learned previously. A colleague had once asked me if I could recommend a paper in French on the myths about dissociative identity disorders (DID), that she could present to an insurance expert who had written that DID does not exist. I could not but realize that I could write such an article and that this paper could be valuable for many psychotherapists facing the same difficulties as this colleague. This became the first article presented in my thesis, dealing with the myths about DID (Piedfort-Marin, Rignol, & Tarquinio, 2021). The starting points were the basic assumptions that we often hear in our clinical work when we exchange with colleagues:
DID is actually schizophrenia;
There is no such thing as DID;
DID develops under the influence of the media and/or therapists in people with fantasy proneness and high suggestibility;
The etiology of DID is therefore iatrogenic and not post-traumatic;
Amnesia for the terrifying traumatic stories that these individuals later report in therapy is not possible; such stories are baseless inventions.
Although this article was written in French to better target French and Swiss colleagues, it attracted the attention of Prof Steven Jay Lynn and colleagues (Dodier, Lynn, & Otgaar, in press), adherents of the socio-cognitive model of DID, who wrote a critical commentary. Quite flattering as a friend said!
Assessing dissociative disorders is not an easy task and requires validated diagnostic instruments. The SCID-D has been widely used in research and clinical practice in different countries. However, until recently it was not validated in its French version and no other diagnostic instrument was available in France and other francophone countries. In 2014, I decided to do a validation study of the SCID-D. This study was longer than I initially expected. Marlene Steinberg, the author of the SCID-D, decided to take the opportunity to make needed adjustments to the DSM-5 and make it available for colleagues using the ICD categorization system in its 11th version. This added more delay in the development of the latest version of the SCID-D. Our research (Piedfort-Marin, Tarquinio, Steinberg, et al., 2021) is the first one to validate the latest version of the SCID-D (Steinberg, in press) applicable to DSM-5 and ICD-11 diagnostic criteria. I am proud that I could make available to French-speaking colleagues a valuable instrument in assessing dissociative disorders. This will allow clinicians to assess their patients with more precision and accuracy. And foremost, this will help patients in their difficult journey, for example in relation to health insurances, who often expect the use of validated instruments, at least in Switzerland. Managing such a study as a psychotherapist in private practice, with no previous experience in research, is a challenge or a sign of madness. I had the chance and honor to profit from the help and support of Marlene Steinberg, the study being a replica of previous research on the SICD-D. Cyril Tarquinio dealt with the statistics. Several colleagues agreed to help with and test the translation, and to view and assess the videos as co-raters. Other colleagues simply gave their moral support, or money, which was also necessary. While monitoring such a study is a lonely job, it is a pleasure to remember that many people were involved.
Treating dissociative disorders is a great challenge. In my journey of writing clinical articles, I did not invent anything new. And frankly, I don’t think that anyone is inventing anything new anymore in psychotherapy methods and interventions. However, I thought that I might address several points of view possibly useful to other colleagues. My basic theoretical framework is the theory of the structural dissociation of the personality (TSDP; Van der Hart, Nijenhuis, & Steele, 2006/2010). Writing clinical articles on dissociative disorders – possibly even so in the context of a thesis – requires going deeper in the understanding of one’s theoretical framework. The TSDP is a far more complex theory than it may appear. Having learned the treatment of dissociative disorders with Ellert Nijenhuis since 2005, I have been trained to integrate the complexity of theoretical concepts in my clinical practice. In the clinical articles that I wrote in the context of my thesis, I was confronted with a conflict of loyalty to Ellert and his teaching. On one hand I knew that there was nothing that I could write that would come close to the genius of his thinking and of his clinical work. On the other. I had to find my own way and be confident about myself, however with no intention of “killing the father”! I hoped to use all that I learned from Ellert and still be myself. This is what the enactive approach (Nijenhuis, 2015, 2017) is all about, in fact. This led to many moments of doubts, but “confusion leads to insight,” according to Milton Erikson. Originally, I believed that writing articles on my clinical work could help others. However, I wonder how many colleagues read articles. There are so many things to read! Finally, I discovered that writing expanded my own understanding of my clinical work. It helped me incredibly to integrate the complex theoretical concepts that I learned over the years. This may sound as an immediate selfish goal, but I guess and hope that my patients and supervisees profit from this.
The joy, the doubts, and a few difficulties
In the four years that the thesis took, there were a few difficult moments, of course, but only a few. When a paper is refused by a journal that is supposed to be open to different theoretical and clinical perspectives, it is never easy. When a paper receives harsh – and sometimes unfair – critical reviews, it is not easy either. I realized that writing clinical papers is difficult because you write about very personal experiences, pertaining to relationships between clients and yourself. And then reviewers and readers will judge and comment on this intimacy, not always respectfully. I feel more fragile when a clinical article is criticized because it relates to an intimate experience, this is the way I consider a therapeutic relationship. In fact, one of the articles selected for my thesis relates to trauma-related countertransference and how to use it in therapeutic work with severely traumatized clients (Piedfort-Marin, 2019). I think we do not explore this issue enough in dissociative disorders trainings, or only at a theoretical level. With this article I wanted to transmit real, subjective experiences of trauma-related countertransference, that could be useful to other therapists. That paper was well received by the reviewers, though.
In 2016, the SCID-D study received the approval of the local ethics committee, which was very helpful in assisting to the fulfillment of the requirements as it was the first time that I engaged in such a complex procedure. Since the study had to be postponed until the SCID-D’s adaptation to the ICD-11 was done, I announced in 2019 that we could now start the study. I was devastated to learn that the procedures had been changed to a much higher level of requirement: Suddenly I needed to become a lawyer, a data protection specialist, an IT freak, a statistic specialist. I had one month to make all necessary changes. Since I was monitoring this study as a psychotherapist in private practice, I wanted my documents to be irreproachable, and I lacked the support of a large hospital. This is the point when I almost stopped the SCID-D study; only the sense of duty kept me going. I thought it would be so stupid to stop at this stage, after all that had been done until then. I downloaded the modified documents on the night of my birthday, during a vacation in the South of France, while my friend was peacefully sleeping. Is this a life?! Maybe the ethical procedures related to research are stricter in Switzerland than in other countries, I do not know. I was particularly concerned that, during or after the SCID-D interview, dissociative participants to the study might do what they often do: have a long switch, hurt themselves badly, etc. This would have led to a hospitalization, the opening of a case by the insurance company, and a hold up of the study by the ethics committee for evaluation. In the end, all went well. Of course, participants with DID switched but the adult part could come back in due time. Since this experience, I have the most respect for researchers, even those publishing research that, I believe, is useless.
Apart from these few short but intensely difficult moments, my thesis was a path of pleasure and joy. I discovered that I enjoy writing, I enjoy thinking about concepts and clinical work. Overall, working on my thesis was a very positive experience. This is what I will remember.
The last moment of stress was a few weeks before submitting my final manuscript, during the Christmas holidays: which subtitle should I choose? I was suddenly unhappy with the one I had chosen which I cannot even recall right now! The title of the thesis being broad, it needed a subtitle that would target the specificity and originality of the text. Suddenly, a few weeks before the end of this journey, I had doubts about the meaning of the whole work! My doubts disappeared when I realized what I have been working for during this long journey, since I had discovered dissociative disorders: I have been working on integrating in my clinical practice the concepts and the therapeutic skills that I needed to learn; I have been trying to understand the horrors the patients had lived and what they awakened in me. And I have been helping patients to integrate their traumatic experiences. The subtitle was then clear: “The difficult path towards integration for patients and clinicians.”
The older, the better
What is the point of a Ph.D. thesis defended at age 58? I believe that there is a big difference between writing a thesis right after your Master degree and much later after many years of clinical and other experience. The difference lies in the ability for experienced clinicians to combine theoretical and clinical perspectives. The feedback that I received from several colleagues is that my thesis has the advantage of connecting the theoretical and empirical perspectives to the clinical perspective. I believe that older, experienced clinicians can do this better than their younger colleagues.
A thesis is typically a solitary experience, and I enjoy writing alone in my country house, seated by the kitchen table or in the garden under the trees. Nevertheless, it is also an experience of sharing. Of course, Cyril Tarquinio supported me fully as my thesis director. I am indebted to the many people I learned from in different ways. Over the years I had many teachings or in-depth exchanges with many colleagues and experts, particularly with Susanne Leutner, Giovanni Liotti, Andrew Moskowitz, Luise Reddemann, Marlene Steinberg, Onno van der Hart, Eva Zimmermann, and last but – by far – not least Ellert Nijenhuis. All that I learned with these colleagues would have no meaning if it was not for the patients with dissociative disorders and other trauma-related conditions that I work with in therapy, and for the patients of the colleagues who trust me in supervision.
The local development of the literature on dissociative disorders
Researchers are encouraged to publish in English, the only scientifically validated language, it seems! I believe that we will support the cause of diagnosis and treatment of dissociative disorders by publishing in other languages. This is the reason I encourage colleagues from the different European countries to publish in their own language in local scientific journals. This may not bring much glory in one’s CV, but may target more directly clinicians who do not speak English, i.e. most of them. This was one of my aims with my thesis which gathers five papers written in French, three in English, and two published in both languages.
In the Francophone countries, clinicians and researchers have at their disposal:
Several screening instruments validated in French: SDQ-20, DIS-Q and DES;
New: a validated diagnostic instrument, the SCID-D, whose publication is in preparation;
New: a translated and adapted instrument to assess the evolution of the therapy of dissociative disorders (DTMI: Kluft, 1994; Piedfort-Marin, Wisler, Piot, & Spagnoli, 2017).
Unfortunately, colleagues from France and other Francophone countries may not be aware of the richness of Pierre Janet’s work which is available to each clinician in its original French version. Janet’s language is easily understandable, in contrast to many authors of that period. But at least they have at disposal the theory of the structural dissociation of the personality (Van der Hart et al., 2006/2010), which offers a modern presentation of Janet’s conceptual work. This constitutes a theoretical base for clinicians to publish clinical articles in French, which will expand the interest in dissociative disorders among other clinicians.
In the conclusion of my thesis, using the epidemiological data we have about dissociative disorders (Dell, 2009), and the official data from health authorities, I calculated how many individuals may be concerned in France and in Switzerland. In France (67 million inhabitants) there may be between 42.000 and 84.000 individuals with a severe dissociative disorder (DID and partial DID) hospitalized in 2019, and around 1.827.000 treated in outpatient facilities. This does not include patients being treated in private practice. In Switzerland (with 8.5 million inhabitants) there may be 41.000 (most reasonable figure) patients suffering from a severe dissociative disorder (in- and outpatient facilities and private practices). These figures raise concern in a more concrete way. With so many individuals with a (severe) dissociative disorder, why are these disorders not listed in the official data of mental health institutions? These figures are easy to calculate, and I encourage the ESTD representatives from each country to reply to this question: How many individuals/patients have a dissociative disorder in your country? Then you may have some basic data, helpful when you want to discuss with the health authorities about the needs of these patients. This is the next step I intend to engage in, in my region, the French-speaking part of Switzerland.
In the field of dissociative disorders, it is very nice to meet at our conferences and publish in specialized journals like the European Journal of Trauma and Dissociation, but we need to be “out there” where we are not expected to be. A doctoral thesis gives this opportunity: to push closed doors and bring dissociative disorders into the universities.
I hope that by sharing my experiences, colleagues will consider doing a thesis that will address one of the many issues of trauma and dissociation. For me the work was worth it, definitely! This is an extraordinary way to increase even more one’s knowledge in the field, and to move forward the recognition of trauma-related disorders and dissociative disorders. There should be many to invade universities with such a project. Just do it!
Dell, P.F. 2009. The long struggle to diagnose multiple personality disorder (MPD): partial MPD. In: Dell, P.F., O’Neil, J.A. (Eds.), Dissociation and the dissociative disorders: DSM-IV and beyond (pp. 403-428). New York: Routledge.
Dodier, O., Lynn, S.J., & Otgaar, H. (in press). A critical analysis of myths about dissociative identity disorder. Annales Médico-psychologiques.
Kluft, R. P. (1994). Clinical observations on the use of the CSDS Dimensions of Therapeutic Movement Instrument (DTMI). Dissociation, 7(4), 272-283.
Nijenhuis, E.R.S. (2015). The trinity of trauma: Ignorance, fragility, and control. Volume 1 and 2: The evolving concept of trauma / The concept and facts of dissociation in trauma. Göttingen: Vandenhoeck & Rupprecht.
Nijenhuis, E.R.S. (2017). The trinity of trauma: Ignorance, fragility, and control. Volume 3: Enactive trauma therapy. Göttingen: Vandenhoeck & Rupprecht.
Piedfort-Marin, O. (2019). When the therapist’s trauma emerge in a psychotherapy session: the use of trauma related countertransference. European Journal of Trauma and Dissociation, 3, 181-189.
Piedfort-Marin, O. (2021). Reconnaître, diagnostiquer et surmonter les troubles dissociatifs: Le difficile chemin vers l’intégration pour les patients et les cliniciens. (Doctoral thesis) Université de Lorraine, Metz, France.
Piedfort-Marin, O., Wisler, D., Piot, M.-E., Spagnoli, D. (2017). Version française adaptée de l’Echelle d’évaluation de l‘avancement de la psychothérapie (EEAP/DTMI). European Journal of Trauma and Dissociation, 1, 241-253.
Piedfort-Marin, O., Rignol, G., & Tarquinio, C. (2021). Le trouble dissociatif de l’identité : Les mythes faces aux études scientifiques. Annales Médico-Psychologiques, 179(4), 374-385
Piedfort-Marin, O., Tarquinio, C., Steinberg, M., Azarmsa, S., Cuttelod, T., Piot, M.E., Wisler, D., Zimmermann, E., & Nater, J. (in press). Reliability and validity study of the French-language version of the SCID-D semi-structured clinical interview for diagnosing DSM-5 and ICD-11 dissociative disorders. Annales Médico-Psychologiques. https://doi.org/10.1016/j.amp.2020.12.012
Steinberg, M. (in press). The SCID-D : Therapeutic Assessment of Dissociation. Washinton, DC: American Psychiatric Association Publishing.
Van der Hart, O., Nijenhuis, E. R. S., & Steele, K. (2010). Le soi hanté : La dissociation structurelle et le traitement de la traumatisation chronique. Bruxelles : De Boeck. Version originale (2006): The haunted self: Structural dissociation and the treatment of chronic traumatization. New York : Norton.