Dissociation, including depersonalisation and derealisation, within police officers was examined by Aaron (2000), and is described as a form of psychological avoidance: ‘the splitting off from awareness, thoughts, feelings, or memories’ (Aaron, 2000:439). Using the Dissociative Experiences Scale (DES) (Bernstein and Putnam, 1986) and the Police Stress Survey (Spielberger et al., 1980, cited in Aaron:439) to measure occurrences of dissociation in sample of 42 police officers, Viginia, USA, dissociation in police officers is found to be a maladaptive coping strategy leading to poor psychological outcomes (Aaron, 2000). Importantly it was found that it was not the stressor that led to an increase in negative outcome, but the avoidant style of coping that led to increased psychological distress.
Indeed, Aaron (2000) found that there is a clear association between stress and dissociation:
‘officers who employ such defences are more likely than those who acknowledge the effect of stressors to develop subsequent psychological or psychiatric difficulties. Conversely, those who engage in the difficult and challenging task of confronting the thoughts and feelings that are a by- product of some aspects of police work can expect healthier outcomes’ (Aaron, 2000:446).
There is broad acceptance that humans have a need to understand the world around them; we do this through creating a narrative that makes sense of our environment and events within our lives. Narrating a story to another requires a coherent structure of speech - this can enable the simplification of a story and therefore enable our own understanding of events: this allows us to move beyond the experience (Pennebaker and Seagal, 1999). Expressing emotions related to a traumatic event whilst in safe and supportive setting provides therapeutic relief, as it is found that individuals who disclose traumatic experience have fewer intrusive thoughts and PTSD symptomology. Indeed, long term benefits of emotional expression are quickly realised (within two weeks of initial disclosure) in comparison to those who do not
38 express their authentic emotions; this includes improved immune system function, and physical and mental well-being (Pennebaker and Seagal, 1999).
However, research has identified how the culture around emotional expression can impede voluntary disclosure due to a sense of shame attached to emotional display, as this can be seen as a lapse of self-control. Individuals who operate in a culture of stigma and shame are less likely to benefit from emotional expression or engage in therapeutic opportunities with any conviction (Kennedy-Moore and Watson, 2001). Overall, emotional expression allows cognitive processing as a way towards self- acceptance and understanding. However, maladaptive expression can lead to feelings of shame and can impair social relationships if the culture does not support expression (Kennedy-Moore and Watson, 2001).
The Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) identifies dissociative disorders to be characterised by ‘a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behaviour’ (American Psychiatric Association, 2013:291). Within the DSM-5 dissociative disorders are purposefully placed next to trauma and stressor related disorders in order to reflect the close relationship between the two diagnostic categories. Indeed, previous studies have found that dissociative tendencies in combat and emergency service personnel were associated with increased symptomatic distress and stress (Weiss et al., 1992; Marma et al., 1996).
The diagnosis of dissociation disorder includes depersonalisation/derealisation disorder (Bernstein and Putnam, 1986; Holtgraves and Stockdale, 1996; American Psychiatric Association, 2013). The DSM-5 provides diagnostic features such as being detached from the self or aspects of the self, such as feelings (hypoemotionality), giving examples such as: “I know I have feelings but I don’t feel them” (American Psychiatric Association, 2013:302). When experienced at the extreme, dissociation disorder also includes depersonalisation, which may present as a split self with one part observing and one participating. However, depersonalisation also consists of symptomology such as emotional and physical numbing, which can be accompanied with a sense of lack of agency and feeling robotic; presenting as a robotic demeanour,
39 hypo-emotionality with others, and hypo-reactivity to emotional stimuli (American Psychiatric Association, 2013). This description reflects the findings of research into the dark side of emotional labour where employees become ‘robotic, detached, and un-empathetic’ (Wharton, 1999:162).
Examining trauma experience and PTSD through a multivariate study, Briere et al. (2005) looked at dissociation combined with experienced trauma. Within the study they controlled for trauma type and intensity of distress. The findings demonstrated that dissociation occurring around the time of the experienced trauma (peritraumatic) may interfere with encoding and processing of memories, thereby increasing the likelihood of PTSD. It was also identified that ongoing dissociation would likely have an even bigger effect, disrupting processing for a longer period. Indeed, dissociation is widely considered an integral element of PTSD.
Continuing their research Briere et al. (2005) examined generalised dissociation, which is dissociation occurring before trauma, and found that it is particularly damaging for those exposed to repeated trauma, as is persistent dissociation (after the event) which has a stronger link to PTSD than peritraumatic dissociation. Both peritraumatic and persistent dissociation contribute to PTSD by blocking normal trauma processing. However, persistent dissociation is more relevant to the onset of PTSD (Briere et al., 2005).
Indeed, it was found that persistent dissociation was a stronger predictor of chronic PTSD than peritraumatic dissociation. Persistent dissociation at four weeks was found to be a significant predictor of PTSD severity at 6 months. Although peritraumatic dissociation may put individuals at risk of PTSD, this affect can be compensated through post event processing - only, those that continue to dissociate are at high risk of persistent problems. (Murray et al., 2002).
Considering Aaron’s (2000) findings it could be considered that the high levels of dissociation in police officers (as a maladaptive coping strategy and consequence of trauma work) could not only contribute to officers diagnosed with PTSD but could also prevent post event processing and therapeutic interventions, where necessary.
40 Indeed, this presents significant implications for treatment. At present exposure- based treatment has the strongest support for the treatment of PTSD, for this to be successful patients need to be able to emotionally engage with trauma treatment - typically involving recalling trauma events. Dissociative PTSD can reduce treatment effectiveness due to lack of emotional engagement and emotional numbing, also found to block emotional learning. Resick et al. (2012) supporting this theory found that patients suffering dissociative PTSD, who were potentially dissociating at time of event need lengthy therapeutic help reconstructing the trauma event memory prior to commencing the PTSD treatment.
Building upon these findings, Lanius et al. (2010) identified the dissociative subtype of PTSD (Ross, 2018). They identify dissociation as a disruption and fragmentation of usually integrated functions of consciousness, memory, identity, body awareness, and perception of the self and the environment. It is a detachment from the overwhelming emotional content of experience of trauma. Often it gives sense of compartmentalisation and leads to cognitive fragmentation or emotional detachment from trauma. PTSD patients with prolonged trauma experience (eg combat trauma) are characterized by dissociation. Lanius et al. (2006) conducted experiment using functional MRI to image utilization of brain regions whilst reading a script the participants had previously written about their trauma. Two significant responses were recorded: 70% of patients showed subjective experience of reliving their trauma and an increase of heart rate; 30% had a dissociative response and showed depersonalisation, derealisation and no increase in heart rate.
Typically, patients suffering PTSD will show emotional under modulation (an inability or tendency to emotionally regulate) and hyperarousal, and responses will include subjective reliving of trauma (flashback). Those experiencing dissociative PTSD displayed abnormally high emotional modulation and regulation in response to trauma memories, including subjective disengagement from emotional content of trauma memory though depersonalisation or derealisation. Further investigation showed ‘dissociation is a regulatory strategy invoked to cope with extreme arousal in PTSD’ (Lanius et al., 2010:642) and involved hyper inhibition of limbic region (amygdala) and decrease in activity of hippocampus resulting in memory
41 suppression. Also, Lanius et al. report that ‘once the threshold of anxiety is reached the prefrontal cortex inhibits emotional processing in limbic structures (amygdala) which in turn leads to a dampening of sympathetic output and reduced emotional experiencing’ (Lanius et al., 2010:643).
This article argues that the neurobiological model of dissociative PTSD that they have identified is consistent with the phenomenological and clinical presentation of dissociative PTSD. Complex PTSD (repetitive exposure to trauma) linked to dissociation and emotion dysregulation. Lanius et al. (2010) also propose that there are two forms of PTSD: hyper aroused and dissociative - and they cannot be lumped together.
Furthering the clinical study of PTSD and dissociation Ross et al. (2018) examined the DSM 5 diagnosis of PTSD: subtype dissociation, which is classified as PTSD plus depersonalisation and/or derealisation - out of body experiences and feelings of unreality respectively. Individuals who were experiencing dissociative PTSD exhibited more severe symptoms of reckless or self-destructive behaviour. Perhaps a reflection of Lanius et al. (2010) findings. Ross et al. (2018) argue that these behaviours could be better predictors of dissociative PTSD. Indeed, they propose that anger and anxiety are significant predictors of dissociative PTSD, with anxiety an important risk factor for dissociative PTSD and anger significantly associated with dissociation, even after controlling for PTSD.
Considering the conceptualisation of emotional labour as the suppression of authentic feelings in order to comply with feeling and display rules, and the symmetry of this with dissociative behaviour in terms of emotional numbing and distancing, this thesis explores the proposition that emotional labour increases the risk of PTSD symptomology in police officers through increased peritraumatic, persistent and generalised dissociation.
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