Indian Journal of Health Social Work
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PSYCHOSOCIAL INTERVENTIONS FOR DISSOCIATIVE CONVERSION
DISORDER AND THE INTERPLAY OF A COMPLEX HOME SITUATION
WITH A HISTORY OF SEXUAL ABUSE: A CASE STUDY
Marinella Humtsoe1 , Sonia P.Deuri2 , Siddeshwara BL3
1Psychiatric Social Worker, Department of Psychiatric Social Work, LGBRIMH, Tezpur, Assam.2Prof.
& Head, Department Psychiatric Social Work, LGBRIMH, Tezpur, Assam. 3Assistant Professor,
Department of Child and Adolescent Psychiatry, LGBRIMH, Tezpur, Assam.
Correspondence: Marinella Humtsoe , e-mail: marbehumtsoe7@gmail.com
ABSTRACT
Dissociation often has a strong relationship with psychosocial stressors, some of which are the
interplay between complex family dynamics and a trauma history of multiple sexual abuses that
significantly influences the manifestation of dissociative symptoms. There are notable gaps in
the literature specifically addressing integrated interventions for dissociative conversion disorders
in the context of sexual abuse. This case study focuses on the necessity for tailored therapeutic
interventions particularly for adolescents and reporting child sexual abuse to the Child Welfare
Committee, which is mandated to investigate and assess children and families involved in the
abuse case. This study also emphasizes the psychiatric social work intervention, which adopts a
holistic therapeutic approach, utilizing comprehensive bio-psychosocial assessments and
multidimensional treatment strategies that focus on the individual and familial level and utilise
resources at the tertiary level.
Keywords:Dissociative Conversion Disorder, Psychosocial Interventions, POCSO, Case study.
INTRODUCTION
Dissociation is a mental process, which produces a lack of connection in a person’s thoughts, memories, feelings, actions, or sense of identity (Janet, 1889). The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) outlines specific criteria for diagnosing dissociative (conversion) disorder, also known as Functional Neurological Symptom Disorder (American Psychiatric Association, 2013; Ali et al. 2015). This includes the presence of a psychiatric condition characterised by physical signs and neurological symptoms (Diseth,2005) that cannot be attributed to any medical or neurological cause, often triggered by psychological conflicts and psychosocial stressors (Ganslev, 2020). According to psychodynamic theories, dissociative conversion disorder can occur when psychological conflict or distress is converted into physical symptoms. This can be seen as an unconscious way of expressing emotional pain which is often verbally communicated. (Ali et al., 2015). Dissociative (conversion) disorders are often linked to trauma, with childhood traumatic experiences frequently acting as triggers for the dissociation process. These disturbing experiences are separated from conscious awareness through dissociation. (Brown et al., 2005). There is an increase in the degree of dissociative experiences in adolescents with a history of sexual abuse, physical abuse, neglect, and exposure to stressful life events. (Brunner & Parzer, 2000) Research has authenticated the impact of stressful life events and stressors on psychological health. Maqsood et al. (2010, 2014) emphasised stressors such as sexual abuse (20%), peer group problems (8%), improper parenting (8%), and learnt behaviour (8%) contributing to dissociative (conversion) disorders in adolescents. Adolescents with a history of sexual or physical abuse, along with common stressful life events, are significantly impacted (Boyer et al. 2022). These events often include family conflicts, changes in family dynamics such as the addition of a new family member or the separation of an existing one, academic challenges like relationship issues with peers or poor academic performance, and experiences of bullying (Samuels et al. 2019). Adolescents are particularly vulnerable due to developmental and environmental stressors. Meanwhile, Binzer and Eisemann(1998) suggest that parental rejection, weak emotional connection, and a lack of affectionate warmth are seen as more influential factors in the development of dissociative conversion disorder. Several studies have been conducted to describe the clinical presentation of the specific symptoms and behaviours exhibited by adolescents with Dissociative (Conversion) Disorder. However, there are very few studies that explore the unique treatment aspects of the disorder as presented in the context of a history of sexual abuse and a complex home situation. This study discusses the psychosocial intervention approach adopted in a 16-yearold female adolescent with a dissociative (conversion) disorder compounded by a history of multiple sexual abuse and complex home situations.METHODOLOGY
This study employed a single-subject case study design that involved a comprehensive, holistic psychosocial intervention tailored for a 16-year-old female adolescent diagnosed with Dissociative (Conversion) Disorder. A qualitative psychosocial assessment both before and after the intervention, was conducted utilising the bio-psychosocial model to assess the needs of the adolescent. Throughout the intervention, observational methods were utilized to monitor her progress, complemented by documentation of the session notes and regular follow-up sessions provided additional qualitative insights into familial dynamics and support systems. Post-intervention, feedback session was conducted to evaluate changes in her emotional well-being and coping mechanisms.CASE SUMMARY
Miss SC, a 16-year-old female belonging to the Hindu religion from a lower socio-economic rural background, studied in eighth (8th) standard but dropped out due to illness symptoms. She was hospitalised for the first time in 2020 due to suicidal risk, followed by two other hospitalisations in 2023. She was brought to the Child and Adolescent Psychiatry Department (OPD), LGBRIMH by her mother and maternal grandfather with symptoms of low mood, increased anger outbursts, suicidal thoughts and deliberate self-harming behaviours, and thoughts of possession by spirit accompanied by episodes of dissociation. The adolescent was initially treated for dissociative conversion disorder, and EEG reports were examined to rule out organicity. Initially, the adolescent was diagnosed with Dissociative (Conversion) Disorder with self-harming behaviours. While building a therapeutic alliance, the therapist created a safe and supportive environment for the adolescent, where her emotions were validated. This process fostered trust, and it was during her second admission that the adolescent felt secure enough to disclose the experience of sexual abuse. In the following years, she was diagnosed with Bipolar Affective Disorder with dissociative symptoms. It was in the second admission that the adolescent disclosed the sexual abuse. The psychosocial assessment revealed multiple layers of family dysfunctions; the father has alcohol dependence, there is domestic violence towards the mother, physical and verbal abuse towards the adolescent, interpersonal relationship issues with the extended families, financial problems, history of suicide in 2nd degree relative and expressed emotions from peers and neighbours.Medication
The adolescent was provided psychotropic medications as part of the usual treatment procedurePSYCHOSOCIAL INTERVENTIONS
The psychosocial intervention was tailored to fulfill the needs of the adolescent, eighteen (18) sessions were conducted each lasting 45- 60 minutes. The therapy was conducted in a hospital setting with homework assignments to monitor the adolescent’s engagement in the therapy skills. The interventions focused on the individual level include stress management, coping skills, emotional regulation, cognitive enhancement, and crisis management. At the Family level, both mother and grandfather were provided psychoeducation, supportive therapy, and referral for parental psychopathology. The community/ tertiary level include liaisoning with other collateral organisations such as the Child Welfare Committee(CWC), Legal-Aid, Child Care Institute (CCI), and local police.Psycho-education (Adolescent and family members):
The adolescent, her mother and her maternal grandfather were part of the psycho-education session where the focus was on understanding the nature of the illness, and how the symptoms manifested due to underlying psychological stressors (stressors, emotional conflicts and trauma) resulting in physical symptoms. The mechanism of the body-mind connection was also explained using the life events and onset of illness as an example for better understanding. Besides, the therapy structure and the treatment process were presented to engage the adolescent and the family in long-term therapy. The importance of managing symptoms (primary and secondary gains) was also discussed through which validation of symptoms and stigma regarding the illness was addressed.Distress tolerance
The adolescent was taught the body-mind connection through the sensory grounding technique to manage the dissociative/ conversion symptoms. Body awareness was taught to focus on the physical, emotional and behavioural signs of stress and anxiety. Selfsoothing techniques like having access to comfort items. Mindfulness and relaxation strategies were also incorporated by practicing diaphragmatic breathing to reduce hyper-ventilating during stressful situations.Emotional regulation strategies
The adolescent was taught to identify and label her emotions to reduce the overwhelming feeling. The strategies used were the physical expression of emotions by engaging in physical activities (yoga while in the hospital, exercises), distraction technique by engaging in comforting activities, and creative outlets (mandala colouring, writing down wishful thoughts).Cognitive behavioural strategies
Identifying automatic negative thoughts that arise in response to certain situations, challenging these thoughts by checking if it is a fact or a feeling and reframing these thoughts by replacing them with more balanced, positive and realistic thoughts.
Crisis Planning
As part of the therapy process, the adolescent was encouraged to develop a plan during crises like emergency contacts, a safe word or affirmations and identifying a safe place or space. One of which was to curate a survival kit that includes sensory comfort items (stress ball, favourite toys, photographs from pleasant memories, personal diary etc.)
Family and social support
The session focused on the adolescent’s mother and grandfather for enhancing helpseeking behaviour and social support. During the process, it was assessed that the adolescent’s mother had depressive symptoms for which she was guided to seek treatment from the hospital. Despite attempts made to include the father in therapy, he declined to be part of the therapy process. Hence to improve the adolescent’s home environment other alternatives were explored. The adolescent was briefly placed in a CCI for two (2) weeks and then moved to her maternal grandfather’s home.
Implementation of the POCSO Act 2012 (mandatory reporting)
During the initial assessment post-admission, the adolescent for the first time disclosed being sexually abused by multiple perpetrators. A detailed psychosocial and mental health assessment was conducted to assess whether the adolescent’s alleged abuse was a result of psychopathology or was a factual account. On confirmation, both the adolescent and the caregiver havebeen explained the mandatory reporting clause in Section 19 of POCSO 2012. Following that, under the Protection of Children from Sexual Offences (POCSO) Act,a mandatory reporting letter was sent to the Chairperson of the Child Welfare Committee, Sonitpur. This legal proceeding was initiated to uphold the legal rights of the adolescent appropriate protection and support was given. There was constant collaboration with the CWC members and Law Enforcement agency, working closely with the investigating officer and legal authorities to ensure that investigations were conducted sensitively and that the adolescent’s mental health needs were considered throughout the legal process.
Implementation of Government Schemes for Vocational Training
The adolescent was assessed on her readiness to engage in vocational training.Support for finding resources for vocational training was provided. The adolescent was then motivated to enrol and engage herself under RSETIs (Rural Self Employment Training Institutes), which is an initiative of the Ministry of Rural Development (MoRD) where free training programs are imparted for training and skill up-gradation of rural youth (16-45 years). The adolescent has completed a one-month Beauty Parlour Management training programme and is currently engaged in helping her aunt in a beauty parlour.
Home and CCI visits for Collateral Contacts
A home visit was made to the adolescent’s home (staying with maternal grandfather) to gather deeper insights into the adolescent’s living conditions, to assess the safety and stability of the home environment and to understand the family’s functioning and dynamics. One of the primary objectives of this visit was to psycho-education the family members who could not come to the hospital for therapy sessions, emphasis was made on enhancing their understanding of the disorder and how they can support the adolescent. A visit to the Child Care Institution (CCI) where the adolescent had briefly stayed (2 weeks) was made to gather additional information about the adolescent’s behaviour and functioning in different settings and also to build a comprehensive support network around the adolescent. A unified approach for care and treatment was initiated by networking with other professionals (a Clinical Psychologist and theSuperintendent of the CCI) involved in the adolescent’s life.
OUTCOMES FROM THERAPY
The understanding regarding the adolescent’s illness and management of symptoms significantly improved throughout the therapy process which was achieved by addressing the adolescent’s specific needs and providing a clearer insight into the nature of the dissociative symptoms. There was a noticeable reduction in the frequency of dissociative symptoms experienced by the adolescent which also reflects the positive outcome of the effectiveness of the psychosocial intervention.The intervention also focused on enhancing coping skills to manage distress effectively through structured therapeutic approaches in which the adolescent acquired practical coping mechanisms that empowered her to navigate challenging emotional situations. The emotional engagement and communication between the adolescent and her mother were enhanced by addressing underlying issues and fostering open communication as part of the therapeutic process which eventually strengthened their relationship.There was regular monitoring and adjusting to the treatment to ensure the therapeutic goals, which made it possible for consistent treatment follow-ups. The intervention supported the adolescent in vocational engagement and daily living activities, promoting independence and skill development. Adolescent’s sense of self was positively influenced by the treatment process, fostering self-esteem and self-awareness. The living situation of the adolescent improved as she transitioned to living with her grandfather, which provided a stable and supportive home environment. Lastly, the efforts to address the perpetrators of any traumatic experiences were successful, with appropriate measures taken to ensure accountability and safety. This was a crucial process in facilitating the adolescent’s healing process and restoring a sense of security and justice.
DISCUSSION
Anna Freud described defense mechanisms as “unconscious resources used by the ego” to reduce internal stress. In this context, the adolescent unconsciously used dissociative conversion as a defense mechanism to avoid confronting the painful emotions and memories linked to the trauma (Bailey & Pico, 2023). The adolescent having experienced severe trauma of sexual abuse resorted to dissociation as a coping mechanism which involved her mentally detaching from the traumatic experience to reduce emotional distress and this dissociation became persistent over time, leading to dissociative symptoms like memory lapses, identity confusion, or depersonalization. Childhood sexual abuse is not a clinical condition or a diagnosis (Seshadri & Ramaswamy, 2019).Sexual abuse changes the adolescents in the way they perceive themselves. There were several factors emerged as potential triggers for the development of Dissociative (Conversion) Disorder in this adolescent, one of which is the history of sexual abuse which appears significant. (Verma et al., 2017).The adolescent uses dissociation as a way to cope with daily life to block out the experience/ flashbacks of abuse. According to Subramanyam et al. (2020), when considering treatment for adolescents with dissociative (conversion) disorders, the interventions should ideally incorporate a range of therapeutic techniques, including psycho-education and skills development, within a flexible and eclectic frameworkhighlighting the importance of adopting holistic approaches that address both psychological and environmental stressors. The case highlights the adolescent’s improvement in stress management, coping skills, and emotional regulation. The psychosocial interventions provided to the adolescent, particularly distress tolerance, emotional coping, cognitive-behavioural strategies and crisis planning helped the adolescent be equipped with strategies to manage dissociative/conversion symptoms effectively. One of the approaches used to reduce the dissociative symptoms and reduce the distress of uncertainty was the body-mind connection through distress tolerance. A study by Miller et al. (2015) emphasises the practical advantages of distress tolerance which enhances emotional resilience, promotes healthier relationships, and serves as a valuable coping strategy for adolescents. The adolescent was also taught emotional regulation skills to identify her feelings and navigate the changes she was undergoing to empower the adolescent to cope with the emotional responses in more effective ways, leading to improved emotional resilience and overall well-being. Effective emotional coping involves reducing emotional vulnerability by practicing techniques like mindfulness to observe and accept emotions without judgment. (Subramanyam et al., 2020). The adolescent through her traumatic experiences has developed impaired negative cognition which led to self-doubt and low selfesteem. Thus, Cognitive Behavioural Therapy (CBT) was employed to identify and challenge irrational core beliefsthrough psychoeducational methods and enabled the adolescent to understand the psychological factors contributing to her dissociative symptoms, helping her to confront feelings of ‘failure’ and recognize the significant psychological gains(Borah,2022). Family intervention plays a vital role in addressing the diverse stressors that contribute to Dissociative (Conversion) Disorder by focusing on dysfunctional family dynamics. Involving the family in the treatment process yields better positive outcomes as this approach fosters a supportive environment that promotes healthier functioning for both the adolescent and their family members (Khan & Sil, 2020). The psycho-education provided to the mother and grandfather was particularly beneficial, as it enhanced their understanding of the adolescent’s condition.This knowledge not only helped the family make sense of the adolescent’s symptoms but also offered the adolescent a sense of safety and control (Subramanyam et al., 2020). Strengthening the relationship between the adolescent and her mother was crucial for addressing underlying home-related issues and allowing the adolescent to express her emotional distress. Creating a stable and nurturing environment, especially during her transition to living with her grandfather, further supported her healing process. However, a notable challengewas in involving all family members, particularly the father, who was uncooperative and declined participation in the therapeutic processwhich impeded a holistic family approach to treatment. Another important highlight of this case was the inter-agency collaboration in managing this complex case, especially where trauma and legal aspects (such as mandatory reporting of sexual abuse) were involved. The mandatory reporting under the POCSO Act and the associated legal processes emphasise the importance of integrating psychosocial support with legal frameworks designed to protect minors from child sexual abuse. A trauma-informed approach to care is crucial in addressing these complex issues, as it promotes healing and empowerment for young survivors. (Shukla et al., 2024). Thus, by incorporating the principles of safety and trustworthiness as part of the psychosocial intervention, the adolescent was empowered to effectively meet her emotional and psychological needs which in a way fostered her resilience and recovery. The adolescent’s vocational training under the Ministry of Rural Development initiative led to skill development and improved her selfesteem.Sherif et al., (2023) highlight the benefits of life skills development as a key intervention for improving adolescent mental health, indicating that life skills programmes effectively reduce depression, anxiety, and stress by teaching adolescents essential psychosocial competencies. A significant aspect of this case was the collaboration among various agencies in managing the complexities of the case, particularly concerning trauma and the legal requirements for mandatory reporting of sexual abuse. This situation underscores the importance of a multi-systemic approach, where effective cooperation between hospitals, legal authorities, and welfare organizations ensures that both the legal rights and mental health needs of the adolescent are adequately addressed. The mandatory reporting provisions of the POCSO Act, along with the associated legal processes, highlight the necessity of integrating psychosocial support within legal frameworks aimed at protecting minors from child sexual abuse. Adopting a traumainformed approach to care was crucial in navigating these intricate issues, as it fosters healing and empowers young survivors(Shukla et al., 2024). By prioritizing safety and trust within the psychosocial intervention, the adolescent felt more equipped to address her emotional and psychological needs, ultimately enhancing her resilience and facilitating her recovery. Additionally, the adolescent’s participation in vocational training through the Ministry of Rural Development provided her with valuable skills and enhanced her self-esteem. A study by Sherif et al. (2023) emphasizes that life skills development is a vital intervention for improving adolescent mental health, and effectively reducing depression, anxiety, and stress by teaching essential psychosocial competencies. This multifaceted support not only addressed the immediate needs of the adolescent but also paved the way for a more hopeful future.CONCLUSION
The case study demonstrates the effectiveness of addressing the complex needs of these adolescents through a multi-systemic approach highlighting the significant impact of sexual abuse and dysfunctional family environments on the development and persistence of dissociative symptoms in adolescents. The psychosocial interventions aimed at addressing the adolescent’s needs, familial support and legal aspects by collaborating with a multi-disciplinary team, including legal authorities and other stakeholders. This research contributes to the existing literature on Dissociative (Conversion) Disorder in adolescents, especially regarding the influence of sexual abuse and challenging home environments.Furthermore, this study can inform practical strategies and module development aimed at protecting at-risk adolescents and enhancing their overall wellbeing.ACKNOWLEDGEMENTS
The authors extend heartfelt gratitude to the adolescent and her family members who participated in this study and provided her ascent and their consent for publication. We also wish to acknowledge the invaluable contributions of the multi-disciplinary team members of the Child and Adolescent Department, LGBRIMH, the Child Welfare Committee (CWC), Sonitpur and the Child Care Institution. Although they do not meet the criteria for authorship, their assistance and collaboration were essential to this work.REFERENCES
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