When You Don't Feel Real: Understanding the Psychodynamics of DPDR and ISTDP as a treatment approach
Updated: 5 days ago
What are depersonalisation and derealisation?
When it comes to the disconcerting situation of what psychologists refer to as DP/DR syndrome (Depersonalisation/Derealisation syndrome), whether it's you or someone else going through it, perhaps the most important phrase to keep in mind is "as if." It is extremely common for an individual having this experience to have intact reality testing, and that's key to the profound work of ISTDP .
The experience of DP/DR can be extremely upsetting. It's easy to take having a recognisable self for granted until it's lost. The absence of a feeling can be more upsetting than the painful feeling the mind refuses to confront. We take that sense of self for granted until it's disrupted (psychologists use the term "disruption in selfhood") because it's always been the backdrop to experience.
You're not losing your mind. Thinking "I know this is my hand, but it feels as if it's not mine" is not an indication of psychosis. In fact, thinking you're going mad can increase anxiety and worry. It can be really difficult to be curious enough about a symptom, especially something deeply psycho-emotional like DP/DR, if the person sees it as a threat to their safety.
But that old chestnut "knowledge is power" is very true, and that's our goal. To demystify what can feel like madness and keep this overarching principle solidly in place:
The experience of DP/DR is very real even though the experience itself is felt as "this isn't real."
To that end, let's begin by defining a few pertinent terms.
A mini-DP/DR primer
There is an important distinction between DP and DR:
Depersonalisation is a feeling of unreality/detachment from yourself. Think: De-person … you feel unreal.
Derealisation is a feeling of unreality/detachment from the external environment. De-real … the world doesn't feel real.
Feeling "spaced out" is actually a good description. A person feels detached from their thoughts, emotions, physical sensations, and behaviour. Others have described DP/DR as "feeling as if I don't exist" or "my hands don't feel like my own." "Living in a perpetual dream" or the sensation that observing others feels like "looking through a pane of glass."
Emotional numbing refers to the inability to feel emotion, but doesn't necessarily mean the emotion or attachment has vanished. Psychology researchers Aoife Ó Laoide and Jonathan Egan identify this suppressed or dulled emotional experience as a core feature of DP/DR.
There are also four versions of "me" which psychotherapists refer to as domains.
The embodied self: "My body doesn't feel like me."
The agentic self: "My actions don't feel like they're my own."
The thinking self: "My thoughts seem distant."
The feeling self: "My emotions don't feel like mine."
Lastly, because clinicians use the term dissociation to describe both a person's DP/DR experience of detachment and other dissociative experiences, including dissociative amnesia, in which people may experience gaps in memory, here's an imperfect but useful refrigerator magnet distinction:
DP/DR: "Whoa. I feel disconnected/unreal, and I know it."
Dissociative amnesia: "Sometimes I don't know what happened while I was disconnected."
It's not an overgeneralisation to say that most of the people who go into psychotherapy do so for one reason: They have something they want to change. It could be healing from a troublesome experience or a desire for deeper personal insight. Interestingly, both often happen at the same time. Working toward healing requires insight. Working toward insight can reveal things you didn't know needed healing, but there you are. Bonus!
The first challenge of ISTDP therapy for someone working through the unrealities of Depersonalisation/Derealisation syndrome is figuring out what's real. Not just is the pool really there—is my therapist really here—but is that really me in the water?
The "I" in ISTDP stands for Intensive, not aggressive
ISTDP has roots in depth psychology, the broad tradition concerned with unconscious processes, conflicts, defences, and how past experiences shape present behaviour. "Freud with his patient lying on a couch" is a good example. The patient talks about whatever comes into his or her head (free association) while the analyst listens for cues and clues to the root issues and gently prompts the patient to stop and explore. No emotion or experience is inherently bad or wrong, nor is the patient "guilty" of anything more than not knowing their own unconscious motives. It's the analyst's job to draw those out. This therapeutic alliance has the end goal of the patient learning to analyse themselves without assistance.
ISTDP therapists do very much the same thing. But while psychoanalysis generally moves more slowly, both on the part of the patient and the analyst, ISTDP tends to be less time-consuming. The client comes in with a specific issue with, generally, an identifiable symptom set, the roots of which are "hidden in the cave of the unconscious." Working together, the ISTDP therapeutic alliance is essentially psychological spelunking in the cave of the unconscious with the therapist's questions as the flashlight.
Also, "intensive" does not necessarily mean "push harder." At least, not all the time. It goes more to regulating anxiety before exploring feelings. Many times the most skilful intensive therapy lies in knowing when not to intensify within the session.
"Short-term" means focused, not one-size-fits-all
ISTDP therapy is tailored to each individual's personality style and specific needs. Here are five of the most common variables therapists take into consideration:
Affect tolerance: The ability to experience strong emotions without becoming overwhelmed.
Anxiety-discharge pattern: How anxiety shows up in the body and mind.
Defences: Automatic ways we protect ourselves from uncomfortable feelings.
Resistance: The ways we avoid confronting feelings or experiences that threaten to upset us.
Capacity for self-observation: The ability to notice and reflect on our own thoughts, feelings, and behaviour without judging ourselves.
Not all ISTDP therapists are comfortable with the phrase short-term. In one interview, Nancy McWilliams expressed her concern that therapies considered "short-term" can sometimes—maybe often—end up taking years for certain patients, and ISTDP is no exception. But who says that's a bad thing?
Think of ISTDP and other focused techniques as being like physical therapy.
Ten different people can have "the same" outpatient hip replacement surgery. There's a fairly standard exercise set—balance, strength, flexibility—but not all patients get the same exercises for the same duration. Some need more of one thing and less of the other. Some need only a few sessions. Others need more.
The Psychodynamics of DPDR
DP/DR struggles are a continuum, not a set on/off diagnosis. Some people have mild and/or temporary detachment. Others experience DP/DR as disabling. It is crucial, though, to remember that psychotherapists don't necessarily "diagnose." They might need to indicate something on a form so the person's insurance will cover treatment, but that's often as far as it goes.
A few key points regarding those dreaded defences
Psychological defences are not the same as "being defensive."
Identifying a possible DP/DR defence doesn't mean that defence is pathological. It's a coping mechanism, not a disease. Defences occur outside our awareness. Dr. McWilliams views defences as existing in "normal" personality structures. They develop through life, increase under stress, and serve to reduce conscious negative emotion.
Defences are not "enemies." Each serves a purpose and only causes trouble either when they're used excessively or when they get out of hand.
Lastly, even though various DP/DR defences have labels—dissociation, isolation of affect (detachment from emotion), intellectualisation (thinking, not feeling)—what they defend against differs from person to person.
Depersonalisation isn't necessarily or always defence. In ISTDP, it may function as a way of detaching from difficult feelings, or arise when high anxiety disrupts thinking and perception. This is an anxiety pathway in ISTDP called "cognitive-perceptual disruption" (CPD). CPD emerges at times of high anxiety and involves disturbances in the cognitive-perceptual domain, such as tinnitus, tunnel vision, difficulty thinking clearly, and dissociation. When CPD is present, unconscious wishes, feelings and impulses generate anxiety. Anxiety regulation, which is also central to ISTDP, takes priority over challenging defences.
Insider secret: isolation of affect can be a really handy tool. Surgeons use it to keep emotion separate from procedure. To convert the human being on their table—about whom they may care deeply, even passionately—into "a thing that needs fixing." Psychotherapists sometimes use it to maintain composure and remain calm and objective when their client expresses an exceptionally strong emotion. (But shh … don't tell anybody!)
How ISTDP therapists model psychologically healthy exploration
For this, we need another mini primer:
Therapist represents a healthy ego, not a punitive observer: The therapist helps the person distinguish their own desires and impulses from an internalised punitive/scrutinising voice. Freud might call the punitive observer a "critical superego" that tries to use internal self-talk to tyrannise, berate, and gaslight. Clinical psychologist Paul Terry writes, “Later Freud described a more sinister superego which prevented recovery by maintaining it was morally wrong and made patients feel guilty about their emotional difficulties.”
In DP/DR, this means the therapist helps the person recognise that feeling detached or unreal doesn't mean there's something wrong with them as a person. Rather than criticising themselves for not feeling "normal," they can begin exploring what's happening without judgement.
Offers useful observation to counter the punitive observer/superego: The question is "What did this symptom [now-ineffective coping technique] protect you from?" The question is not "Why on earth would you want to do this [now-uncomfortably unhelpful] thing to yourself?"
The therapist might ask, "What was happening emotionally just before you began feeling disconnected?" rather than "Why do you keep shutting yourself off from your feelings?" The focus is on understanding what the dissociation may be protecting the person from, not blaming them for it.
Reassures that there are no "unallowable feelings" in therapy: A person's rage, needs, and desires can feel like they're harmful/unbearable to another, which in turn can trigger guilt, shame, and anxiety. The therapist models the stance, "It's OK to feel and express anything and everything in here because even your most frightening feeling toward yourself or someone else can't hurt me personally."
The therapist might reassure someone who feels frightened by their own anger: "You can be furious with someone you love—even with me—without that feeling making you dangerous or bad." The person can gradually discover that they can experience difficult emotions safely rather than escape them through detachment.
How ISTDP can help with DPDR
ISTDP can help a person recognise what happens emotionally just before DP/DR starts. The goal is for the person to learn that when a situation, person, or thought triggers feelings that produce overwhelming anxiety, it doesn’t have to result in depersonalisation.
Basically, you train your heart and mind to trade unconscious responses for emotional awareness, increased tolerance of anxiety, and the ability to experience difficult feelings without—well, without spacing out! What is the key to all this amazing change? One question:
"What is the defence costing me?"
Your ISTDP therapist’s number one job—once trust is established, and anxiety is manageable—is to help you answer this question by directly challenging you to confront defences that are costing you more than they’re helping.
It’s no accident that ISTDP has its roots in classic psychoanalysis. You’ll learn to go as deeply as you’re able and, eventually, go a little farther. But in a way, it can be a little easier because you probably won’t feel as alone.
Unlike the psychoanalyst who turns down the light and sits just outside your peripheral vision, your ISTDP therapist will leave the light on, and you get to see their face for the entire session!
Jake Freedman is a psychodynamic therapist working in Fitzrovia, Central London. His main areas of experience and interest are in states of depersonalisation and derealisation, relational trauma, and trauma-related dissociation.
Kathryn Levison is a psychoanalytically-informed freelance writer/editor with a focus on psychology and human nature.
Sources
Abrahams, Deborah & Rohleder, Poul — A Clinical Guide to Psychodynamic Psychotherapy
Abbass, Allan — Reaching Through Resistance
Frederickson, Jon — Dissociation: Defence or Result of Cognitive/Perceptual Disruption? (ISTDP Institute, 2013)
Freedman, Jake — Depersonalisation and Childhood Trauma: A Psychodynamic Perspective
Freedman, Jake — Depersonalisation and Identification with the Observer
Freedman, Jake — Depersonalisation: Trauma, Alexithymia, and Psychodynamic Therapy
McWilliams, Nancy — Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process
Ó Laoide, Aoife; Egan, Jonathan; Osborn, Kristin — What Was Once Essential, May Become Detrimental: The Mediating Role of Depersonalization in the Relationship Between Childhood Emotional Maltreatment and Psychological Distress in Adults
Simeon, Daphne & Abugel, Jeffrey — Feeling Unreal: Depersonalization Disorder and the Loss of the Self
Terry, Paul — A Clinician’s Guide to Understanding and Using Psychoanalysis in Practice
The Psychodynamics of DPDR
