Working with Trauma and Dissociation in the NHS

Using a composite clinical case, this paper describes working with complex trauma, non-recent child sexual abuse and dissociative identity disorder within an NHS setting. The clinical work of an NHS trauma service is described in both historical and current terms. The case history elucidates the use of specialist group work for non-recent child sexual abuse and then individual work within a trauma team setting as the diagnosis of dissociative identity disorder comes to light. The recognition of the role of shame in both non-recent sexual abuse and dissociative identity disorder presentations serves to highlight the countertransference experiences of disbelief or inauthenticity. This is linked to the history in psychoanalysis of the shift away from external realities of abuse and to its exploration of the concept of dissociation. The question of acknowledging and attending to the reality of abuse continues to be an issue within many aspects of British psychotherapy and psychoanalysis and has perhaps added to the disbelief that the diagnosis of dissociative identity disorder often seems to engender. The consideration of setting in relation to the NHS and limitations on lengths of treatment is also addressed for these complex patients.