Holding Dissociation in the Borderlands of Madness: Therapists’ Lived Experiences and the Development of the DAFTO Clinical Framework

Abstract

Dissociative Disorders (DDs) occupy the clinical borderlands of madness, trauma, and meaning-making; however, cultural beliefs, societal stigma, and an absence of standardized assessment protocols often lead to their misinterpretation in India, thereby hindering accurate diagnosis and effective treatment. This research investigates how therapists in Sikkim experience, understand, and clinically hold dissociation, diagnose and manage DDs, and formulate a culturally attuned clinical model. Using Interpretative Phenomenological Analysis (IPA), comprehensive interviews were conducted with five therapists who have intensive DDs management experience. The resulting transcripts were analyzed to discern superordinate and subordinate themes. Sixteen superordinate and forty-one subordinate themes were identified. In the absence of standardized assessment tools, therapists acted as diagnostic and relational gatekeepers, utilizing clinical acumen and psychoeducation to engage with families. This gatekeeping function extended beyond diagnosis to relational containment, as therapists mediated between states of dissociation, culturally sanctioned meanings of madness, and families’ anxieties about psychological explanations. Cultural beliefs, gender-specific vulnerabilities, and observed behaviors influenced the manifestation of symptoms. Treatment approaches integrated CBT, DBT, pharmacotherapy, pranayama, mindfulness, and grounding techniques, with a focus on emotional expression and contextual trauma narratives. Progress was gauged through functional and behavioral modifications rather than through formal assessment tools. These insights led to the development of the DAFTO model, comprising Diagnostic and Relational Gatekeeping, Assessment and Formulation, Faith and Cultural Integration, Therapeutic Process, and Outcome Evaluation. This pioneering research from Sikkim presents a culturally sensitive, trauma-informed framework for holding dissociation at the interface of madness, meaning-making, and care in under-resourced settings. The study speaks to the special issue’s concern with diagnostic critique and cultural ontology, positioning dissociation not merely as a diagnostic construct but as an experiential reality navigated at the intersections of madness, culture, and care.