Review2024
From undergrad to postdoc: Advocating for survivors with trauma & dissociation
Just wanna summarize what I have been doing over the past 12 years
BSS(SW) 2012 to 2016
MSSAPSY 2016 to 2017
PhD 2018 to 2022
Postdoc 2022 to 2024
#Background
I began my research journey with the hope of telling the world: “Hey, trauma and dissociation are not as rare as we think! Hey, there is something wrong in the medical and social service systems.”
I saw how patients with complex trauma and dissociative symptoms got mislabeled as being psychotic. I saw how some of them got treatments that resulted in unnecessary side effects. I saw that their psychosocial stressors sometimes got ignored in the system.
When I was still a student, I told the world that, “Hey, trauma and dissociation are not as rare as we think!” The response I got was, “You are just a student. How can you know about this?” If you ask clinicians in the systems, most of them would tell you that they rarely see cases of complex dissociative disorders (DDs) throughout their careers. Despite the existence of a rich clinical and empirical literature on trauma-related dissociative symptoms and dissociative disorders, some, if not most, service providers just don’t believe that they would meet a case of DID/MPD. Many, if not most, of them just couldn’t recognize these phenomena in their clinical settings.
I am a small potato without any resources or power. I think, oh, if you don’t believe me, it’s fine, but maybe you would believe what data shows, right? That’s why I started doing research. My hope is that, maybe, if I can have some convincing data, the world would then believe in what I say.
While the same opinion voiced by a high school student would be laughed at and ignored, it is respected, valued, or even paid for when voiced by a PhD holder.
I tell the world that we can recognize and better support those with trauma and dissociation. Fortunately, some would listen to me now.
Yet, I told the same 12 years ago. Almost no one listened to me. #夫以人廢言者眾矣
#1 Complex DDs exist in the local community
If you surf the Internet and look at how people say about dissociative disorders in general, or DID in particular, you will find that many resources say that these are extremely rare in our society. Some would even argue that these cases can only been found in the North America. I then tell the world, hey, there are such survivors, and we just didn’t recognize them. To do so, we have published a few case reports (e.g., Fung, 2016a; Fung & Ross, 2024; Lao et al., 2024). I have even done an interesting study revealing that the phenomena of dissociative symptoms have actually been witnessed and portrayed in the ancient Chinese medicine literature (古代 #中醫醫案 )(Fung, 2018).
#2 Trauma and dissociative symptoms are common in the Chinese context, too
Many believe that these phenomena are much more rare in the Chinese context than in the Western cultures. I told the world that’s not true. No one believed me in the past. I, therefore, conducted a number of studies that looked at trauma and pathological dissociation in a variety of Chinese samples. As a result, I published several papers in top scientific journals, showing that childhood trauma and dissociative symptoms are in fact common in both clinical and nonclinical settings. Consistent results have been found in Hong Kong (Fung, Ho, et al., 2018; Fung, Ross, Yu, et al., 2019; Fung, Wong, et al., 2022), mainland China (Fung, Geng, et al., 2023), and Taiwan (Fung et al., unpublished data; Wu et al., 2022).
My data support the idea that dissociative symptoms are cross-culturally associated with trauma and stress (Fung, Chien, et al., 2023; Fung & Lao, 2017). These symptoms are not culturally bound and cannot be simply explained by iatrogenic effects. Although the trauma model is not perfect, trauma is one of the most preventable risk factors for dissociation (Cheung et al., 2023; Lam & Fung, accepted pending minor edits).
#3 We should recognize the underlying trauma & dissociation behind the presenting problems
Complex trauma survivors generally have many comorbid conditions. Their major problems include post-traumatic and dissociative symptoms in addition to a variety of other psychiatric symptoms. And this could lead to diagnostic challenges (Chien & Fung, 2022a, 2022b; Fung et al., 2017).
Many earlier clinical reports and studies, such as those reported by Dr Ross and Dr Dell, showed that patients with complex DDs could present with more psychotic (or Schneiderian first-rank) symptoms than those with a psychotic disorder. I observed the same (Fung, 2016b). I have also done a number of studies showing that sometimes psychotic symptoms might involve dissociative processes, or are closely associated with trauma and dissociation (Fung, Chan, & Ross, 2020a; Fung & Geng, 2024; Fung, Ling, et al., 2020; Fung, Liu, et al., 2019; Fung, Wong, et al., 2023).
Dr Ross used to report that ~90% of patients with DID experienced major depressive episodes. Professor Şar proposed that there may be a dissociative subtype of depression. Consistent with these observations and ideas, I have further found that individuals with pathological dissociation may be even more depressed than those with depression but no dissociation (Fung, Chan, Ross, et al., 2020), that dissociative symptoms are common among those with depressive symptoms (Fung, Chien, et al., 2022), and that dissociative symptoms predicted subsequent depressive symptoms (Fung & Cheung, 2024).
These data remind us that we should be aware of the possibility that trauma-related symptoms remain unrecognized behind other presenting problems, such as depression and psychosis.
#4 There are tools that can help us recognize trauma and dissociative symptoms
Although standardized measures are not perfect and cannot replace clinical judgment, these tools could facilitate early identification and prevent clinical bias, especially when the service providers are not very familiar with the assessment of trauma and dissociation. To facilitate systematic research and early identification, we have also developed and validated a few measures for assessing trauma, PTSD symptoms, and dissociative features in the Chinese context (Fung, Chan, et al., 2019; Fung, Chan, Lee, et al., 2020; Fung, Choi, et al., 2018; Fung et al., 2024).
When I provide training and share my thoughts with health and social service providers, I always recommend that standardized measures be used to aid clinical assessments. In fact, clinical diagnosis based on clinicians’ judgment is not as reliable as we believe. Validated tools cannot replace clinical judgment, but these may help a lot. As what Dr Ross shared with me in personal communication many years ago, dissociative disorders are rarely diagnosed clinically.
#5 There are things we can do to support survivors with dissociation
Even though some clinicians believe that complex dissociative disorders exist, many of them do not think they could help them. I have observed that some survivors eventually got the DD diagnosis, but they were still provided with medication treatment only. Professor Brand and her colleagues have done a number of important works on showing that trauma-and dissociation-informed psychological interventions could be helpful. Unfortunately, this treatment literature is still very limited. I have proposed that even generalized social workers can play a more active role to support those with complex DDs, through family interventions, psychoeducation, and skills training, etc (Fung & Ross, 2024; Fung, Ross, & Ling, 2019).
Considering the fact that many survivors could not access dissociation-informed services, Dr Ross and I published a self-help book for those with trauma and dissociation (Fung & Ross, 2019). This package has been used in my PhD project. I found that receiving the web-based psychoeducation program using this package was associated with potential clinical benefits in those with dissociative symptoms (Fung, Chan, et al., 2022; Fung, Chan, & Ross, 2020b). My colleagues and I have also done one of the first RCTs in the field of dissociation, showing that the web-based psychoeducation program could help dissociative individuals improve emotional regulation (Lam et al., under review).
After #12years
I keep saying what I said 12 years ago. No one listened to me in the past. I hope that, through my research, I could now promote a bit positive change in the mental health service system.
I am fortunate enough to be one of the most productive researchers in the field of dissociation since 2022. Without the encouragement from many people, and without the support and involvement from those survivors, I could have done nothing. I was so lucky to get the RGC Postdoctoral Fellowship 2022/23. The resources that I have received have allowed me to continue doing what I think would be important to the society.
12 years ago, what was on my mind was, “I was lucky to be taught by those survivors and those masters in the field. If I don’t do something, who will?”
It is always exciting to be a part of the medical and scientific literature (haha, it was my childhood dream to become a scientist).
The world doesn’t need to remember who I am, but please remember what my data have shown.
After 12 years, I still believe that many mental health problems are in fact preventable and can be better managed. Many survivors could actually suffer less. Some side effects are not necessary.
#不知所云
FHW 20240309
andyhwfung@gmail.com
www.reunetwork.com
Cheung, C. T. Y., Cheng, C. M.-H., Lee, V. W. P., Lam, S. K. K., He, K. L., Ling, H. W. H., Lee, K., Ross, C. A., & Fung, H. W. (2023). Could family well-being moderate the relationship between adverse childhood experiences and somatoform dissociation? A preliminary investigation. Journal of Trauma & Dissociation. https://doi.org/10.1080/15299732.2023.2233095
Chien, W. T., & Fung, H. W. (2022a). The challenges in diagnosis and treatment of dissociative disorders. Alpha Psychiatry, 23, 45-46. https://doi.org/10.5152/alphapsychiatry.2022.0001
Chien, W. T., & Fung, H. W. (2022b). Commentary: The assessment of dissociative pathology in culturally and clinically diverse contexts. Alpha Psychiatry, 23, 104-105. https://doi.org/10.5152/alphapsychiatry.2022.0006
Fung, H. W. (2016a). Individuals having cerebral palsy with tertiary structural dissociation: A preliminary report. Indian Journal of Cerebral Palsy, 2(2), 100-104. https://doi.org/10.4103/2395-4264.204406
Fung, H. W. (2016b). Trauma-related pathological dissociation in a case with cerebral palsy. Journal of Trauma & Dissociation, 17(3), 286-293. https://doi.org/10.1080/15299732.2015.1080780.
Fung, H. W. (2018). The phenomenon of pathological dissociation in the ancient Chinese medicine literature. Journal of Trauma & Dissociation, 19(1), 75-87. https://doi.org/10.1080/15299732.2017.1304491
Fung, H. W., Chan, C., Chien, W. T., Chong, Y. Y., & Ross, C. A. (2022). The acceptability and potential benefits of a web-based psychoeducation program for people with pathological dissociation: A pilot evaluation study. Journal of Trauma & Dissociation. https://doi.org/10.1080/15299732.2022.2119457
Fung, H. W., Chan, C., Lee, C. Y., & Ross, C. A. (2019). Using the Post-traumatic Stress Disorder (PTSD) Checklist for DSM-5 to screen for PTSD in the Chinese context: A pilot study in a psychiatric sample. Journal of Evidence-Based Social Work, 16(6), 643-651. https://doi.org/10.1080/26408066.2019.1676858
Fung, H. W., Chan, C., Lee, C. Y., Yau, C. K. M., Chung, H. M., & Ross, C. A. (2020). Validity of a web-based measure of borderline personality disorder: A preliminary study. Journal of Evidence-Based Social Work, 17(4), 443-456. https://doi.org/10.1080/26408066.2020.1760162
Fung, H. W., Chan, C., & Ross, C. A. (2020a). Clinical correlates of hearing voices among people seeking interventions for dissociation: A cross-cultural investigation. Psychosis, 12(4), 328-338. https://doi.org/10.1080/17522439.2020.1773910
Fung, H. W., Chan, C., & Ross, C. A. (2020b). A web-based psychoeducation program for people with pathological dissociation: Development and pilot testing. Journal of Evidence-Based Social Work, 17(4), 427-442. https://doi.org/10.1080/26408066.2020.1760990
Fung, H. W., Chan, C., Ross, C. A., & Choi, T. M. (2020). A preliminary investigation of depression in people with pathological dissociation. Journal of Trauma & Dissociation, 21(5), 594-608. https://doi.org/10.1080/15299732.2020.1760168
Fung, H. W., & Cheung, C. T. Y. (2024). The bidirectional relationship between depression and dissociation: A longitudinal investigation. Asian Journal of Psychiatry.
Fung, H. W., Chien, W. T., Chan, C., & Ross, C. A. (2023). A cross-cultural investigation of the association between betrayal trauma and dissociative features. Journal of Interpersonal Violence, 38(1-2). https://doi.org/10.1177/08862605221090568
Fung, H. W., Chien, W. T., Lam, S. K. K., & Ross, C. A. (2022). Prevalence and correlates of dissociative symptoms among people with depression. Journal of Psychiatric Research, 154, 132-138. https://doi.org/10.1016/j.jpsychires.2022.07.054
Fung, H. W., Choi, T. M., Chan, C., & Ross, C. A. (2018). Psychometric properties of the pathological dissociation measures among Chinese research participants – A study using online methods. Journal of Evidence-Informed Social Work, 15(4), 371-384. https://doi.org/10.1080/23761407.2018.1456995
Fung, H. W., & Geng, F. (2024). Childhood adversities and psychotic symptoms among high school students in China: The role of dissociation. Asian Journal of Psychiatry. https://doi.org/10.1016/j.ajp.2024.103964
Fung, H. W., Geng, F., Yuan, D., Zhan, N., & Lee, V. W. P. (2023). Childhood experiences and dissociation among high school students in China: Theoretical reexamination and clinical implications. International Journal of Social Psychiatry. https://doi.org/10.1177/00207640231181528
Fung, H. W., Ho, L. Y. K., & Ross, C. A. (2018). Pathological dissociation and its relationships with aggression and delinquency in a college student sample in Hong Kong. Journal of aggression, maltreatment & trauma, 27(2), 147-163. https://doi.org/10.1080/10926771.2017.1421283
Fung, H. W., & Lao, I. W. (2017). Complex dissociative disorders: Cross-cultural trauma disorders (in Chinese: 複雜解離症：跨文化的創傷心理障礙). Clinical Medicine (in Chinese: 臨床醫學), 79(1), 39-48. https://doi.org/10.6666/ClinMed.2017.79.1.008
Fung, H. W., Lee, C. Y., Lao, I. W., & Lin, E. (2017). Assessment and differential diagnosis of dissociative identity disorder (in Chinese: 解離性身份障礙之評估和診斷). Taipei City Medical Journal (in Chinese: 北市醫學雜誌), 14(4), 425-439. https://doi.org/10.6200/TCMJ.2017.14.4.03
Fung, H. W., Lee, K., Wang, E. K. S., & Wong, J. Y.-H. (unpublished data). Trauma-related mental health problems among mothers in Taiwan and their relationship with children’s emotional and behavioral problems.
Fung, H. W., Ling, H. W. H., Ross, C. A., Tse, J. W.-L., & Liu, R. K. W. (2020). Dissociative, schneiderian and borderline personality symptoms in a non-clinical sample in Hong Kong: A preliminary report. European Journal of Trauma & Dissociation, 4(1), 100076. https://doi.org/10.1016/j.ejtd.2018.07.004
Fung, H. W., Liu, R. K. W., & Ma, Y. H. E. (2019). Hearing voices and its psychosocial correlates in four Chinese samples. Psychosis, 11(2), 162-173. https://doi.org/10.1080/17522439.2019.1598477
Fung, H. W., & Ross, C. A. (2019). Be a teammate with yourself: Understanding trauma and dissociation. Manitou Communications.
Fung, H. W., & Ross, C. A. (2024). Social work service needs of persons with complex dissociative disorders. European Journal of Trauma & Dissociation. https://doi.org/10.1016/j.ejtd.2024.100379
Fung, H. W., Ross, C. A., & Ling, H. W. H. (2019). Complex dissociative disorders in social work: Discovering the knowledge gaps. Social Work in Mental Health, 17(6), 682-702. https://doi.org/10.1080/15332985.2019.1658689
Fung, H. W., Ross, C. A., Yu, C. K.-C., & Lau, E. (2019). Adverse childhood experiences and dissociation among Hong Kong mental health service users. Journal of Trauma & Dissociation, 20(4), 457-470. https://doi.org/10.1080/15299732.2019.1597808
Fung, H. W., Tse , H. W.-Y., Chau, A. K. C., & Lam, S. K. K. (2024). Psychometric properties of the Chinese version of the Post-traumatic Maladaptive Beliefs Scale: A brief report. Asian Journal of Psychiatry, 103912. https://doi.org/10.1016/j.ajp.2024.103912
Fung, H. W., Wong, E. N. M., Lam, S. K. K., Chien, W. T., Hung, S. L., & Ross, C. A. (2022). The prevalence of dissociative symptoms and disorders: Findings from a sample of community health service users in Hong Kong. Asian Journal of Psychiatry. https://doi.org/10.1016/j.ajp.2022.103351
Fung, H. W., Wong, M. Y. C., Chien, W. T., Moskowitz, A., Hung, S. L., & Lam, S. K. K. (2023). Association between psychotic and dissociative symptoms: Further investigation using network analysis. Journal of Trauma & Dissociation. https://doi.org/10.1080/15299732.2023.2293776
Lam, S. K. K., Cheung, C. T. Y., Chien, W. T., Chiu, C.-D., van Emmerik, A. A., Ross, C. A., & Fung, H. W. (under review). Effects of an online psychoeducational program for people with dissociative symptoms: A pilot randomized controlled trial.
Lam, S. K. K., & Fung, H. W. (accepted pending minor edits). Can dissociative symptoms be explained by coping and emotion regulation? A longitudinal investigation. Psychological Trauma: Theory, Research, Practice, and Policy.
Lao, I. W., Grant, R., & Fung, H. W. (2024). Working with Chinese trauma survivors with dissociation: Lessons from two cases in Macao. European Journal of Trauma & Dissociation. https://doi.org/10.1016/j.ejtd.2023.100360
Wu, Z. Y., Fung, H. W., Chien, W. T., Ross, C. A., & Lam, S. K. K. (2022). Trauma and dissociation among inpatients diagnosed with schizophrenia spectrum disorders in Taiwan. European Journal of Psychotraumatology, 13(2), 2105576. https://doi.org/10.1080/20008066.2022.2105576