Combination Treatment With Individually Deep Brain Reorienting (DBR) Processing and Group Intervention for People With Complex Dissociative Disorder

Integrating Individual Deep Brain Reorienting with a Supportive Group Intervention for Complex Dissociative Disorders:

A 16-Week Feasibility and Pilot Study

• Background and current state of knowledge Complex dissociative disorders (CDD), including dissociative identity disorder (DID) and other specified dissociative disorders (OSDD), are severe conditions that often develop as a consequence of early, repeated, and overwhelming traumatic events. Patients frequently present with extensive dissociative symptoms such as amnesia and identity confusion, emotional dysregulation, relational difficulties, and marked functional impairment. Despite high levels of burden for both patients and health services, there is very limited research-based knowledge about effective treatment for this group.

For PTSD in general, trauma-focused exposure treatment is recommended as first choise (NICE guidelines). There is increasing evidence that such approaches may also be useful in more complex traumatization (Oprel et al., 2021; Raabe et al., 2022; Sele et al., 2023; van Vliet et al., 2021), while some studies suggest that patients with particularly high levels of dysregulation often need a more phase-oriented approach (e.g., Bohus et al., 2020). For complex dissociative disorders, there are currently only two randomized controlled trials (RCTs) that specifically target this patient group. In Brand et al. (2025), a psychoeducational skills training program ("Finding Solid Ground") as the first phase of treatment showed a significant effect over and above usual individual therapy. In another RCT, where a 20-week psychoeducational group intervention was compared with standard individual therapy, both groups showed improved functioning, but there was no additional effect of the group and no clear symptom reduction (Bækkelund et al., 2022). There are no RCTs testing the effect of trauma-focused exposure treatment for individuals with CDD.

International guidelines (ISSTD, 2011; Brand et al., 2012) recommend a phase-oriented approach to treatment of CDD. In phase 1, work focuses on stabilization and skills training before progressing to more direct trauma processing. A central clinical dilemma is that these treatment courses often become very long, and many patients never reach phase 2, where the traumatic memories themselves are processed. The field lacks methods that can safely address the core of the trauma before patients have built substantial capacity through long-term stabilization work.

Deep Brain Reorienting (DBR) is a relatively new, transdiagnostic trauma treatment based on neuropsychological and neurobiological research (Corrigan et al., 2024). The method aims to access and process traumatic experiences by following the original sequence of physiological responses that occurred when the midbrain was alerted to a threat or relational injury that exceeded the person's integrative capacity. DBR focuses on processing the "shock" in subcortical, pre-verbal systems, and targets the orienting response and the subsequent fear sequence (Corrigan et al., 2024). Rather than working directly with trauma memories, DBR can address current trigger situations and process underlying shock responses without necessarily activating the most overwhelming feelings and memories.

A randomized controlled study (Kearney et al., 2023) of eight web-based DBR sessions compared with a waitlist condition found substantial reductions in PTSD symptoms immediately after treatment and at three-month follow-up. The active treatment group had nearly 50% symptom reduction, and many participants no longer met criteria for PTSD. The results suggest that DBR may be as effective as established trauma treatments, while appearing more tolerable and having a lower dropout rate. Further research, including fMRI studies conducted by the research group around Lanius and adaptations for more complex patient groups, is underway (e.g., Corrigan et al., 2024; Gerge, 2025).

The field has so far not identified methods that can safely address the traumatic events and the causes of dissociative symptoms early in treatment, before patients have built significant capacity through extended stabilization work. For some patients this can take a very long time, and some never reach genuine trauma processing. DBR appears to be a promising approach for working with the "imprint" of trauma without necessarily having to activate the trauma memories themselves, and may potentially enable earlier processing than what has been common so far. This constitutes the background for the present study.

• Aim of the study

The aim of this study is to carry out a feasibility/pilot study of a 16-week integrated treatment program for patients with complex dissociative disorders, in which individual DBR is combined with a supportive group intervention. More specifically, we aim to:

• assess the feasibility and acceptability of such a program at the Trauma Outpatient Clinic at Modum Bad (recruitment, attendance, dropout, tolerability, and treatment integrity),
• explore participants' experiences of receiving DBR in combination with a supportive group, including perceived benefits, burden, and suggestions for improvement,
• examine preliminary changes in symptoms, functioning, and quality of life (pre-post and 6-month follow-up), as well as evaluate the usefulness of two new DBR-specific measures.

In the longer term, the project may contribute to developing a more targeted treatment offering for a patient group that currently has a large unmet need, and provide a basis for a subsequent, larger controlled study.

• Description of the intervention

The intervention is delivered on an outpatient basis at the Trauma Outpatient Clinic and includes:

• 1-3 preparatory individual sessions to assess symptoms and treatment goals, and to introduce the method.
• Two initial group sessions, where we:
• provide psychoeducation about the background and rationale for the method and how it is conducted,
• introduce and practice a central orienting exercise ("Where Self"),
• work to establish a safe and supportive group climate.
• 16 weeks of treatment, consisting of:
• one weekly individual DBR session with a DBR-trained therapist at the Trauma Outpatient Clinic,
• two brief digital group meetings per week:
• the first to identify a suitable focus or issue for the upcoming DBR session and to practice "Where Self" to strengthen orienting capacity,
• the second focusing on further adaptation of "Where Self" and deepening new perspectives and experiences arising from the DBR processing.
• During the treatment period, we collect self-report data,
• After 16 weeks: one individual summary session and one focus group interview
• After 6 months: a new focus group interview and completion of self-report questionnaires
• Research questions

• Feasibility and acceptability

• To what extent is it feasible to offer a 16-week DBR program combined with a supportive group intervention to patients with CDD (recruitment rate, attendance, dropout, tolerability)?
• How do participants describe their experience of taking part in such a program, and in what ways do they experience it as helpful or burdensome?
• Preliminary clinical changes

• What changes in symptoms, functioning, and quality of life do participants report from before to after treatment and at 6-month follow-up?
• Evaluation of two DBR-specific process measures - To what extent are these instruments useful and meaningful for this patient group, both as research measures and as support for their own processing?
• Rationale for choice of design, data, and methods The aim of the study is to examine (a) feasibility and acceptability of a DBR-based combined individual and group program for patients with CDD, (b) participants' experiences of taking part in the program, and (c) preliminary changes in symptoms, functioning, and quality of life.

We therefore use a mixed-methods approach:

• Quantitative data (pre-post and 6-month follow-up) from self-report questionnaires make it possible to describe trends in change in symptoms and functioning, and to test two new DBR-specific measures (Where Self Awareness Scale, Shock Induced Vigilance Scale).
• Qualitative data from focus group interviews provide access to participants' own descriptions of how they experienced the treatment, what they found helpful or challenging, and how the program can be improved.
• Research participants We plan to include 10 adult participants who meet criteria for DID or OSDD (CDD) and who have already been referred for treatment at the Trauma Outpatient Clinic.

Such a sample is too small to provide sufficient statistical power to draw firm conclusions about effectiveness, but is considered sufficient to:

• provide indications of possible clinical changes,
• test recruitment and feasibility parameters (attendance, dropout, tolerability),
• collect qualitative data about participants' experiences.

The study is thus explicitly designed as a feasibility/pilot study.

Recruitment Patients referred to the Trauma Outpatient Clinic at Modum Bad in Oslo are assessed according to the clinic's standard procedures. As part of this assessment, the most suitable treatment offering at the clinic is considered. Patients who appear to be a good fit for the DBR program are informed about the study verbally and in writing, and invited to an assessment session where the study is reviewed in more detail.

• Analysis The qualitative data from the focus groups will be suitable for hermeneutic-phenomenological analysis, with the aim of illuminating participants' experiences of the treatment, how they understand their own change processes, and what adjustments to the program they propose.

The quantitative pre-post measures will be analysed descriptively and with simple statistical analyses to explore possible trends in change in symptoms, functioning, and quality of life, and to assess the usefulness of the DBR-specific questionnaires (Where Self Awareness Scale and Shock Induced Vigilance Scale) as outcome and process measures.

Given the small sample, the analyses will be exploratory and hypothesis-generating, not conclusive.

• Ethical considerations - potential benefits and burdens Potential benefits

• Participants may experience it as meaningful and validating to contribute to research in an area where their patient group has traditionally been underrepresented, and where their experiences can influence the future development of trauma treatment.
• They may gain access to a structured treatment program (combined DBR and group) that could contribute to symptom reduction, improved functioning, and a greater sense of coherence, although this cannot be guaranteed.
• At a broader level, the project may contribute to the development of better treatment offerings in specialist mental health services for people with CDD, a group for whom there is currently little research.

Possible disadvantages/burdens

• Participants may find it burdensome to take part in focus group interviews and to complete self-report questionnaires.
• Some will have prior experience with assessment in psychiatric services, whereas others may be asked to report on trauma experiences and symptoms for the first time; this may lead to emotional reactions and new insight into their own difficulties.
• Patients who want the treatment but do not wish to take part in the study may experience a certain indirect pressure related to the wish for timely access to treatment. This is addressed through clear information and the availability of alternative treatment options.

Measures to reduce risk and burden

• Participants receive both oral and written information about the purpose of the study, the content of the questionnaires and focus group interviews, and the voluntary nature of participation.
• They are informed that they can withdraw at any time without providing a reason, and without any consequences for their other treatment.
• All assessments can take place at the treatment site, with a project staff member available if support is needed.
• Focus group interviews will begin with clear information that the interview is not about the traumatic events themselves, but about experiences with DBR treatment. Participants are informed that they may take breaks, decline to answer questions they do not wish to answer, and regulate how much they share.
• In the DBR intervention, during assessment, and in the focus group interviews, the emphasis is on present-day experiences, coping, and process rather than detailed descriptions of traumatic events. This is considered a measure that reduces the risk of retraumatization.
• The project staff are experienced trauma clinicians, accustomed to handling strong emotional reactions and to conducting data collection in research settings.

Overall, the burden of participation is considered moderate and within what is usual for treatment at the Trauma Outpatient Clinic. The potential benefits for individual patients, the patient group, and society are considered substantial.

• Justification of the project Participation in the project is voluntary, and the DBR intervention is not yet part of the standard treatment offering. Patients who do not wish to participate in the project will be cared for through other treatment options at the clinic.

Previous clinical experience with DBR suggests that the method is well tolerated and perceived as helpful. These experiences have informed the planning of the study. The project staff assess that most participants will find it meaningful to provide feedback on their treatment and contribute to the development of the field.

The benefits of the study (the possibility of improved treatment offerings for a highly vulnerable patient group, and knowledge development in an area with substantial knowledge gaps) are judged to outweigh the risks of burden associated with participation. Given the established measures to protect participants, the project is considered ethically justifiable.

• Information, consent, and data protection

• Written informed consent will be obtained from all participants prior to inclusion.
• Participants will be informed about the purpose, methods, voluntary nature of participation, right to withdraw, and how data will be handled.
• Data will be collected in de-identified form using a code. The key linking codes to personal identity will be stored in a secure area on Modum Bad's servers, accessible only to the project leader.
• Audio recordings from focus group interviews will be transcribed and de-identified on a PC without internet access; the audio files will then be deleted. Transcripts and questionnaire data will be stored on secure servers at Modum Bad.
• A Data Protection Impact Assessment (DPIA) will be carried out at the institution, and the project will not commence until this has been approved by the local responsible authority at Modum Bad.
• Implementation plan and organization

• Project leader: Peter Sele, PhD, Acting Head of Research at Modum Bad.
• Project responsible (day-to-day management, adherence to procedures, data collection, analysis, dissemination):
• Ingunn Holbæk, clinical psychologist specialist and PhD candidate with many years of specialization in complex dissociative disorders and several publications in the field.
• Project staff:
• Katinka Thorne Salvesen, clinical psychologist specialist with many years of specialization in complex dissociative disorders and several publications in the field.

Both the project responsible and the project staff member have additional training in body-oriented trauma treatment (Sensorimotor Psychotherapy), EMDR, Narrative Exposure Therapy, and DBR, and more than 20 years of clinical experience with this patient group.

The Trauma Outpatient Clinic aims to be innovative and contribute to the development of more effective treatment methods. The clinic leader supports the project. Modum Bad has its own research department with available resources that has been involved from the project planning phase.

User involvement is ensured by systematically collecting patients' experiences through focus group interviews and using these to improve the treatment model.

Frank Corrigan (psychiatrist, developer of DBR) has contributed input on the study design and provided relevant DBR-specific questionnaires. He will provide clinical supervision to the therapists to ensure good treatment integrity.

• Dissemination of results

There are no restrictions on publication. The results will:

• be published in scientific articles in peer-reviewed journals,
• be presented at national and international trauma conferences,
• potentially be disseminated in professional forums, seminars, and internal teaching sessions at Modum Bad.

All dissemination will be at an aggregated level and in a form that makes it impossible to identify individual participants.

Inclusion criteria

• Age ≥ 18 years
• Meets criteria for complex dissociative disorder (DID or OSDD; e.g. F44.88/F44.81)
• Referred to the Trauma Outpatient Clinic
• Own motivation to participate in the DBR intervention and the associated group program

Exclusion criteria

• Ongoing severe substance abuse

• Violent behavior
• Severe current crisis
• Ongoing high risk of suicide
• Psychotic disorder