According to Kathy Steele, MN, CS, dissociative disorders often present in subtle ways that may be tricky to identify.
So in the video below, she walks us through some key signs that can help us differentiate dissociative identity disorder and structural dissociation from more mild forms of dissociation.
She’ll also share several critical steps for working with clients who dissociate.
Take a look.
So the question is, what are we looking for in a client to diagnose or to assess for a dissociative disorder like DID or the lesser form we call other specified dissociative disorder. I think about it as a mini-DID. It’s parts, but they’re not quite so separate. So the question is, what are we actually looking for?
We’re looking for amnesia because that is a criteria for DID. And we’re not just looking for amnesia for the trauma because lots of people have amnesia for at least parts of the trauma, including people with PTSD. So what we’re looking at is we’re looking for more pervasive amnesia. Like I don’t remember anything between the ages of six and 10. That’s pretty significant. Or I don’t remember anything about life at home. I remember school fairly well, but not life at home. And so we’re looking for larger gaps. And also we’re looking for, in dissociative identity disorder, we’re looking for amnesia in the present. And again, if we’re making a distinction between spacing out and structural dissociation, people who space out and stare at the wall can go for hours and not remember what happened, because number one, they’re not present. And number two, they’re not doing anything. So they can have what we might consider amnesia for four to five hours in a day. But they’re sitting there doing nothing. What we’re looking for in dissociative identity disorder is an amnesia that indicates one part of self is active while another part of self is not paying attention. So on one level with spacing out, nothing is being encoded, memory is not being encoded – but with structural dissociation, you have an encoding of memory in some part of the self, but it’s not accessible to another part, at least at the moment. So you might look for people who can remember some times and not others.
I think the first thing that a clinician should do, if they suspect that they have a dissociative client is take a deep breath. It is not that difficult to treat dissociation. It has a bad name. There are some complications to it, but I think once you get the training, that’s fine, but try not to rush into starting to explore parts right away. I’ve seen too many clients who have been a bit overwhelmed by that. If you really think about dissociation to association is about hiding from yourself. It’s about not wanting to be that, seeing that experience, that little girl, that memory, I don’t want those things. And so to be confronted by that all of a sudden is often quite overwhelming for clients. So I would suggest to therapists just to go slow, talk a little bit about dissociation in general, try to get clear in your own head some of the distinctions between ego states and dissociative parts, because it’s pretty easy to confuse those if you don’t know a lot about dissociative disorder. Take your time and let the client take his or her time.
And so there is some literature out there about mapping the system, let it unfold like the onion layers like we do with all other kinds of psychotherapy, not diving in too quickly. And yes, we don’t want to just hang out forever. But I think beginning to explore, how does the client feel about talking about it? Because what I notice for many clients is even asking them about dissociation or giving them a kind of assessment instrument for dissociation creates all kinds of freeze and shut down and flight kinds of experiences. If they’re unable to even talk about it without going into a big reaction, then you have to slow down much more. On the other hand, you will see clients who talk about it just fine, and they go home and fall apart or self-harm. Those people are more depersonalized in session. And they’re kind of talking about it from here up, not aware of the reactions they’re having. And so we really want to be clear that a client can accurately report how they’re doing when they’re talking about something and really track carefully their physiological reactions in the session.
To hear more expert strategies for working with dissociation from Kathy and other masters in the field of trauma (like Bessel van der Kolk, MD; Janina Fisher, PhD; Stephen Porges, PhD; and more) check out How to Identify and Treat Dissociation (Even When It’s Subtle).
Now we’d like to hear from you. What strategies have you found to be effective when working with dissociation? Let us know in the comments below.
Excellent. Insightful and practical. I work with clients who have cancer
and often do not have the available energy to explore their disociative disorder or PTSD. Also, most times, they are not inclined to want to explore new avenues of self discovery. I provide patients with short, do-able mindfulness exercises to help them experience short windows of time being present. I email reminders regularly. I also refer to feldenkrais & encourage simple breath and movement.
Yes, good. There is so much trauma underlying a severe condition like this; in order not to retraumatize the client and jeopardize the therapeutic alliance, you have to be very careful and patient, and allow them to reveal themselves as they feel safe to do so.
This is very helpful indeed. Thank you.
The person who you really ought to invite to present on this topic is Joanne Twombly. She is a breath of fresh air and really understands how to treat trauma and dissociation.
Her book Trauma and Dissociation, Informed Internal Family Systems is a must read.
Joanne should be invited to present at NICABM. As soon as possible
agree. Her book adds to IFS just what is needed for severely traumatized clients.
IFS is considered extremely controversial among many people with DID. Many people with it are extremely well read on the topic as a survival skill having dealt with many clinicians who either don’t know what they are doing or are down right harmful, often telling them they don’t believe them and sometimes not practicing basic therapy much less specialized skills.
Neurofeedback has been life changing for me along with working with an informed therapist who knew that I needed treatment for dissociation not medication. Many years of my life went past me because of not being diagnosed correctly. I am no longer afraid of myself, or the word and/or concept, dissociation. I feel whole and in my body for the first time in my life. It’s a wonderful experience!
Body language, phrases that they use, facial expressions, handwriting, forms of dress and make-up…all can change and change in the middle of activity. Some people with “pieces-parts” will mask for their other part so that they appear “normal” but the tells are there if you are looking for them. But, I have seen a lot people walk free and live without medication but it takes someone that is quite brave and willing to unmask the trauma completely and also be willing to let their “parts” retire when their core personality is strong enough to handle things. There is a lot of hope and there are a lot more people with these problems than we think.
I have a client with c ptsd and significant medical issues from a very bad car accident.
I suspect did- but due to traumatic brain injury- I wonder if the tbi impacts assessment and diagnosis
I used to dissociate. I don’t any more. I had 4 years and 6 months of continuous healing ministry which ended in June 2021. I am still stable and not dissociating. I take 20 MG of Prozac a day. I can’t keep depression at bay without it. I had a smorgasbord of medication before that. the programme tools were developed by Bethel Church in Redding USA. I had what were called advanced sozos. I hope this is helpful in some way.
Dissociation is tricky as a person begins to recognize they have gaps in their life with no memory, and are left wondering what did I miss? Also the implications of not being fully present when raising children, continuing to work, multi-tasking, etc.
The big key is learning how to become grounded in the body; somatic psychotherapy is the most effective journey back to association and stability. Body awareness and grounding is a lifelong need as the beginning of ‘lift-off’ is felt. Feldenkrais offers very effective audio sessions to accomplish this.
Great input. Really helpful. I will be even more cautious and looking for amnesia as a key criteria. It reminds us again that approaching difficult subject shouldn’t be rushed but takes it time
I love this ! Thank you. It is of deep and abiding interest to me on my journey, and I just want to learn more and more. I don’t (yet) have clients, formally, but have – since my post-grad counselling diploma several years ago – delved deeply into personal growth and healing. And here in Scotland I have has a wonderful teacher/therapist.
Recently I have thought more clearly about practising and my renewed interest (understatement) in Trauma in the body – starting with Peter Levine – has been so exciting, both for me personally as I learn how relevant this is to my own growth, and also to the realisation that I have much to share and help others. This piece today is very pertinent to my journey. It resonates hugely with me.
that’s very helpful, thank you