How to Identify and Treat Dissociation (Even When It’s Subtle)
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with Peter Levine, PhD;
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with Peter Levine, PhD; Ruth Lanius, MD, PhD; Stephen Porges, PhD; Bessel van der Kolk, MD; Thema Bryant-Davis, PhD; Kathy Steele, MN, CS; Janina Fisher, PhD; Bethany Brand, PhD; Pat Ogden, PhD; Ruth Buczynski, PhD
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Thank you for providing these resources free to the world. I greatly appreciate the high standards upheld in the preparation of the material, the way it’s been organised so that we can easily follow, the kindness and generosity of each and every expert that shares with us their knowledge and experience. I find it deeply touching that you have produced resources that can be helpful to therapists but also to anyone who is interested and willing to use the knowledge provided. I greatly appreciate the balance between providing a new language to understand more about trauma, and very practical strategies that can be used. Knowing about common mistakes and how we can go wrong, ie empathy, is also a very valuable tool. Thank you, I am so happy that I enrolled in these sessions!
Thanks for these very informative & helpful sessions. Particularly the section about common mistakes for therapist when working with dissociated clients. The use of empathy/empathic resonance with dissociative client, instead of being more matter of fact with the client
– But the client that was previously severely abused by others, may have had their abuse preceded by kindly empathic speech-so the client perceives therapist’s empathic resonant speech, as a threat.
Thank you for this very informative session! It helped me learn clear signs to look for in my coaching clients when they are in a dissociated state. One tip I’ll put to use is the “sigh.” I’ll more proactively model breathing and occasional sighs to help them and me self-regulate. I’ll also be more cognizant of the power of co-regulation.
Tuning into the signs that I may have as a clinician through Polyvagal Theory ro notice if a client is dissociating during session is interesting to me. I also appreciate the emphasis in working in true collaboration with the client in breathing exercises to regulate and ground.
Day 2: extremely informative. The work on DID was all new to me and I will now go on and learn more about it. Love the way the course is structured with clips, lists of what we are about to learn and a recap. Perfect pedagogy. Excited for tomorrow. Warm regards from Australia.
How to detect subtle signs of dissociation in clients and first step in to take with client – deep breath and slow down
I am sitting with the concepts of the “fault lines” between attachment and defensive actions/responses.
It was spoken about within the context of a child being abused by their caregiver.
I am seeing this same kind of pattern happening for a woman experiencing pregnancy and child birth, especially her first, with an abusive partner, especially in an all ready isolated relationship. She is biologically vulnerable, seeking attachment/safety/protection in similar ways children biologically seek attachment. I can now see very clearly that this is a very ripe recipe for very serious dissociation that can lead to a very tough, self loathing road through parenting. Eventually, as the time passes, and babies ween and the body hormonally returns to “normal” and those biological cues that encourage attachment fade away, there can be a really key moment where dissociation and self harm may really take root. The self harm could simply be a deepening of her inability to leave her abuser.
So much more to say, I was just very struck by the new insight of this being similar to the biological need for attachment that children experience. And how pregnancy, and repeated pregnancy, can actually be a tactic of predatory abusers.
Also, really loving the advice to never ask someone to do something without doing it with them. This is hitting home on the parenting front and what a different dynamic this sets for the child. It comes kind of naturally when they are very young, but noticing the value in continuing to at the least offer it as an option when the child is facing something new as they grow older. Also the value that it has in general in relationship as a way to really support someone through a transition and how it quenches the need for connection and can really help to fully arrive through a transition. Ha! Also recognizing as good self talk, too! “Okay all my parts, we a going to do this together! No one is alone!”
Big thanks, really enjoying the format of these presentations.
Thanks for the insight about pregnant women in abusive relationships. It really helps explain things I’ve seen. Also, I think it helps explain betrayal blindness, ie the inability to recognize that a relationship is abusive. The more vulnerable a person feels the harder it is to recognize betrayal/abuse.
Feb 18,2025
Hello
I continue seeing a therapist,I will talk to her, listened and taking notes on dissociation, trauma challenges, contradictions,self distructive behavior,3 red flage of,ex talk down about people in our lives, ex, fears of leaving the house,my fears are with being around difficult hurtful people,as I suffered from the fight or flight,myself being the flight, hiding, ex, not finding the right medications,haven’t worked etc, I listened,with a curious heart,,safe in our body, I felt confused, inadequate, I suffered from trauma dissociation, parts, somatic ex, hopeless state,sad,other self, feeling assertive state, cognitive,thoughts its all my fault,I became curious about myself, not living in the monent, attention, of my self,,I suffered all my life, child ,as i’m an adult, I have felt, spacy, I didn’t like the comments like, i’m sorry you had to go thought this, that was trigging,I will practice breathing techiques,calming my nerious system, i suffered from attachment needs, that were not meant as a child, i’m mindful of my nerious system feeling stuck,I think is structural dissociation,have had emotional truama and phyiscal pain,, I have early life, trauma,thank you for the free educational,update, I’m curious about, myself, I’m an on going learner,faith in my prayers,I do want to continue my healing journey with chidhood trauma
I will be more mindful of structural dissociation. Some things I will use are asking “are you with me?”, “what % of you is with me?”, using a supportive voice tone, subtle movements, slow eye movement right to left. That voice hearing is an after-effect of trauma is useful information–where does that research come from? Thanks, Jim
Fascinating material. I grew up in an undiagnosed DID household in a small town in the 50’s. Needless to say it was not recognized until many years later. I instinctively know much of this material but I am excited to have it become so normalized and the recognition that this material needs to be shared with the helping community is profound. Can’t wait to see the rest of the series. I have purchased the Gold also.
Very informative and practical samples provides.
Hi, my name is Andreea Octavia, I am not a therapist, but I am certified trauma informed meanwhile and have been on a journey of recovering from burnout and cptsd since 2022, so I am here to learn. I took as many notes as I could, as if I would have to practice all of it forward… but first, I am here to help myself first of all and all my future clients, when I’ll feel ready to start….Thank you for the opportunity to learn with you and to understand from multiple perspectives at once – therapist, client, patient, fragmented parts, Internal Family System, Structural Dissociation model etc.
Probably my biggest AHA moment was that compassion (which is my current focus, compassionate or non violent communication method) is not always helpful … The reflex to offer compassion and empathy from our own experience can backfire … if it’s too quick … since proximity with another human in the past might have preceded the abuse (emotional, physical etc) … so a kind compassionate voice can be a cue for pain … and the hypervigilant fighting part is showing up and gets the client out of the window of tolerance zone and into hyperarousal. Learning: when that happens and the client goes into dissociation or outside the safety zone and the Nervous system gets hyeperarousal upon hearing a compassionate kind empathic tone, switch to a more matter of fact tone of voice, a more neutral, emotions free type of voice and attitude, to come back to the safety zone … of neglect … until the part holding compassion can be accessed …
This hit me so strong, as it is sooooo true also in my experience … and it brought clarity to some painful moments in my life…and I am crying myself while writing this as it hits me as well … I’ve seen it happening around me, I’ve experienced it in me … so many times around compassionate people that I got attached to and then I got traumatized by the same people … who told me they gave me too much compassion … I think now looking back that they haven’t even accessed it yet … just like me, still working on some compassion boxes most likely… before being able to start to offer my time emotional presence and compassion fully to another person
More notes I took that had an impact on me and helped me understand better the work with trauma and DID future clients:
Recognize the signs of structural dissociation
1) Paradoxes and contradictions – shame and superiority, devalues and idealization, the hypervigilant attacking part and the cry for help part … that are producing the inner conflict (this is another focus topic of mine lately – inner conflict, inner peace)
2) consistent terminal ambivalence – indecisive, incapable of taking decisions on big or small things – step fwd then it looks like self sabotage – why? there is a part of self that does NOT TRUST taking a step forward – this hit me as well … I am trauma informed certified since a year now … and yet not doing the steps forward fully to start to give to others … now I’ll go access my self distrusting part …
3) Nervous System based dissociation – from the client or from self nervous system – co-regulation happened or not?
in 75% of the cases we can recognize dissociation (walking away, zoning out) … but the Fragmented personality is often diagnosed as DID instead of what it is… neglect trauma, cptsd, fragmented personality
How fragmented self is connected with Overwhelm wound …. When the trauma experience is so overwhelming – that is stored in another part of the brain – fragmenting your patient sense of self … If we are severely traumatized and have intense intense emotions … to even consider looking at these states and parts and emotions can be severely overwhelming …. So we split the states – one part holds the trauma – one part gets on with life … and the more trauma we get … the more 1001 paper cut cptsd events of trauma happen … the more split and fragmented parts of self will exist, that need to be unboxed and looked at…. safely …
Critical concept of Structural dissociation model by Dr. Cathy Steel – Trauma brings us into a tug of war between two internal systems… the attachments system and the defense or safety system …
The more trauma, the more split parts exists
Even as therapists, we stay safe from what we fear – that is a mistake for DID, that has a lot of unmet attachment needs, sometimes never, neglected, frozen or dissociated away
Important to track both the patient and the inner experience of our nervous system for feeling either co=regulated or dysregulated with another nervous system next to us => feeling confused? Occurs often with highly fragmented client …
Work first with the fears of the persecutory parts that does their best to keep the client safe and not attaching in a traumatizing way again … before working with the vulnerable child or victim parts too early
The perpetrator or offender or critic in us is dehumanizing others or ourselves and it teaches clients to erase themselves, to become invisible, unseen, unheard … or hiding from the overwhelming parts and emotions and memories that they cannot manage yet
Healing this inner experience = Visibility instead of erasure, honour myself, be present with myself, show up for myself … Integrated and authentic acceptance of myself, coming home to myself … increasing the capacity of the nervous system to hold more and to feel less and less overwhelmed …
Need to be able to spot cues on the client when moving out of the window of tolerance, when scratching or self harming in the session … and breathe/sigh/ground with them again .. or using imagery – the chest of triggers method … or using psychoeducation to place the focus on the nervous system, so the client does not feel shame … or use a welcoming, surprised, curious, funny, inviting tone when a dissociative spacey part shows up, to increase awareness and noticing on the client part about this and to decrease their shame …
The 4Cs to achieve – Cooperative, Coordinated, Coherent, Cohesive = are a bigger project that can be achieved through a blended mix of approaches, not limiting to mind and awarenes talks only
Somatic approach – identify the collapsed state and the powerful assertive state … and discover the middle state, the balance, the posture from which you feel both sides are included and none is excluded … testing until you find that middle harmonious balanced posture and somatic experience in the body.
Grounding strategies -> When someone dissociates (zoned out eyes, fast eye movement, a lack of responsiveness in freeze state, or shallow breathing … self not being there fully present, not feeling safe) – invite the possibility to get back into the room and the body, if desired, invite some small movements to bring all the self in the present moment, invite a choice, invite agency, which was not available in the past to them… but now, they can have a choice, they can take that choice, they can feel safe now to protect their inner child from any kind of abuse, emotional or otherwise, to embody safety and sovereignity, to embody choice…
Cognitive approach – very important to learn first to put a gap between a thought and the identification with the thought, between truth and a perspective … it is very helpful in learning how to identify, name and compartmentalize parts and emotions and feelings, parts that are terrified, yet the client is willing and curious and feels safe to explore together, even though the experience of terrified comes up first.
Experiential approach – unblending chaotic cohesive parts and putting them into a safe dialogue is essential in trauma therapy
Ask the client of 5 types of DID
1 Depersonalization
2 Derealization
3 Identity alteration
4 Identity confusion
5 Dissociative amnesia – chunks of time missing
Help the client on regulating their disorders, teach them how to get safe in their body
Key strategies for effective treatment of DID and cptsd
1 Stabilization – learn what symptoms, sensations, emotions are, NS, how to regulate that.
2 Improvement of safety – start learning about your body, windows of tolerance etc when they are getting into hypoaroused and hyperaroused, what are their self harm signals,
3 Development of the relationship – what are safer ways to support themselves, relationship with themselves, the therapist, with others.
What you do is so important – When you help someone heal from trauma – you change the course of civilization
NICABM has numerous resources for you. Bessel van der Kolk has a conference coming up soon in Mass. You can find it on his website orvask NICABM.
Good summary. If you want to work with a therapist forbyourself, Perhaps contact Kathy Steele website to find a counselor or therapist who trained with her. She has a lot of referrals on her website.
Very powerful insights from this session; as I reflect on a range of experiences that have affected the parents and children to different toxic racist attacks. When I examine within my family ways we physically, emotionally, and somatically responded to different aspects of a chain of racist events within the community, their child’s school, among everyone’s respective interactions with others about this event.
I am impressed by the expertise of you all! Today I am an informed, stable counselor and expert from The Netherlands (Europe), but I did experience early childhood traumatization, PTSD, DID myself and had years of therapy. Because I experienced everything myself and had a high IQ, I saw through a lot, and I grew past therapists. But not today!!
I’ve heard knowledge that is not only so true about the topics where we talking about but also very much helping. Your knowledge is incredibly necessary in Europe, I’m so glad you release it. I have never had such accurate, good and above all constructive lessons. Who do not pity but empathize, do not elevate ‘the people with the knowledge’ but stand beside the client and point out the step forward. Well done and thank you so much.
I am really enjoying how you weave together these experts’ comments into a nice training with tips at various levels of therapeutic expertise. It is really useful for my work with and understanding of victims of sexual violence (my work). I am finding the comments about the Gold Package to be intrusive when they happen in the midst of the training. At the start or at the finish is understandable. The information is easy to see and to find about the Gold Package.
Useful reminder to not ask the client to do something e.g. deep breathing, without joining with them in it
it’s all very very very very very. Very. Slow and inconsistent. 1 hour for saying what we can say in 8 minutes. I can’t imagine even spending so much money for getting even more hours of nothing with a bit of something into it. we’re not kids, we suppose (and you write it) you all are speaking to a community of adults, so why do you speak in these 1 hour sessions to us as you speak with a 5 years old? I can’t stand it and I can’t imagine spending money on it.
Intuitvely I have felt that direct verbal expression of compassion and empathy is contraindicated at times . Good to know there is clinical reasons as to why this is so .
So very much appreciate this content . In gratitude
I found many things helpful, but especially common mistakes – showing empathy and how this can provoke a threat response… really useful. Thnak you!
Yes, this was insightful for me as well.
I really appreciate the emphasis on the therapist’s position/response in light of the unfolding disclosures of the client who has experienced trauma. I have several pages of notes to prompt my own reflections and deepen my clinical engagement.
Hello. I am an RN and the owner of Marina’s Emotional Wellness Support. I so appreciate what you do and I have taken courses before. This is such a treat you are offering to not just health care providers but lay people as well by providing us with very valuable information to help understand what is really going on with their clients on many levels: physical, psychological, emotional, social, etc. I find it especially valuable to be aware that dissociation is something that one’s nervous system does to help humans survive and also how to work with clients exhibiting signs and symptoms of being in dissociative states. Also learning to differentiate fragmentation from personality disorder is incredibly important.
The misdiagnosis of structural dissociation as personality disorder was very interesting. The point about a patient who wants to get close, but then feels threatened and attacks, resonated with a case my colleague was discussing recently.
Bessel van der Kolk’s description of experiential techniques feels like it overlaps to some extent with Imagery Rescripting techniques I use sometimes, and can be very helpful.
I also found the point about empathy possibly being problematic at times to be a very good point.
I have found the sessions so far very useful and interesting!
In recent years in the U.S., sexual abuse victims were stigmatized as having borderline personality disorder. They were labeled as untreatable.
Thank you! I have attended some of these webinars before and they always give me pause for thought. I highly respect the speakers and appreciate their willingness to keep doing webinars like this. You are each a gift to the world. Thank you!
Go Raibh Mile Maith Agat!
The welcome you offer to all is so encouraging.
As a SOUL student – School Of Universal Life –
the societal sharing and potential in this course is beautiful.
“in the particular is contained the universal” James Joyce
Thank you all for sharing
This presentation was clarifying for me with the current methods and techniques I use, and it was helpful to learn new strategies that can support me to better work with clients with dissociation challenges. Thank you
This webinar was very validating to know that I’m on the right track and am using the skills well. Thank you for it. I signed up because I had one client who dissociated so much in session that she couldn’t be helped with what I knew. She refused to try to breathe, to stand up, to touch the table, to shift in any way. She was in such a state of freeze that I couldn’t access her. I didn’t know what to do except be with her in silence. I asked her if that was ok and she slightly nodded her head. I asked her if she wanted to leave and she said no. We sat there in silence for quite a bit. At the end of her session she got up, zipped herself back together and said good bye. She said she’d be just fine because this is what she does all the time. Any thoughts on what else I could have done? Was my sitting in silence with her affirming or triggering? Hard to know.
Thank you,
Dawn
Hi,
The various treatment methods represented here might be of help to study more in-depth. I have studied all the people here except for Bethany. I would recommend starting with Bessel Van der Kolk, Kathy Steele, Janina Fisher, and Ruth Lanius. Those are tte main people I studied to learn about helping DID clients. Kathy Steele studied with Janina Fisher. They both have books and longer teachings you can get through NICABM.
Although you might not be able to help that specific person – because she told you she has a habit of doing this with various therapists – at least you will begin to expand your knowledge.
That happened with me. When I realized I could not help two clients, one female and one male, who told me they had several previous therapists, I took a break to learn from NICABM. The methods of NICABM are new. They have dozens of methods and teachers. This Masterclass is just a sample. Finally, if the client’s DID is very deep, she (or he) might not be able to be helped until or unless they are free of the influence of perpetrators. It is best to also keep yourself safe against retaliation and not go further than the client is willing. It is up to the client. We are merely observers and “coaches.”
Today’s information on learning to recognize subtle disassociation has provide insight on what to watch out for in session and help the client address it in a helpful and non-judgemental approach. The hope is to help the clients gain insight to understanding these different parts and themselves to better navigate life in a healthy manner.
Thanks so much for this series. I have a client that was in a severly physically abusive relationship for many years; severe enough to have lesions on her brain that correspond to scares on her head. She came in for counseling several months ago and has returned to begin to work through her abuse again. After this second session she again began to miss appointments. Our work to date has been psycho-ed regarding the window of tolerance, but even that may be a lot. I will use this NICABM session to better understand her resistance to participate and let her know that her concerns, fears or apprehensions are ok and welcome her healing self back when she is ready.
I was pleased to be reminded again of the importance of doing some of the physical work with the client as opposed to just telling them to breathe or to stand up or describe something in the room, etc. I have found this makes a huge difference in building trust in a safe and environment.
thank you for exposure to this information. i plan to continue reading, observing my interactions and helping rather than hurting….whomever, wherever.
maybe even initiating conversation.
very introverted and content, but still like to help. Tools helpful! practice is necessary!
Concept of window of tolerance and the need to acknowledge observations re nervous system to help ground and so client can begin to identify when they have moved out of their tolerance level.
“Oh, the spacey part is here!” Acknowledge without triggering shame. Very helpful.
This helped me understand that when a client literally can’t respond that there is possibly another protector part that is blocking them from getting to the truth of a matter.
I’m not a registered anything, but am learning. I have a friend who is diagnosed with DID (among many other issues), primarily resulting from intense childhood sexual trauma. Watching the first 2 videos (2nd especially) has given me a lot of tools (the spacey part is here, window of tolerance, gestures to ground them, how much of you is here right now?). Took tons of notes, wish I could afford the whole course, but it’s given me a lot of ideas. Thank you!
Thank you for the info on structural dissociation…and the 3 red flags. Very helpful.
The whole session was very good. thank you, again!
I just wanted to thank everyone involved in putting this series together. I attend many webinars on trauma healing, consume many podcasts, books, lectures, etc.. And this particular offering has tremendously helpful! The information is clear, up to date, non-pathologizing, easy to understand and extremely helpful. Thank you!!!
I am overwhelmed with appreciation for how many advances have been made in the diagnosis and treatment of DID and Disassociation since I began this work in the early 1990’s. Today I simply wish to express my gratitude for your commitment to serving a population that has been terribly misunderstood and dismissed. Loving these teachings. Thank you to each of the presenters.
As Pediatricians, we are trained to not lose sight of the patient’s and parent’s perspectives in order to help the family navigate their health concerns. So naturally, one can draw the conclusion that the more empathetic we are, the better care we can provide and can ensure more positive outcomes. It was eye-opening, and somewhat shocking, to be shown how in certain situations empathy may actually backfire and become harmful. This module gave me a deeper understanding of less emphasized, but not less significant, trauma response.
This is excellent. I do circle work with incarcerated men to address and heal trauma through an organization called Jericho Circle. As you might imagine, it is a hugely underserved population and most of us are not therapists but folk from other professions who have done our own personal growth work. I myself was a teacher for 37 years before I retired and took up this work. I will share this with others in our organization.
Jericho Circle. I am not familiar with this. However, I highly recommend volunteer pastoral counselors learn about DID. I worked with incarcerated men. I relate to your comments. The team I worked with were Pastoral Counselors. The inmate men chose to attend. The chaplain himself was extraordinary. But he had no clinical training in recognizing DID. I had clinical training so I could observe when child or youth alters popped out to receive pastoral support from us as motherly people. The men told us their stories of being fatherless, being neglected, abused. The setting was pastoral, ministering to a grouo of 80 men. To properly assist their individual recovery, actual clinical psychological support was needed. Even highly educated pastoral counselors do not have clinical training. The chaplain advised me that if some of the inmate men became too vulnerable in session, there would be retaliation later. These would be “protective alters.” But I could not seem to give a diagnosis or explain DID process to the Chaplain. it was an extremely difficult job for the Chaplains. We worked with two long-term chaplain. Prison management were very resistant to inmate men receiving pastoral support. The Chaplains had to be cautious and protective. When a few inmates were discharged, we were able to obtain actual clinical treatment for them. We saw the men regularly, so we observed some good work was accomplished in their personal lives. You are correct. It is an under-served group but rehabilitative care is urgently needed for these men to achieve human dignity and manly identity.
Hello,
My name is Meytal.
I’m not a therapist. I’m actually diagnosed with CPTSD.
I joined the course to learn more, from both from a patient’s and an educator’s points of view.
I’m a design educatore. I find the resemblance between psychology and design to be amazing and must be connected furthers.
I believe the future of design will integrate the needs of the mind and not just of the body.
Thank you for the opportunity to learn un understand.
Have a wonderful day,
Meytal
Learning that when their child voice comes out, i can directly address it. was an insight I hadn’t expected. I can directly say, “I’m talking to you as a whole about getting grounded. what makes you uncomfortable with that to make you interrupt when we’re trying to do grounding together?”
J Fisher share on how Clients can be fragmented but therapist label as personality disorder. That is why there are folks with so many failed interventions.We need to understand what fragmentation looks like so we can understand and assist.
Dr J Fisher is a rarity among therapists. The human compassion she invests in her work is authentic and genuine. That factor allows her to see deeply into the clients’ heart and soul and reach them at a deep level where true healing takes places. Compassion and intuition rules and reaches where all the techniques and methods point to but cannot reach without the genuine human touch.
The same could be said for all the NICABM team. But Dr. J. Fisher is the most sterling embodiment.
I found hearing about the red flags very useful, as well as the part about how to ask informative questions regarding DID. I really liked the “sigh” exercise and how it is important to do it together with the client.
Yes, many years ago, clinicians did not recognize the “sigh” response. They were taught to shame the client for having a “sigh” response. NICABM stands far above. I have had lots of psuedo-clinical training in Master’s programs for pastoral counselors. Much harmful information was taught. Victims of childhood abuse were emotionally abused and mistreated by clinicians who were ignorant of DID and mislabeled DID as “female disorders, untreatable.” That is why clinicians themselves must be constantly updated. NICABM is generous on supporting clinicians learn.
It’s wonderful to see the impact Internal Family Systems has had and how it has been integrated into how our leading professionals present dealing with trauma!