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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I am a chaplain and former nurse. Skillfulness with recognizing dissociation seems so essential. I wish everyone, especially in the “healthcare” field, would learn about it. I particularly like the idea that dissociation be thought of in the place of labeling personality disorders. I appreciate having greater awareness of my own dissociative behaviors.
Great information, especially the tip of using empathy or the need for matter-of-fact to help regulate. The need for all people to understand this information so we stop judging each other and start creating real connection–it’s the only way, as was stated yesterday, that “we change the course of civilization.” This is more necessary now than ever! Thanks
My big takeaway today is offering that container of strength for the part that is dissociating and not moving too quickly into empathy. Thank you for offering these sessions free!
Thank you this was very informative, given me lots to work with with my clients, such good reminders
This is such powerful work you all are sharing. The insights about identifying dissociative states, and in particular the care needed in understanding the adult protective states surrounding childlike states, offer nuance helpful in art therapeutic and pedagogical contexts. Very grateful to be part of this community, and to have collective access to these resources and emergent clinical research.
Another great session. Loved hearing Pat talk about the dangers of empathy! Lots to think about. Thank you to the whole team. Very grateful for your expertise and insights.
Thank you! Very interesting and highlighting.
I’ve found it very usefull for my pratice. Good, prractical advices!
Great session, very helpful concepts and ideas that can be put into practical use.
I was taught 4 Cs, and added one of my own. Communication, Cooperation, Compromise and Consensus. And my 5th C is used in the first 4..Creativity. It is often the first voice of parts in a person with DID. Art Therapy, structured and guided and unstructured and self directed by client. It is a window for therapists and especially for the client, and provides a foundation and tool to achieve the 5 Cs and provides a safe place for parts to start the process of reaching Co-Consciousness and on to Integration. And it provides the Therapist with a broader view of the clients life outside sessions, and inside the internal system of parts. The arts have long been the voice of Trauma of all kinds, to express the unspeakable, and to speak truth about injustices while under threat of reprisals. All the approaches mentioned here are very important, we need all these types of therapy, they help the whole person, and those treating them to see the whole “Elephant”..not just one part or the other.
YES!! Thank you for that, Valera-
Love the addition of the 5th C. I too agree that the use of this modality (creativity) can be incredibly helpful in helping the client explore their part(s) in a safe way. The very act of representing the part outside of the body, immediately provides a new perspective. I would add that by giving the image permission to have a voice of its own, rather than the client (or practitioner) ‘interpreting’ the image, is where profound change comes from. E.g. using the ChrisLin Method.
Thank you for your passion and information.
Thank You for Your generousity. God bless your work with your patients!
I think that is very interesting and also very helpful!
Your suggestion of the five Cs (interacting together,) would seem like an instant, safe and more naturally, healing way; into integration for the patient.
This approach could even squash the possibly, undisclosed belief of the patient, and the patient’s own personal labeling of their experience as ‘vastly misunderstood and complicated, scientific phenomenon’.
Without a more threatening belief itself; it would seem that a patient should feel that much less threatened about their work involved, in their recovery journey. It would also seem, a much better ground for their full integration.
Without the fifth C; as it stands in practice now, a patient might just feel much more intimidated about the healing process, than they need to be.
The creative component to the parts may bring more self-empathy and understanding to the patient.Thus speeding up the healing and the hope; that the patient can finally feel confident enough to start living their best life!.
So I believe that your idea or approach ought to be more closely examined. Thank You very much for sharing this! Wonderful Job!
My comments regarding the fifth C are to: Lindsey Wheeler
Thank You Lindsey!
I think the experts talking about what NOT to do left out one important thing that happens quite a lot–terminating the client abruptly while blaming the client for their own trauma and responses to it. Many clients with trauma report to subsequent therapists that they have been abruptly terminated by previous therapists because of their trauma. Practitioners should not attempt to treat clients with childhood trauma because these clients become attached to their therapists only to be abandoned by them once the attachment has happened. Therapists untrained in treating trauma recognize they aren’t competent to treat these clients, so they simply abandon them without regard for the re0traumatization they are creating. Therapists must screen for trauma very early in their relationships with all their clients and refer them early to skilled trauma therapists before the clients have become attached and are going to react badly to the abandonment and betrayal of abrupt termination. Often these clients never engage with other therapist, so if a client does try again with a subsequent therapist, it’s also very important for a subsequent therapist to acknowledge the incompetence of the previous therapist om helping with trauma and to deal directly with the abandonment and rejection issues that such terminations have created in these clients. Many clients have actually experienced abandonment by several therapists. Too often subsequent therapists look at whatever went wrong as the client’s problem/fault or simply don’t believe what their clients tell them about their abandonment experiences with previous therapists. Unless a client who has been abandoned by a previous therapist is validated and feels a new therapist believes their story and the validates the feelings associated with it, nothing positive will come from the new relationship with another therapist because the ability to trust has been further destroyed–adding to the trauma these clients already carry.
Fantastic point!
This is absolutely true and accurate. I agree with every word. I have been in the field for a long time and encountered many DID clients who were “let go” by previous therapists. Some experienced great emotional devastation.
However, there is a dark reality that with our present-day understanding of tge problem, some are truly untreatable with the methods we have today.
Some clinicians must release a client they cannot assist. Some clients are still attached to perpetrators when in a DID state. Some clients actually will have at least three or four different levels of treatment houng on but will not disclose. They might have a paid clinician, plus an unpaid pastoral associate. They will often adapt the alter system to the person helping. For example, if they go to a male minister, they will show only child or teen alters. Usually, a minister does not have clinical training so he does not know what is hidden. This is just one example. The sad truth is many DID clients have internalized their perpetrators and will try to harm the counselor. Maybe a future NICABM session will address this hazard to clinicians.
Dear NICABM – experts ,
Hearing about 3 key flags to structural dissociation , was superlative concise and good to get clarity on .
In addition, how to easily smoothly ask client to do the “ sigh breath “ of move their body in session ( per Janina Fisher) / was very insightful and revealing that our NS is present in these early session – when a client with complex or horrific trauma – size up the situation , the therapist & nurse etc/ to see if they feel safe .
How to communicate when there is “ spaciness “ apparent in session. How to not process or discuss too much all in one session – was exceptional advice, in my lived experience . Blessings & my gratitude to all for these shared teachings, on the Video !
Claudia Eyre RN, CPMHN ( C) in Ontario Canada June 18/2024
It was an eye-opener to learn that complex trauma / Dissociative Identity Disorder can be mis-diagnosed as schizophrenia. Now I know that this is what happened to someone I was supporting emotionally, because the medical treatments were ineffective.
I liked the simplicity and clarity of each therapist and easy to understand and apply awareness with dissociation. I appreciated the normalizing of DID and how to gracefully begin to build a safe enough relationship with the client with DID. It can be so overwhelming to know where to start when this emerges from the client
One practice I’ve worked with a lot to get in touch with the body and its messages is Qi Gong, aka “moving meditation”. You get to create the sensations through the various movements. You can then sort out the impact of each movement on the body. You get to experience and explore relaxation states vs action oriented states (yin vs yang), and how, through flowing movements and different breathing techniques, to calm the nervous system. It can also be an amazing practice for grounding, and for growing a sense of relationship with other people, the world and the universe. An all-round supplementary support for dealing with dissociation? I found it so.
Exactly my thoughts as a yoga teacher. So important to work WITH the body. Not against it. Overstepping its boundaries and working against its signals is traumatizing. Learning to listen to the body is a great tool for self-help as well. Thank you for adding the benefits of all forms of “moving meditations.” to today´s session.
I was glad to hear Dr. Peter Levine address clients presenting to their primary care physicians with physical symptoms that were actually a consequence of psychological issues. We were training interns to screen for this in the context of the medical interview back in the 1970s using the Biopsychosocial model with Dr. George Engel at the University of Rochester School of Medicine. It’s refreshing to hear this knowledge is still considered relevant.
There are several things that I take from today’s session and will be implementing. The techniques shared when clients dissociate in session will be very helpful. I don’t ever want to cause a client to feel shame for coping. I will also be helping my clients to recognize that a part of them is fearful, sad, etc, and not all of them. This will be powerful. Lastly, I will be remembering to watch for my client’s response when I am offering empathy. I have noticed a client dissociating in the past after offering empathy and I wasn’t sure what to do to repair it. Thank you for all this information!
I am an LCSW and child trauma therapist – dissociation with my clients occurs frequently. It is scary because I do not want to cause harm and grounding has always been my go-to. I provide psychoeducation, validate their past need for dissociation, then gently shy away. Today I feel confident that I have the tools needed to effectively interact with different parts (especially the self-harm parts) and more confidently return responsibility to these parts while questioning what they fear in the healing process and pacing myself as we work together. I feel secure that I now can see it in their face/eyes, what I should say/not say, and the tone of voice I use needs to adjust itself. The biggest aha moment for me was that my kind gentle tone can be triggering. Thank you so much for this!
I am am still getting my clinical hours. I believe I have at least three teen clients who have significant dissociation symptoms and possibly DID. I feel that I am in the woods without a path at times. The main take away from this for me was to s l o w d o w n and remain very attuned to what is happening for the client moment by moment.
Excellent as always. I was not familiar with the concept of window of tolerance, though think I have generally instinctively been able to feel the escalation and respond. Thank you
Thank you for this very helpful and informative session. First time to hear of a window of tolerance and how to introduce a sigh.
My main takeaway is to remain mindful of my impulse to use an “empathic voice,” because joining with the client in that way can feel threatening or overstimulating.
Extremely helpful information. Thank you.
Thank you so much for today’s session. DID is a very difficult condition to work with as a complex trauma. Very helpful the insights of the experts, I guess for me the best is about the pace of intervention, to go slow, not to rush.
RE: Over/misdiagnosis, pharma/poly-pharma, chasing symptoms not ROOT CAUSATION from the bigger picture, etc. FIRSTLY, love these courses!! I send so much honor, respect and appreciation. QUESTION: How to know know the SYMPTOMS are not FROM PHARMA and/or Sensitivites/OEs aka: intensities (via Dabrowski Center)? Very happy to see the new info on misdiagnosis and sussing out differences better. re: “Hearing voices” … just listening to Danish researchers on the NORMAL-ness of “hearing voices” (in different cultures, different situations and individual make-up… ie: HIGH IMAGINATIONAL OE/ intensity, which is one of 5 OEs common in many gifted persons is also a possibility). This ties into the the OVER / MIS-DIAGNOSIS / DRUGGING (pharma meds, poly-pharma and stigmatizing … “You are ‘mentally ill’ ) that often results due to hyper-use of pharma-tied DSM “bible”.
***** A S K: C U I … B O N O (who benefits?) ***** (cont. below)
Instead of training counselors/therapists/doctors how to suss out what is really going on and what is needed, a COMMON PRACTICE is hasty diagnosis/treatment DRIVEN BY “symptom-ology –> using the pharma-backed/written DSM”, to “diagnose and drug”. Knee-jerk pharma-drugging often results in new, additional symptoms developing, then more drugs prescribed (poly-pharmacy… at times, ending up on ~ 6-18 different meds for various symptoms. (ie: Poly pharma can start with high blood pressure or loss, feeling a bit blue, etc. then given one drug which can spiral from there.) Thing is, when drugs are mixed A NEW DRUG IS MADE… like a compound and/or conglomerate to react H O W exactly on the whole body? (Many makers do know and have been exposed/sued for hiding them from the public).
Many people develop sometimes permanent life-altering brain/organ functioning (not limited to sexual dysfunction, Akathisia, anxiety/depression, enlarged hearts, etc. … and never feel “normal” again after starting pharma.
Yet, pharma keeps pushing the sales via media, pharma backed medical schools, buying and/or altering “bastardized faux science” and “peer-reviewed” journal entries. Drugs easily get sent to the masses by using their Corporate Captured FDA; owning Congress — (see OpenSecrets.org … #EndCitizensUnited), and demanding NDA’s to gag victims after winning billion dollar harms settlements.
These are powerful petro-chemicals that affect the brain, organs and every bodily system! They should not be viewed as “magic pills” or dispensed like candy… especially without proper INFORMED CONSENT (lacking from most docs). Each prescription needs to include details on HOW to continually monitor, even subtle inter/intra behaviors via self/family/friends/doctor (write down daily) for any changes what-so-ever.
Most therapists are not trained to understand how different life variables (nutrition, environmental toxins (inside/outside of home), on ultra-processed “food”, etc.) —- including petro-chemical P H A R M A —- can produce symptoms that fit under a pharma-paid-DSM diagnosis. We all need to remember: FIRST, DO NO HARM!
Thank you for the explicit and confirming strategies for recognizing the differences between DID and Dissociation. The Window of Tolerance was also extremely helpful in setting up a structure to help my client engage with their own inner landscape. Thank You!
I am taking away a more acute awareness of fragmentation and differentiating this from personality disorder.
An excellent and informative session. Thank you!!
What I learned today and willl definitely use in practice is to deliberately use a more ‘matter of fact’ tone instead of a more empathic tone when a client is overwhelmed.
Thank you
Structural dissociation is new for me. I recocnize what happened to some clients now. Now i understand why some poeple get burnout of it. I cost them so much energy to be in some many states. And why sometime people don t want me to be empatic. Because that might be a trigger from a childhoud trauma.I will be observing from now on. And will be more carefull. Thanks!
It reminded me the importance of helping others to recognise that the fear and trauma is only one part of them. To help them see that they can in the present, do something about it.
A very helpful masterclass. I enjoyed the variety of voices. Very useful: clarifications and repetition of terms and definitions; specific and practical examples of what to say/do exactly in specific situations. Thanks also for the reminders regarding taking it slow as well as the comments on attachment and the patient – therapist dynamic.
Such wonderful content being shared here. So appreciative of the many insights and tools that will help us provide compassionate care for our clients.
Thank you so much, i think it is verry important what you have shared. Sharing = caring. I work with DID clients and learned some new things. Thanks alot!
Muchas gracias por todo esto que comparten me ayuda muchísimo a tener más comprensión sobre estados de disociación y me ayuda con herramientas practicas para las personas que acompaño en terapia, soy terapeuta somática
This course is amazing, thanks for everything
Most are about adults but how can we apply with children of 12?
Thank you so much for this webinar series. I am a Board Certified Behavior Analyst, and find this learning tremendously helpful to both bring trauma-informed components into my work with parents and teachers as well as knowing some signs that we need to refer out and/or find additional psychological services for our clients that can more appropriately understand the function of the client’s behavior and/or offer more accurate diagnoses. I know many children/young adults whose behavior was discussed in the structural dissociation description, who may have been labeled with ODD or ADHD. Finding excellent psychological partners sooner for greater wrap-around care can help the client’s progress toward a fulfilling life.
Thank you for making this session available . Great content on dissociation and very useful to hear from so many experts. As a criminologist working with domestic and psychological abuse, dissociation is a constant occurrence. Some very insightful strategies in working with and approaching dissociation have stuck with me from the programme as well as early signs that client dissociate . The work you do in trauma field is appreciated !
I work with many teens that are more reluctant to engage in somatic work or breath. I loved the suggestion of incorporating a sigh together in an organic way.
I loved the suggestion of reframing by saying “you had the thought that you are inadequate” to introduce the gap between self and parts that have thoughts that are not necessarily reflecting truth.
I appreciated the correlation between attachment styles and dissociation.
I enjoyed all of it. I will come back to purchase the package when I can better afford it. Wonderful.
Thank you for a wonderful informative session with all the practical pointers. Very helpful. Appreciate that you are offering the course free of cost!
Thank you for a very informative session! I am someone that used to dissociate frequently. My somatic therapist helped me the most with guiding me to feel my body in situ, awareness of where my tolerance level was and then starting to identify the different parts. With curiosity and time, I was able to, in effect, introduce these different parts to each other and then integrate. I still occasionally disassociate, but I now have the tools to get regulated quickly and the curiosity to look at the why and to reassure myself that I am safe. I will be eternally grateful to my therapist for the journey we took together.
I have the utmost respect for all of you professionals working with individuals. You really do make a difference. Thank you,
Very many thanks. It is good to be updated on the developments of the nuances in types of dissociation, and how to differentiate complex trauma from DID, and schizophrenia. Also like the advice on pacing to stay within the ‘window of tolerance’.
I have seen a 12 year old boy with visual hallucinations and hearing voices, with suicidal intent; currently 1:1 care to keep safe. I would be interested in research on children with Dissociative Disorder or DID. Thank you.
Yes.. me, too! I ALWAYS want to know the complete background life history (preceding Rx)… any traumas (including home, school, church, etc.), environmental exposures (metals, pesticides, in-home, neighborhood, etc.) nutritional habits and comprehensive blood work, tick bites (lyme), etc. ….. Then IF and WHAT kinds of pharma Rx they are on. .. and the history of that process (blow-by-blow). After watching/listening to Studio Chicago Akathisia Stories (wow!), the Harvard Placebo Center’s report on lit. review of SSRI research (effective as placebo!); “Suicide by Prescription”, “Medicating Normal” , “Anti-Depressed”, and researching that the DSM is written by “experts” funded by pharma corps, Dr Chris Palmer (Harvard) on toxins/nutritional effects, Dr. Breggin’s books/videos, Dr. Mosely’s (sp?) info on how to safely get OFF SSRIs, etc. and more… there is enough info out there to point to the importance of NOT JUST LOOKING AT SYMPTOMS but the whole picture.
I have seen a kindergarten bite, hit, tip tables… behaviors parents never saw at home. After looking “deep”, they figured out the classroom had gotten NEW CARPET that summer. The toxic “GLUE” was off-gassing and his little nervous system could not handle it. ……. FYI – he was a bright/gifted, highly sensitive (OEs/Intensitiies… via Dabrowsky (Center.org) Theory). I am seeing MANY BRIGHT/SENSITIVE/ OE and 2e kids get MISDIAGNOSED & MIS-TREATED with pharma drugs! IMO, it is criminal malpractice.
Thank you for another good session and part of my psycoeducation. Janina Fischers comment about the trouble of choosing was particulary helpful. Understanding why moving foreward out into the world is so difficult.
understood the importance of psychoeducating clients about window of tolerance, will start doing that from now on. And also include somatic approach in therapy. Thank You
Fantastic. Very eye opening and clear. This also plugs right into my 2012 research “Lives unseen: unacknowledged trauma of non-disordered, competent Adult Children Of Parents with a Severe Mental Illness”. (Masters Research thesis, Department of Social Work, Melbourne School of Health Sciences, The University of Melbourne) and some of the short articles I’m invited to write for an e-publication aimed at psychiatrists and mental health practitioners which I then place on medium dot com for free for the general public. Thank you!
HMMN… as a retired therapist now age 80, I no longer practice. I find myself looking back at some of the techniques I was trained to use back when, and how they provided ways to work with clients that clearly now are being explained by the concepts your programs present.
We did some things well!
We may not have know why they worked in the same way your presenters do. But it seems that there are now intellectual structures to support and explain what effectivness we were able to achieve. Well I should really say “I ” instead of “we”, here.
I was relatively effective with low income, multi-problem clients, I especially loved working with court assigned families who never would have made it into conventional mental agencies. In one of these jobs I saved a juvenile court system between $250,000 and half a million $ in institutional costs in just one calendar year.
I myself cleared $3,000. that year, and then asked for a living wage for the next year. However, the county commissioners did not want to increase my pay to meet the level of their backhoe driver.
I had a child to support, so I had to move on, which I did with great regret.
Now tho retired, I do wish that I could afford to buy your programs myself, but I cannot.
I have tried to send my community/religious organization your way in the past,(but… without success,) when they were searching for a process to deal with “sexual misconduct” within their religious community.
I did also try to contact you directly to see if there were any no-cost options for that kind of use of your materials, but there was no response from your organization.
Today was the first time in a long time that I saw a notice of a presentation I could access without cost. (I may just have given up exploring your emails) I saw it, literally just 5 minutes before it began! I am glad I did.
Take care,
It is great that you shared all of this experience. it is a perfect snapshot of what was new in the field when you were involved. As Ruth B said, this material is new. Please observe, these people teaching us are pioneers. Many of them actually developed the theories in their research and they themselves are often in their 70’s and older. some who do not present but taught others are in their 90’s. For example, Ruth Lanius has learned from a research medical doctor man in his 90’s. In the past, the false memory foundation caused many clinicians to leave the field.
. Bessel went through extreme persecution to keep treating male clients and expose perpetrators in religious organizations. We cannot expect pastors in religion to be clinicians because many do not have knowledge of psychology. Perhaps most clinicians are female because they can understand both religion and psychology.
Thank you so much for making this available for free at different times of the day. I’m in Australia and often miss out on these webinars and seminars. I enjoy the different input from the different therapists. It is all very useful information.
It would be helpful to have the closed captions available, as sometimes it’s difficult to hear.
I’ll be using the ideas to ask more pertinent questions. Also, to slow down and breath myself. I teach all my clients to breath and to practice it at home, but I will be using it more in my practice room.
I really appreciated the explanation of dissociation of hiding from the self, erasing the self, neglecting and dishonouring the self. It helps to understand more about people in domestic violence relationships and working in jobs where they are exploited and retraumatised.
Yes, closed captions or even the transcript instead would make a big difference for those of us with plugged sinuses or those of us who learn better via reading.
I am so delighted that you are offering this course again. Hearing the different ways that each of the presentors describes and deals with the symptoms brings an integrated picture and ways of working with different patients. I wish I new all this 30 years ago, I probably would not have done some mistakes which probably harmed clients. And Ruth, who coordinates the session and sums up each section, does an excelent job to make it so inciteful and easy to take in. Thank you!
The examples of specific behaviors to help identify clients with disassociative disorder and suggestions for responding effectively were especially helpful. Thank you for sharing your expertise in this area.
Thank you for the information you provide. I am a follower of your trama series and would like to know how integration of dissociated/fragmented parts is achieved. Thank you for any information.
For children, some resources would be ARC by Margaret Blaustein and SMART by Alexandra Cook. For adults, Structural Dissociation by Kathy Steele, TIST by Janina Fisher, Finding Solid Ground by Ruth Lanius, IFS by Frank Alexander and Richard Schwartz.
Thanks! Smiles!