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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Wonderful presentation. I also would like to see you address state-dependent dissociation: that some personalities only take executive control when the client has caffeine or drugs on board or is being influenced by the internal pharmacy created by anger or fear. I think think the most irrational thing about DID formal diagnostic criteria is that alcohol cannot be a cause, when alcoholic blackouts are the clearest example of state-dependent dissociation imaginable.
I really loved hearing Janina Fisher speak to “Secondary Gains” and explain that sabotage often comes from a part that does not trust. The concept of secondary gains has been used too often as a way to blame the patient for something they either don’t understand and/or cannot control and I find it abusive. It’s so much more inclusive and supportive to recognize it from a parts perspective and I really appreciated hearing Janina’s perspective on that.
Totally agree, good distinction.
“Structural dissociation:” now I have a phrase for what has been keeping me stuck in a dark place for quite some time.
I have to applaud the emphasis on the idea that the client who is structurally dissociated should be viewed as “fragmented” rather than viewed from the usual perspective, which comes through the lens of the diagnosis of a personality disorder.
For a very long time, I have believed that BPD in particular has been used as a “catch all” diagnosis for a great number of clients who have been structurally dissociated rather than actually having a personality disorder.
Thank you so much NICABM for presenting these invaluable sessions! From the perspective of a client, they are highly informative, offer fabulous guidance for anyone working in any capacity with someone who has been traumatized, and have at times triggered me in painful but productive and positive ways. You have my deepest gratitude!
Recieving my Masters of Social Work, my emphasis was on complex trauma. But I have to say that I am finding these talks very insightful bringing together idea’s that are more hands-on. One concern I did have and maybe I mis-understood-but I don’t necessarily agree that paradox’ in medication being a red flag. Many anti-depressants after long term usage can create additional nervous system disorders and usage of them have been shown to be ineffective after even several months. But that aside, I finding this very helpful. I also appreciated one of the last discussions on the go-to for working with the child states. I always have had a gut response when clients tell me that they did inner child work and I think this discussion clarified it for me why I’ve had such a visceral effect when I have heard that in a clients history. Thank you so much for bringing us together, I truly appreciate this work.
It seems to be about staying present as a practitioner, letting go of judgements and being in a playful and curious state.
This was a wonderfully succinct and packed package os information. I have always felt lacking in empathy, and was pleased to discover that that limit might in fact be helpful. I will continue to utilize the multifaceted approaches that were described here; I hadn’t thought of walking as grounding; had relied on breathing and body awareness; I’ll use that!!The parts approach is very helpful, and I like the attention to avoiding shame response. Thank you all!!
Excellent, interesting, and informative video with therapists with advanced degrees. I appreciate you very much.
I have realized in this session where I may have wrongly diagnosed a few of my clients and have not even felt qualified to help with this but believe now that I can help with this. Looking forward to learning more.
I am not a practitioner, but as a person recovering from trauma, I learn a lot through these presentations. It also helps me know what to look for in seeking a qualified therapist, especially in dealing with what I now know is dissociation. Thank you for providing this material.
The screening questions for DID were very helpful as well as not jumping in too quickly about giving them a diagnosis. Thanks for a great presentation! Very practical!
I’m not a practitioner… I’ma person healing from trauma. Thank you for a helpful presentation.
I’m grateful for the awareness of terminal ambivalence. I struggle with that sometimes.
I’m super looking forward to next week’s talk.
One day at a time!
can visual hallucinations be a sign of a Childhood trauma? or disorganized attachment?
marvellous presentation
with gratitude
Hearing about the somatic approach sparked an interest to learn more about this approach.
It might be helpful to distinguish dissociation from physical medical issues. Thank you so much for these trainings.
I can’t thank you enough for sharing the content of these magnificent presentations and topics! I am presently a Functional Nutrition Counselor and bring to this work over 18 years of experience as a counselor. As you shared this new research and approaches, it helps me to integrate insight and tips to better serve my clients. Research shows that there is a direct correlation between the functioning of the body, especially the digestive system and the brain, and nutrition can play a key role in assisting clients and patients with the healing process from trauma. Inflammation in the body that may be caused by eating processed foods, or the client/patient is not aware of food sensitivities or allergies might trigger a heightened response in the central nervous system. When inflammation caused by this is reduced, the client/patient’s central nervous system is better equipped to respond to treatment.
Thank you again!
Thank you again!
I appreciate the information on the rationale regarding clients who self harm. I have often use the breathing and sighing strategies. I do have clients that hear voices. The questions to ask regarding voices is very helpful.
I will use every one of the skills and approaches for varying clients of mine who I thought about throughout the hour long presentation today. Fascinating, informative and SO needed for clinicians to understand and treat those individuals who have felt stuck and/or lost within the repetitive cycles, some many for years, of their varying trauma states. Todays focus on dissociation, how to identify it and what to do to facilitate the healing process both psychologically and physiologically, was extremely helpful.
CF psychotherapist in NJ
Thank you Dr. Buczynski. This training has been invaluable to me as a volunteer crisis specialist on 988 Suicide and several other crisis lines, including the Trevor Project. Nearly everyone who calls is struggling with the after effects of trauma. Dr. Bryant-Davis gave such a good description of the experience of being minimized, dismissed, or erased. Many suicidal people have to be convinced that in attempting to erase themselves, they are agreeing with the persons who have done this to them and completing their work for them. We have to find the part of them that is the outraged, protective adult and encourage them to fight back and live. Your panel’s discussion of working with the adult and not so much with the wounded child was so true. I didn’t realize until watching this program on dissociation how many of them are dissociated. Some people call and say, “I am dissociating.” They usually mean they are shutting down, although some have BPD and are in a manic state. Thank you for giving me some new tools and ideas to identify when they are dissociated or dissociating and work with them. Our goal is to get them safely through today’s crisis and eventually get them to a skilled professional who can help them recover and heal. The “window of tolerance” diagram and the subsequent discussion of how to down-regulate to stop cutting behavior was also a very helpful for understanding what we do in dealing with hyper-regulated or hypo-regulated persons. Many cutters and people having panic attacks call the crisis lines asking us to help them get back into their “window of tolerance”, although I’ve never heard that phrase before. They usually say they just need to talk to someone so they can feel better and not have the urge to cut or panic. The suggestion of using a “sigh” for people who can’t do the 4-7-8 breathing was also helpful. Could you provide these trauma sessions free to the National Suicide Prevention Lifeline staff around the country? Thank you again for your work. You are changing the world! P.S. We don’t ask, “Have you experienced trauma in the past?” because for many who call us, that will be an hour or more of horrible events and experiences, which will re-traumatize them, as you pointed out in the training on trauma, but we do encourage them to share what is on their mind today, because that is what is causing today’s crisis.
Thank you for doing the work you do. ❤️
Ruth Lanius’s tip for reinforcing/maintaining dissociation in the short term by placing intrusive thoughts/memories in a locked chest so that the client can continue to function until they are resourced with enough time and support to work through the trauma might really be of use to you. It allows the adult to keep functioning. You just have to be careful that traumatized parts do not feel dismissed and imprisoned.
Your approach of explaining that self harm is completing the work of the abuser is brilliant.
I am really very grateful for your generosity, I work as Psychology with patients in the field of human reproduction, high-risk pregnancies, gynecological problems, newborns with health risk (malformations, syndromes, prematurity, etc.), patients who face diseases such as breast cancer, ovarian cancer, etc. I will apply the knowledge with patients who, due to some childhood trauma, do not allow a medical examination to be carried out, or who face the need for amputation of the breast or womb or that their pregnancy is the product of sexual abuse.
I congratulate you for your noble work. I hope to make myself understood since my English is not very good.
Your English is beautiful and I am so touched that you are learning about this to better support your patients who have gone through some very difficult experiences. You are wonderful!
Thank you to all of the practitioners for sharing theirs experiences and advice. I’m
Working with a 17 Yr old girl who has described feeling dissociated on a regular basis for almost year. The main things I’ve taken away to help inform my practice is thinking about integration and coherence, as well as Pat’s thoughts about noticing the body and posture as representations of different parts of the self. The questions to check if possible dissociation in the room were helpful also.
Many many thanks for sharing your experiences. Best wishes, Colleen
In this broadcast and in many recent trauma workshops I’ve attended, there’s emphasis on going slowly, with astute awareness of how the client is reacting to the interaction between us at the moment, so we can keep the client in or on the edge of their window of tolerance. I’ve been much more careful in this regard, and find it extremely helpful in assisting the client in moving forward in their integration and healing from trauma. In many ways I let my clients know that we can go as slowly as we need to so they don’t become overwhelmed with their emotions. I check in with them a few times during the session.
Thank you for this really interesting material. I appreciate this it the result of many years of practice and to hear it is a privilege. I take many points from your session, but as a psychologist often carrying out evaluations, it was great to hear specific questions that can be used to better understand the nature of a person’s underlying difficulties. Thanks again.
I felt today’s session validated the way I work with my clients as well as assisting in hightening my awareness regarding tracking how a client is going and assisting them in doing this for themselves when possible. I also feel more strongly the necessity to maintain openness to how I’m doing as the therapist and ask myself questions re this.
Thank you so much for today.
Thank you very much for making this valuable training available to all regardless of socio-economic factors.
The screening questions are very valuable to add to my resources.
Ruth your comments are so encouraging, I always come away feeling empowered with a sense of validation for my practice.
Much appreciation 💛
GREAT SESSION WITH IMPORTANT INSIGHTS, THE IDEAS ARE SO HELPFUL, ALL OF THEM. THE KINDNESS AND GENTLE PACE TO SUPPORT CLIENTS WITH A MINDFUL APPROACH IS MY TAKE AWAY FROM THIS SESSION. THANK YOU!
I really enjoyed getting inputs and practical guidelines on identifying and intervening in spaced out clients. Also on triggers that therapists are often not aware and better self observational tools on conducting sessions.
Thank you so much!
I am not a therapist. Your work is supporting me to know and understand myself as I am guided and supported by my psychologist.
I am curious and open and want to heal do I can be the change.
Much gratitude❣️
🙏
I would love to get more teachings about structural dissociation.Thank you in advance
I like the caution to go slow!!
Is there any way we can pause the session and then come back to it.
The most important I heard is THE RESPECT TO THE SO CALLED CLIENT AS A SUBJECT.
Don t be carried away from the so called “good feelings” and “care” and treat the so called client as a child.
Remember the attachment issues and respect the need for the so called client to keep a distance .Trust and respect his need not to be touched embrace etc. till a change ,after the possibility of verbalisation along with the possibility of regulation , occures
Never ask the client to do smth physical with out me doing it with him.That is never look at the so called client as an object.
Loved and going to practice the breathing Janina Fisher (I think) showed
Respect the client s limits and take all the theurapetic time we both need for the so called healing.For a translation towards the possiblity of attachment ; of social tiews’ of t r u s t THANK YOU.
Ada Klampatsea Psychotherapist /analytic orientation.
This was very enlightening for me.I am naturally empathetic and I have a new understanding of how that can be experienced as threatening. My takeaway is to notice when this happens and to perceive it differently than I have previously so I will respond in a way that honors the person’s window of tolerance.
All the speakers, including Ruth, reminded me of the nuanes of both the client and therspiat.Our responses are so important especially as this need to dissociate erupts even with seeming well adjusted individuals. Unfortunatly, this is becoming more prevalent as our society is not regulated.
Thanks for the reminder to challenge ourself in the process and to do so with finesse of the interchanges between therapist and client. Seeing this lately more often and made this even more. It is easy to miss the subtleties. I had not been seeing the quality as dissociation, probably due to my own triggering.
I know sleep and calm in a dysregulated world is so necessary. I will strive to assure it is in place despite the recent demands of our societal problems. There was growth for me with all the speakers and I thank you.
I love learning from you all at NICABM. In my work as an Integrative Health Coach for people suffering with depression, this is so valuable for me to be able to identify issues my clients are struggling with, and receive professional advice on what to do and what NOT to do. Some very helpful advice I gained: to slow down, not take the client’s opinion of me personally, to be aware that I need to stay calm and matter-of-fact and express support but not pity (confused as compassion), and to invite the client to breathe WITH me.
I wish this were a required course for ALL people who work with people. (That’s almost everyone.) And all people who deal with their own trauma (that’s definitely everyone, to various extents.)
I also saw that I used to have a low level of disassociation mySELF, so it helped me understand ME a bit better. I used to space out and lose time a lot, and often lost touch with a sense of who I was/am. Now, fortunately, I feel a whole lot more clear, present, and with an integrated sense of who I am in my various roles and parts.
This was very insightful, useful content with genius ideas that make so much sense but I have not learned from other research and training, like how complaints of physical pain can be a form of dissociation.
thank you! I found usefull (very!) the structural dissociation model, the ”red flags” for indentify dissociation. I love how Pat Odgen explained how empathy and compassion can be couterproductive with certain clients.
Thank you so much. I have followed your 2 sessions. At some moments today it was difficult to understand because there weren’t subtitles. I’ll look again and try to understand more the second time watching. English is the third language I speak.Many thanks again.
I will use the” blame the nervos system”; the grounding; taking a break; the “window of tolerance”.
Thank you 🙂
As a therapist who survived trauma , I am more aware then ever what the impact is in the room with my client, always work step by step and even go back before your mind is wanting forward, and bring the explanation of trauma reactions as a clear body survive mode, I am very thankful for this contribution so I can work better with trauma and DID,
I will be more careful with empathy and always do physical activities together and use breathing during the session to ground.
I appreciated the reminder to go slow. really liked the integration of the use of the window of tolerance, and good practical info about not causing shame with efforts to help the patients regulate their emotions. thank you for providing this info for free.
Thank you for the opportunity. I am a Psychiatrist from Brasil, and the paid version is really above my financial possibilities. I will use the tips on investigating more closely DID and trauma/fragmented self in patients who are refractory to treatment with medication and have paradoxical adverse effects.
Thank you for clarifying the difference between dissociation and actual Dissociative Identity Disorder. I appreciated the distinction also between Schizophrenia and Structural Dissociation. It helped me understand some elements in a patient I’ve been treating for a long time, who often cannot ground, though I have know her for a long time. I now realize that during her childhood groundedness was dangerous, because it meant she would either encounter hostility and abandonment or “nothingness”, no response.
Mimi Dickman, Psychologist
Israel
Hugely helpful to remember that over-empathising can be a trigger for some clients with early trauma. Caregiver tendencies can reinforce a child part not integrating with the adult – remembering this is an adult in a child state and supporting the client to see that. This is something I will immediately put into practice.
Thank you so much – training as a counsellor has been an expensive journey and left me still with knowledge/practical application gaps, and these free webinars are very much appreciated. I have purchased others as and when I can afford them, and today’s free webinar will enable me to support the change in even more lives – I really valued your final words, thank you.
Thank you. I wonder if you could comment on working with psychotic (by which I mean aspects of functioning that are totally disconnected from any kind of shared reality) aspects fit into the dissociative picture
These are the things I will work on this week because of this session:
1) Being aware of how my nervous system connects to and responds to my clients and use this information to guide my intervention.
2) Asking two questions at the start of my relationship with clients; have you experienced a traumatic event in your past, something that was frightening for you, and 2) how can I make you more comfortable?
I’ve often felt incompetent and dysregulated and confused with some clients not knowing where to start. This session has helped me make sense of this and really does make me feel an awful lot better about myself as a therapist!
Thank you so much for this information – it will help me a great deal. As a naturopathic doctor providing therapy, most of my clients are dealing with CPTSD. But clearly, for one clients DID is also present in the room. Now I better understand how the fractured parts have remained unintegrated and are contributing to the disabling symptoms they experience with DID. I will apply these learnings to better identify and understand how to help those suffering with DID. I will be using adjunct therapists as well when possible.
Wonderful info–thank you for informing on this very under-diagnosed issue that is so prevalent.