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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Well designed session for all levels of care from early career trainees to experts-in particular the focus on grounding for medical/dental/physio procedures. I develop with my clients a note for their provider outlining the client’s triggers, cues to watch for and preferred grounding strategies in the event they lose their capacity for speech (eg dentist).
I especially like the somatic approach as described by Pat Ogden (moving between 2 postures, back and forth) for clients who noticeably shift postural states but have limited awareness of their internal world/thoughts/images.
Thank you!
I work in a child disability service and today’s session has really prompted me to think about some of the parents I support with regard to understanding their child. As such, I don’t work with adults on their own issues but I really liked the refresher on paying very close attention to the adult’s window of tolerance and when noticing dis-regulation emerging, suggesting that we both take a breath and modelling a sigh! I really liked the prompt to consider that a matter of fact approach might be more tolerable than a very empathic approach with some adults; the value of attuned pacing and overall the sensitizing of my lens to consider possible parental trauma, amongst the families I support, even when that is not obvious or flagged. Thank you for a wonderful presentation.
Fascinating info as a trauma-informed yoga instructor working with veterans at PTS retreats. I learned from this video that our organization follows much of what was presented here in our Experiential Exercises and the Somatic Approach explores the modality that yoga offers. I like the verbal queues that are helpful when participants lose attention and of course practicing the breathing and imagery/meditation that I do in yoga class ties in with the other therapy of the retreat. Our goal at retreat, too, is to bring them “home”. I know I am “just a yoga teacher” and “stay in my lane” but deeper understanding of traumatic challenges and responses help when faced with situation. I enjoyed this very much. Thank you.
Hi Carol
Just a yoga teacher? This ancient system of healing underlies a lot of the modern somatic approaches and more general psychological approaches. You may feel you need to stay in your lane but don’t undervalue your wonderful skills, they are the cornerstone of many modern day therapies.
Blessings Andrea, Counsellor and trauma informed body worker
As a psychiatrist, I am really pleased that this information is being made available so widely. In the best of worlds, this would also be accepted and shown to residents training in psychiatry. There is a dearth of information about dissociation/DID (as well as denial) in the medical system. We need to make this a better world. Thank you so much.
I agree Carole! We have a similar problem in Canadian psychiatry training where the patient with complex trauma and dissociation is unfortunately dismissed, disbelieved and scapegoated.
I get most referrals from Gastroenterologists, One in particular believes that more than half of his patients have deep underlying trauma particularly of childhood. Chronic Pain Syndrome is the first manifestation.
lately the presentation also includes many auto Immune disorders needing
Psychotherapy.
Sadly the some patients with cancer get stuck in the ‘concrete-ness’ of it and find it difficult to work with the PsychoBiological side of this horrendous trauma /assault on their bodies ; actually believe that only
Narcotics can take care of this Persistent pain.
I cannot agree with you more. I worked in public mental health system in CA, and while PTSD is recognized as a disability by the State, it is deliberately left out from even screening in public mental health system. We have a long way to go to advocate for people with DID/OSDD.
For everyone: look up the International Society for the Study of Trauma and Dissociation (ISSTD), International Society for Traumatic Stress Studies (ISTSS) and traumadissociation.com for further reference. Michael
I am a Priest in France ministering to SRA survivors, who frequently exhibit DID and to other abuse victims with some form of structural dissociation.(in collaboration with a psychologist ans a physical therapist) Thanks a lot for thèse explanations and recommandations. I shall remember specially thé advice not to show too much empathy and compassion.
Thank you for what you do. It is not for a faint of heart to extend a hand to those who suffered SRA. Knowing people like you exist in this world make a real difference to the survivors, and make the world a better place, too. Sending supporting thoughts your way from the USA 🙂
Thank you for all the practical information. The thing I’ll take away today is not to make the client a physical action without doing it myself as the practitioner. Because getting stared at can be shame-arousing even if it is only taking a breath.
Thank you. Very informative and useful. I have worked a lot as a mental health nurse in assessment of people in crisis and have been with people when they’ve been in some really dissociated states. To be able to help ground by communicating “you’re showing me things are getting too much right now.” Is really helpful.
But how can we best support those who aren’t in therapy but are frequent attendees to the emergency department who are in these states. I guess more training around grounding and the ‘window of tolerance’ would be crucial otherwise mental health services are entering in to the risk of re-traumatising.
Now I work mainly with first episode psychosis and come across cases that feel more DID bit they are very much entrenched in the sympathetic response and aren’t able to verbalise without ‘dissociating’ or ‘the delusional beliefs coming to the for – it feels as a way to deflect the difficult emotions surfacing.
– Kent, England
Thank you – how would you work with a child who dissociates .
Professional Chaplains train with supervisors using their personal stories for awareness and interpersonal group feedback. The four “A’s” of training are anxiety, anger, authority, and attachment. My question is in the training of professionals, what is helpful both for group and individual training, when you notice the person is disassociating, because of painful areas of trauma in their history. I might add most chaplain residents in training are required to go to therapy, but I am asking how they can maintain their integration while in training and in the group, without shame.
Thank you for this webinar, so enjoyed the interaction of speakers and sharing, so good to refresh knowledge and skills. I’m not a lover of PD labelling, your approach mirrors my philosophy.
Slow down.
Track person and myself
Use of voice.
As a person who has a history of multiple traumas beginning in the womb as a sole survivor of womb triplets, and an abortion survivor, the most important take away from this session is the differentiation between dissociation and DID. In my therapeutic recovery, I have encountered so many that get edgy when I mention dissociation, and automatically assume it means multiple-personality-disorder or DID. There are great differences, and it is critical that helping professions understand this.
Also not necessarily to frame it as a mental health issue, but rather as a gift your brain gives you to deal with overwhelming situations, something we can learn to work with and regulate.
I agree. In my experience, too, that mental health professionals in general tend to be hostile towards dissociation, let alone DID/OSDD. Dissociation is a normal everyday experiences we all have to certain degree. It is such a shame that there is great aversion for even a simple acknowledgement.
Thank you for the information. I learned not to try to bring someone back for “spacing out” because it may be a mechanism they are using to defend a fragmented state, however by being too empathetic I may cause them to further dissociate. However as an LPN, I will need to refer to my supervisors as to the protocol when I sense a patient should not be approached physically and the procedure is time sensitive. Looking forward to more suggestions next week.
Hi Iea, we need more nurses like you who care not only about the physical well-being of patients, but also emotional states! In my experience, it is still helpful even when a person looks like “checked-out”, to let them know what you are going to do before you do it (such as “I’m going to stand now and come next to you.”) And to move slowly and not to make any sudden moves. Your patient might look like (s)he is not registering or silent, but there is a part who is observing it all. I think here were some great tips in the first session as well.
This has been most helpful. I’m a therapist in Wales, Uk and have worked with DID for many years. I’ve really enjoyed this last session… especially how much empathy can backfire. I have come to the conclusion recently that so many of my “ordinary” clients have some dissociation. I’m working with a new client right now who has disclosed a really scary event age 4. I don’t think there was anything else but I do believe that this event has changed my client into believing that whatever she does she is alone. That child part is uppermost in her big decisions. It was good to have teaching on just dissociation. I’m looking forward to the rest of the course.
I’ve just read a comment on “don’t let trauma define you”. I have another client who has been diagnosed with complex trauma. She refers to her PTSD as though it owns her..
thanks for your final comments….. i wanted to cry, I’ve lived through so many professionals not understanding DID
THANK YOU
Hi Linda, I’ve experienced extreme trauma from early childhood and I too felt that the trauma and I were one. I was unable to separate me and my feelings and my identity from the fear and shame and paralysis in life that the abuse left me with, ie: I was my trauma. So when various therapists tried to get me to distinguish my “self” from my experience of trauma, I was unable to and I ended up feeling very much alone in the room and completely misunderstood. Some people are just SO hijacked by their pain (and depending on the severity of it and the delicateness and vulnerablility of a person’s nervous system, it’s totally understandable) that you may need to proceed very very gently. My best wishes for your success in helping her, Michael
I just wish to express my gratitude to you all at nicabm for making it possible, for me and for many others, to watch it for free.
Thank you so much
I found this session excellent. I got great courage and insight as I am working with a client who has shared a lot of trauma with me. Thank you so much. I look forward tonext week.
As the Survivor Outreach Liaison for Beauty After Bruises charity I am often speaking with clients over the phone while they are in what they believe to be a crises. I can often “hear” and sense that they’ve become dissociative and need to ground. Asking them to stand up and take a few steps while reminding them that this is something they couldn’t do as a child during active abuse may be lifesaving. Such a simple thing to suggest, and yet may keep them engaged and safe on the other end of the phone line.
Thank you!
What a wonderful (valuable) application of lessons learned! Thank you so much for sharing, Kim. Deeply appreciated.
Janina fisher’s parts in the presentation really spoke out to me about taking the element of shame away by reframing an observation to a shared experience of a spacey moment. Really felt that it was a collaborative therapeutic experience from her. Taking a breath, a sigh together. Beautiful
From the first two sessions, I am more aware of what I have been taught and have integrated as a clinical psychologist. I feel more grateful for my training, and grateful for life long learning. I want to be more attentive and aware of what I am doing, especially with patients who I feel have continued to struggle despite treatment. I am now also contemplating again that as a therapist, fostering attachment can contribute to dysregulation, and unintentionally interfere with progress. Thank you,
I was particularly struck by learning that a trauma-based dissociative disorder could easily be mis-diagnosed as a personality disorder, creating a subset of untreated clients who are also being unintentionally misunderstood and mistreated (in every sense of the word). Control-Mastery Theory has a lot to offer in this regard about how clients “test” their therapists (and everyone else) in the service of their “unconscious plan for health,” and how therapist can (and must) align with that plan for successful therapeutic outcomes.
I was fascinated to hear that not responding (or having paradoxical responses) to antidepressants is a red flag for dissociation. Can anyone talk to the nervous system factors/biological factors that are in play that lead to this? And as always, what a wealth of knowledge in this webinar. Thank you, NICABM.
Thank you, So much. This was a great presentation. I will use this strategies to help with regulation with my clients. It help me to be more mindful and aware of the signs and how to adjust the right language. How much more important is the language and tone of voice with the trauma patients with dissociation.
I like your end statement. It is very similar to a handout I have used since first receiving in a training in the 1980s… “One person’s healing affects another… that person can I soire other family members… that family can help other families… these families can inspire whole communities… I missed much of today’s episode. I didn’t see the text on time. I have participated in the past in paid NICaBM trainings such as what to do with stuck clients. Keep the conversation going! Thanks for the text message alert to the training… Sorry I missed it… Deep into other training curriculum until May 2021 bit always keeping my eyes and ears open for I love yo learn and NICABM has been an asset to me amd my clients. Thank you for all that you do.
Very informative, it feels very compatible with the way that I work with clients (CFD / Person centred), I particularly liked what Janina said about responding to a client who is spacing out, welcoming that part, and avoiding the client feeling shame. Similarly, not putting the spot light on the client when inviting them to regulate / breathing exercise.
All speakers offered something very valuable. Thank you all.
I liked the tips about how the help clients reduce their shame around dissociation. The spacey part is here. Your nervous system is idling high. Let’s both take another deep breath together. Sigh
Totally get the spaced out behaviour.
Thanks for an interesting & very informative session.
Thank you for the information on disassociation. Good points on working with the entire client, not just the child parts. It is easy to go down that path. Also good point about not moving to quickly and checking in with the client. We may see the root of the problem clearly and move to quickly to the solution, but the client may not be ready or keeping the same pace. We need to take a deep breath slow down and check in with the client.
Hi all, thank you for your generous output of therapist training. I have a client that has difficulty grounding, they are triggered easily and often dissociate. The information from J FIscher below is very useful to me:
“Grounding to return: oh look the spacey part is here! Just in the nick of time, in a way that makes the client curious, instead of ashamed, and be mindfully aware of the parts. Psychoeducation about the window of tolerance: “oh it looks like the nervous system is taking over” at the time they are dissociation.Working with the breath – we have to do that breath with the client. “lets pause for a moment and take a breath” both breath together. And sigh, breathing out. The next breath in is spontaneous.”
Great session! I especially appreciated the information about the possible negative impact of empathic responses. Thank you!
Very helpful and integrative… I have had several years experience integrating yoga positions, especially standing positions of Mountain, Tree and Warrior ! and Warrior 2 as physical manifestations of grounding… I am wondering if others have tried utilizing yoga and breathing to connect the client’s body with the emotional and intellectual brain?
Just a quick thank you for providing this very informative presentation …with the option of watching once at no charge, or ordering the Gold Pkg. I have signed up for several other “paid” sessions, but my interests continue to broaden.
The biggest take away for me was the potential to misdiagnose clients with dissociation as having a personality disorder. Issues of attachment are so crucial in both areas. The lack of DID diagnosis brought up, poses an interesting area for clinical consideration.
Thanks again!
Thank you so much for sharing these techniques and strategies, and also how to identify things. Extremely helpful and practical, especially when just starting out. It helps to provide some direction to go along with the concepts I am learning.
I loved the discussion of the mis-diagnosis of trauma clients as personality disordered (Borderline PD, anyone?). I used to joke with one therapist client with massive prolonged trauma history that she had CATS – chronic adaptation to trauma syndrome. We organized our work around how brilliantly she had managed to not only stay alive, but love, care for others. I think of her courage often.
It can be hard and painful work to tackle integrating a past of trauma and the painful experience that results in a protective dissociation… but Susan’s reminder to organize her and her client’s work around HOW BRILLIANTLY SHE HAD MANAGED TO STAY ALIVE AND CONTRIBUTE and her recognition of her client’s COURAGE are, I think, essential ingredients in applauding the courage it takes to integrate body and mind and emotion and intellect to overcome past pain. This work should be a celebration of the body and mind’s ability to survive trauma through what may over time become dysfunctional responses, in the long term.
The tone of respect and admiration for a client’s courage and perseverance is inspiring and essential, in my view. Thank you again, Susan, for modelling this respect.
Thank you. I watched this because I am working on healing my own trauma. The take away that I had never heard before is asking my shadowed self what it was like when I experienced my trauma. I had never thought of approaching things this way. Thank you for your help and for making this information available both for practitionerrs and for those of us doing the work on ourselves.
I think the switch from an empathic response to a more matter of fact approach was a good reminder for me that too much empathy can trigger a client who might associate that voice with a trauma event. Thank you.
Thank you all for sharing your experience and wisdom. I really like Janina’s way of welcoming different parts with joy and kindness and taking the shame out of their arrival. Definitely using that. I have also encountered the hiding/invisibility defense in my clients often and know how tricky it can be to get past that ingrained habit. As an art therapist, I love that focusing on a medium or project can help the client express themselves in a way that is not triggering. Looking forward to next week!
Very useful. I work with 5yr olds as a principal in a primary school in NZ. Reviewing trauma and trauma approaches keeps me constantly coming back to the child. Gives me language for talking with the parent. All in a way that obviously has to be tempered with compassion and wisdom. Thanks for the opportunity.
Donal mclean
Thank you! This was so helpful for me to think about what I’m seeing and hearing in sessions to better identify when clients are dissociating. I will be able to use this information to help me be more aware of when I might be moving too quickly in treatment for a client’s comfort/safety.
I learned new assessment and interview strategies got better understanding dissociative states; I learned that I was already fairly aware, thanks to a great clinical supervisor; I increased my awareness for pacing trauma treatment well.
Thank you for the session. Some very interesting prompts. Best, Steve
thanks so much for validation that personality disorder needs to assessed, and that dissociation can be separate from it. NJW
Great thank you – lots of really useful ways to help my clients who dissociate – another great session from NICABM.
Great talk on disociation learnt so much
I’m a trainee Psychotherapist in my final year at university. This module presented on dissociation is so insightful and beneficial to use in my clinical practice. Its also free so thank you!!!
Excellent program. I am a psychotherapist for 35 years and still learn from this program.
Thank you. I really enjoyed this session. I especially connected with the speaker who talked about just because you hear voices does not mean that it’s a diagnosis of schizophrenia. I think it’s really important to remember that and share with clients because there is an incredible amount of fear to get through when clients share their voices. Looking at a DID diagnosis with the client is helpful . Thank you again so much for the free learning!
Extremely informative and professionally presented.
Difficulties with decisions! I thought of that as “executive function” issues, not a symptom of dissociation! Thank you!
Pardon my prolix: Helen – BRILLIANT, for reminding us of that with your pithy nugget!! (When placed as “executive function,” then self- blame and self- humiliation and a person’s sense of a “lack” in one’s willpower and judgement only worsens the already horrible occurrence of trauma. In a sense it RETRAUMATIZES the person. Too, a therapist oriented towards executive function will completely miss the boat and possibly work on a level of CBT and NEVER get to the REAL ISSUE which is inner emotional conflict of parts with dissociation, compounding the person’s suffering. Grateful again for your comment, it helped me ALOT! Michael. Addition: that is, the “faulty” executive function is not the CAUSE of the difficulties with making decisions or in taking action but the RESULT of a more insidious and destructive, yet INVISIBLE (dissociated) PROCESS. Your one sentence changes the whole orientation of how a therapist should proceed if they want to really help the client. Focusing on the ego’s executive function is a decoy when the underlying process of inner CONFLICT (the struggle of inner dissociated conflicted parts) is really the place for the therapist to go. Freud spoke of inner conflict non- stop and we’ve since forgotten it. Once again, thank you.
Working in a prison setting, I am often pushed to provide therapy ‘quickly’. Thank you for the reminders to slow things down
Thoroughly enjoyed this session, I missed the first one. Very practical and succinct guidance and explanations.
Early start to the day watching this from Australia ?? but well worth it.