Question 1

I work with a lot of youth who have experienced some level of trauma and often identify dissociation on some level. Does dissociation always need to be addressed if the client is functioning well?

Kathy Steele · Accepted Answer

It depends on what you mean by dissociation. Is the client just checking out or does the client have dissociative parts. I would suggest addressing any kind of checking out, even if functioning well. Also assess whether the client has OSDD or DID. Such clients can sometimes function well but the underlying dissociative disorganization will emerge under stress.

Question 2

Question 3

My client is distressed by "no attraction" to his partner during sexual intimacy, feeling "bored" or detached though liking her. This happened with others. Is he dissociating? What approach to take?

Kathy Steele · Accepted Answer

I would probably need to know a lot more. Sometimes narcissism and/or avoidant or dismissing attachment can involve boredom and detachment. Suggest you check for other symptoms of dissociation and try to distinguish whether this is a function of avoidant/dismissing attachment in which the client is defensively avoiding intimacy. You might ask if it is happening in sessions with you.

Question 4

I am working with an adolescent who is often feeling dissociated.  This person has a preliminary diagnosis of bipolar 2.  No reported history of trauma.  Does dissociation occur without trauma?

Kathy Steele · Accepted Answer

It depends on what the client means by feeling dissociated. A feeling of depersonalization or derealization; a feeling of not being present; emotional numbness; checking out or zoning out; watching oneself from a distance?? All of these symptoms can occur with other disorders, including depression and anxiety. Dissociative symptoms can occur under stress, illness or fatigue, and can be part of emotional distress that is outside the window of tolerance. Sometimes awareness of trauma is limited with amnesia, so that is something to double check. Or the client may have trouble tolerating an kind of emotion.

Question 5

Is dissociation the same as emotional numbness?

Kathy Steele · Accepted Answer

Dissociation can mean emotional numbness, but also can mean spacing out or having dissociative parts, as in Dissociative Identity Disorder. Sometimes people have alexithymia, which literally means feelings without words. These clients are not necessarily dissociating, but rather have never learned to identify emotions. There can be a general emotional numbness without a dissociative disorder, or a dissociative part that is numb may be prevalent in cases of OSDD or DID

Question 6

How can you help a client get out of a dissociative state while it's happening?

Kathy Steele · Accepted Answer

Generally I speak in a calm voice with very simple language, not talking too much. The prefrontal cortex is not online, so the client can't process complex information. I ask the client to open their eyes to get better perceptual grounding, and listen to the sound of my voice (hearing a human voice can activate the ventral vagal system). Small body movements first (bat your eyelids, move your fingers a little), then larger movements (deep breaths in and out, move arms around, stand up and walk around). I usually do these exercises with my clients so they feel I am with them.

Question 7

What strategies can be given to clients for them to help themselves get out of dissociation when it occurs?

Kathy Steele · Accepted Answer

The first thing is that clients have to be aware they are dissociating. I try to work with clients to recognize likely triggers, recognize early signs of dissociation (like sleepiness, a little spaciness, difficulty focusing). Then help them practice - a lot of regular practice is necessary - skills, such as breathing, somatic exercises to decrease activation in the case of hyperarousal or increase activation in the case of hypoarousal. Exercises that are less focused on noticing internal states and more on noticing the external environment, as many dissociative clients are so avoidant of inner states.

Question 8

Why is it that some people who dissociate find that mindfulness can exacerbate the symptoms?

Kathy Steele · Accepted Answer

If mindfulness is focused on being more aware of internal states that they want to avoid and they don't have adequate skills to cope, they can get worse. I try to start with getting grounded in the present using external stimuli - noticing and naming colors or objects, noticing the trees and sky as you walk, etc., and stay away from noticing inner experience until I understand the extent of avoidance and degree of skills.

Question 9

How can you tell if someone is dissociating?

Kathy Steele · Accepted Answer

It depends on how you define dissociation. If we look at it as checking out / zoning out / emotional numbness, we look for trouble staying present. Even if the client appears to be present, they might have the subjective feeling of not being present. If we define dissociation as a division of self, as in OSDD or DID, we look for amnesia (past and/or present); hearing voices (of dissociative parts); feeling as though one's body is controlled by someone else; a sense of one's thoughts being inserted or withdrawn or censored by someone else;  significant symptoms of depersonalization; the subjective sense of feeling like more than one person or of being highly fragmented; and more general identity confusion. These are often accompanied by significant depression and anxiety and sometimes self-harm and suicidality.

Question 10

Is it possible that many in therapy might be reciting a well-rehearsed account of events from a dissociated state without feeling much and therefore no increase in self-regulation or symptom relief?

Kathy Steele · Accepted Answer

Absolutely yes. This is very common in my experience. Often these clients go home and self-harm or have other evidence of dysregulation. I not only ask my clients if they feel present, but how do they know they are present. Often clients think they are present, but you can pick up significant symptoms of dissociation by asking how they know they are present. I want to hear things like, "I see and hear you clearly; my mind feels clear; I notice my emotions; I feel my feet on the floor." If clients are not feeling anything at all, then they are not likely to be fully present.

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