Treating Dissociation

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

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.

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parts); feeling as though one's body is controlled by someone else; a sense of one's thoughts being inserted or withdrawn or censored by someone else; significant symptoms of depersonalization; the subjective sense of feeling like more than one person or of being highly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.

I spend a lot of time in therapy exploring with clients how their defenses help them. Then gently look at the other side: is there any way this hurts or holds you back? For example, does the client still have flashbacks of the experience that will continue if the experience is not integrated, or does detaching from the painful experience also involve detachment from positive experiences? Then I try to help the client explore fears of what might happen if they did acknowledge the painful experience. That also might help you both understand more of the intensity of the avoidance.

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.

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.

It is strongly recommended that clients with DID not switch with their children and remain in a responsible adult state at all times. The first step is to work compassionately with the client to help her control her switching. The second is to have the children assessed to make sure they are OK. If child parts are active, other more malevolent parts could also be active wit the children. My suggestion is to explain that the mom has PTSD rather than try to explain DID. It's so important not to treat parts like real people, and families have to learn this too.

DBT or ACT skills are helpful. I try to start with every day emotions that are small and help the client gain mastery over something like a very mild disappointment or irritation, staying away from traumatic emotions until more mastery is built. Pairing mindfulness with a focus on the difference between facts and feelings, and a focus on regulating physiology can be helpful.

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.

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.

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.

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.