Dissociation

Overcoming fears and resistance in psychotherapy

One of the great contradictions of working with people who are suffering is that, of course, they want to stop suffering – that is why they come to see you in the first place and generally keep coming, week after week, hoping for change. But sometimes those same people seem to do everything in their power to resist actually changing. They might not do their homework, instead expecting you to provide some kind of therapeutic magic in a single hour a week. They may say, ‘I know you’re right, but…’ over and over. Or they may resist the change process in countless subtle ways, which are hard to detect without a keen eye on the transference and what’s actually happening in the room.

In schema therapy terms, we could say there is at least one part of them, the Healthy Adult mode, that very much wants change. This is the mode that brings them to therapy in the first place, even if they are scared, mistrustful or sceptical that you can actually make a difference after a lifetime of suffering. And this is the mode we want to work with, encourage and build throughout therapy – I often use the metaphor of a weak muscle that needs training to become stronger and more powerful in the person’s life.

But of course there is often at least one part (and often more, especially with complex cases) of them that absolutely does not want to change. In mode terms, this is commonly the Detached Protector, which tries to protect them by avoiding strong emotions, upsetting material, or intimate connections with other people. Detached Protectors keep people in their heads, where it’s safe, or make sure relationships are superficial and so non-threatening. Clearly, this part is not overly fond of the emotionally intense and relationally intimate process of long-term therapy…

And of course we want to help reduce the impact of this mode, in our clients’ lives and especially in the therapeutic process, because it blocks progress. But it’s crucial that we also respect the resistance, because this is a protector mode – it is blocking change for a reason. Perhaps the person finds their emotions overwhelming, so has learned to avoid or minimise them to feel safe. They may have had strong messages as a child that being rational was good and emotional bad or a sign of weakness.

The uncomfortable comfort zone

Some people fear that if they risk change, things might get even worse. Better to stay in what I call the ‘uncomfortable comfort one’ – it’s not very pleasant, but it is familiar and therefore safe. So we never want to push our clients to change, or rush them. Real change takes time, patience, encouragement, understanding. We can work with the modes that are blocking change in all sorts of ways – using imagery or chair work, for example.

But we need to work hard to help our clients’ Vulnerable Child feel safe first, which in real terms means lots of attunement, kindness, saying the right things and, more importantly, behaving in trustworthy ways. And then change, slowly and miraculously, occurs.

If you would like to know more about overcoming your client’s fears and resistance, come along to any of the workshops below. And if you have any questions about my workshops, call me on 07766 704210 or use the contact form to get in touch.

Warm wishes,

Dan

Upcoming Schema Therapy Skills workshops include:

WORKING WITH IMAGERY: POWERFUL, TRANSFORMATIVE TECHNIQUES TO ENHANCE YOUR CLINICAL PRACTICE

In schema therapy, there is a strong emphasis on using experiential techniques such as imagery rescripting and chair work, which are seen as more effective and transformative than just talking about problems from the client’s past and present. This one-day workshop will teach you how imagery techniques can help rescript even the most traumatic experiences from your client’s childhood, such as incidences of abuse or neglect.

Cost: £180 including refreshments, all training materials and certificate of attendance confirming 6 CPD hours

Next date: 31st May 2019

WORKING WITH MODES: EMBRACING COMPLEXITY & ACHIEVING INTEGRATION

This one-day course will explain the concept of ‘modes’, which are different aspects of our personality that are activated in different situations and by particular triggers. In addition to a brief overview of the theory of schema therapy and schemas/modes, you will learn how to assess and formulate your clients’ modes, as well as specific techniques such as imagery and chair work for working with key modes.

Cost: £180 including refreshments, all training materials and certificate of attendance confirming 6 CPD hours

Next date: 21st June 2019

Why do your clients dissociate – and how can you help them?

Dissociation is an unconscious coping mechanism that happens when we feel overwhelmed, highly anxious or panicky, or under threat, so our brain decides that it’s too much to handle. The brain then shuts some of its systems down to help us cope, until the threat or overwhelm has passed. Clinically, we see dissociation showing up in problems like panic disorder, Borderline Personality Disorder, simple and complex PTSD and other trauma-related presentations, as well as a whole range of dissociative disorders.

In my practice, I have often seen dissociation as a key part of bingeing behaviour, where clients go into trance-like states or ‘zone out’ while they are bingeing, distracting themselves with TV, gaming or watching YouTube videos while they overeat. And of course we see dissociation as a central component of dissociative disorders including those with unexplained somatic or medical symptoms, and when clients have dissociated memories, trauma, or whole parts of their personality, as in Dissociative Identity Disorder (DID).

When I started working as a cognitive therapist I initially found dissociation confusing and hard to treat. It is confusing, certainly for our clients, who find it frightening and bewildering, but can be hard to conceptualise and work with for therapists too. That was one of the reasons I trained in schema therapy, because I needed a way to understand and formulate complex presentations like those involving dissociation, and a framework with which to treat them – ST was created for just that reason, so is brilliant at providing clarity and structure when it all seems confusing and overwhelming.

I’m also lucky enough to have two brilliant supervisors, who are both experts in treating trauma, complex cases and dissociative disorders – Robin Spiro, in New Jersey (the spiritual and geographical home of schema therapy) and Dr Fiona Kennedy, in the UK. Dr Kennedy co-edited the excellent Cognitive Behavioural Approaches to the Understanding & Treatment of Dissociation – highly recommended as a resource if you would like to know more about this fascinating area – and devised the Wessex Dissociation Scale, which will help assess the type and severity of dissociation your clients are experiencing. You may also find the Dissociative Experiences Scale helpful.

SIMPLE GROUNDING TECHNIQUE

When my clients start dissociating in-session, I always take time to help them ground or ‘associate’, coming back into the room, into the here and now, being present in their body and mind with me. If not, it’s hard to do any kind of clinical work, as they will not be ‘encoding’ the information I’m offering them; they may be spacey or numb, so not able to process anything emotionally; and are probably feeling highly anxious or unsafe for some reason, which I really want to address to help them feel calmer and reassured.

Here’s a great mindfulness technique to help your clients ground themselves in the present moment. I usually get them to start with some deep breathing (I use a technique called Compassionate Breathing, four seconds in and out, breathing abdominally, which really helps people feel calmer), then ask them to describe three objects in my office in great detail. So if they are describing a painting, that might be ‘I see a painting, which is a large rectangle, with lots of oranges and browns, I think is an abstract painting of a town, maybe? Or a face?’ Or whatever they see in it…

It’s import to elicit as much detail as possible, not just ‘I see a painting/plant/coffee mug’, as this both brings them into a mindful, moment-to-moment experience of their immediate surroundings, but also distracts from whatever thoughts/feelings made them feel so fearful they started dissociating. This works really well, even with my most anxious, dissociation-prone clients.

If you would like to know more about dissociation and how to understand/treat it, you might be interested in my one-day Schema Therapy Skills workshop, Working with Trauma & Complex Cases: A Schema Therapy-Informed Approach to Formulation & Treatment. I hope to see you there!

Warm wishes,

Dan