Dissociative disorders

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