Lots of people talk about trauma and dissociation, but how can you is identify if a client is dissociative? Firstly, you need to be able to recognise if a client is actually dissociating in session. You also need to be able to recognise if the client has a pattern of dissociating that is interfering with day to day living.
How can you pick up if someone is experiencing dissociation in front of you?
Sometimes you, as therapist will experience a feeling of floaty-ness, sleepiness or absence that you’re not sure belongs to you. Other times the client’s eyes will seem different/vacant, or they will be triggered in such a way that they are qualitatively “other”. Sometimes it is a sense of “Where did she go?” or “Something is not quite right”. Check out your hunch. Ask the client how they are feeling, if they feel different in some way. Or you can simply observe that “Something just happened?”, and ask if the client noticed. Your response depends on how well you know the client. You don’t want the client to feel they have done something wrong, so your intervention needs to come from a place of gentle curiosity. Hopefully your client will be learning that- from your bones- you are non-shaming, accepting and curious about the dissociation.
Some clients can shift in the energy of their presence when they dissociate. So they might regress, or become someone who is very angry, or lost, or determined, in a way that the client does not usually present. This may indicate that the client is accessing a different part of herself. (Some people become itchy when I start talking this way about the client’s experience. I regard parts of self as a normal human experience, as is dissociation. Yes, it is true that both of these experiences exist on a continuum from helpful to unhelpful, but it is important to acknowledge that it is common.)
Sometimes the client will present as if they have gone to “another dimension”. When this happens your gut instinct will be to “bring them back”. And that is very much what you need to do! When this happens it will be important to see if you can work out whether there was a particular trigger prior to the client “leaving”. We don’t want clients to use dissociation in session, and if we can locate a pattern which can be avoided, then we need to use that knowledge in the service of our client remaining present in the session. My post, Grounding a Dissociative Client, looks at this important client safety issue.
Some people present as having very distinct parts, even to the extent of being unaware of the other parts’ existence. The client may feel fragmented, at war within, confused about what is real, who they are, how to make decisions. This may possibly indicate the presence of a dissociative disorder, as not knowing about discrete aspects of self is generally regarded as being further down the dissociative continuum… But labels are not always helpful, and I do not use them. It is the person who matters, their safety and their journey to a place within they can call home.
Some clients may be aware of a different part speaking but it may be news to them that this aspect of self has been influencing their choices, their reactions and their relationships. (That’s in some ways a normal process in therapy: don’t we talk about owning the Shadow, or disowned aspects of self? In some ways these are both forms of dissociation, but not the kind of dissociation this blog post is talking about).
How can you recognise a daily pattern of using dissociation?
We are looking to see if the client’s experience of the world is whole, integrated and co-operative on the inside. Or are there times when the client is deeply thrown by a part who acts on its own, out of awareness? Are you feeling, as therapist, confused about who is speaking at one moment and then who is speaking later in a session or on another day? Does it seem like there is more than one client? Are there unexplainable memory lapses? Lost time in a session that does not fit the normal patterns of working deeply? Does the client send emails with differing fonts or colours, together with shifting tones of voice? Does the client frequently forget sessions, or get confused about session times? You are looking for patterns of these things.
It is ok to ask a client if the room ever feels foggy or cloudy. Or have they experienced life as if they are watching from the ceiling? Or that things seem further away or closer than they really are? Or does their body feel like it is not theirs, or that the person in the mirror does not feel like them? Do they find they are a chameleon, not ever really one person in a settled sense? (We all change ourselves a bit to fit in, but this is much more pronounced.) All of these are indicators of dissociation.
I think it is important to be grounded and matter of fact about all of these dissociative experiences: they are simply (on one level) indicators of separate neural firing. The brain has protected the client, if you like. Or clients have protected themselves by putting trauma into silos in the brain, waiting for an appropriate time to integrate and heal, to fire together and wire together. That is a little simplistic, yes, but it is a thumb nail sketch of the physiological reality of a traumatised brain. Our job is to have the skills to work with these experiences once we have identified them, and/or to have good referral networks. See my future post, Are you qualified to work with trauma and dissociation? for further discussion.