In my previous post Identifying Dissociation I mentioned the importance of keeping dissociative clients present during a session. Or of bringing them back to the room if they have energetically absented themselves. (Believe me, you will usually know if this has happened.)
I start with a foundational belief that if a client is dissociative in session, then the dissociative pattern needs to be addressed. It needs to be a priority. Otherwise we do not have a client in the room. Sure, they may still be sitting on the chair, but they are not usefully engaged in the therapeutic process. So our interventions need to be tracked so we can identify if we are contributing to the dissociative behaviour in any way. Also, we need to be learn what works for this particular client in the battle to remain engaged with the therapeutic process, rather than absent themselves.
Note: Some clients may have learned to come to therapy in order to dissociate. Look for my future post Getting Hooked on Dissociation.
The client is doing nothing wrong when they dissociate: it is a learned response which has kept them alive/sane/functioning. We need to join with them discovering together how we can help them be in relationship with us: the very thing that may be triggering them. (See my posts about the therapeutic relationship: Relational Psychotherapy and Working Relationally).
There are several tools that may help your client either “return to the room”, or not “leave” in the first place. Many of these tools are useful to most clients.
Use the body: If I sense a client is dropping into deeper awareness or feelings that are distressing, I ask them to place their two feet on the ground, and to notice the ground under their feet. Sometimes I get them to notice that the floor will hold their feet without them working hard, to feel the floor actively pushing up against their feet. (a teaspoon of mindfulness?) If they have “gone” I encourage them to try to move slightly in the chair: this is especially useful if they have “frozen”: a learned response to extreme terror/trauma. Sometimes they can wrap their arms around their body.
Use your voice: Sometimes I can sound like Kath and Kim: “Look at moy, look at moy”, I chant. The sound of my voice, the reminder they are not alone, the connection with me…any of these things may help the client stay present. (Unless my presence is the trigger! But that is another post)
Pacing: If you think you are moving slowly with the client, and they are triggered, then you need to slow down. This work is S-L-O-W. Respect that, don’t fight it. Breathe into the pacing that works for this client. It is their process. It may feel laborious and like you are getting nowhere…But remember that you are not trying to get anywhere. You are attempting to facilitate the client’s presence in the room. To be “there”. Not anywhere else. Not moving. Not making progress.
Self-Regulation: I teach the client to rate their level of distress on a scale of 1-10. (Thanks to Babette Rothschild, The Body Remembers (Books) for this tool). We practise this skill when the content is fairly innocuous: “Zero is very relaxed, 5 is alert, 7 is uncomfortable, 10 is “I want to leave”. I might refer back to a moment earlier in the session and see if the client can assign a number to their level of distress. The instruction is given that 8 as a rating is getting too high, and they need to learn to go to the safe place inside to bring that number down to 4 or 5. I emphasise they are not to be noble, and push through, as going too fast will actually slow us down. Then I invite the client to practise going to a safe place, having a mini holiday from the work of therapy. So they may invent a safe place, or remember a well-known safe place from reality. Once they have entered a meditative space internally and have indicated they have found a safe place(usually with a nod), I use each of the senses to deepen the client’s experience of their safe place. (Like a guided meditation in a gentle way, matching the client’s capacity). I take the time to practise going to the safe place several times in that session. Whenever the work gets demanding we take a break: I want to model the importance of slowing down. The next session I would start with a safe place practice.
Educate: Give your client basic information about trauma and dissociation. Give them information about what is happening, but don’t drown them in technicalities. (Clients are often not ready to hear details: they will find this out for themselves when they are ready.) Normalise their reactions to triggers as appropriate life-saving coping strategies which have been important until now. (Shame is ever present where there is trauma, so this step is important.) Teach that now it is time to add to their repertoire, to be more present. If you think they are ready teach some basics about the brain and what happens in the brain when they are triggered. This helps normalise their responses, assuring them they are not “crazy” as some suspect they are.
Teach mindfulness: At first this may be very basic and short in duration. I provide a glass of water in session to help the client be more grounded (and hydrated), and sometimes we drink together, both sipping our water slowly/mindfully. We play with the speed of that, also a grounding thing to do! Sometimes mindfulness practice may be as simple as asking a client to put hand cream on in a focussed attentive and compassionate way at home. Instead of slapping it on the hands as they race to work, get them to take a minute or two to be gentle and present. Check out with the client if they feel comfortable to try this…The very idea might be too much. (It is a good idea to check if this was too much for them in the following session.)
Laugh. Play. Take time out. Vary intensity in sessions. Try to balance hard sessions with lighter sessions where you practise mindfulness, work on giving information, building skills. Get up and move together. Perhaps a stretch would be good?
Check with the client: What do they need. Encourage them to find and trust their inner wisdom. Trust their knowing. You may be sitting too close or too far away for the client. Check this out if you think it may apply. I have counselled a dissociative client with my back to them for several sessions so they could stay present. Be open, accepting and respectful of what works for the client.
Pay attention to breathing: I may just work more generally with awareness of the breath, or I may teach slow belly breathing to the client. Often I will match their breathing rate with my own to facilitate a shift, or even to deepen empathy. The simplest intervention I use is to help the client recognise they have stopped breathing, or they are breathing very fast, and to see if they can modify that.
Go back to basics: Track the session, observe the patterns, do the work. Avoid getting lost in the drama.
Ground the client at the end of a session so they can travel safely. Leave time for this. Take it seriously. We have a duty of care to do our best to make sure the client can get home safely. I might ask clients to name 10 items they can see in the room: chair, lamp, painting etc. Or I might use a few of the senses to get them to notice things in the here and now: hearing, seeing, feeling etc. Or I might ask them what they had for breakfast. I want the brain to kick start in a different mode. (Think NLP/TA/Neurophysiology). Sometimes I ask the client to find a café and have a cuppa after the session, or sit in the car for a few minutes. I will also check their plans for the day, and see if we can transition to those plans, again shifting focus to the everyday.
What did you have for breakfast?