Month: October 2022

10/05/22 (Wed)

How does trauma affect the brain and body – and why can this trigger dissociation?

You’ll get clear strategies for addressing dissociation in a session (even when it’s subtle) and hear how to bring your client back online quickly and skillfully.

My guests will be Bessel van der Kolk, MD; Peter Levine, PhD; Pat Ogden, PhD; Ruth Lanius, MD, PhD; Janina Fisher, PhD; Kathy Steele, MN, CS; Stephen Porges, PhD; Thema Bryant-Davis, PhD; and Bethany Brand, PhD.

Here’s the agenda for today’s session:

• Key Signs and Symptoms That Let You Know Your Patient Has a Tendency to Dissociate
• Structural Dissociation – What It Is and 3 Distinct Ways to Work with It
• How Trauma Affects the Brain and Body – and Why That Can Lead to Dissociation
• Common Mistakes That Stall Treatment with Clients Who Dissociate
• Two Difficult Challenges of Working with Dissociation – and How to Overcome Them
• When Dissociation Is Triggered in a Medical Environment: Key Considerations for Medical Professionals

Working with Structural Dissociation: Link

Three Warning Signs of Structural Dissociation: Link

Trauma, Shame, and the Nervous System – A Polyvagal-Informed Approach to Working with Hypoarousal: Link

How to Differentiate Between Dissociative Identity Disorder and Schizophrenia: Link

Notes:

• Trauma does not have to be a life sentence. Do NOT let it define who you are!

• How to precisely identify dissociation:

Dissociation means Dis-association. The trauma is stored in a different part of your mind, a different part of your being. Trauma can fragment a patient’s sense of self.

Your patient’s self splits into two or more parts. One part holds on to the trauma, another part tries to go on with daily life.

• Key signs and symptoms to know if your patient is experiencing dissociation:

• Introduce the structural dissociation model:
• When your patient’s defense parts are working in opposition with each other, it can become highly stressful for the patient and everyone around it.
• 3 Red Flags:
• a. Paradoxes and Contradiction:
• This signals the inner struggle between two parts
• e.g. patient reports struggling with shame, but at times also talks down on others.
• The patient may alternately Devalue and Idealize the Therapist.
• b. Terminal Ambivalence:
• Clients can’t move forward or take a step forward, and then self-sabotage.
• The sabotage may come from a part that doesn’t trust taking a step forward.
• c. One of the biggest red flags: The client reports that they’ve had no benefits from any medications, or paradoxical side effects (e.g. SSRI that’s normally activating, puts the client into sleep).
• Somatic indicators of dissociation
• d. The therapist starts to feel “out of whack” with the client in session:
• We can feel coregulated or dysregulated with another nervous system.

• What to do if your patient dissociates in session?
• a. Clinicians should take a deep breath. Try not to rush in to explore parts right away. It can become too overwhelming for clients.
• Dissociation can also involve patients erasing themselves, to not feel, and to neglect themselves when experiencing inter-personal trauma.
• Help the client with Visibility, not Erasure ~ to see themselves.
• Help your client with ~ Coming Home ~ Integration with themselves.
• The four “C’s” to help your patient who dissociates:
• Cooperative ~
• Coordinated ~
• Coherent ~
• Cohesive ~
• 3 Approaches:
• Somatic ~
• help your patient find the posture that includes both parts (Posture and Movement)
• Use the body to bring those parts together and integrate them
• Experiential ~
• help your client to meet a hated, unacceptable part of themselves and let that part tell them what it felt like back then
• Cognitive ~
• The goal is to help your patients investigate their thoughts and help them identify which parts of their thoughts belong to their parts.
• Thoughts are just thoughts.
• Let them become mindful that it’s just a thought that they’re having.
• Help them find the part which has that thought.

Help your patient ground and return to the present:

• Signs that your patient has started to dissociate:
• attention starts to fade, the patient starts to zone out, quick eye movement then things shift, shallow breath, less responsive.
• a. zoned out eye gaze
• eye movement
• lack of responsiveness
• shallow breathing
• Ask, “Are you with me?”. There may be a delayed response, and you know that the patient has drifted off.
• Ask, “How much of you are with me right now?”.
• Ask, “What do we need to do for all of you to be safe here?”.
• e.g. walking ~ let them imagine they can walk away from the threat.
• When an adult has experienced adult trauma, they may need help from you in completing the action they need to take to walk away from the trauma.
• If a client starts to space out:
• a. Let your client know that the “spacey part” is here now. e.g., “Oh, look, the spacey part is here” to bring about their curiosity in exploring this further.
• If you say, “I’ve noticed that you’ve become spacey”, then it might cause the client to feel shame.
• b. Also, use psycho-education to decrease shame. Let them know that it’s because their nervous system is becoming overwhelmed. ~ “The window of tolerance” helps your patient track their overall level of arousal. This can help your patient talk about their dissociative symptoms, without triggering shame.
• c. Work with breath. Do it with them, so your client won’t feel like they’re doing something and just being stared at. Do it together with your client. And “Sigh” your breathing out.
• As soon as your “sigh” it out, there’s then a relaxing in-breath that follows.
• d. Polyvagal-based approaches are another strategy (check up more on this)
• e. Bring up positive imagery and containment imagery: e.g. imagine putting all the intrusive material into a chest and putting it away somewhere until your client is ready to deal with it.

• Common mistakes that can stall treatment:
• If your client is having a difficult time getting regrounded, then you know that what you were talking about previously is too much for your client right now. The patient has gone out of their “Window of Tolerance”.
• Usually, the self-harm starts in a state of hyper-arousal, e.g. patient starts scratching themselves during therapy.
• a. Empathic Content with the Client:
• This comes from a helpful state, but it can stimulate parts that are not ready to be integrated, especially parts with attachment needs. Be careful of stimulating those needs too quickly.
• Sometimes, an empathic tone or closeness might cue threat, esp. for clients who have experienced sexual abuse. Instead, be more matter-of-fact, and keep the client at the edge, but not over the edge. – Track your patient’s nervous system.
• Ask the client, “How are you doing?”, or “Are you still with me?”, or “That was a bit too much, was it?”, etc.
• b. What can keep patients “stuck”? A most common finding is by overlooking dissociation.
• If the client has a history of different interventions that haven’t worked ~ it can be because the client’s dissociation is being seen as Fragmentation (a personality disorder).
• See dissociation as “spacing out”, and “fragmentation”, and “compartmentalization”.

• How dissociation can be triggered during an examination, how to try to prevent it, and what to do if it occurs.

• Physical symptoms can be a form of dissociation ~ Bodily symptoms as a way to dissociate away from emotional experiences. Complaints of physical pain and dissociation from emotional trauma.
• Your patient might even start talking like a child ~ dissociating back to previous traumatic experiences. The therapist should back off, don’t touch the patient. Let the patient know that they’re safe.
• Always observe your patient’s responses.
• See if your patient has sleep disruptions, nightmares, etc. Ask if your patient has experienced any traumatic events. Ask if there’s a better way to work together.

• How to differentiate dissociation from dissociative identity disorder (DID)?

• DID: appearance change, look differently on different days
• Assess for dramatic changes in your patient’s presentation
• Ask if your patient ever loses chunks of time. If they say yes, and they can’t remember what happens when they lose time, then the chances of having a DID is higher.
• Ask if they ever feel detached from their own body. Does their body ever feel like it doesn’t belong to them?
• Be very sensitive when you ask about “voice-hearing”.
• In patients with early life trauma and dissociative experiences, voice-hearing is very common (and not that the patient has schizophrenia).
• Often people with schizophrenia do not have child voices.
• The earlier the onset of voices, the more likely that it’s DID (not schizophrenia).
• If it’s more than 3 voices, then it’s more likely a DID (and not schizophrenia).

• If the patient is hostile to the therapist:
• Don’t take it personally. Understand that that part is trying to be protective.

• Working with your patient’s child parts:
• Recognize that this is an adult in a child state. Don’t work with them as if they’re a child.
• Get to know what the concerns are with that child state coming out and not willing to remain grounded as all the parts working together.
• Goals for working with DID:
• Stabilization ~ Help them identify when they’re getting aroused (hyper or hypo). What are their symptoms?
• Improvement of safety
• Development of the relationship

In this week’s QuickStart Guide, we cover: 
 

• Four Imagery Practices That Can Help Calm a Patient’s Nervous System When They Dissociate
• Three Distinct Approaches for Helping a Patient Integrate Their Dissociative Parts
• Specific Questions to Use When Screening for Dissociative Identity Disorder
• How to Help Clients Reframe Negative Thoughts About Dissociation

1. Three Signs That Structural Dissociation Could Be Stalling Your Client’s ProgressAccording to Janina Fisher, PhD, there are three explicit red flags that can help you recognize structural dissociation.Dr. Fisher: [1. Paradox/Contradiction] The first thing to look for are paradoxes and contradictions. For example, the client reports struggling with shame, but at times we notice that client also is very superior. They talk about how, “My boss is so stupid,” or “My partner is emotionally unintelligent.” Right there is a contradiction. A client of mine had such fears of leaving her house, she was so agoraphobic, except in the middle of the night, she would go running at one or two in the morning.One of my favorite signs, is when the client alternately devalues and idealizes the therapist. Again, it’s a paradox. If I’m such a wonderful therapist, why are you attacking me? And if you’re attacking me, and if I’m so terrible, why are you still with me?Those are two different parts. The attached part, or cry-for-help part, idealizes the therapist. On the other hand, the fight part is hypervigilant, mistrustful, and wants to keep the therapist at bay.[2. Ambivalence] This is when a client cannot make a decision about big things or little things. They can’t go forward. They take a step forward, and then they can’t take the next step. Or they take a step forward, and then they “self-sabotage.” I came to realize that the sabotage may come from a part that doesn’t trust taking a step forward.[3. Somatic Indicators] One of the biggest red flags is clients who report that either they’ve had no benefit from any medication that they’ve tried, and they’ve tried them all, or clients who report paradoxical side effects. For example, an SSRI that is normally activating puts the client to sleep.

2. Three Distinct Approaches for Helping a Patient Integrate Their Dissociative PartsHere, Pat Ogden, PhD, and Bessel van der Kolk, MD, offer three distinct approaches that can be useful when helping a patient integrate their structurally dissociated parts – a somatic approach, an experiential approach, and a cognitive approach.Dr. Ogden: [Somatic Approach] I track for how parts are represented through different movements and postures in the body, and then use the body to help integrate them.For example, with one client, she had a collapsed posture. Then there was another posture that was hopeless. It was a shut down, hopeless state. Yet another part of her was assertive and wanted to move through the world and accomplish things.So if we’re working with integration, we are at risk of overriding certain parts through our physical resources that we develop. I asked her to go back and forth between that part that was assertive, and the part of her that felt collapsed and shut down, and I said, “Let’s see if we can bring them together through your posture.”So she would explore back and forth until she could find the posture that included both of these parts, and then that became her homework. I’d say, “For this week, why don’t you pay attention to that posture that doesn’t override that collapsed part but instead includes it.”Dr. van der Kolk: [Experiential Approach] I want to stay in the experiential mode where people learn to meet themselves, a hated or unacceptable part of themselves, and set up a dialogue with that hated, unacceptable part. I want to have them tell that part what it was like back then, and really help them make the separation.“Right now, feel your butt in the chair. I’m here. Do you feel scared of me now?”‘No, I don’t feel scared of you.’“Now, let’s go and visit that little kid who got molested, who I have despised my whole life for being so weak and so whiny that she couldn’t take care of herself. That’s not me as an adult – that’s me as a child.”But the two get blended, and our job is to try to unblend these parts.Dr. Ogden: [Cognitive Approach] When working with dissociation, it’s helpful to identify thoughts as thoughts, not as the truth. If the client says, “It’s all my fault,” I’ll say, “So that’s a thought, isn’t it?” I might even ask, “What happens when you have that thought?”We’re putting a gap between their identification with that thought, and it’s a way of helping them become mindful. That’s really helpful with all clients, but especially with highly dissociative clients. That can prevent dissociative patterns, because you’re catching them before they’ve fully gone into the part that holds that thought.Then I might say, “Well let’s find out about the part of you that has that thought.” Right away then, we’re working with communication. There’s the part that has the thought, and then there’s the bigger part that can stay with me and learn about that part.It’s the same with terror. If the client says, “I’m so terrified,” I’ll say, “Okay, there’s a part of you that’s terrified. Let’s find out about that part.” We’re working with the communication rather than having the client identify with, and go into, that terror.When a client can become curious about how they’re organizing their experience internally through their thoughts, emotions, movements and sensations, that is so empowering. You’re getting underneath the content to what’s really driving the content.

3. Key Signs That a Patient Is Beginning to DissociateIn order to skillfully work with dissociation, it is important to recognize when a patient is beginning to dissociate. Here, Ruth Lanius, MD, PhD, offers a few key signs to look for.Dr. Lanius: If attention starts to fade. If people start to look zoned out. Often, their eyes change, they’re looking upward. You see a lot of the white of the eye. Sometimes, you see quick eye movements. Sometimes the breath becomes really shallow, and people are much less responsive. Those are all things to watch for.

4. Grounding Techniques That Can Help Your Patient When They Dissociate in a SessionA patient may begin to dissociate during a session. When that happens, it’s critical that we have strategies to help them get grounded and return to the present. Here’s how Ruth Lanius, MD, PhD, and Janina Fisher, PhD, work with their clients when they dissociate.Dr. Lanius: I always ask, “Are you with me?” There may be a delayed response, and then I know they’ve drifted off. Then I ask, “How much of you is here right now?” What I’ve learned is that people can always answer that question. So they may say, “50% of me is here right now.”Then I would say, “What do we need to do for all of you to be here? Or most of you?” This could be standing up or a change in posture to feel more powerful. I often find walking helps people to ground. It helps make them aware that now they’re an adult and they can walk away from whatever they want to walk away from. That can be very grounding.Dr. Fisher: If a client starts to space out, I say, “Oh, the space-y part is here. How interesting.” This idea that spaciness can be a part is so effective because if you say to a client, “I notice you’re spacing out,” it triggers shame. But if I say, “Oh look, the space-y part is here, just in the nick of time. How lovely.” It can bring the client back in a way that makes the client curious, rather than ashamed.If I’ve given clients psychoeducation about the window of tolerance, I can also say, “It looks like your nervous system is getting up there. Do you notice that too?” If I blame it on the nervous system, clients don’t feel shame. They say, “Yeah, I am getting a little hyper.” Then I say, “Yeah, your nervous system idles high. It really is sensitive.” Or I say, “Yeah, your nervous system is really traumatized. We’ve got to help it.”If the client’s not breathing, I’ll take a breath. But we never ask a client to do something physical without doing it with them. Otherwise, the client is going to be asked to do something, and then get stared at, which is very triggering. So I’ll say, “We’re doing a lot today, and I don’t want you to get overwhelmed. Let’s both take another breath.” Then I’ll model a sigh, which is my favorite breathing technique. Because as soon as you finish sighing, there’s a very relaxed in-breath, that’s very easy, very fluid. So it’s a very easy way to help people regulate their breathing, which regulates the nervous system.

5. How to Avoid Common Mistakes That Can Stall Treatment with Clients Who DissociateWorking with dissociation can be complex, and sometimes a small misstep can stall treatment. Here, Bethany Brand, PhD, Pat Ogden, PhD, and Janina Fisher, PhD, discuss some common mistakes that are made when working with dissociation – and how to avoid them. Dr. Brand: If a client has a very difficult time getting re-grounded with me, and it’s taking an inordinate amount of time, then whatever we were just talking about was too big. If a therapist moves too quickly, some people begin to get very hyperaroused and agitated. They may start to engage in self-harm right there in session, because that’s their way of regulating. They may be more prone to start drinking, using drugs, or self-harming outside of session, too. If they start engaging in self-harm in my office, I say, “when you’re scratching yourself, you’re showing me that was too fast. I might have missed it right there. Let’s work together so we can both see when you’re starting to get flooded with too much emotion.”Dr. Ogden: One common mistake is around empathy, empathic contact, and resonance with the client. This comes from a very compassionate place for all therapists – the place of wanting to help. With a highly dissociative client, that can stimulate parts that are not ready to be integrated, especially parts with attachment needs. Most of our traumatized clients had attachment needs, but theirs were not met. So we have to be careful about stimulating those needs too quickly before the client has the integrative capacity to tolerate the strong attachment-related emotions. Instead, I would be much more matter-of-fact, and I would track the response. If I track that they’re going over the edge, I get more matter-of-fact and more definitive, with less emotional contact. If the client’s starting to go too far over the edge, I often ask, “How are you doing? Are you with me?” In that way, I’m also getting them to regulate. I might say, “That was a little too much, wasn’t it?” And they’ll say, “Yeah.” That track, contact, and recover are essential.Dr. Fisher: The most common reason I find that a case has bogged down and gotten stuck, or the client has a history of many different treatments, none of which have worked – I would say probably 75% of the time, the answer is that this client is structurally dissociated, but no one has picked up on it. We certainly recognize spacing out as dissociation. But fragmentation, or structural dissociation, is most often diagnosed as a personality disorder. The fact that we underdiagnose structural dissociation and dissociative disorders means that we have a whole subgroup of traumatized clients who are not improving because we see them as personality disordered, rather than as fragmented.

6. Dissociation in a Medical Environment: Key Considerations for Medical ProfessionalsDissociation can show up in many ways in a medical environment. A patient’s physical symptoms can be a stand-in for emotional trauma. Some patients may begin to cry or talk like a child during examinations. Peter Levine, Ph.D., Kathy Steele, MN, CS, and Bethany Brand, Ph.D., highlight some key considerations for medical professionals to keep in mind with their patients. Dr. Levine: A reason why people go to see a primary care doctor – when there’s nothing physically wrong – is there’s some kind of emotional trauma. Physical symptoms can be a form of dissociation. Instead of feeling the emotion of the trauma, they have bodily symptoms. They may have all of these physical symptoms as a way to dissociate from the emotional experience. Ms. Steele: In a primary care setting, the provider can notice when a client’s spacing out in the exam room. They can notice when a client is in that fight, flight, freeze kind of experience. Maybe this person is switching to a traumatized child state. Primary care providers can be given some simple instructions on what to do if they see that: back off, help calm the client, don’t touch the client, and create a little distance from them. Say, “You’re safe. I’m going to stand here and just talk to you. I’m not going to touch you. It’s okay for you to sit up.” Give them instructions, help them feel safe and don’t continue to do what you’re doing (like give an exam). It should just immediately stop. The same with giving injections. Medical procedures can be very triggering for clients because it’s reminiscent of being held down, not having control, and being in pain that somebody else is giving. It’s a big trigger situation. Dr. Brand: I think anybody who is working directly with patients should be asking general questions of, “How is your sleep? Do you have nightmares?” Often, trauma survivors have tremendous trouble with sleep. You also can ask, “have you experienced any traumatic event or anything that was terribly frightening to you in childhood or adulthood? Is that likely to have an impact on how we work together? What would be the best way for us to work together so you feel in control?” It’s helpful to ask about that and be sensitive, and give them some room to tell you, “Well, let’s just go slowly, and could you have your nurse in here with me?” That can help a client get through the exam.

7. Specific Questions to Screen for Dissociative Identity Disorder (DID)Here, Ruth Lanius, MD, PhD, provides the specific questions she asks her patients to screen for dissociative identity disorder. Dr. Lanius: I start by asking, “Do you ever lose chunks of time?” If the person says, “No, this never happens to me,” then I think it’s unlikely. However, if the person says, “Yeah, there are minutes, hours, sometimes days,” then I ask, “do you remember what happens when you lose time?” If they say, “No, I have no idea,” then the chance of having dissociative identity disorder is higher. Then I follow up with, “Do you ever feel detached from your own body?” If they say yes, I get them to explain that. I would ask the follow-up question, “Does your body ever feel like it doesn’t belong to you?” And if they say yes, then again, it’s much more likely that somebody has a dissociative identity disorder.I also ask about voice-hearing, but you have to be very careful when you ask about voice-hearing. People often don’t disclose it because they’re afraid they’ll automatically be diagnosed with schizophrenia. So I normalize it, and say, “We’re now finding out that in people with early life trauma, voice-hearing is very common. So I’m going to ask about that and rest assured if you are experiencing that, I don’t think you automatically are suffering from schizophrenia.” When I say this, people will disclose hearing voices much more readily.If they say yes, I would ask about child voices because often people with schizophrenia don’t have child voices. I would ask about the onset of voices. Again, the earlier the onset of voices, the more likely it’s a dissociative disorder, not schizophrenia. I also would ask, “How many voices do you hear?” If it’s more than three voices, it’s more likely a dissociative early life trauma or dissociative disorder.

8. Two Challenges of Working with Dissociative Identity Disorder (and How to Overcome Them)According to Bethany Brand, Ph.D., there are two common challenges practitioners face when working with a dissociative identity disorder. The first challenge is when a patient blames or is hostile towards, the practitioner. Dr. Brand: Don’t take it personally when you’re being criticized. Understand that part of the mind is doing its very best to keep the patient safe. Based on their past history, they know that others can be harmful. They may have the understanding that if they let down their guard with anybody, they’re going to get hurt. They may be trying their best to not attach to you because they have attachment fears. That’s a crucial element. The second challenge comes up when the therapist gives too much attention to a patient’s child parts. It’s critical to keep in mind that the child parts are the traumatized parts – not the adult we’re trying to form a relationship with. Dr. Brand: Often, therapists are drawn to child parts. If a therapist starts to work with DID in childlike states – because they’re sweet, they’re hurt, and they need help – you can start to lose a sense that this is an adult with a child state. Some therapists, out of the compassion in their hearts, start to work with the client as if they are children and attend to that too much. Instead, what’s more, helpful is, rather than going that early, to get to know what the concerns are of the persecutory voices. You might ask, “What is the fear that comes up when I’m talking to you about getting grounded, and you’re trying to interfere or interrupt that process? What is your concern about grounding? Why does that feel like it’s not a good idea?”

9. How to Work with a Client That Alternately Idealizes and Devalues You as a TherapistAccording to Janina Fisher, Ph.D., one sign of dissociation is when the client alternately idealizes and devalues you as a therapist. Here, Ron Siegel, PsyD, and Usha Tummala-Narra, Ph.D., explain how they would work around this with a client. Dr. Siegel: The challenge is to be able to hang in there when we’re feeling devalued. Most of us are okay with being idealized. We can handle that for a bit. But when we’re being devalued, we start to have difficulty. If we can link it back to the trauma, if we can help people to see that this tendency to overvalue or devalue us and others is a natural result of their trauma history, that may be a way forward. Of course, we can’t deflect the devaluation. We have to start with a genuine response and reflect. Maybe we were insensitive, or maybe we didn’t understand something. But then we need to look for a way to link this back. Dr. Tummala-Narra: I might say to the client, “I noticed that you’re feeling different towards me, or that you’re feeling differently being here with me. Am I picking up on something? How would you feel about telling me what that is?”I pay attention to my own observations and my internal feelings and dialogue, and I try to reflect that back. I don’t keep it to myself. Rather, I’m in favor of being transparent about things that I’m picking up and sharing that I noticed something is different. If it’s something explicit that the client tells me, for example, “I just feel like I’m getting nothing out of being here,” or, “I’m really annoyed by coming in today. I didn’t want to come in.” I might want to then explore with them, “Why do you think that is? If you’re hesitating to tell me, I want to assure you that I want to hear it, even though it’s hard to talk about.”Part of this is also assuring the client that I’m open, and I want to know when they don’t feel great things about being in a session or being with me. I might be more specific and ask about it, “Was there something that happened between us?” Or, “Is there something I did or said that led you to feel that way? What do you think?” That’s some language that I would use.

10. Four Imagery Practices to Calm the Nervous System of a Patient Who DissociatesImagery practices can help calm the nervous system when a patient gets triggered and begins to dissociate. Here, Ruth Lanius, MD, Ph.D. describes four specific imagery practices she uses to help her patients stay within their window of tolerance. Dr. Lanius: [1. Locked chest] One image I think is very helpful for clients when they become overwhelmed is imagining a chest and putting all the intrusive material that’s come up into that chest. Then, lock the chest and put it away somewhere until they’re ready to deal with that material more fully.[2. Safe Place] Another image is to get the individual to create a safe place that’s fully under their control. They can put anything in that safe place that they need to feel safer, and more grounded, and stay within their window of tolerance.[3. Dials] Another piece of imagery that I like using is having two dials. One is for the speed of therapy and one is for the emotional intensity, and the client has control over the dials, and if things are going too quickly, we can talk about magically dialing the pace down a little bit or dialing the emotional intensity down.[4. Swing] Lastly, I bring out the imagery of being in a swing, especially when traumatized clients have difficulty with breathing. I use this when they experience breathlessness, they can’t breathe, or breathing triggers them. For example, if they have a history of suffocation. Imagining oneself on a swing can actually self-consciously bring the breath online. Engaging in the swinging motion can be very helpful.

11. How to Help Clients Reframe Negative Thoughts About DissociationClients who dissociate may experience feelings of shame or blame from their response. Kelly Wilson, PhD, uses the following strategy to help his clients overcome those negative thoughts and feelings.Dr. Wilson: My plea to people is to not make an enemy of their complexity or their inner world. When clients have thoughts about how astonishingly broken they are or how they’ll never fit, that is such a tight slot in which to live life. All they’re left with is this narrative about how they’re not going to be able to keep it up, or that they’re not doing a good job of pretending to look like someone is there.I’ll say, “It must tire you so. What might it be like for you to set down that burden, even for a moment?”As a therapist, I am not hurrying to go in there to try to change their mind or give them countervailing evidence for that thought. As soon as I start trying to change that thought, I have basically affirmed their worst fear that this thought must not be here in order for me to function. So I try to recognize the gravity and the weight of that thought without making an enemy of it. Without trying to contradict it or push it away. That easing of the relationship with that thought makes it possible for other things to emerge in awareness. Then I’ll say, “I wonder, as you think about carrying that thought, are there things that you care about that you’ve missed? I wonder what those might be?”

Shutdown vs Freeze: