I often get asked how to handle dissociation when it occurs in therapy. As a behaviourist it is good to ask, “What is the behaviour that I am labelling as dissociation?” as there are a number of different forms. The general theme is that the person has detached their attention from the room and usually has turned it inwards. Occasionally the client can enter a ‘fugue state’ where they simply lose conscious awareness whilst retaining some functioning e.g. enough to travel by bus or train. However this is rare.
It is helpful to see dissociation as being on a continuum from a momentary lapse of attention at one end, to – at the other end -the client getting completely caught up in some internal thought or memory and seemingly oblivious to normal ‘call-back’ cues such as the sound of their name or a wave of a hand. Another factor to consider is how involuntary this seems to be. At one end is the attentional hi-jacking caused by an unwanted traumatic memory, whilst semi-voluntary daydreaming during a boring lecture is towards the other end.
It is useful to start by describing what the client does that you can actually see, and noting what he or she reports about the internal experience. Are there vulnerability factors that make this more likely? Are there any specific cues that always seems to set it off? Pay attention also to the contingencies that follow dissociation, are there any potentially reinforcing consequences? Remember, just because the consequences are reinforcing it does not mean the patient intended to get them. Behaviours can be reinforced outside of our awareness.
For example, I had a client who was a witness to a crime and was desperate to have the perpetrator apprehended. However, when she tried to give a statement to the police she would dissociate and the interview would be stopped. Trying to make the interview less stressful through a variety of methods did not reduce the dissociation. When the police decided to continue with their line of questioning, repeating the question of necessary and just waiting for her to re-attend, the phenomenon stopped. The client had wanted to make the statement, but perhaps her subconscious mind had found a way to relieve her of the trauma of doing so without her active consent. Once this involuntary action no longer worked (i.e. did not get her out of the situation) the dissociation went away. The dissociation in no way indicated conscious reluctance to take part. Clients need to understand that attending to possible reinforcers of the behaviour does not imply it is currently under their conscious control.
Once you have got some data about the phenomenon you can look at the range of options open to you as interventions. These are also on a spectrum from a minimal response to maximum intervention; e.g. ignoring it, or just mentioning it, instructing them to do something different or adding a contingency, analysing what just happened, and coping ahead for times when this might happen in the future. Occasionally if someone does something very dangerous whilst in a dissociated state they might need to be detained (again this is rare).
Audial cues can reorient attention, such as saying the person’s name and describing exactly where you would like them to put their attention, e.g. “Emma, you are staring into space, tap your feet on the floor and turn your attention to my voice.” Tapping the table or clicking your fingers are socially accepted cues for getting someone’s attention. Talking in a firm voice is more likely to produce a response, only because we are more attuned to firm voice-tones at times of stress. If there is a bull and a rabbit in a field, we are programmed to focus on the bull. Coaching in grounding techniques encouraging the client to use the sensation of touch for example, can also help, as can mindfulness.
Ask questions to identifying starting and stopping points of the dissociation episode. For example, asking, “Can you repeat what I just said?” If the client says, “sorry I can’t remember”, then you know that they at least heard the question.” If they say, “Sorry? What?” then at least they were associated enough to know that you were speaking. Ask, what is the last thing they remember hearing or seeing?
Dissociation can be a problem if the client is working through traumatic material. Professor Edna Foa, developer of the prolonged exposure protocol for PTSD, describes how some clients can be ‘over-involved’ in the traumatic memories as they recount them during treatment. To mitigate the effects she introduces strategies that help the client to get more protective distance from the material. For example, keeping their eyes open instead of closing them, imagining that they are viewing images through glass, and if necessary raising their hands as though they are touching a sheet of glass in front of them. In some circumstances she has allowed the client to write down their narrative rather than speak it out. These strategies have to be balanced against making sure the client is able to access the emotion associated with the trauma, as without experiencing emotion the trauma cannot be processed.
Physical strategies can help. Martin Bohus researching trauma treatments in Germany does trauma work with the patient standing on a wobble-board. If dissociation becomes problematic in therapy you can ask the patient to sit on a yoga ball, which requires ‘present focus’ to stay balanced. Even putting a book under the back legs of the client’s chair can tilt the seat just enough that they have to stay more focussed than usual to prevent sliding forwards. You can explain this to the client by saying, “this dissociation seems to be a problem so we need to do some things to try and keep your focus in the here and now, here are some ideas I have – we can try them one at a time”. Over time, by experimenting, you should be able to identify some controlling variables.
It is important that you don’t change your normal intervention in the face of dissociation. If clients in DBT for example have difficulty with chain analysis because they can’t remember what happened, ask them to choose their best guess, “so where were you when you harmed yourself?” “I don’t remember.” “Ok, do you think you were inside or outside?” “Inside, probably” “Upstairs or down?” “I don’t know” “Just choose the most likely” “probably upstairs” etc. Clients are responsible for their behaviour whether they are dissociated or not, so it is vital for them to rehearse strategies for any potential problems. And even if you have not got the chain absolutely, as long as you are working on roughly what happened and doing solution rehearsal it is fine. They might end up saying, “I don’t think it was like that…” at which point you can alter the solutions to fit the scenario they think was more likely. Similarly if clients get panicky because there is a gap in their memory – “I’m really scared because I have no idea how I ended up at Claire’s house” Ask them to fill in what they think is the most believable scenario, and we’ll go with that. If they say, “But what if something awful happened?” Then you can reply, “let’s assume the best until we have firm evidence that this was not the case.” If they cite their own worry as evidence, ask them to try and put it to one side and see what other evidence turns up.
Finally, there are some useful behavioural rehearsal exercises for dissociators. One is a practice where you tap the table and they have to give an internal observation, then you tap again and they have to give an external one: E.g TAP “I notice the thought – this is weird” (internal) TAP “I notice the carpet is blue” (external) TAP “I notice a sensation of tightness in my tummy”(internal) TAP “I notice the glass of water on the table is sparkly”(external) TAP “I notice a mental image of the sea” (internal)TAP “I notice the shadow of the bookshelf on the wall” (external). Developing recognition of the difference between internal and external foci of attention is a vital skill. High emotion has a way of demanding our internal attention so this exercise needs to be practiced during gradually more intense emotional experiences.