According to Kathy Steele, MN, CS, dissociative disorders often present in subtle ways that may be tricky to identify.
So in the video below, she walks us through some key signs that can help us differentiate dissociative identity disorder and structural dissociation from more mild forms of dissociation.
She’ll also share several critical steps for working with clients who dissociate.
Take a look.
So the question is, what are we looking for in a client to diagnose or to assess for a dissociative disorder like DID or the lesser form we call other specified dissociative disorder. I think about it as a mini-DID. It’s parts, but they’re not quite so separate. So the question is, what are we actually looking for?
We’re looking for amnesia because that is a criteria for DID. And we’re not just looking for amnesia for the trauma because lots of people have amnesia for at least parts of the trauma, including people with PTSD. So what we’re looking at is we’re looking for more pervasive amnesia. Like I don’t remember anything between the ages of six and 10. That’s pretty significant. Or I don’t remember anything about life at home. I remember school fairly well, but not life at home. And so we’re looking for larger gaps. And also we’re looking for, in dissociative identity disorder, we’re looking for amnesia in the present. And again, if we’re making a distinction between spacing out and structural dissociation, people who space out and stare at the wall can go for hours and not remember what happened, because number one, they’re not present. And number two, they’re not doing anything. So they can have what we might consider amnesia for four to five hours in a day. But they’re sitting there doing nothing. What we’re looking for in dissociative identity disorder is an amnesia that indicates one part of self is active while another part of self is not paying attention. So on one level with spacing out, nothing is being encoded, memory is not being encoded – but with structural dissociation, you have an encoding of memory in some part of the self, but it’s not accessible to another part, at least at the moment. So you might look for people who can remember some times and not others.
I think the first thing that a clinician should do, if they suspect that they have a dissociative client is take a deep breath. It is not that difficult to treat dissociation. It has a bad name. There are some complications to it, but I think once you get the training, that’s fine, but try not to rush into starting to explore parts right away. I’ve seen too many clients who have been a bit overwhelmed by that. If you really think about dissociation to association is about hiding from yourself. It’s about not wanting to be that, seeing that experience, that little girl, that memory, I don’t want those things. And so to be confronted by that all of a sudden is often quite overwhelming for clients. So I would suggest to therapists just to go slow, talk a little bit about dissociation in general, try to get clear in your own head some of the distinctions between ego states and dissociative parts, because it’s pretty easy to confuse those if you don’t know a lot about dissociative disorder. Take your time and let the client take his or her time.
And so there is some literature out there about mapping the system, let it unfold like the onion layers like we do with all other kinds of psychotherapy, not diving in too quickly. And yes, we don’t want to just hang out forever. But I think beginning to explore, how does the client feel about talking about it? Because what I notice for many clients is even asking them about dissociation or giving them a kind of assessment instrument for dissociation creates all kinds of freeze and shut down and flight kinds of experiences. If they’re unable to even talk about it without going into a big reaction, then you have to slow down much more. On the other hand, you will see clients who talk about it just fine, and they go home and fall apart or self-harm. Those people are more depersonalized in session. And they’re kind of talking about it from here up, not aware of the reactions they’re having. And so we really want to be clear that a client can accurately report how they’re doing when they’re talking about something and really track carefully their physiological reactions in the session.
To hear more expert strategies for working with dissociation from Kathy and other masters in the field of trauma (like Bessel van der Kolk, MD; Janina Fisher, PhD; Stephen Porges, PhD; and more) check out How to Identify and Treat Dissociation (Even When It’s Subtle).
Now we’d like to hear from you. What strategies have you found to be effective when working with dissociation? Let us know in the comments below.