Demystifying dissociation: a clinician`s guide

“That client is always zoning out in group. It’s like they’re not even here, not even listening to me or paying attention to what is going on.” “I’m working with the client and then suddenly it feels like I’m speaking to a 4-year-old, especially when I say something they don’t want to hear.” “This person has been sober and doing well for months. Now they just don’t seem to be present anymore. It’s like everything they learned is just going out the window."

Perhaps you have made statements such as these in your journey as an addiction professional. Sometimes we make such declarations out of frustration—we do everything we are trained to do and the client isn’t sufficiently tuned in to receive it. In other situations, hitting these roadblocks in our work as addiction professionals can show a lack of understanding about trauma and dissociation.

Awareness of trauma and its impact on human behavior is becoming more widespread among addiction professionals. However, dissociation, which is clearly connected to unhealed trauma, remains a mystery to many in recovery circles.

In this article, we seek to demystify dissociation and its role in the interplay between trauma and addiction. Although we do not expect every addiction professional to become an expert at working with all the technicalities of clinically significant dissociation, having a basic understanding of dissociation and how it shows up in treatment and recovery is paramount to success in working with all clients with addictions.

Defining the concept

“Dissociate” comes from a 16th century Latin word dissociare, meaning to divide or to sever. The experience of division or separation with dissociative clients can run the range of manifestation. Lightly zoning out or separating from the present moment when they are too overwhelmed in group might be one way we witness dissociation. In other cases, people operate from distinctly different senses of self or parts that have developed in their internal world in response to trauma, stress or other adverse life experiences. Although not all clients with trauma-related diagnoses dissociate to a clinically significant degree, we can safely ascertain that all clients with dissociative symptoms or diagnoses are battling unresolved trauma.¹

All human beings dissociate to varying degrees at different times throughout each day. We all have parts of us that make up our whole being. Demystifying dissociation and the role trauma and addiction play in society, recovery or treatment is the act of destigmatizing the judgments we have about something we may not know much about. The way the mind weaves in dissociation is quite beautiful, particularly in clients who are addicted.

We can safely ascertain that clients with addictions have high levels of dissociative symptoms due to the nature of addictive behavior. The act of “getting high,” “getting out of myself,” or “numbing” with addictive behaviors is dissociative. From a trauma-informed perspective, addiction can be a coping skill or defense mechanism to manage adverse life experiences.

Dissociation functions similarly. Dissociation is one of the earliest defense mechanisms to develop. When trauma affects us at a young age (prenatal to age 3), our brain has no other choice but to disconnect until the threat is resolved. If the threat is not resolved, there may be no other choice but to create a separate system to deal with trauma in order to survive. As we develop and mature, so do our defense mechanisms.

To understand what dissociation looks like, we must first consider how unresolved trauma shows up in the human experience. Unresolved trauma is present when there are overwhelming reactions such as “fight or flight” (i.e., hyper-arousal) or a shutdown response such as “freeze or appease” (i.e., hypo-arousal) to a distressing stimulus. Distressing stimuli may be direct and come in the form of people, places and things. They also can include indirect references made in group, interpreting body language, unpleasant topics, or simply a “felt sense” of what it feels like to be in rehab again. Our “felt sense” refers to an implicit memory system that helps us navigate similar settings and power dynamics as a felt resource. This helps us successfully achieve our goal of completing a new task or being socially competent in new but familiar settings. The implicit memory system is survival’s automatic pilot. One of the biggest concerns about triggering that implicit network is that our treatment re-creates an education-like setting, and therapeutic relationships are often modeled on primary relationships or what primary relationships were expected to look and feel like.

The school setting and our primary relationships may be the two biggest areas where original traumas occur. These indirect associations set up the perfect conditions for clients to re-enact traumas and their coping skills (i.e., dissociation, splitting or other defense mechanisms) through implicit memory. Therefore, it is important to understand your own implicit system because this is what gets triggered when clients trigger your own stuff.

Clinical manifestations

In our clinical practice of addressing addiction we regularly see clients avoiding, deflecting, minimizing and projecting. There is also the world-famous addiction denial system that makes the professional believe a client is “not ready” for recovery. However, the client is sitting in front of us hearing the message, so there must be some part of the client that wants recovery or wants the pain of addictive using to end. So, where is the disconnection?

This begs the question: Is the denial seen in addiction really dissociation? Your answer to this question could be a missing piece to many case conceptualizations and could help make sense of why the client is not responding to treatment. It may also answer questions such as why the client cannot remember what happened, why the client is not retaining information taught in groups, why the client is not able to make appointments, or why clients are not able to admit that they did something wrong, because it would destroy who they know themselves to be.

Besides understanding traumatic responses to unresolved trauma, other important elements to identifying and understanding the clinical presentation of dissociation are the amnesic barrier, the part turned perpetrator², switching, and collaboration.

The amnesic barrier is the wall that we put up to protect our identity. Often in treatment and in recovery circles, the goal is to break through this wall of denial. However, in dissociation treatment, breaking down this barrier therapeutically before its time is contraindicated because it can be traumatizing.³

The Dr. Jekyll and Mr. Hyde is well known in active addiction. However, what might not be asked is where did clients learn to become Dr. Jekyll? Who are the clients modeling? The part turned perpetrator is when a distinct part of an individual presents as if they were the abuser that abused them. This is often represented in the self-critic or doubting Thomas. But in addiction terms, this part can be conceptualized as the addict identity.

Switching, depending on how fluid, can happen seamlessly or can feel like a new person in the room. This is not to be feared, but to be honored. The parts are well known to clinicians and can be seen in the recent work of Dialectical Behavior Therapy (DBT), Ego State Therapy, and Internal Family Systems. It is important to understand the individual system because it allows access to what makes up the person, how the person operates, and how you can best support the client in achieving treatment goals. However, having separate selves does not mean that the person is broken, because separation occurs in order to survive. What it means is that there is greater opportunity for healing, and that has to be done in collaboration.

Collaboration occurs when various parts of us work as a cooperative collective. It is the idea that our inner workings are cooperating and we are working in our optimal performance zone. Ideally, collaboration is self-sustaining and done in a healthy way. However, often the parts are working toward the same end but using contradictory means (e.g., managing symptoms of PTSD by coping with alcohol and other drugs). In this instance, we can rely on our Motivational Interviewing skills to help create collaboration. Seubert⁴ uses “RUG-C” (Recognize, Understand, Gratitude for the parts working toward achieving the Goals, and Collaboration) to outline a clinical approach and how to help move the client toward collaboration.

How to recognize

In our work as addiction professionals we are truly addressing unresolved addiction (which can be traumatic in its own right), as well as unprocessed trauma. Clinicians must include dissociation in their assessment of clients’ addiction in the scope of being both trauma- and addiction-informed in practice. The connection between trauma and addiction has long been understood in our field, but the recognition of dissociation’s role in developing addictions, or addiction as an act of dissociation, is not commonly represented in textbooks or in substance use education.

As you become more familiar with dissociation and its manifestations, you may consider using screening tools in your clinical settings. In the opening of this article, we referenced some of the common signs of dissociation (e.g., zoning out/checking out, suddenly behaving as if they are a different age when confronted with distressing triggers, difficulty staying present). Other common signs of dissociation include, but are not limited to, excessive yawning/tiredness, referring to oneself as “we,” or verbalizing content that is fantastical or dreamlike in nature when referring to daily life. If you notice any of these signs in early treatment, consider administering the well-validated Dissociative Experiences Scale (DES), which can be easily accessed and scored online.⁵

Information on the DES and how to score it is offered and explained on the site, in addition to a variety of other tools that you can administer for screening and/or diagnosing issues related to dissociation. Some clinicians working in highly traumatized environments give a DES as a best practice to all clients, and others will make use of it only when it seems needed. Our biggest caution is not to just send a client home with it or stick them in a side testing room and have them complete it on their own. Because some of the items can bring up distress, consider having the client do the screen in your presence and then go over it together to further the conversation.

Above all, consider taking and scoring your own DES first so that you will have familiarity with the instrument. You might even obtain a sense of how your own tendencies to dissociate may manifest.

Importance of education

Educating yourself on dissociative issues and disorders is critical to enhancing clinical efficacy. Personally evaluating yourself in this way and considering your own dissociative profile will be a major step in your learning process. There are many ways to expand your knowledge of dissociative disorders, such as reading personal stories of trauma survivors with dissociation.

We beg you, please do not obtain your education on dissociative disorders, or what are sometimes still erroneously called multiple personalities, from Hollywood. While film and television have taken some major steps forward in shedding light on mental illness, most portrayals on dissociation (most recently M. Night Shyamalan’s “Split”) are blatantly inaccurate and perpetuate damaging, stigmatizing stereotypes.

If you are interested in dissociative identity disorder (formerly called multiple personality disorder), consider checking out When Rabbit Howls by Truddi Chase (1987). For excellent, clinically sound overviews of the entire dissociative spectrum with pertinent case material, check out The Haunted Self⁶ or The Dissociative Mind.⁷ If you learn better from personal stories, consider checking out Eleanor Longden’s TED talk on learning to make her dissociative identify work for her, in “The Voices in My Head.”⁸

In addiction counseling, we spend significant energy discussing shame and the importance of treating addicted individuals in a way that empowers them instead of meeting them with interventions that follow old shame scripts. We’ve learned that language can be very powerful in this process (e.g., your addiction is a disease or problem that can be treated, vs. you are a bad person). We challenge you to use some of these same, non-shaming language and empowerment strategies in working with dissociative individuals. There is such power in normalizing the experience of dissociation, especially in early recovery, while still setting solid boundaries and expectations for treatment.

For instance, instead of chastising people for “zoning out” in group, explore what has become so overwhelming about the group or their experience in treatment that causes this level of flooding. The solution is not to click your fingers and expect them to automatically “come back.” Rather, teach some solid grounding skills to that individual, either within the group or privately, so that they can use these when they experience this sense of overwhelm. Here are some complimentary strategies online.

By discovering the source of the distress that can cause the dissociation and developing a trauma-focused treatment plan accordingly, you will enhance clients' chances for success in overall recovery. Consider normalizing the language around the parts that people express (e.g., the inner child/little girl, or the hothead, just to name some classic examples). Avoid cutting them off and saying they’re being fantastical or attention-seeking. Rather, come to embrace those parts as an important structure in their survival mechanisms, and learn to work with them.

In our experience, your willingness as a professional to validate clients' frame of reference around their different “parts” within their internal world will automatically strengthen your clinical rapport with clients and open them up to greater dialogue on how to approach treatment. Shunning “parts” language will shut clients down and make them believe they must literally hide certain parts of themselves to “pass” or get out of treatment. This reaction on clients' part will be antithetical to honesty and authenticity, two key qualities in the foundation of successful, long-term recovery.

Jamie Marich, PhD, LPCC-S, LICDC-CS, REAT, travels internationally to teach on topics connected to trauma, EMDR therapy, mindfulness and the expressive arts. She maintains a private practice in her home base of Warren, Ohio, where she operates the Institute for Creative Mindfulness, a training program in EMDR therapy and expressive arts therapy. She is the author of six books on trauma recovery. Her newest book, Process Not Perfection: Expressive Arts Solutions for Trauma Recovery, is due out in the winter of 2019.

Adam O'Brien, LMHC, CASAC, is a Licensed Mental Health Counselor and Credentialed Alcohol and Substance Abuse Counselor in New York state. He specializes in chemical and behavioral addictions, dissociation, and prenatal, intergenerational, historical, medical and complex trauma. He is an approved consultant working with Dr. Marich and the Institute for Creative Mindfulness. For more information, click here.

References

1. Marich J. Trauma Made Simple: Competencies in Assessment, Treatment, and Working with Survivors. Eau Claire, Wis.: PESI Publishing; 2014.

2. Paulsen S. Looking Through the Eyes of Trauma and Dissociation: An Illustrated Guide for EMDR Therapists and Clients. Charleston, S.C.: BookSurge Publishing; 2009.

3. Lanius U, Paulsen S, Corrigan F. Neurobiology and Treatment of Traumatic Dissociation: Towards an Embodied Self. New York City: Springer Publishing Co.; 2014.

4. Seubert A. Parts/Ego State Work in EMDR Practice: From Essentials to Advanced. Visit https://c.ymcdn.com/sites/emdria.site-ym.com/resource/resmgr/2016_conference_handouts/session335/s335_presentation.pdf

5. Carlson EB, Putnam FW. An update on the Dissociative Experience Scale. Dissociation: Progress in the Dissociative Disorders; 6:16-27.

6. van der Hart O, Niejenhuis ERS, Steele K. The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization. New York City: W.W. Norton & Co.; 2006.

7. Howell EF. The Dissociative Mind. New York City: Routledge; 2008.

8. Longden E. The Voices in My Head (TED Long Beach). Available at https://www.youtube.com/watch?v=syjEN3peCJw