Signs of dissociation in therapy sessions

In this blog post, we will talk about the signs of dissociation in therapy sessions, why it happens, and what to do when this happens.

What is dissociation?

Dissociation is defined as an out of body experience, where the person disconnects from reality and their feelings, usually feeling numb, dead or shut down. 

It happens with everyone once in a while, for example shutting down while driving or doing monotonous tasks. When it’s connected to a traumatic incident, there is a complete sensory shut down. 

People have described it as living in a fog, barely remembering that you exist and a complete detachment from their feelings. Some withdraw within themselves, while some have described it as leaving their physical form. 

Those who dissociate experience a change in their sensory perception.

It may feel like familiar things are now unfamiliar, or you may feel detached from reality as if you are in a different reality (also known as derealisation).

How can you identify if your client is dissociating?

There are clear signs of a client dissociating, which are :

• The client feels that they are in a fog
• They constantly ask the therapist to repeat what they said 
• The client feels as if they are far away
• They can’t hear your voice or it sounds very faint
• They are unable to remember parts of the session or the session altogether 
• The client has a hard time differentiation between what’s real and what’s not
• They feel as if they are empty and there is nothing inside them
• The client stares off into space or seems zoned out for a long time now, their eyes may look glossy
• They may start monologues and forget that the therapist is sitting in front of them
• Some clients may close their eyes mid-session, slump forward or backwards, and it may seem as if they are drifting off
• The client doesn’t respond to your voice or gentle touches

If we see any of these states in our clients, it is important to realize that they may be dissociating. This is a sign that there is some trauma that we are not aware of, causing the client to dissociate.

It can be easy to miss these signs or not realize that the client is dissociating if you are still new to this.

When we have identified that the client may be dissociating, we can ask the client to identify the physical signs of dissociation :

• Tunnel vision
• A sense of floating 
• Dizziness
• Heaviness in arms or legs, making it difficult to move them
• A headache that is distinctive to zoning out
• Feeling that everything is moving away from them

Causes of dissociation

These symptoms are usually a result of repetitive trauma, abuse or neglect in the individual’s early years. If the symptoms are emerging when the person is older, it is mostly due to the presence of some traumatic event. 

Dissociative symptoms are mostly an attempt to block out painful memories and feelings connected to the traumatic events. 

It is a coping mechanism used involuntarily or voluntarily when thinking of or facing a traumatic past event.

Those suffering from dissociative disorders may feel quite confused and perplexed when they behave aggressively, panic and feel threatened when faced with a certain situation, freeze when they feel terrorized or behave differently when faced with an abusive relationship.

If a child experiences repetitive trauma or abuse during their early years and has no means to cope with it, they may develop dissociating as a coping response. If they experience another traumatic event after a few years, they would be more likely to dissociate rather than try to deal with the situation.

In some cases, dissociation happens even if there was no previous trauma. Some children are more sensitive to emotions and prefer blocking out emotions they can’t deal with. In other cases, they may pick up on these habits from their parents or friends and continue using this without realizing how harmful it is.

For that reason, therapists shouldn’t assume that because a person is dissociating, they have suffered trauma, a few sessions should be taken to identify the root of the problem. 

Dealing with dissociative symptoms

The therapist helps the client realize that what they are experiencing is known as dissociation, and why it is happening so that the client is able to relax.

Then the therapist reassures the client that they won’t be stopping them from dissociation, as it is a safety net for the client. They will just be recommending some techniques they can use when the client feels that they are about to dissociate. 

They will help the client stay in touch with reality, and will help them deal with threatening situations.

Identify dissociation triggers

It is very important to identify dissociation triggers, as it is a survival response that kicks in when the client feels threatened. Identifying and working on those triggers helps the client feel safe, and re-grounds the client. 

You can ask these questions to help identify the catalysts :

• What was the topic? What or who were we discussing before you felt that you were starting to dissociate?
• What emotion was the client experiencing before shutting off?
• Any physical body sensations that could be threatened them?
• Was any external factor, such as a loud crash, sounds similar to a gunshot, or a lighting change that could be related to the traumatic event?
• What was the client thinking about right before checking out?
• Was visual stimuli the cause?

This is the first step the therapist and the client take when trying to identify what may trigger the dissociation. There can be both internal and external stimuli that can be the catalyst for this response. 

Processing these triggers gives the therapist the opportunity to use psychotherapy by normalizing this as an involuntary survival response due to the repeated events of the client’s childhood.

Using techniques to stay grounded

Grounding helps the client stay in the present, and deal with their anxiety.

Some techniques that may help in this situation include :

• The 54321 technique – for this technique you notice 5 things around you that you can see, 4 you can touch, 3 you can hear, 2 you can smell and 1 thing you can taste
• Holding a warm or cold object
• Thinking about the texture or weight of an object sitting in front of you or that you can feel
• Listening to relaxing music
• Moving around, jumping, standing
• Talking out loud about what is visible to them right now

These techniques should be practised daily so that the client gets used to the techniques and can use them when they feel that they are shutting off.

Anxiety management 

Using techniques such as slow and deep breathing, relaxation techniques, self-calming techniques can help manage the stress which is causing the dissociation.

Some therapists use the “graded exposure” model to deal with the trauma. This involves talking about the feelings associated with the trauma, the events leading to the trauma in a gradual, step by step fashion. It gives the client the time to deal with the event, without overwhelming them.

Helping the client come back to reality

As soon as you notice that the client is dissociating, use these techniques to help the client get back in touch with reality :

• Stop talking, the client has already zoned out, and will anyways not listen to you or remember what you were saying
• Ask the client if they are feeling emotional
• Get the client to place their feet on the floor or focus on parts of their body that are touching other things, such as their arms or thighs
• Talk to them about a non-emotional topic or ask them to point out a few things they can see in the room, such as naming 2  yellow objects in the room
• Reassure the client that nothing bad is going to happen to them, you are there with them and will protect them
• Once they have settled a bit, and are feeling a bit comfortable, ask them to stand with their feet shoulder-width apart, and rotate their hip joints. Then twist side to side, with your arms following the same movement. 

Some people have described it as the same motion of a washing machine. 

Conclusion

In this blog post, we listed signs of dissociation in therapy sessions, talked about what is dissociation, the causes and how to treat it as a therapist.

Frequently asked questions: signs of dissociation in therapy sessions

How do therapists deal with dissociation?

Therapy focuses on dealing with the painful emotions that cause dissociation. We acknowledge and process those emotions, and change how the client responds to them.

Constant therapy sessions can reduce the length and number of dissociative episodes. A therapist can also teach you coping skills to use on your own.

How do you ground someone who is dissociating?

Using these techniques :

• breathe slowly and deeply
• listen to sounds around you
• walk barefoot
• wrap yourself in a blanket and feel its texture and weight
• touch something or sniff something with a strong scent

What is the best therapy for dissociation?

Psychotherapy or talk therapy is the primary treatment for dissociative disorders. It includes counselling and psychosocial therapy. The aim is to talk about your concerns with a mental health professional, who can help you deal with them.

When do you shut down in therapy?

When there is any topic that makes you feel scared or uneasy, and you want to avoid talking about it, you shut down. Both therapists and clients can shut down during therapy. 

If the client is feeling terrified, helpless or out of control, they may shut down.

What are the four types of dissociative disorders?

• dissociative amnesia – inability to remember important information in one’s life, maybe a specific event or a series of events
• dissociative fugue – a severe and rare type of dissociative amnesia
• depersonalisation disorder – constantly feeling as if you are viewing yourself from the top of your body and/or a detachment from reality
• dissociative identity disorder – the presence of at least 2 personality characteristics in one person’s mind

Anyone who experiences a traumatic event or has a tendency to block off emotions, may experience any of these disorders and dissociate anywhere from minutes to weeks on end.

How long do dissociative episodes last?

Periods of dissociation usually last for short time periods, such as minutes or hours. In some cases, they may last week, and in extremely rare cases they may last for years. Most people with more than 1 dissociative disorder experience dissociation which lasts a few years.

References 

The Path to Safety: Treating Dissociation with Movement. Retrieved from 

The Path to Safety: Treating Dissociation with Movement

Ferentz, L. What You Need to Know When Clients Dissociate— Part 1. Retrieved from https://www.psychologytoday.com/us/blog/healing-trauma-s-wounds/201803/what-you-need-know-when-clients-dissociate-part-1

Ferentz, L. What You Need to Know When Clients Dissociate — Part 2. Retrieved from 

https://www.psychologytoday.com/us/blog/healing-trauma-s-wounds/201804/what-you-need-know-when-clients-dissociate-part-2

Silberg, J. When Your Client Dissociates. Retrieved from 

https://www.psychotherapynetworker.org/blog/details/946/when-your-client-dissociates

Dealing with Dissociative Symptoms. Retrieved from 

Dealing with Dissociative Symptoms

Dissociative disorders. Retrieved from 

https://www.mayoclinic.org/diseases-conditions/dissociative-disorders/symptoms-causes/syc-20355215