In our first episode of season 4, we tackle one of the top concerns we hear in our PTSD EBP workshops and consultation… “But what if my client dissociates?!”. If this has been on your list of clinical worries, worry no more! In this episode we are joined by one of CDP’s PTSD experts, Dr. Kelly Chrestman to dig into what is dissociation (and what isn’t)? What is its function? How can we best assess it? When is it likely to show up? AND most importantly, what providers can do to manage it in the context of their EBP work!
When asked to provide a working definition of dissociation, Dr. Chrestman responds, “There's a couple of kinds of dissociation that DSM recognizes as potentially being part of PTSD. So depersonalization is one, and this is sort of feeling detached or like you're an outside observer of your own experiences or outside of your body, kind of an out of body experience. And then derealization is more like ‘out there’, I'm sort of detached from out there, everything feels kind of unreal or I'm not connected to it in some way…people might also describe that as numbing.” One important point we discuss, regardless of how it shows up, dissociation is on a spectrum. And while many providers are most anxious about the severe forms, milder and perhaps less obvious forms show up during therapy for lots of our clients.
But why? Dr. Chrestman explains “dissociation does serve a function for the patient. And when we think about people who are highly dissociative or who dissociate in response to things that are painful… that's a skill they developed and it serves a function of taking away some of the emotional connection to a painful experience.” This “function” is essential for the provider and client to understand – that it is a skill that is developed in response to emotional pain. And for some clients, it becomes their go-to skill. This might be due to the absence of other skills or it just becomes the preferred skill. If that is the case, what can we, as therapists, do? Dr. Chrestman reminds us that “it depends how many other skills your client has. It depends how strongly they dissociate and what happens when they dissociate.”
Which brings us to some of the actionable intel discussed, the first being the importance of assessing dissociation as part of PTSD. Pay attention to how your client discusses their trauma, and look for clues and signs about if/when/how your client dissociates. Assess the client’s awareness of when and how they dissociate, what triggers it, and how they respond to it when it happens. Finally assess other coping skills the client may be able to use to manage or prevent dissociation. If the client recalls a specific episode, a chain analysis can be helpful to identify and understand the factors that lead to dissociation. Getting a better sense of these factors can empower you and the client to anticipate situations that might trigger dissociation and identify more adaptive coping strategies that can be used to “break the chain.” These strategies include self-soothing and grounding techniques that help to reduce the intensity of distress and anchor the client in the moment, and coping skills that help the client respond more adaptively to triggers in the longer term.
But that’s just the surface of what was discussed. Don’t miss out on this truly fascinating conversation with Dr. Chrestman who wants to help clinicians to think about dissociation in a less mystical way, and see it not as some sort of supernatural experience taking over our clients but as a skill, employed by our client, that can be understood in context and replaced with more functional behaviors that allow for growth and successful EBP work!
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Jenna Ermold, Ph.D., is a clinical psychologist working as the Assistant Director of Online Training, Technology and Telehealth for the Center for Deployment Psychology at the Uniformed Services University in Bethesda, Maryland