The word dissociation is derived from a Latin root word meaning to sever or to separate. In clinical understanding, dissociation is the inherent human tendency to separate oneself from the present moment when it becomes unpleasant or overwhelming. Dissociation can also refer to severed or separated aspects of self. In common clinical parlance, these separations may be referred to as "parts." Older terminology (e.g., "alters," "introjects") may still be used, although parts is generally seen as more normalizing and less shaming as a clinical conceptualization strategy. Just like all humans dissociate, all humans have different parts or aspects of themselves. In cases of clinically significant dissociation, the separation of parts is typically more pronounced.

The word dissociation is derived from a Latin root word meaning to sever or to separate. In clinical understanding, dissociation is the inherent human tendency to separate oneself from the present moment when it becomes unpleasant or overwhelming. Dissociation can also refer to severed or separated aspects of self. In common clinical parlance, these separations may be referred to as "parts." Older terminology (e.g., "alters," "introjects") may still be used, although parts is generally seen as more normalizing and less shaming as a clinical conceptualization strategy. Just like all humans dissociate, all humans have different parts or aspects of themselves. In cases of clinically significant dissociation, the separation of parts is typically more pronounced.

The triune brain model espouses that the human brain operates as three separate brains, each with its own special roles—which include respective senses of time, space, and memory [5]:

Triggers are limbic-level activities that cannot be easily addressed using neocortical interventions alone. If a stimulus triggers a person into reaction at the limbic level, one of the quickest ways to alleviate that pain/negative reaction is to feed the pleasure potential in the limbic system. As many traumatized individuals discover, alcohol use, drug use, food, sex, or other reinforcing activities are particularly effective at killing/numbing the pain. For children growing up in the high distress of a traumatic home, dissociation can become the brain's natural and preferred way to escape the pain. Cultural commentators and scholars have referred to dissociation as a "gift" to the traumatized child for this reason [7].

Precise neurobiologic explanations of dissociative phenomenon are still being investigated, and understanding remains incomplete. In their comprehensive review, Krause-Utz, Frost, Winter, and Elzinga summarize that there is a suggested link between dissociative symptoms and alterations in brain activity associated with "emotion processing and memory (amygdala, hippocampus, parahippocampal gyrus, and middle/superior temporal gyrus), attention and interoceptive awareness (insula), filtering of sensory input (thalamus), self-referential processes (posterior cingulate cortex, precuneus, and medial prefrontal cortex), cognitive control, and arousal modulation (inferior frontal gyrus, anterior cingulate cortex, and lateral prefrontal cortices)" [9]. Electrical neuroimaging studies show a correlation between the temporoparietal junction—an area involved in sense of self, agency, perspective taking, and multimodal integration of somatosensory information—and dissociative symptoms, and specific forms of dissociation are connected with brain areas in question [10].

There is a variety of myths and misconceptions regularly encountered from clinical professionals and from colleagues who also work as trauma trainers. The most common are the usual fears about people with dissociation acting out and causing harm to self or to others, although clinical experience and evidence suggests that there is no more risk of these behaviors than with other diagnoses [12]. The next set of myths revolves around treatment. There can be a sense that people with clinically significant dissociation, especially DID, do not respond well to treatment and cannot live full and functional lives. In many cases, professionals who hold such myths generally do not have enough grounding in trauma-informed or trauma-focused care to realize the connection between unhealed trauma and the successful treatment of maladaptive dissociation. The other major treatment myth is that for successful treatment of DID or another dissociative disorder to occur, there must be an integration of the various alters or parts into one presenting person. While this is discussed further in the section on treatment, for the time being, please know that many exist functionally and adaptively with the help of their system, and integration in the simplistic sense is never achieved—nor does it need to be.

There is a variety of myths and misconceptions regularly encountered from clinical professionals and from colleagues who also work as trauma trainers. The most common are the usual fears about people with dissociation acting out and causing harm to self or to others, although clinical experience and evidence suggests that there is no more risk of these behaviors than with other diagnoses [12]. The next set of myths revolves around treatment. There can be a sense that people with clinically significant dissociation, especially DID, do not respond well to treatment and cannot live full and functional lives. In many cases, professionals who hold such myths generally do not have enough grounding in trauma-informed or trauma-focused care to realize the connection between unhealed trauma and the successful treatment of maladaptive dissociation. The other major treatment myth is that for successful treatment of DID or another dissociative disorder to occur, there must be an integration of the various alters or parts into one presenting person. While this is discussed further in the section on treatment, for the time being, please know that many exist functionally and adaptively with the help of their system, and integration in the simplistic sense is never achieved—nor does it need to be.

Many individuals with DID or other dissociative disorders do not shun the word integration, but instead view integration as a healthy sense of cohesion or communication between the system. The term working wholeness may be preferred. However, when working with a client with dissociation, integration can be quite a triggering word, because previous providers may have used the term incorrectly or abusively, making them believe that they must integrate if they want to live a normal life. This can cause upheaval in the system, especially if more vulnerable parts believe they are going to be forced out. Consider this metaphorical comparison: For many years the United States was referred to a "melting pot" of sorts, suggesting the people from various backgrounds came together and blended. This metaphor has garnered criticism because a melting pot suggests that various peoples come together, melt down, and then a single, ideal alloy of an "American" emerges. While some people would like this to be so, it is neither culturally inclusive nor sensitive. An alternate metaphor refers to the United States as a salad or a bowl of stew, indicating that each ingredient brings their own unique flavor while contributing to the whole. This metaphor is also workable when referencing dissociative systems.

Although clinically significant dissociation can develop in adulthood as a response to trauma or other distress, its etiology is usually traced to significant, complex trauma in early childhood. Often, this trauma is of a developmental nature, meaning that it happened when a child was still vulnerable and often involved betrayal by someone they loved or trusted. Useful distinctions between trauma as an incident or event (typically associated with the PTSD diagnosis as presented by the DSM) and complex or development trauma is that complex trauma experiences [13]:

The dissociative disorders formally debuted in the DSM-III in 1980. The PTSD diagnosis also appeared in that edition as an anxiety disorder, but dissociative disorders were presented as a separate category. Although new to DSM-III, their discussion and inclusion were not new to the field [15]. With every iteration of the DSM since then, up to the current DSM-5, there has been intense debate and scrutiny over the dissociative disorders as being worthy of inclusion. In reality, many leaders of the field, especially those on DSM work groups, openly doubt their existence [16]. The purpose of this course is not to engage in this debate—clearly the position of this course is that dissociative disorders do exist and are potentially more widely prevalent than once thought and reported. However, major medical and psychological groups continue to report that dissociative disorders are extremely rare. This approach to dissociative disorders and resistance to their existence is borne from the same discomfort about trauma and responsibility that Freud encountered in the early days of his work. Although the general phenomenon of dissociation can show up in a wide array of clinical diagnoses, it has been established that unhealed trauma is a major etiologic factor in the development of clinically significant dissociative disorders [17].

Clinicians interested in reading more about the history and debate around dissociation, trauma, and memory are directed to Anna Holtzman's article exploring the "memory wars" in the field of psychology, written in the wake of the Harvey Weinstein trials (Resources). The memory wars refer to decades of debate in the field about the trustworthiness of memory, particularly as it relates to accusations of abuse by survivors of trauma. She discusses the history of the False Memory Syndrome Foundation, founded by the parents of Dr. Jennifer Freyd (a former president of the International Society for the Study of Trauma and Dissociation [ISSTD]). Dr. Freyd accused her parents of abuse and their response was to establish an organization to discredit survivors of abuse.

DID, formerly called multiple personality disorder, develops as a childhood coping mechanism. To escape pain and trauma in childhood, the mind splits off feelings, personality traits, characteristics, and memories into separate compartments which then develop into unique personality states. Each identity can have its own name and personal history. These personality states recurrently take control of the individual's behavior, accompanied by an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. DID is a spectrum disorder with varying degrees of severity. In some cases, certain parts of a person's personalities are aware of important personal information, whereas other personalities are unaware. Some personalities appear to know and interact with one another in an elaborate inner world. In other cases, a person with DID may be completely aware of all the parts of their internal system. Because the personalities often interact with each other, people with DID report hearing inner dialogue. The voices may comment on their behavior or talk directly to them. It is important to note the voices are heard on the inside versus the outside, as this is one of the main distinguishers from schizophrenia. People with DID will often lose track of time and have amnesia to life events. They may not be able to recall things they have done or account for changes in their behavior. Some may lose track of hours, while some lose track of days. They have feelings of detachment from one's self and feelings that one's surroundings are unreal. While most people cannot recall much about the first 3 to 5 years of life, people with dissociative identity disorder may have considerable amnesia for the period between 6 and 11 years of age as well. Often, people with DID will refer to themselves in the plural [20].

The most common of all dissociative disorders and usually seen in conjunction with other mental disorders, dissociative amnesia occurs when a person blocks out information, usually associated with a stressful or traumatic event, leaving him or her unable to remember important personal information. The degree of memory loss goes beyond normal forgetfulness and includes gaps in memory for long periods of time or of memories involving the traumatic event [20].

Having depersonalization has been described as being numb or in a dream or feeling as if you are watching yourself from outside your body. There is a sense of being disconnected or detached from one's body. This often occurs after a person experiences life-threatening danger, such as an accident, assault, or serious illness or injury. Symptoms may be temporary or persist or recur for many years. People with the disorder often have a great deal of difficulty describing their symptoms and may fear or believe that they are going crazy [20].

The chapter of trauma- and stressor-related disorders (which includes PTSD, acute stress disorder, adjustment disorders, reactive attachment disorder, and disinhibited social engagement) does make mention of dissociative symptomology as a potential feature of PTSD. In the DSM-5 version of the PTSD diagnosis, there is a qualifier option of PTSD with predominant dissociative symptoms. Dissociation can play out in all five symptom areas of the PTSD diagnosis, with flashbacks (under Criterion B, intrusion) specifically being described as a dissociative phenomenon. In DSM-5, depersonalization is defined as "persistent or recurrent experiences of feeling detached from, as if one were an outside observer of, one's mental process or body" (potentially an avoidance or negative mood/cognition manifestation) [19]. Derealization is defined as "persistent or recurrent experiences of unreality of surroundings" (potentially a part of the PTSD symptoms of intrusion, avoidance, or negative mood/cognitions) [19]. Although depersonalization and derealization still appear as their own diagnoses in the dissociative disorders category, those diagnoses should be ruled out if PTSD is the better explanation.

The Dissociative Profile is a process used to evaluate and become aware of one's own tendencies to dissociate, both adaptively and maladaptively, and identify best strategies for directing one's knowing awareness back to the here and now. Therapists and helping professionals should first know their own dissociative profile and by doing this, will help clients to investigate their own [21]. This exercise is not only valuable as an exploratory device—the knowledge gleaned from it can become a valuable part of treatment planning, especially in managing distress that may rise between sessions. This approach is presented prior to discussion of formal psychometric measures with the intent that a general understanding and ability to identify association will help you truly understand these psychometrics and how to use them.

At a minimum, clinicians should be familiar with the Dissociative Experiences Scale (DES), developed by Eva Bernstein Carlson and Frank Putnam [22]. This is a screening device, not a pure diagnostic evaluation, so a clinical interview will be necessary in order verify a diagnosis. Even as a screening device, the DES can be a conversation starter and vehicle for investigation, regardless of a person's specific diagnosis. The DES is a 28-item screen in which people are asked to give a general impression of how often they engage in a certain behavior or activity that can be potentially dissociative. Sample items include [22]:

To get an average score on the DES-II, you add up the total number of percentages and then divide by 28 (the number of items on the evaluation). Anything above 30% is generally considered to be cautionary for a clinically significant dissociative disorder. Anything greater than 40% is generally considered to be in the range of a clinically significant dissociative disorder. The DES is a starting point for clinicians and clients alike who are not familiar with addressing dissociation. Of course, nothing significant occurs at 30% or 40%; these are simply meant to be a guide for further diagnostic evaluation. One concern is that training programs in specialty therapies that use the DES to screen for dissociation can promote fear. For example, in the EMDR therapy community, some programs can promote the idea that people with a DES score greater than 30% are not appropriate candidates for EMDR or other types of deep trauma work. This is another of the myths and misconceptions. If the DES is greater than 30%, precautions should be taken and therapists can use the information gleaned from the DES to obtain a better sense of a person's relationships to dissociative responses based on their trauma.

In the spirit of getting to know one's own dissociative profile and relationship with dissociation, clinicians should take the DES for themselves first. It can be scored, but it may be more valuable to investigate how some of the higher scoring items fit into the Dissociative Profile exercise completed in the previous section. Other psychometrics in use clinically include:

One of the classic concepts and articles in the field of dissociation studies is Fraser's Dissociative Table Technique. This concept was key to introducing the idea that a person with dissociative parts could get to know their system and how the various parts inter-relate with each other. Publication of Fraser's seminal article led to the popularization of the "conference table" metaphor for individuals with dissociation mapping out their parts and how they inter-relate. Fraser introduces a variety of other metaphorical possibilities as well for this mapping, with an emphasis that the table metaphor is only one part of his larger technique [23,24]. In his core article, he discusses the use of the following approaches that make up the Dissociative Table exercise [23]:

One of the classic concepts and articles in the field of dissociation studies is Fraser's Dissociative Table Technique. This concept was key to introducing the idea that a person with dissociative parts could get to know their system and how the various parts inter-relate with each other. Publication of Fraser's seminal article led to the popularization of the "conference table" metaphor for individuals with dissociation mapping out their parts and how they inter-relate. Fraser introduces a variety of other metaphorical possibilities as well for this mapping, with an emphasis that the table metaphor is only one part of his larger technique [23,24]. In his core article, he discusses the use of the following approaches that make up the Dissociative Table exercise [23]:

The two main terms used in the Theory of Structural Dissociation are apparently normal personality (ANP), which is similar to Fraser's idea of the center ego state, and emotional part or personality. Emotional parts remain to protect or to meet a need, and some systems contain a more complicated interconnection of emotional parts and ANPs than others. While this is a bit of an oversimplification of how structural dissociation plays out systemically, it gives people new to this theory a good frame of reference. The model also makes use of the terms primary structural dissociation (which is more likely to be used in relation to PTSD and other trauma-related disorders), secondary dissociation (mainly related to personality disorders, dissociative disorders other than DID, and complex PTSD or developmental trauma), and tertiary dissociation (classically presented as DID). Figure 1 provides a visual presentation of how this may play out.

The two main terms used in the Theory of Structural Dissociation are apparently normal personality (ANP), which is similar to Fraser's idea of the center ego state, and emotional part or personality. Emotional parts remain to protect or to meet a need, and some systems contain a more complicated interconnection of emotional parts and ANPs than others. While this is a bit of an oversimplification of how structural dissociation plays out systemically, it gives people new to this theory a good frame of reference. The model also makes use of the terms primary structural dissociation (which is more likely to be used in relation to PTSD and other trauma-related disorders), secondary dissociation (mainly related to personality disorders, dissociative disorders other than DID, and complex PTSD or developmental trauma), and tertiary dissociation (classically presented as DID). Figure 1 provides a visual presentation of how this may play out.

In working with clients with dissociation and identifying your own dissociative tendencies, clinicians can lean into the metaphorical possibilities that people can develop as they endeavor to understand their systems and how they work. Fraser's metaphors are a solid start, and the circles and shapes often used to represent structural dissociation are a good jumping off point. However, because creativity and expression are part of what defines the dissociative mind, using more creative metaphors may be better serving to you and to your clients [21].

The therapist asks Ms. M if she sees her parts in any specific way, and she answers immediately—"Yes, I see them as a dollhouse!" She goes on to describe that each part has their own room, and that when she wants them to come together and have a discussion, she senses that they all meet in the living room for a gathering of sorts. They use this mapping of her system as vital information in developing her treatment plan and approach. Interestingly, Ms. M did not require assistance in developing this metaphor—it was already innate within her, and she just needed permission and space to speak it. Other clients may require more of a guide or some examples to help them map out their parts and how they interplay within a system. This can be a creative exploration to understanding the self whether or not a person has a clinically significant dissociative disorder. Other metaphorical possibilities include:

Some clients will develop names for their parts, some will refer to them just as numbers or ages (as in the related experience), and others will refer to them just by descriptive qualities (e.g., my angry side, my soft side, the shame part, the inner child). Before beginning work with people using Fraser's Table, mapping in the spirit of structural dissociation theory, or one of these more creative metaphors, clinicians are encouraged to first do some mapping of their own internal system. In essence, this is an important continuation of the Dissociative Profile exercise.

The addiction treatment field is making steady steps toward becoming more trauma-informed, but a deficit in professionals' ability to identify signs and symptoms of dissociation persists [26]. This is a problem, especially because of the strong interplay between dissociation and addiction. Many clients will be unaware of dissociative symptoms experienced in childhood because drinking and using drugs can become their dissociative outlet in adulthood. Specific dissociative symptoms (e.g., "zoning out" at work or when emotionally overloaded) can develop in sobriety, and will require trauma-focused treatment. This phenomenon is relatively common in recovery circles, but it is often written off as "the pink cloud of recovery is passing," or "things are getting tough." When a person has a difficult time staying sober after getting sober, unhealed trauma is usually the culprit, and dissociation is a possible manifestation [6,26].

In an article on the importance of dissociation-informed treatment, several other dissociative behaviors that manifest clinically but that professionals often fail to identify were identified [26]. They included clients struggling to pay attention in group, at 12-step meetings, or during lectures; a client changing tone (e.g., "It's like I'm suddenly speaking to a 5 year old") when something distressing comes up in sessions or in group; and other manifestations of blocking or resistant client behaviors. When a client gets belligerent or angry, this may be a sign of dissociation. In some clients, these types of behaviors could be a part speaking out to protect the system or to get a need met.

The term addiction is controversial in the modern era, because many critics feel that term is stigmatizing and not adequately trauma-informed [28]. To address this, the Addiction as Dissociation Model defines addiction as "the relationship created between unresolved trauma and the continued and unchecked progression of dissociative responses" [27]. In presentations where primary addiction treatment has failed to address trauma, dissociative experiences may produce a dissociative disorder or clinically significant symptoms of dissociation. Similarly, if dissociation in trauma has not been treated accordingly, addiction can often manifest [29]. The model contends that addiction develops in relation to trauma and dissociation, because trauma (cause) produces dissociation (effect).

Mergler, Driessen, Ludecke, et al. examined the relationship between the PTSD dissociation subtype (PTSD-D) and other clinical presentations [31]. In a sample of 459 participants, the PTSD-D group demonstrated a statistically significantly higher need for treatment due to substance use problems, in addition to higher current use of opioids/analgesics and a higher number of lifetime drug overdoses. They ultimately concluded that PTSD-D is related to "a more severe course of substance-related problems in patients with substance use disorder, indicating that this group also has additional treatment needs" [31]. Such a connection seems like clinical common sense, but it has not been fully explored in the treatment literature.

This contention does not suggest that time-honored interventions for treating addiction should be abandoned. However, these interventions should be fortified based on the light of evolving knowledge about trauma and dissociation [6]. Solutions worth highlighting include developing the power of nonjudgmental support communities and the importance of cultivating daily practices that lead to lifestyle change. As such, the community of mutual help fellowships also benefits from an understanding of trauma and dissociation. Peer support services and fellowships like Alcoholics Anonymous, Narcotics Anonymous, Al-Anon, and Adult Children of Alcoholics can provide a safe place to discuss solutions, as long as there is a reasonable degree of trauma-informed ethics in the culture of the meeting.

Ultimately, incorporating trauma resolution and memory reconsolidation therapies is essential to bring about healing of the root of the problem, not just the symptoms. Memory reconsolidation is based on the belief that the brain, through a process of memory retrieval and activation, can delete unwanted emotional learning [35]. Progressive counting, emotional coherence, brainspotting, deep brain reorienting, and EMDR therapy provide more direct ways of resolving traumatic/addiction memories [4,35,37,38,39].

No instant cure or approach to psychotherapy exists for healing trauma, dissociative disorders, or any mental health conditions. In fact, if a professional claims that they have the curative answer for working with trauma and dissociation, proceed with caution. Particularly when working with dissociative systems, the answer to successful treatment rests in finding the approach or series of approaches that works best for that client to achieve their treatment goals. With the intricacies of parts and dissociative systems, it is very likely that a variety of tools and approaches will be necessary, as what works for one part may not resonate with another. This is where being an eclectic or integrated therapist, albeit with a solid understanding of trauma, will serve best.

This section does not endorse any one specific approach for working with or treating dissociation. Some people approach coming to treatment to address clinically significant dissociation as a process of healing maladaptive dissociation while fundamentally working to embrace the aspects of having a dissociative mind that serve them. As with treating any mental health condition using any approach (or approaches) to psychotherapy, it is important to get a sense of what the client's goals and intentions are for engaging in treatment. Never assume that integration is the client's goal or promote any biases that integration is what is required for a person to heal and to live an adaptive life, especially when a client presents with DID or any other dissociative condition that involves parts. Plausible goals that may appear in a treatment plan include:

The stages and their tasks, as presented in modern language are [40]:

Put simply, clients work to become prepared to handle the symptoms that show up in day-today life while also preparing for a deeper level of work, if they have the intention to go there and heal trauma at its root. Treatment should also include preparing clients to adjust to the changes in their life that happen as a result of unhealed trauma being addressed and transformed. Trauma resolution is only part of treatment—it is not the entire process. Preparation and adjustment to life are also major components of treatment.

Many of the approaches to treatment that exist in the mental health field make wide use of guided imagery or visualization in preparation; these techniques are exclusively cognitive. In working with trauma, especially complex trauma and dissociation, it is vitally important that clinicians have a wide variety of skills that they can offer clients for use during and between sessions. These skills should work with all of the senses and many avenues of human experience [6,43]. Grounding is the very practice of using all available senses and all available channels of human experience to remain in or return to the here and now.

Skills that may be used for preparation and widening affect windows of tolerance generally fall into the following categories:

Some may be further ahead than others in use of such skills in clinical practice, so some clinicians may require a deeper investigation on how to use these skills personally and teach them to others. Regardless of the skills a clinician uses, it is important to trauma-inform the language and leave people plenty of options for modifying. Reading an exercise out of a book, showing a client a video, or even reading one of the skills word-for-word from this course will generally not be sufficient. If a client expresses that something is not working, it could be that they are overwhelmed; a general best practice is to modify the skill either in length or style.

In modern clinical work, many of the skills advocated for helping people to ground or widen their affective window of tolerance can be described as mindfulness practices. Mindfulness is fundamentally about remaining in or returning to the here and now. Consider that dissociation, by its nature, is the antithesis of mindfulness. Forner posits that mindfulness is fundamentally about connection (e.g., to the self, to the present moment, to others), whereas dissociation is ultimately about surviving disconnection [44]. If a person dissociates long enough or becomes bonded to this state (as proposed in the Addiction as Dissociation Model), they can become phobic of mindfulness. As with any other phobia, the answer is not to avoid teaching mindfulness strategies. Rather, clinicians should be cognizant of the idea that when mindfulness strategies are presented to people who dissociate, they are being asked to try something that can feel radical and new. Small steps are required to help people become more comfortable with being present.

Strategies for trauma (and dissociation)-informing existing practices are diverse [1]. First, remember that eyes can stay open. Many clinicians and approaches to therapy or meditation automatically will tell people to "close the eyes," either because they have been trained to do this or because closed eyes help them to focus more effectively. Consider, however, that many people feel claustrophobic or closed in/trapped when their eyes are locked shut. This can promote anxiety. Moreover, closed eyes can be a dissociative response that can create a greater sense of drift or separation from the task at hand. Any exercise can work just as well with the eyes open, and for many clients with dissociation, keeping the eyes open can create a very necessary dual awareness between the room they are in (the present moment) and the memories or experiences that they are visiting in their work.

Second, time in the exercise is variable. Different approaches to clinical work and meditation will often write up skills with suggested lengths of time spent in each strategy, ranging from 3 to 5 minutes up to 25 minutes. Skills on the high end are generally too long for people who dissociate or who are just getting used to working with mindful skills and strategies. Clinicians are always empowered to alter the length of time that they guide a person through an exercise. Even 15 to 30 seconds at first can be an accomplishment for a client, and they can always build on this progress.

Next, let people know how long the exercise, particularly the silence, will last. Many people are triggered or further activated to dissociate when they are not sure how long something will last, especially periods of silence. While a goal may be to help people sit with silence for longer periods of time, be advised that a clinician's voice can be an anchor in many of these exercises. If there will be a period of silence in a meditation or skill, preface the exercise with, "We will now sit silently for the next 30 seconds."

Be open to variations in practice. Some people associate mindfulness as purely a sitting meditation practice. While this is a popular and potentially very beneficial way to work with mindfulness, any activity can be a vehicle for practicing mindfulness. Many find that walking, engaging in expressive arts practices, using grounding objects (e.g., rocks, crystals, soft blankets), or even activities of daily living (e.g., cleaning, cooking) are better avenues, especially at first. It is all about the intention and where the client is keeping their focus.

The following grounding skills are written in language that clinicians might use with clients, with the intent to model the principles of trauma-informing exercises. The modifications and variations presented are not exhaustive. Consider what else might be coming up as variations that can be used in presenting these skills. For example, some may not like a word like "grounding," especially if they feel shamed for not being able to ground. Words like "anchoring" and "settling" may be viable modifications. It is important that therapists not expect all-or-nothing adherence to these skills. This can be modeled by saying things like, "Get as grounded as you can," or "Get as comfortable as you can." These modifications are especially important for people living with disabilities or chronic pain.

Basic Grounding and Sensory Scan

Take a look around the space that you are in right now. Start naming the different things you see. Be as specific as possible. For instance, you might say "I see the carpet below my feet. The carpet is blue with some bits of brown in the thread. I see the lamp on the desk. The base of the lamp is brown glass, and the shade is beige." Keep going for as long as you need, until you feel fully present in the space.

If you need, move on to the other senses. What are you hearing (or not hearing) in this moment, in this space? Observe and describe. What are you smelling? What are you tasting? Use your hands and either touch your clothes or make contact with the chair or the table. Observe and describe the touch sensation.

If you are working with an entire system, feel free to ask if all of the parts in a system feel sufficiently grounded and "here." If the answer is no from the presenting adult or the person/parts you work with primarily, invite those part(s) to engage in the same exercise. In using strategies like this, it is recommended you continue to speak to the present adult, using only a middleman (Fraser's term) or speaking directly to the parts in question if needed. In the case of DID in which there are multiple ANPs/presenting adults, the general advice is to work with whoever is present with you.

Mindful Breathing

In working with complex trauma and dissociation, it is important to recognize that breath work may be both a trigger and a resource. So, while deeper breathing strategies may be appropriate eventually, know that starting with basic breath tracking is sufficient.

Pay attention to your normal breathing for 30 seconds to 1 minute. If your mind starts to drift, that is okay, just bring the focus back to your breath.

A whole minute can be a challenge to start. Do not worry; start slowly and be gentle with yourself. If you can eventually work your breath practice up to three minutes, you will find that your breath will be there for you to help you calm yourself when you need it most. It takes practice. If you need the extra help, consider using this classic mantra as a guide, saying it to yourself as you breathe: "As I breathe in, I know I'm breathing in—as I breathe out, I know I'm breathing out." A simple "in-out" also works.

Clench and Release

Start with your hands, if they are available to you. Clench your fists together and notice your edge. Do not hurt yourself. Once you feel you are squeezing as tightly as possible, begin to notice your nails make contact with your skin. Notice the tension. As you do this, bring to mind a person, place, or thing that is causing you distress. Hold the clench as long as you can, at least 10 to 20 seconds.

The therapeutic connection clients experience with providers can be more important than any technique, strategy, or modality used [48]. While the therapeutic alliance is an important feature of any therapy and in working with any population, issues around therapeutic alliance should be attended to in a special way when working with the spectrum of dissociation. A clinician's willingness to admit that dissociation is real and that a system is not manifestation of one's imagination is a great start in building rapport. As always, clinicians should be mindful not put their own agendas or projections on to a client, even in taking a more normalizing approach to dissociation.

Navigating the particulars of the therapeutic relationship can be sensitive. For instance, some parts in the system may not like a therapist or not be a fan of therapy in general. Clinicians are encouraged to roll with this resistance and take great care not to take any insults personally. Rather, consider what that particular part may find distressing and work to explore a solution. In doing clinical work, "hearing out" a part is generally more beneficial than trying to fight it.

Another potential problem area is a tendency for therapists to over-attach to younger or more vulnerable parts. There can be a desire for younger parts to turn the therapist into a parent figure, and this can cause some enmeshment and blurring of boundaries. While it is certainly possible to validate a client's or system's desire to see one as a parent, it is important to be clear that you are not their parent. This can feel cruel, but many of clients suffer because good boundaries were not modeled for them in early childhood. So, clinicians are in a position to validate their feelings and also challenge them into action, all while modeling and offering instruction about healthy boundaries. If this type of relationship is developing, ask the client/parts what qualities are being exhibited that they may have needed in a parent. These qualities can be used when evaluating what resources need to be built or worked on for younger parts in the system.

Protector figure resources may include people (real or imagined), spiritual entities, or even fictional characters to whom the client has a special attachment can be used. Another adjective may feel better than protector, including guardian, nurturer, advocate, or healer. Precautions should be taken, especially if using people who are still alive or may qualify as a mixed resource (i.e., they possess adaptive and maladaptive qualities). The exercise is written to go slowly and be adapted to the specific person and their system. Guided visualization may be used for this, as can expressive arts strategies or any strategy that works in the system of therapy in which you are trained.

When a client (and their system) experiences an adequate sense of preparation to move forward, the system can begin heal using any number of therapeutic strategies. Before continuing, it can be helpful for clinicians to contemplate what they consider to be their primary therapeutic orientation or orientations. In many cases, professionals can use what they have already learned to help people reach their established goals by assisting them to process or modify how traumatic memories are stored in the brain.

Expressive arts therapy, which refers to using any and all available creative forms (e.g. dance/movement, writing, art, drama, music) in combination, or any of the creative arts therapies as singular strategies can be a solid adjunct to any strategy available for processing or transforming trauma's impact in the brain. In many cases, parts in a system are young in terms of chronological age or exist in a state that cannot easily be accessed by words or language. Drawing or dancing may be a way to access the material that needs to be processed. Expressive arts strategies can be used in concert other approaches to trauma-focused therapy if the clinician has a sense of adventure and a willingness to personally try these strategies [45].

In the treatment recommendations provided by the ISSTD, no one specific treatment modality is endorsed for doing stage 2 work. What is important is that clinician and client has a solid therapeutic alliance established with good boundaries, and that they understand how to work with abreaction (when material shifts from the sub-conscious into consciousness, with some type of affective release typically accompanying it). Working integration will help a client and their system be able to put the past in its proper place and allow all facets of experience to be attended to. With a system involved, this may not be an easy task; it should be handled with care and attention to the system. The client-driven An Infinite Mind organization also does not endorse any one modality in the treatment of DID. Instead, they emphasize the importance of finding a therapist who believes in dissociation and who is willing to work with it, while also giving a client/survivor of trauma options for care.

In the treatment recommendations provided by the ISSTD, no one specific treatment modality is endorsed for doing stage 2 work. What is important is that clinician and client has a solid therapeutic alliance established with good boundaries, and that they understand how to work with abreaction (when material shifts from the sub-conscious into consciousness, with some type of affective release typically accompanying it). Working integration will help a client and their system be able to put the past in its proper place and allow all facets of experience to be attended to. With a system involved, this may not be an easy task; it should be handled with care and attention to the system. The client-driven An Infinite Mind organization also does not endorse any one modality in the treatment of DID. Instead, they emphasize the importance of finding a therapist who believes in dissociation and who is willing to work with it, while also giving a client/survivor of trauma options for care.

An estimated 10% of the adult population is estimated to have a dissociative disorder; the majority are living typical lives and making valuable contributions to society [46]. Prevalence rates are higher in certain populations (e.g., psychiatric inpatients). For the sake of these patients, biases or preconceived notions about the impossibility of healing and optimal functioning in people who clinically dissociate should be put aside. These clients deserve the best available care to address their traumatic memories and improve their quality of life. The third stage of the three-stage consensus model of trauma treatment is generally called reintegration, and its primary objective is to assist people to make adjustments based on healing gains in therapy, ultimately living more adaptive, fulfilling lives.

An estimated 10% of the adult population is estimated to have a dissociative disorder; the majority are living typical lives and making valuable contributions to society [46]. Prevalence rates are higher in certain populations (e.g., psychiatric inpatients). For the sake of these patients, biases or preconceived notions about the impossibility of healing and optimal functioning in people who clinically dissociate should be put aside. These clients deserve the best available care to address their traumatic memories and improve their quality of life. The third stage of the three-stage consensus model of trauma treatment is generally called reintegration, and its primary objective is to assist people to make adjustments based on healing gains in therapy, ultimately living more adaptive, fulfilling lives.

Another question that arises is whether or not people with DID especially will require continued treatment or care for the rest of their lives or if termination is possible. In many ways, DID and other dissociative disorders are no different than any other major mental health disorders when contemplating termination. Some people will need long-term care as they adjust to living a more adaptive life aligned with their goals and intentions; others will reach a place where regular therapeutic care is no longer necessary. Like many issues in mental health, a case-by-case approach should be taken. Pharmacotherapy is outside of the scope of this course, but clients with dissociative symptoms or DID might be prescribed medications under the care of a psychiatrist or addiction medicine specialist. If this is the case, as a therapist, it is important to have regular contact with these providers to assure continuity in care and interprofessional collaboration.

Parts journaling is an exercise based on Gestalt principles and other time-honored strategies in the field of psychotherapy, with an expressive arts twist. Like any exercise in this course, clinicians are encouraged to personally complete it first, and then consider sharing it with clients.

Parts journaling can be particularly useful for clients working with material in the system between sessions. There are also many implications for this sense of dialogue and communication can be used to help one's systems and internal world live more adaptively. When using this exercise with a client, it is strongly advised that it is personally completed first and that the client do the exercise in the presence of the clinician the first time it is attempted, so they have assistance working through any distress or overwhelm they might experience. As always, it is vital to use good clinical judgment about assigning this as therapeutic homework between sessions. Clients may do very well with this on their own after they understand its intention—to give voice to parts of the system that may need to speak and to engender a higher degree of communication. Although one should begin writing between only two parts to start, the voices of other parts can be brought in, especially if they have a mediating influence or hold an important part of the solution.