Checking Out

The ‘checking out’ phenomenon, otherwise known as dissociation, is one of the most feared symptoms experienced in our profession (next to suicidality and psychosis of course).  Specifically, those clinicians who have decided to dedicate their career to focusing on trauma, addictions, eating disorders or personality disorders are starting their path with an understanding that dissociation may show up somewhere along the journey.  Other clinicians hold the blissful denial that they will never have to deal with it.  Reality is, dissociation shows up in all of our offices at some point, and it is advantageous to know when it does.  Then of course is the logical next step, what to do.

In the context of experience, dissociation is a natural phenomenon in all human beings. Consider a time you took a regular route in your vehicle and you remember getting into your vehicle, starting it, backing out, then starting on your way.  Then sometime later you realize you are pulling into your destination with little memory of actually how you got there.  A phenomenon we can all relate too.  This is the most basic of dissociation levels.  Bruce Perry, M.D., Ph.D. postulates “Dissociation is the most primitive of reactions: earliest life forms, infants, and the very young rarely escape dire situations of their own accord. For infants and young children, dissociative response to extreme stressors is common. If it’s prolonged it is connected with increase in PTSD symptoms.”  Under this explanation we understand that trauma in the developmental timeframe of childhood, commonly results in dissociation.  Continual trauma in childhood results in the regular occurrence of dissociation which can eventually become habitual. 

What does it look like in your office? On the simple end of the spectrum it can be experienced as a client stating they feel foggy, floaty, or numb.  On the more complex end the client may describe feeling robotic, disconnected from the present moment, or even shift before your eyes into someone quite different than what you have experienced in your client before.  A lot of times clients do not really know they are dissociating.  Those who do it often do not know that it is something unusual, and frankly if they do they are embarrassed to let others know.  In my experience they do not come out and tell you this is something they do regularly, because they think it makes them ‘crazy’ (their word not mine). 

I’ve learned to ask in my intake process about childhood experiences, this can be done in a psychosocial, genogram, timeline, or family history assessment.  When trauma’s are mentioned by the client, I make it a point to add in an element of psychoeducation on trauma, it’s impact on the brain and common reactions/symptoms of trauma.  Part of that psychoeducation includes explanation of dissociation.

That is the beginning process of how to notice it and then what to do.  As the clinician the next step is teaching the client ‘present living’.  Present Living is part of many treatment models today, including many marital/relationship models, family models, and solution oriented models.  These models are about helping the client live in the moment and out of reactivity.  This is exactly what the objective with clients who dissociate is as well.  For those clinicians who practice ‘present living’ models, just add one additional step of teaching a client who regularly dissociates how to ground.  Simply put, it’s teaching the client to be mindful or aware of when dissociation is happening and then giving them the tools to stop the dissociative process and return to the present moment. 

Watch the following video to get an example of an effective therapeutic tool to use to help ground clients who are dissociating. 

Or click on the following link to watch a demonstration of the “Senses Bag” a technique I use to teach clients how to ground.

Dissociation doesn’t have to be scary.  At the simplest explanation it’s a symptom.  Now you the clinician have some resources that can help address and eliminate this symptom for a client.

****Dislcaimer- Complex forms of dissociation should only be addressed by clinicians trained to address the complexity of those symptoms (e.g. DID, dissociative fugue, and depersonalization disorder). However basic forms of dissociation can be addressed by all clinicians.  If the symptom persists or gets worse, seek consultation. ****