The Dissociation Spectrum

Psychiatrist and trauma expert Frank Anderson says we’ve been missing something crucial about dissociation—and as a Harvard-trained psychiatrist who’s devoted three decades to understanding and treating trauma, he’d know. Over 30 years ago, he began his career at The Trauma Center, working alongside Bessel van der Kolk during some of the most formative years of modern trauma treatment as we know it today. Since then, he’s become a sought-after educator and written several books, including Transcending Trauma and the memoir To Be Loved: A Story of Truth, Trauma, and Transformation.

Like other trauma experts featured in this issue, he sees our field’s view of dissociation as woefully out-of-date and in desperate need of a rebrand. But dissociation’s old image—of being rare, dramatic, obvious, maybe even reminiscent of a horror movie plot point—is hard to shake. According to Anderson, even if you don’t consider yourself a trauma therapist, you’re likely seeing dissociation regularly in your clinical work (though you may call it something else, like daydreaming, distraction, or simply spacing out.)

In this interview, along with demystifying dissociation, Anderson offers practical guidance on recognizing the subtle moments when clients shift their attention or disconnect—and most importantly, on helping them return to the present through embodied, relationally attuned interventions.

Livia Kent: What do you think most people don’t understand about dissociation?

Frank Anderson: A lot of therapists don’t really recognize that dissociation exists on a spectrum. It tends to only be associated with dissociative identity disorder (DID), or in the old days, multiple personality disorder (MPD). The myth is that it’s always extreme and only shows up in people with the most severe trauma histories. But we know from researchers like Ruth Lanius and Stephen Porges that a common subtype of PTSD is blunted or numbing and dissociative. Some people are in the sympathetic branch with hyperarousal activation: energy, panic attacks. But many others are what Porges calls the dorsal branch, with shutdown and disconnection. Others still are cognitive and partially dissociated: they don’t have access to emotion or physical sensation, but they’re always in their heads thinking. In the normal range of the spectrum, daydreaming is a form of dissociation. Everybody daydreams. When you’re driving in your car and thinking about something else, spacing out, that’s a form of dissociation.

Even within the field, a lot of people who are not trauma specialists tend to be nervous about dissociation because they think they haven’t worked with it and don’t really know how to handle it. But you can get more comfortable with dissociation when you see it on a spectrum. After all, with the world being as overwhelming as it is, people are using more and more things like phones or tablets for dissociation. You get numbed out, and then it’s like, Oh my God, what have I been doing for the last two hours? Dissociation is disconnection. There’s a disconnection from being in the present moment.

LK: What are some common forms of dissociation you might see in a session that therapists often miss?

Anderson: If somebody shifts the focus of their attention or looks away even for a moment, I always wonder, Wait a minute, what just happened there? They could be like, “Oh, I just started thinking about a work email.” And maybe that’s true, but it could be a subtle form of disconnection from something that felt too uncomfortable to sit with. Neurobiologically, dissociation is a top-down process. So thoughts get suppressed first, then emotions get suppressed, then the body. And when you’re having somebody recover from dissociation, it’s a bottom-up process. They’re going to recover in their body first, then in their emotions, and then later, they’re going to recover in their thoughts. That’s how healing works.

LK: Walk me through this. I’m your client. You notice that I’ve experienced some subtle form of dissociation. What’s the bottom-up intervention here?

Anderson: Well, if you’re more globally dissociated and it’s obvious, I’m going to do two things. First, I’m going to focus on body sensation. I’m going to see if you can move your fingers, wiggle your toes. Is your body alive? Then I’m going to ask, “Do you have any feelings?” Last, I’d ask about what you’re thinking. This helps me check to what degree you’re dissociated. Usually when somebody dissociates and they space out, if I see the shoulder twitch, the fingers move, I’ll know, Ah, okay. They’re recovering. So I’m watching the body first because of that top-down wiring.

Since dissociation is a disconnection, the other thing I do is try to empathically resonate with them. I’ll see if I can connect to what’s under the dissociation. So I’ll say I know what it’s like to be really frightened, or that I’ve also felt really betrayed before, and kind of try to get to the emotion under the protection. That’s another way to help people recover from dissociation: connection.

LK: That’s beautiful. So you’re using yourself, your own vulnerability, as a tool.

Anderson: In those moments, you’ve got to ask yourself, What am I feeling? Early in my career, when people would dissociate and disconnect in front of me, I’d start to talk more—blah, blah, blah—just to fill the space. And it really made them more disconnected. The more I pushed, the further away they went. Over time, I realized that my attachment wounding would get activated when somebody dissociated. My little parts inside would get nervous and anxious, which caused me to get to be way too forward-seeking in trying to get the connection with them back, which had the opposite effect. It wasn’t until I was able to process my own attachment trauma that I got comfortable with silence. You have to tolerate silence in order to tolerate dissociation.

LK: I noticed you used some parts language. There seems to be a bit of a debate in our field about whether Internal Family Systems Therapy is really the best framework to use when treating dissociative tendencies. As a former IFS trainer, what are your thoughts on that?

Anderson: Well, it’s interesting. Through a parts approach, IFS normalizes that our personality has different aspects. The belief in IFS is we’re not supposed to be whole; having parts is normal. Naturally, you might think, Oh, then does everybody have dissociative disorders? One side of the debate claims, “You’re fragmenting us all when we’re supposed to be whole.” My response to that is to refer back to the spectrum. To what degree are your parts separate? And to what degree are your parts communicating with or connected to each other?

Another piece of the debate comes from the mistaken belief that if you work with parts, then it’s natural for you to work with DID. That’s not necessarily the case, because people who are on the further end of the spectrum have much more distinct separate entities within them than the normal range of different parts or aspects of our personality. And a lot of people in the DID community take issue with how IFS distinguishes between the Self and parts. They say, “I’m whole in my parts. All my parts are part of me. It’s not like my parts are one thing and myself is another.” They see the parts as a sum of the whole, whereas IFS says, “Your Self is different from your parts.”

Personally, I do believe that parts have Self in them. And the distinction that I make sometimes is the difference between the human Self and the soul. So human Self could include parts or not, but the soul is more, for me, an entity that may be connected to spirit in some way different from our Self or our parts. In the end, I think there’s merit in both sides of the debate. Neither is right or wrong.

LK: In your experience, does treating more extreme dissociative tendencies with IFS cause more destabilization? What’s the goal in terms of integration?

Anderson: Yeah, it’s interesting, what many people with DID experience is that the parts hate the Self. This is because parts feel like, You left me to get abused by Uncle John or whomever. With trauma, there’s a chasm that gets created between the Self and the parts. Parts don’t love the Self. They hate the Self for abandoning them or leaving them. There’s a repair that needs to be created. I think of IFS work on parts as repairing the chasm that gets created between the Self and the parts. You’re almost doing internal attachment work when you’re working with DID.

Plus, there’s a contingent of the DID population that says, “I’m not here to get rid of my parts. I’m not here to have them be fully integrated. Parts are normal aspects of my personality.” We’re aiming more for flow than integration. It’s not like, “We’ll solve you when you’re whole.” It’s more like, “Your parts are a part of who you are. And healing may be seamlessly moving between Self and parts, and parts and Self.

LK: That sounds very normalizing.

Anderson: Part of the issue with dissociation is the word itself. It’s very pathologizing. I think we need to come up with a new word that’s more user-friendly for therapists and clients alike. Needing space, instead of dissociative. Or maybe we should just call it taking a break. In neuroscience, they call it “disconnection or blunting.” Shame is a form of dissociation—a disconnection from being seen, or known. There are a lot of ways we disconnect in the service of survival. Different words might help people feel more comfortable with the concept.

But also, I think it’s important to ask how the client’s part wants to describe itself. No part calls itself dissociative. It may say something like, “I’m the one who shuts down. I’m the one who hides. I’m the one who protects.” If we let the part name itself, it gives us a window into its function.

LK: It sounds like the answer to the question about whether IFS should be used with dissociative tendencies is, “Yes, but carefully.”

Anderson: Carefully, yeah. And be careful not to impose the IFS dogma on dissociative clients. Be open to their experience using their language.

LK: Like, “This is your firefighter part. This is your manager part.”

Anderson: Nobody’s a firefighter or manager, unless they literally are.

LK: I know you’re moving away from IFS and toward a more integrative view of practice. Are there any other modalities that you would bring into work with dissociative clients?

Anderson: IFS can be very mentalizing, and people tend to stay in their heads with it, so I’m moving to a much more integrative somatic type practice. I’m moving to embodying parts instead of just talking about them. A client might say, “I’m angry.” I’m like, “Show me anger. Don’t just tell me about it. Has it got sound? Has it got movement? Show me what anger looks like.” I’m doing a lot of bilateral stimulation to encode therapeutic moments. It’s been very effective.

LK: Do you remember what it was like to work with dissociation early in your career?

Anderson: I worked at Bessel van der Kolk’s Trauma Center in the early ’90s as a psychiatrist. When I first got there, I wanted to know more about DID and dissociation, because I didn’t really understand it. So, I asked someone in our supervision group, “How can you tell if someone is dissociative?” And they said, “There’s a feel, a quality, you just sense it.” And I was like, “What the hell are you talking about?” I was lost as to what that meant as someone new to this work. But now, I can totally see it. There’s just a way about someone who’s dissociating or spacing out. It doesn’t have to be exhibited in dramatic shifts where you’d think, Oh my goodness, this person speaks a new language and is in a whole different state. But there are subtle shifts in how they process things, move their bodies or interact that you can track. You can pick up on a certain quality that’s hard to describe.

LK: One of our writers who lived a long time with DID didn’t even realize she was dissociative. She didn’t really have a memory of her childhood, but otherwise she was just living her life. She maintains that a lot of people are living that way.

Anderson: One hundred percent. There are so many people who’ve suffered from traumatic childhoods and have learned how to adapt to survive. Dissociation is the ultimate protection. Disconnecting to survive protects us from the trauma, but it also protects us from the pain of knowing what happened to us. It should be handled with caution and treated with the respect it deserves. The more we know about it, the more we can honor it and help those who’ve heroically endured the unspeakable.