The TIST Approach to Treating Dissociation

In 1989, I was working as a psychology predoctoral intern on a psychiatric unit when I was assigned my first patient. Rebecca, 20 years old, was a drummer with flaming red hair who’d been admitted to the unit after threatening suicide. In our first session, she described how she’d been hearing voices that would call her all sorts of nasty names and tell her she should kill herself. The standard of care for such patients was not to dispute the voices and see them as part of the disease. But not knowing that, I suggested she tell the voices she didn’t want to die, and that if they wanted to get out of the hospital, they should stop telling her to kill herself. By the next morning, the voices were quiet.

A few days later, Rebecca arrived for our session looking disoriented and confused, wearing a black lace tutu and combat boots. “I didn’t know how to get dressed this morning,” she said. “I didn’t know how to tie my shoes. It was weird!” Then, as I opened the door for her to enter my office, she suddenly froze. “I can’t go in there!” she screamed in a frightened, childlike voice. “Where’s my mother? I want my mother!” Luckily, I’d just spoken with Rebecca’s mother that morning, so I reassured what was clearly a child that I knew her mom and had her permission to speak with her.

Reluctantly, she came in, sat down in her chair with a childlike plop, and began to tell me how much she loved school. “Guess what?” she said. “I’m in the red reading group! Everybody knows that’s the best reading group.”

I was used to talking to children, having two of my own, so we began chatting about reading groups. It wasn’t long before I discovered that this child was in the first grade—the age at which Rebecca’s mother told me she’d been sexually abused by her older brothers. Somehow, even though she’d suffered a horrible trauma at the hands of the family members she most adored, she could still find a way to be proud of herself.

I was deeply impressed by Rebecca’s resilience and knew she possessed the tools she’d need to process her trauma and keep the voices at bay. But the truth was that, for most of us therapists, dissociation was uncharted territory. It would be years before I’d create Trauma-Informed Stabilization Treatment (TIST), a therapeutic model that treats dissociation by stabilizing the nervous system and helping clients provide reparative experiences for their traumatized parts. Even with the best of intentions and the sharpest trauma treatment tools of the time at our disposal, our interventions were flawed. All of us were in the dark.

Turning a Blind Eye?

Dissociation doesn’t just present one way or affect a particular kind of person. In fact, some therapy modalities, like Internal Family Systems, believe that multiplicity is normal, that all human beings have multi-consciousness rather than uni-consciousness. The truth is that we dissociate all the time, like when we daydream, or get lost in a book, or space out on the highway on long drives. Dissociation is a valuable resource for peak performers like professional athletes who, with the aid of dissociative states, can perform on little sleep, under stress, and separated from emotions that could distract them. And dissociation is essential in the work of doctors, nurses, and paramedics, who need to keep information and emotion separate during emergency situations.

Dissociation allows one part of the brain to remain alert and skilled while another part is horrified, frightened, or overwhelmed. Our brains go on autopilot so we can function without awareness of what we are doing as we do it.

Of course, these mild types of dissociation are different than those experienced by a victim of domestic violence, or a soldier in combat, or an abused child like Rebecca. For these individuals, the symptoms are often more severe, and can involve amnesia, profound detachment from self, emotions, and reality, and identity shifts that can lead to confusion, emotional numbness, distorted perceptions, and significant functional impairment.

But despite the prevalence of dissociation, the mental health field seems largely uninterested—even afraid—of it. How did dissociation become a bad word and a questionable diagnosis?

The answer lies in our early thinking around trauma. Trauma wasn’t recognized or included in diagnoses until 1970, when PTSD was first included in the DSM, and back then, it applied primarily to combat veterans and rape survivors. Over the next decade, astonishing cases of “multiple personality disorder” were reported—not in professional journals, but in the public media and autobiographical books. At first, this disorder, in which dissociated parts of the personality took over the body and acted outside of conscious awareness, seemed too extreme to be real. Leaders in the field labeled it a “factitious disorder,” in which clients sought attention by acting as if they were different people of different ages.

Meanwhile, many of the therapists who’d been working directly with these clients could feel the authenticity of their dissociated parts and see how they’d emerged organically from the client’s traumatic past. Their hearts were touched by the vulnerability of wounded child parts—which frequently led to them becoming over-involved in trying to manage the chaos and care for them. Throughout the ’80s and ’90s, many therapists became overinvolved with their MPD clients, drawn in by their empathy.

I remember this era well. Even expert trauma specialists had few treatment approaches to MPD, and so I did play therapy with child parts, took walks with them, and tried to get my clients to believe what these younger parts were disclosing. But the more I did for my clients and their parts, the worse their symptoms became. The popular assumption was that the therapist should help each part download its memories and, in time, share them with the client or “host.” This approach quickly led to the destabilization of even well-functioning clients. Doing therapy with each separate part led to more dissociation, not less.

By the early ’90s, MPD was being diagnosed more frequently, and having worked with even one MPD client gave me credibility as an “expert” in working with this disorder. What we didn’t realize was that none of us were experts. We were trying to apply a psychodynamic model to a syndrome we didn’t fully understand.

It only took one session with Rebecca to teach me that MPD was not only real, but a normal trauma response. And yet misconceptions were rampant. By the mid-’90s, MPD had developed such a negative connotation and had been rejected by so many professionals that in 1994, the DSM-IV removed the diagnosis completely and replaced it with dissociative identity disorder (DID). Many lawsuits were filed against therapists because they’d made MPD diagnoses or asserted that their clients had repressed memories of abuse. The “false memory” movement did further damage, creating a backlash that ensured few individuals would be given a DID diagnosis in the years that followed.

What the Research Says

Despite landmark advancements in trauma treatment, barriers to acceptance of the existence of dissociative splitting and dissociative disorders remain, partly due to an absence of studies demonstrating a scientific basis for such dramatic, difficult-to-treat symptoms. Theories about parts tend to be metaphorical, not biological or brain-based. But this doesn’t mean there isn’t strong evidence for why dissociation happens and how it functions.

In the face of abuse and neglect, especially at the hands of those they love, children need enough psychological distance from what’s happening to remain psychologically intact. Preserving some modicum of self-esteem and hope for the future requires victims to disconnect from what has happened or dissociate from their experience.

Dissociation allows us to observe events from a distance, as if we were watching a movie. A trauma survivor might be horrified by what’s happening to them, but in their mind, the event is happening to someone else, not to them. In their mind, that child is the “bad child,” and because they’re being treated as bad, that must mean they are bad. Dissociation capitalizes on the brain’s innate capacity to split or compartmentalize. So there also exists a “good child,” who might be sweet and helpful, or perfectionistic, or quiet and shy, and can remain acceptable and safe in an unsafe world. Dissociation allows one side of the child to be hypervigilant, wary, angry, or sad, while the other side plays with friends, finishes homework, and sits down to dinner with family.

As children of abuse move through adolescence and into adulthood, the splitting of the self supports another important aspect of surviving trauma: mastering normal developmental tasks, like learning in school, developing peer relationships, and finding interests. The “good” child is free to develop normally while the “other” child bears the emotional and physical imprint of the past, scans for signs of danger, and braces for the next threats and abandonments. To complicate matters, neither self is likely to have well-developed memories of the traumatic events that could aid in self-understanding.

But why does dissociation persist long after the traumatic event has ended? In order to ensure that the rejected child is kept out of consciousness, the individual must continue to rely on dissociation, denial, or self-hatred to enforce the disconnection. In the end, they have survived abuse, betrayal, and others’ failure to provide safety—at the cost of disowning their most vulnerable and most wounded self. Many survivors struggle with feeling fraudulent. As they work to stay away from the “bad” self and identify with the “good” one, they have a felt sense of “faking it” or “pretending,” which can lead to crippling shame and self-doubt.

Brain science also contributes to our understanding of dissociation. It’s generally accepted that dissociation is the brain’s approach to managing stress, and research shows that traumatic memories are encoded differently than other memories. In a landmark 1995 study from Bessel van der Kolk, subjects were asked to recall a traumatic event while undergoing a brain scan. The results showed that the areas responsible for verbal memory and expression shut down, while areas related to nonverbal emotional and somatosensory memories became highly activated, suggesting that our brains often fail to encode traumatic experiences as past narratives. Why? One hypothesis is that this causes an increase in vigilance and mistrust, bracing us for the next inevitable traumatic event. If we perceived a traumatic experience as over and done, we could relax. But that would be very dangerous in an unsafe world.

While the left brain handles verbal and logical operations, the right brain is emotional, intuitive, and nonverbal. Children are right-brain dominant for most of early childhood, while the left brain develops more gradually over the child’s first 18 years of life. In addition, the corpus collosum, the brain structure that enables right to left-brain communication, also develops slowly and only becomes fully elaborated around age 12. This means that in the early years of childhood, right-brain experience is relatively independent of left-brain experience, making it vulnerable to dissociative splitting.

In his years researching brain development, Harvard psychiatry professor Martin Teicher observed a correlation between a history of abuse and underdevelopment of the corpus callosum, which supports the hypothesis that trauma is likely to be associated with independent development of right and left hemispheres, essentially leaving survivors with “two brains” instead of one integrated brain. And without an exchange of information via the corpus callosum, the left hemisphere may have little to no memory of the right hemisphere’s affect-driven actions and reactions.

Attachment research also shines a light on dissociation. Researchers have found that children with disorganized attachment status at age one are significantly more likely to exhibit dissociative symptoms by age 19 and to be diagnosed with borderline personality disorder or DID in adulthood. Meanwhile, Structural Dissociation Theory posits that functioning and coping are instinctive in mammals and just as instinctive as our survival responses. Through the frame of these models, the creation of different parts is a survival response primed to anticipate the next threat, which gives meaning and dignity to the fragmentation and internal conflicts. They show us that parts aren’t simply repositories of memory; they’re a means of surviving.

Changing Our Approach

Historically, trauma treatment has focused heavily on “the talking cure,” and treatment models have usually focused on traumatic events, neglecting to see trauma as the result of environmental conditions. The reality is that abuse occurs in a context, a family environment in which the child is not safe, attachment figures are not protective, and anticipatory fear is ever-present.

I have long believed that trauma treatment must address the effects of the traumatic past, not the events themselves. Being able to tolerate remembering a horrific experience is not as important a goal as feeling safe right here, right now, or being able to relate to shame, grief, and anger as the feeling memories of dissociated parts. In my view, healing can’t truly happen without reclaiming the lost “not me” children and welcoming them “home” at long last, making them feel wanted, needed, and valued.

How do we do this? Our first priority must be to challenge the client’s subjective perception that their symptoms are indicative of current danger or proof of their defectiveness. When they are provided with psychoeducation about dissociation, encouraged to become mindful and curious instead of reactive, and helped to develop new responses to triggers, most clients begin to develop a greater capacity to self-regulate and “be here now.”

Many clients feel relief when they’re able to reinterpret their stuckness, resistance, chronic depression, fear of change, entrenched fear and self-hatred, crisis and conflict, and even suicidality. When the therapist helps them become curious and interested in their symptoms, they can observe their distressing feelings as cries for help from parts that fear for their lives and don’t realize that the danger has passed. Knowing that each part is charged with the mission to survive, each in its own way, helps clients realize that how they survived was more crucial than how they were victimized. Understanding how each part participated in their survival creates a sense of “we, together” and replaces the sense of being abandoned and alone with a feeling of warmth and empathy for one’s young, wounded selves.

The TIST Approach

To move dissociated clients toward healing, I use Trauma-Informed Stabilization Treatment (TIST), a trauma-informed parts approach that offers new possibilities for addressing the challenges of dissociation. Treating symptoms as manifestations of parts allows the therapist to encourage mindful observation. Rather than helping trauma survivors “get in touch” with the emotions of the parts—which can be overwhelming and evoke anxiety, depression, or impulsive behavior—they learn to notice or observe their experience. First, simply noticing through mindful awareness allows them to achieve dual awareness, the ability to stay connected to the emotional or somatic experience while still observing it from a distance. Second, a parts approach allows us to titrate emotions or memories. If one part is overwhelmed by emotional pain, the client’s observing mind can notice it rather than drown in it.

It’s important to note that the language of the brain doesn’t have the same impact as the language of parts. Saying “I can sense my medial prefrontal cortex is curious about the negative mood state connected to right subcortical areas of my brain” doesn’t evoke interest, emotional connection, or self-compassion. But when a client says, “I can sense in myself some curiosity about the depressed part’s sadness,” they feel more connected and attuned to their emotions and sensations—the first step toward being able to have compassion for themselves and their parts.

Once clients have been taught to mindfully notice their child parts’ distress and understand it as their pain, they’re encouraged to empathize with the child parts’ feelings. This isn’t always easy for clients whose way of distancing the “not me” parts has been to loathe their feelings. But in TIST, they are asked to practice noticing their thoughts and feelings as evidence of parts until it becomes natural and habitual.

When clients pause to be curious about the child part that’s communicating fear or hurt or grief, the therapist can ask, “How old does this part feel? Does the part feel very small, or more like an adolescent child?” Acknowledging the enormity of what this child part has experienced tends to evoke compassion as long as the therapist is clearly asking, “What kinds of things has this child experienced?” which helps the client see the child as a helpless, innocent victim. Conversely, asking “What happened to you at this age?” can evoke narrative retelling or trigger implicit reliving.

With the help of a therapist who reframes problematic emotions and issues as communications from parts, clients learn to identify the key features that indicate signs of a part’s presence. They learn to observe distressing or uncomfortable physical sensations, overwhelming or painful emotions, negative or self-punitive beliefs, internal struggles, procrastination, and ambivalence. Automatic reactions, repetitive thoughts and responses to triggers, negative reactions to positive events or stimuli, and “overreactions” should also be flagged as likely signs of parts activity. The practice of being repeatedly asked to be curious and notice all the possible signs of parts activity has a number of benefits.

Mindful observation evokes activity in the prefrontal cortex, counteracting trauma-related cortical inhibition. For the first time, clients might notice that they can have a relationship to a feeling rather than being consumed by it. They can separate from the intense reactions of a part, express curiosity or compassion toward the part’s feelings or perspective, create ways of soothing or managing emotions, and choose to react differently to foreseeable events or triggers than they have in the past.

In the TIST model, the focus isn’t on memories of traumatic events, but on the “legacy of trauma” as it’s carried by the parts and continues to intrude into the minds and bodies of survivors. Processing the trauma requires that the therapist continue to emphasize how the parts are feeling and how they have helped the client survive. The goal isn’t the elimination or “integration” of parts, but rather to create a sense of safety for these parts that’s shared by the client. In the end, the parts are less easily triggered, and the client responds compassionately to their fears and feelings rather than being threatened by their intense emotions.

Spotting Dissociation in Your Practice

Just as everyone responds to trauma differently, clients’ structurally dissociated personality systems are unique. But there are commonalities you can use to identify dissociation. Individuals with complex PTSD might shift between clearcut emotional states—sometimes irritable, sometimes depressed, at other times anxious—without loss of consciousness. People with a BPD diagnosis might present as regressed and clinging in some sessions while rageful and angry in others. With mild to moderate dissociative disorder not otherwise specified (DDNOS), the therapist might encounter clearly observable compartmentalization and some difficulty with memory short of amnesia. Patients with DID can be distinguished by the classic DSM diagnostic criterion: two or more parts of the personality can take over the body and operate outside the individual’s consciousness. Reports of time loss, switching, or dissociative fugue experiences are often indicators of DID. Here are some additional symptoms that can alert you to the presence of underlying structural dissociation.

Signs of internal splitting. The client functions highly at work, where there are “positive triggers,” like work assignments, collaboration with peers, and responsibilities, while regressing in personal relationships. The client might also report alternating fears of abandonment followed by pushing away those who try to get close.

Treatment history. The client reports a number of previous treatments that have resulted in little progress or clarity or describes those treatments as rocky and tumultuous or having ended in some unusually dramatic way.

“Regressive” behavior or thinking. Sometimes, the client’s body language seems more typical of a young child than an adult of his or her chronological age. They might appear shy, collapsed, fearful, unable to tolerate being seen, or unable to make eye contact.

Patterns of indecision or self-sabotage. Often misinterpreted as ambivalence, a client’s inability to make small, everyday decisions or having problems carrying out expressed intentions can reflect conflicts between parts with opposite aims. This phenomenon often manifests in frequent job or relationship changes, in a history of success alternating with self-sabotage or inexplicable failure, high functioning alternating with decompensation, or hard work being suddenly undone by self-destructive behavior.

Memory symptoms. While memory gaps and “time loss” are cardinal symptoms of dissociative disorders, all of the following memory issues are common manifestations of parts activity: difficulty remembering how time was spent in a day, difficulty remembering conversations, blackouts, getting lost while driving somewhere familiar (such as going home from work), forgetting established skills (such as how to drive), or engaging in behavior one does not recall.

Patterns of self-destructive and addictive behavior. Many studies have demonstrated correlations between suicidality and self-harm with a history of trauma, so it shouldn’t be surprising that therapists encounter traumatized clients who struggle against their own self-destructive behavior. In TIST, unsafe behavior indicates the activation of fight- or flight-driven parts by trauma-related triggers. While some parts of the client seek therapy because they’re committed to living, fight parts engage in high-risk behavior or attempt to harm or kill the body in an effort to get relief from implicit memories at any cost. Parts driven by the flight response tend to be associated with eating disorders or addictive behavior that alters consciousness, allowing distance from unbearable feelings and flashbacks. Fight-related parts are prone to more violent actions, whether manifesting as aggression toward others or self-harm and suicidal behavior.

The Opposite of Dissociation

Dissociated parts want to be heard, and in trying to be heard, they disrupt the client’s attempts to live a normal life to avoid being left behind in what they experience as a dangerous world. When we encourage our clients to step back and express curiosity about these struggling parts, to notice the bodily and emotional signs that communicate their feelings, and then experiment with what might help these parts feel safer, better protected, and less ashamed, we’re processing post-traumatic memory. Each time these parts are acknowledged, heard, and feel the client’s interest, there’s a reparative emotional experience. When they assign feelings to their wounded younger selves, clients learn to feel less afraid of their intense emotions and more connected to and protective of their self-states, rather than ashamed of them and alienated by them.

When I first became a therapist decades ago, the field didn’t know that healing past traumas required transforming memories, not reliving them. TIST has helped so many of my clients put words to their experiences instead of becoming overwhelmed and dysregulated by thinking about them. It’s helped them experience spontaneous and heartfelt self-compassion—for their parts and for themselves. I like to say this work is the opposite of dissociation: by associating parts with compassion instead of pain, we can help our clients be truly present.