CBT for Dissociation

When I was in a trauma treatment center, we all had the same "relapse prevention" CBT course. It didn't matter if the relapse was dissociation, addiction, sui, self-injury, or impulsive behaviors, the worksheets were the same.

It went like this....

1. Identify the triggering event(s).

Ex. Some man touched me on my shoulder.

2. Identify the emotions.

Ex. Scared, shocked, angry, sad.

3. Identify the thoughts that went with the emotions.

Ex. Scared - "I don't want to be here anymore. I am afraid of that man. I am afraid of men. I think he's going to attack me."
Ex. Shocked - "I hate surprises."
Ex. Angry - "That man invaded my space! I hate him!"
Ex. Sad - "I am not the strong person I used to be. I'm always afraid. I'm sick of being afraid and scared."

4. Identify the relapse behavior and the reinforcements you get from that particular maladaptive coping skill.


Ex. Relapse behavior: Dissociation, switching (often an automatic response)
Ex. Reinforcements: Escape, increase safety

5. Identify adaptive coping skills (responses) for the thoughts.

Ex. I can communicate with my different parts of self to find out what happened when I lost time and/or was co-conscious and switched.
Ex. I can find other ways to escape while staying grounded, such as walking away from the man who touched me.
Ex. I can find other ways to increase safety, such as having a friend with me or carrying an umbrella with me that can be used for self-defense or ensuring that I am in safer surroundings by being alert, present, and grounded, as well as prepared before an event.

6. Challenge automatic thoughts.

Ex. I can face what is scary. I can work with my system to face scary things.
Ex. I have a right to my feelings. I can work with my system to understand emotions within me.
Ex. I have a right to state my boundaries: I can tell the man to not touch me.
Ex. I have a right to my safety: I can prepare in advance while being aware of my surroundings through grounding techniques. I can work with my system to ensure safety. I can ask for help when I feel unsafe.
Ex. I can remain grounded and find safe objects and good things in my environment.
Ex. I can share these tools and tips with my alternate personalities.

7. Consequences of relapse behaviors: Dissociation, switching (often automatic)

Ex. Losing time
Ex. Others are confused and possibly scared of seeing my outer shell switch and change personalities, if overt.
Ex. Others are confused when I cannot remember events that they remember.
Ex. I will have a hard time reporting victimizations to the police if I cannot remember or be fit for trial to fight against injustice.
Ex. I will feel less safe by losing time.
Ex. I will constantly be avoiding things in life that I can enjoy instead of hiding from.

There might be a step or two missing, but this is what I have down from memory.

This is where internal family systems were mixed in with a type of CBT. Really, anyone could use this CBT, as I've seen many people with different disorders in a trauma treatment facility use this, and it helped all of us diverse beings - can you believe it? For those with dissociation (incl. DID), an extra step of knowing grounding techniques as well as internal family systems needed to be learned for this to work more effectively; otherwise, the automatic switching or losing time would be confusing to work with - that was the only difference.

My T would always say to me at the end of our sessions, regardless if it were light or heavy with the emotions, that I should state 3 positive things about myself (affirmations) as well as 3 positive things about what I plan to do after our session. This helps to deescalate the intensity of the therapy session, and felt safe and consistent every single session.

For example, at the end of the session, I would say:

1. I am good enough.
2. I am right where I need to be.
3. I am thoughtful.

Then I would say:

1. I will eat something nutritious.
2. I will find something I enjoy doing.
3. I will prepare for a good night's sleep.

I like the three things that you do at the end. I might adopt that, or some version of it.
In therapy right now we are working on trying to stay present without switching. There are a couple of fronting child alters that consistently come out to relieve the pressure on the fronting adult alters. We are beginning to have success with an informal version of the CBT thing you have explained here. We are trying to verbalise feeling triggered as soon as it happens, and then T leads us through something very similar to those steps. It is an imperfect technique at present, although at our last therapy session the adult fronting was able to stay present without switching throughout the entire session, so that is a "win". I would describe our therapy strategies as being mixed in with modified IFS techniques as well. The IFS lens works well for those in our system who prefer to hold on to a non-DID version of our story.
Thank you for sharing this.

@Amyjay

Thank you for sharing your experiences. I hope I can find a T like yours one day. It's hard to get my system to trust T's though. We just work together in a covert way while learning what we can from the therapy the VA offers us. Our therapies have been short-term lately, so I've learned to deal with revolving therapists. If I had attachment issues, no one would be able to tell because I'm used to changing therapists, and I'm totally fine with leaving a therapist who isn't right for me. I'm still not sure what disorganized attachment is, but since no one has diagnosed me with any attachment disorder, I won't worry about it.

I can totally understand holding on to a non-DID version of your story. I think. Or, well, hmm... maybe not. I'm still trying to figure out my system, and I'm patient. At least I'm not losing time anymore. That was the scariest part about my diagnosis.

I am still confused about attachment experiences as well. I wouldn't say we are "attached" to our therapist, and I believe that is a good thing. We are attached to our therapy, our process of growing and changing, and our therapist is merely a tool for that. I feel that we use her more than we "trust" her. She has skills that we need a person to have, so that works for us. If she terminated with us tomorrow I don't know that we would be bothered other than the fact that it would be a pain to find another T in this area with the same skill set.
However, I must concede that she is very reliable and consistent from one session to the next, so there may be trust in that. But we certainly have not let our guard down much with her. We maintain responsibility for us. If she were to try anything, we would be out of there within seconds, and be none the worse off for it.