Dissociation in children and adolescents

[00:00:05] Bronwyn: Hey, mental workers. You're listening to the Mental Work podcast, the podcast about working in mental health for early career mental health workers. As always, I'm your host, Bronwyn Milkins, and today we are talking about dissociation in children and adolescents.

Why dissociation? Well, I'm currently working as research coordinator at a research institute, and I've been lucky enough to work closely with young people who experienced dissociation and with the clinicians who support them. I've conducted interviews, I've done data analysis, and I've developed a training program for clinicians, and through that I've come to realize just how misunderstood and overlooked dissociation is in clinical practice.

Dissociation can really change how young people show up in therapy, but most clinicians don't get formal training or assessment in this area. I know I didn't. This can lead to misunderstandings and incorrect assumptions about young people.

So in this episode, I wanna give you a crash course introduction to dissociation and children and teens. We're not going to cover everything. One podcast episode just isn't enough, but we'll explore what dissociation is, how it can present, when to assess for it, and how you might start to work with it safely and effectively.

To help guide the conversation and keep it a bit more dynamic, I've invited our podcast editor, Michael to jump in and ask me the questions.

Hi Michael.

[00:01:26] Michael: Hello everyone, and fun fact, I actually do a little bit of dissociation research myself. I do a bit in developing dissociation assessments, but we'll save that for another day.

[00:01:39] Bronwyn: Yeah , it's really exciting what Michael is doing actually. He's creating a visual illustrated dissociation assessment for children, which is hopefully gonna be much better than what we currently have. So thanks, Michael, for your expertise and for coming on to interview me and keep it a bit more energized and dynamic, and for editing the podcast, as always.

[00:02:00] Michael: Okay, well, how about we start with a really nice, easy, simple question to ease into things, and that is, what is dissociation?

[00:02:08] Bronwyn: So, simple question with a complex answer, but I'll try to keep it basic. It is good to know though, that dissociation is a multidimensional concept. It's not a, one single thing. In saying that, I'll try to give you the one single thing. Dissociation is the disconnection from memory, feelings, actions, thoughts, body, consciousness, perception, and or identity. And this happens in the presence of overwhelming emotion. So stuff that is extremely stressful or traumatic.

I like to think of dissociation as a survival strategy, because it enables the person to separate themselves from traumatic and stressful events that would overwhelm their capacity to cope. And you can think of it as a really sophisticated strategy. It means that during trauma we can compartmentalize our memories so that that doesn't intrude on our daily lives. So it really is an ingenious, automatic solution that our body comes up with when faced with trauma.

It's important to note though that dissociation can also occur in other survival strategies. So if we're in fight or flight, we can also compartmentalize. We can disconnect from what's happening, so we can be, I guess, smashing stuff up and also dissociating at the same time, and afterwards, we might not remember that we have smashed stuff up.

[00:03:31] Michael: So it sounds like dissociation is quite an extreme, uh, response to trauma. Is it something that your everyday clinician really needs to know much about?

[00:03:42] Bronwyn: Yeah, it can sound like it's extreme, but there are very mild and subtle presentations that we can see in clinical practice. So what I say to mental health professionals is that most of them will encounter clients who experienced dissociation, and who present with it in therapy without knowing it.

So they'll go along with their treatment, they won't know that they're dissociating and let's say they try to process trauma, it's then that the dissociation may interfere with that process because it becomes too activated to be, enable the processing of trauma. So it's really important that clinicians know how to identify it, know how to work with it properly, otherwise you're going to flood your client and overwhelm them, and they're not gonna get much benefit out of treatment. So research shows that with our standard treatment, say EMDR, the effectiveness can be lowered when a client is highly dissociative.

And I think another reason why clinicians should be concerned about dissociation is that it's not rare. So there's a major study conducted by a researcher in Adelaide, Mary-Anne Kate, and she looked at university students and the presence of dissociation there. She found that about 10% of all university students who she surveyed met criteria for a low level dissociative disorder, so that is depersonalization derealization, and they had clinical symptoms of that disorder. Um, so that means that maybe quite frequently young people in that sample are feeling disconnected from reality or disconnected from the bodies, or disconnected from themselves.

So again, it's not rare, it's, it's more common than we think, and while it is an ingenious survival strategy, it can become quite unsettling and interfere with daily life for people when it's chronic. So when it's chronic and persistent and you're disconnected from your body, you might engage in self-harm behaviors. You might have suicidal thoughts and you might not be able to feel like you're in control of your body or that it's somebody else doing these things.

I guess ongoing dissociation as well is also linked to the development of PTSD. So after trauma dissociation can be helpful, but if it keeps on going, it can lead you to automatically chronically avoid traumatic material and that can keep it going.

[00:06:00] Michael: So not only is dissociation not rare... It, it sounds like it's something that clinicians will encounter in their daily practice, regardless of where they're working, but it also sounds like dissociation, or the symptoms of dissociation, can be like a bit of a, a blocker to effective treatment.

[00:06:21] Bronwyn: Yeah, exactly. And I should say that there are some studies which say, look, it's not much of a blocker, but there's other research that does say that dissociation can interfere with therapy. And I think the nuance here is in the type of dissociation, the severity of dissociation. So it might be true that, let's say, a client who is stuck in absorption, which is kind of like you're not paying attention to the therapist in front of you, you're looking out the window a bit, that kind of mild distancing of consciousness may not interfere with therapy if you're doing it for like 30 seconds out of a 50 minute session.

If you're doing that chronically, or it's more severe that you're going into your own fantasy land and then not able to pay attention to the content at all of what's being said, then that might interfere more with the effectiveness. So yeah, again, I think it's the nuance here.

[00:07:10] Michael: So I understand that your research is largely focused on young people, what does dissociation actually look like in young people? And is it the same as what we see in adults?

[00:07:22] Bronwyn: Yeah, so my research has looked mostly at dissociation young people, so that's kids and teens. And it's really interesting, so when we think of the DSM, which is the Diagnostic and Statistical Manual of Mental Disorders, so it's the, I guess, psychiatric bible of disorders, interestingly, for dissociative disorders, it's all based on adult presentations and adult criteria. That's why our research institute is looking at this, because it's a big gap.

We know that young people aren't just mini adults. There are lots of differences in the presentation of mental health concerns in young people compared to adults, but it hasn't been looked at. It has been described in books, but not, I guess, kind of empirically tested a lot.

[00:08:04] Michael: Okay, so if I've got a young person in my office, then I suspect that maybe dissociation is happening. What, what should I be looking for exactly?

[00:08:12] Bronwyn: So it really depends on the age, and I'll talk through children and adolescents. So in preschool kids, that's three to five years old, they are more vulnerable to dissociation, and that makes sense to me because when you think of trauma and overwhelming stressful situations, children lack the capacity or ability to be able to run away or to fight. So dissociation becomes their body's automatic survival strategy there.

What you might see in therapy is them staring or zoning out. You might see forgetfulness, so they might forget important events or conversations. You ask them about their birthday, which just happened and they might forget it. You might also see rigid play themes and controlling behaviors. Sleep issues, so nightmares or fear of sleeping alone. Visual hallucinations , they might describe a shadow in the corner of their eye, or seeing ghosts. Enuresis and copresis can also be a common presentation. You might also see feelings and thoughts projected on two objects like toys. So it might be that my doll is thinking this, or they're angry. And they might also be easily overwhelmed and disconnected from emotions.

 And I think what's important to keep in mind is normal development, to avoid us jumping to like, uh, that's pathological, conclusion. So some of these behaviors are normal, and what I'll go on to say later when we talk about assessment is that a comprehensive assessment is really needed to discern whether this is dissociation or something else. You really can't take any one thing and be like, that's dissociation.

Now, as kids get older, there are some changes in what we might see. So the thing with kids getting older is that they might have more clear, differentiated dissociative identities. So this is a hallmark feature of dissociation when we think of dissociated identities. But the thing is it's less differentiated in childhood and it can become more differentiated as the child gets older.

There's a concept called transitional identities when it comes to kids. So what we know is that imaginary friends are completely normal in kids, normal up to about ages seven or nine... after 12 is less typical. And then what, uh, clinician researcher, her name is Joyanna Silberg, she's written most of the literature on dissociation in kids, she came up with this concept of transitional identities, and she says that they act like a transition between normal fantasy, like the imaginary friends, and dissociative self states. So these are separate states of identity where the person may have amnesia and not actually know that these separate identity exists.

In kids they're not fully formed dissociative states, but they're more than just imagination, and Silberg says that there are a few clear differences. So she did a study looking at 19 inpatients on a children's unit in a mental health hospital in the us and she compared them to, uh, quote unquote normal children. And she was looking at what's the difference in imaginary friends between these two samples, so dissociative kids and not dissociative kids. She found that in dissociative kids, their imaginary friends take over and make them do things. They try to boss them around. They blame you, and they argue about you. They only come when you're angry and the kid wishes the imaginary friend would go away. As opposed to quote unquote, normal children. The imaginary friend comes whenever you want. They come when you're happy, and they know that they're only a pretend friend.

So there are some key differences there, and I'll make a link to Joyanna's book where she goes into more detail about this.

[00:11:49] Michael: That sounds really interesting. Imaginary frames can be quote unquote, uh, normal child experience, but they can become maladaptive, if I'm getting that right?

[00:12:00] Bronwyn: I guess they can become ways of coping that are utilized more often by children. So what we know is that dissociation, I guess, and its progression can be prevented through the absence of further trauma, helping the kid process that trauma or caregiver responses that help the child manage their emotions.

When those things are absent or they're frustrated, a child can move up what we call the dissociation continuum. So they can move up from their body automatically using dissociation in really stressful situations to their body, going into dissociation when they detect any sort of threat, and it may not actually be threatening. So they may be in a completely safe situation with a safe adult, but their body might not know that they're safe, so they're gonna dissociate.

[00:12:49] Michael: It's become, like, generalized.

[00:12:51] Bronwyn: It is become generalized. Exactly. Um, and when that happens, we can see some of these symptoms, like transitional identities becoming more apparent and more fragmented because the child needs these imaginary friends or transitional identities to be able to cope with the emotion and continual exposure to the threat they think they're experiencing.

[00:13:14] Michael: Transitional identities is a term that, uh, a lot of people might not be familiar with. They might be familiar with multiple identities. Is this the same thing?

[00:13:23] Bronwyn: Yeah. So transitional identities are a little bit different to multiple identities, and I think that the differences in these states, again, it's nuanced. It's like, there are identities for people who experience Otherwise Specified Dissociative Disorders. So that's what it's called in the DSM, there are identities where people can have, they have their own feelings, thoughts, behaviors, and there may be more or less amnestic. So that means that they can be more or less known to the central identity, and that goes along in continuum as well.

With these transitional identities, they're not fully formed dissociative states, but they're more than just imagination. So it's a real, I guess, nuance on the continuum. We're not saying that they're acting as fully formed identities where the child has no recollection, but they're kind of projected onto toys, or they might say that, uh, Mr. Smiley, here, tells me to do things, and they might be aware that there's a different part of them that is more self-critical than other parts of them.

[00:14:26] Michael: So dissociation can really present in a lot, a lot of different ways. They might have memory gaps, but you might have other kids who are aware of other fragments of identity, I guess.

[00:14:39] Bronwyn: Yeah, so look, here's some of the things that kids might say when they have transitional identities. They might say, it's my clever friend who stops bad things happening. Or in my head, I go to a land where I'm in charge, or when I don't like it, I just switch off that part of my body with my magic switch.

So from the research I've conducted as well, we know that kids use a lot of fantasy elements when describing the different parts of them, and that seems to be a distinguishing feature, um, compared to adults that children rely on more fantastical kind of explanations, and they may describe these imaginary friends in those sorts of ways as well.

[00:15:13] Michael: Something that I've come across in my little bit of reading about dissociation is disavowal. So lots of, oh, that wasn't me. I didn't do that. So parents and teachers may say that, you know, this child lies a lot, but really there's something much more complex going on behind the scenes that they're not aware of.

[00:15:34] Bronwyn: Yeah, I think that points to something important. So disavowal is something we say, and that is literally the child say, smashes a vase. And then you ask them about it later and they're like, I didn't do that at all. And a parent or teacher can conclude that they're lying, that they're being manipulative.

But I think the thing to understand about dissociation is that it can really be that powerful. That you can do something and not remember it at all. And that's, I guess, the sophistication that comes in the survival strategy.

[00:16:03] Michael: Okay, that makes sense. The other thing that I've come across in the literature is that dissociation can be really present in certain contexts, but not others. So you might have, uh, a parent that says, my, my child is really naughty, when really it's dissociation that's happening behind the scenes. And then that child goes off to school and the teacher's like, oh, I don't see any of this? I have no idea what this parent is talking about. Can you just explain what's going on there?

[00:16:31] Bronwyn: Yeah, so one of the things with dissociation in kids that can make it really hard to identify is this fluctuation in how they behave in different circumstances. And so that can be really confusing, which is why a comprehensive assessment with multiple informants, and I guess a conceptualization of what trauma is for this child. You'll always be wanting to ask yourself as an assessment, does this behavior have a traumatic basis? Because dissociation and trauma are just intrinsically linked together.

So if a teacher is saying, we don't see that at school, and the parent is saying, we see that at home, believe them, um, that could be happening. Absolutely. And it could be due to differences in the setting. So a teacher might not see it at school because the child has a safe place that they can go to. They're not impeded from, I guess having their imaginary friends with them. There's not an automatic reliance that the body needs to have for dissociation. Whereas at home, maybe home is unsafe, and so their body is like, well, we need to be in chronic dissociation here just to survive.

[00:17:29] Michael: It sounds like a bit of a clue to me that this inconsistency might be a hint that something else is going on.

[00:17:35] Bronwyn: Yeah, and I think that might be a difference... Um, so with ADHD, for example, the diagnostic criteria, at least for adults, say that you need to be exhibiting these behaviors across a few different settings. With dissociation, you don't need that. So it's, it is entirely consistent with dissociation to be inconsistent, which makes it really difficult to pick up, but it is a clue.

[00:17:56] Michael: I want to take a step backwards a little bit here. Why, why does dissociation happen to young people in the first place? You've mentioned trauma a bit, but is that the only reason that dissociation might come up?

[00:18:09] Bronwyn: There's lots of theories about why dissociation occurs in children. A lot of them do favor trauma. There is another theory which I quite favor, and it's created by Joyanna Silberg, I mentioned her earlier, she's a big writer in this area. And her theory is called a effect avoidance theory. So she says that a child's environment, which can include trauma, but it can also include attachment disruptions, creates a really, painful level of effect. So attachment disruptions can look like getting confusing or scary reactions from a caregiver if the child is injured, not being able to receive caring or soothing from the caregiver. And without a caregiver to help the child regulate their emotions, their body learns to habitually avoid and disconnect from the arousal that they're experiencing.

And that makes sense if you are completely frightened, dissociation is the perfect strategy to help disconnect from that. The thing is, is that over time this avoidance becomes quite rigid, inflexible, and immune to, I guess like external influences. So you can say to the child, you are safe here, like as a therapist, you could say that to the child... Their body doesn't know that, so they're going to habitually continue to rely on that inflexible responding of using dissociation.

Over time, the child's mind and body becomes organized around dissociating from emotion, and that's both positive and negative emotion. Everything... even when they're calm, it can feel frightening. And this is how Silberg explains the transitional identities. She says that these avoidance strategies begin to take on their own identity features so they get their own thoughts and feelings. And these deeply ingrained avoidance scripts become how the child operates. So they're kind of operating on autopilot in every situation they go into. They've got this template, or their body has this template of, I dissociate in this situation... instead of being like, is this situation safe? So I guess bringing their prefrontal cortex to make that judgment.

Instead, they're relying on this automatic strategy that has helped them get by in other situations, and that can lead to problems in functioning. So it's like if you're habitually disconnecting, you might not pick up on cues from other people that they actually are safe or that you actually are in a safe environment. So it just leaves you feeling frightened and unsettled a lot of the time.

[00:20:29] Michael: So it sounds like these kids can become real experts in dissociation. It's almost like a superpower in itself that they can lean on in any perceived threat. Someone without that same background might rely on other strategies to to get by and to cope that might be less dysfunctional.

[00:20:50] Bronwyn: Yeah, exactly. And I should say, so to summarize that, I guess it's not just trauma that can lead to dissociation, it can also be attachment disruptions or injury or loss in early childhood. And, what we're finding now with research, and I find this a really interesting direction, is that we're linking specific types of trauma to different types of dissociation.

So for example, I went to a webinar the other week with Mary-Anne Kate, so she's a researcher in Adelaide. Wonderful. And she was talking about her research, which is found that, for example, sexual abuse and trauma has been linked to more severe forms of dissociation and more enduring forms. And she also pointed out physical violence, and that includes choking in early childhood, and that seems to be linked to more severe dissociative symptoms as well.

But I think it's really important for clinicians to know, and I guess have a broad breadth of what they can consider trauma, because this is something that I've, I've seen in clients that they feel that their dissociative responses are being dismissed or minimized because the clinician is like, well, you didn't really experience trauma, so this doesn't make sense.

And I think it's really important for us to realize, for example, that neurodivergent folks or disabled folks are living in a world that is not catered for them and they're more vulnerable to specific types of trauma that we who are able bodied or neurotypical might not be aware of.

So really important that if you're seeing some of dissociative behaviors or a client is reporting them to you to go to supervision and really do a thorough formulation and get some external perspectives on what you are considering trauma and not trauma.

[00:22:28] Michael: So the takeaway I'm hearing there is it doesn't have to be an acute traumatic event in a client's history in order for dissociation to be a- a valid response.

[00:22:37] Bronwyn: Correct, particularly for children and young people who have less coping survival responses available to them.

[00:22:44] Michael: It makes a lot of sense to me that if you are in a position of where you, you lack power, agency, you aren't able to escape and get yourself out of a bad situation, the last place of escape is within your own mind. And if that works, you're gonna keep on doing it, right?

[00:23:04] Bronwyn: Yeah, absolutely. And it's one of the challenges that clinicians face when they wanna support clients to rely on dissociation less or their body to less go, to go into it less is that going into your mind can be a great place. It's, like, there are kids in the literature who say, I love going to la la land. That's a good place. Nothing bad happens to me there. And then we've got clinicians in therapy being like, oh, could you dissociate a little less? And it's like, why would I.

[00:23:30] Michael: So it sounds like it would be a real big challenge for therapists to try to reduce these dissociative experiences because it has worked so successfully. How do you even go about starting to reduce the reliance and dissociation

[00:23:45] Bronwyn: Um, so the answer is slowly, yeah, that's slowly and safely is, is the overall answer. So with dissociation, we don't wanna remove it completely. And I like to think of it like anxiety. So when I work with clients on anxiety, I say to them, we're not gonna remove your anxiety completely, and that's not even the goal. The goal is to improve your relationship with anxiety. So instead of your anxiety being like a smoke alarm that goes off when the barbecue is firing up, when there's no real fire, we want your anxiety to be really honed in so that when there's a fire, it goes off, instead of going off on everything and being constantly alarmed, but maybe not knowing when exactly to take action.

So that's what we want it to be with dissociation, we want it to be a finely tuned survival strategy, not a broadly generalized applied survival strategy that you use in every situation despite it being safe.

So you want that inner harmony to be able to promote that safety. And so when clinicians want to go in with that goal of promoting more flexibility in how dissociation shows up... so that rather than it controlling you, it's like you're working well with it... I think that's a good goal and that's a good way to, I guess, reduce clients being like, why the hell would I do this is kind of like, let's help you have more inner harmony.

And I guess remembering as well that with these child presentations, if there is a dissociative voice, it's often conflictual. So it's not a nice voice that's telling them to do things. There are some fantasy elements for some kids, but for other kids, it's this voice telling them to like, that they're no good, that they're not worthy, um, that they're disgusting, that they're unlovable. So we've got these very critical voices and these parts of them, which may have served them well in that moment to help protect themselves, but might not be serving them well in the present. And we've also got these parts which may be stuck in what we call trauma time. So they're not updated with the present. That trauma is no longer happening, so we need to get that part up to speed as well.

I think the other thing to point out is that there is sadly no clear treatment protocol available for managing children and adolescents experiencing dissociative disorders. So, yeah, boo. A bunch of our researchers conducted the systematic review, looking into this, and they found nothing. I've done further reading and I've found that through the Australian Psychological Society, they did a review of all therapies and treatments in 2024... they said that no research study has examined the efficacy of psychological treatments in the treatment of dissociative disorders to children, adolescents. Um, so yeah, it's, it's no good. Um, and that's why we wanna research this in the future and make sure that there's some help and support available for kids.

 In the meantime a few clinician researchers offer dissociation specific treatment approaches in books. They haven't been evaluated, but they're quite good, in my opinion. But that's all we have, we have like clinical guidance that hasn't been empirically evaluated, and that's the best we have.

[00:26:48] Michael: So we can't really say with certainty that any of the treatments for dissociation are quote unquote, evidence based at this point in time?

[00:26:57] Bronwyn: At least for kids and adolescents, yes. For adults, there is this world first groundbreaking research taking place from Bethany Brand and her research team. And they've created the first psychoeducational program for dissociative patients and they've been doing randomized control trials, looking at the effectiveness of that, and- and then they've found really good results. So they've found that dissociative symptoms have gone down. And they also enrolled clinicians in their psycho-ed program at the same time. Clinician knowledge has gone up, clinician confidence has gone up.

But again, to stress, that's a psychoeducational program rather than a treatment per se. And it does cover a lot of stuff, but they don't go into like trauma processing or parts work, specifically, which might be needed to integrate more harmoniously, dissociative identities.

[00:27:46] Michael: It sounds like this is a really exciting time for dissociation research and ther therapy.

[00:27:52] Bronwyn: Yeah, it is, it is. And I think, like I just wanna point out as well to clinicians that, what I've heard from clinicians is that they say to themselves, well, our general treatments can help with dissociation, like, why do I need a dissociation specific treatment and why do I need to target dissociation specifically? And the answer to this is that, a few studies have found if you give people who are dissociative general treatments, like if you give them EMDR without targeting dissociative symptoms, specifically, the emotions in response to trauma might go down. So you ask them like, how distressed are you when you think of this image? It might go down to like zero or one outta 10... but their dissociation can still be plaguing them in day-to-day life in an unsettling way.

So obviously, if a person has a good relationship harmoniously with dissociative identities, not an issue. But what this research study is saying is that people are receiving general treatments, dissociative symptoms are not improving. And so they're saying unless you target it specifically, these symptoms are not going to get better.

[00:28:59] Michael: So if listeners are interested in learning one particular model about dissociation to help them understand it and how to approach treatment, is there any recommendations that you have?

[00:29:10] Bronwyn: The one treatment I would recommend for kids is trauma focused CBT. So that is the most well researched, empirically based treatment for trauma in kids. And there are a few chapters on how to adapt that to make sure that dissociation is targeted.

So the main adaptations to trauma-focused CBT for complex trauma and dissociation are that they recommend more time on stabilization. So about half the session should be stabilization, and the way I think of that is, if you think of the window of tolerance, so there's a, a green zone where we feel that we can regulate our arousal and dissociation is going into that red zone, the purpose of stabilization is to actually gently increase that window of tolerance so that they can stay present with affect, um, in more situations, because people with trauma, they tend to have a very narrow window of tolerance.

So that's why we need about half of those sessions on stabilization 'cause it needs to happen slowly, um, and it needs to be expanded just a little bit.

[00:30:08] Michael: Bigger windows, everyone.

[00:30:09] Bronwyn: Bigger window.

And the other adaptation for trauma-focused CBT is that you need to treat dissociation like any other coping strategy and teach them more adaptive coping strategies. So other strategies that can be used in situations where they detect threat. So it might be, soothing strategies that connect with their body instead of disconnecting from their body. It might be seeking co-regulation from safe adults, and that's a really important one for kids. We shouldn't be expecting kids who have experienced complex trauma to be regulating on their own. They need the presence of another safe adult to help them do that.

Another thing to note is that we need to teach them skills that match their. Emotional development, not just their chronological age. So kids with complex trauma, you may be seeing them as a 12-year-old chronologically, but they're actually a 6-year-old developmentally. And you need to use simple techniques, for example, like mirroring their, their words, mirroring their body language, labeling emotions. These things are really important.

And co-regulation again is really key. So therapists need to model this calm, regulated behavior, even when behaviors can be confronting. And so supervision is a must because like how we were talking about earlier, kids can be doing stuff that that is confronting. They might be angry and they might feel unsafe and pull away from you and then try to move closer to you in that disorganized attachment style.

It's really important to get supervision so that you're interpreting these behaviors empathetically, compassionately, and working to regulate yourself.

[00:31:44] Michael: In addition to directly supporting the children, what advice could clinicians give to the caregivers of these children in order to help support them between sessions?

[00:31:56] Bronwyn: So parent child therapy is really supported when it comes to dissociation, and I've been saying to clinicians that the family is essential. They need to be involved at all stages of the child and adolescence treatment and support, and really recognize that the family system is crucial to helping the child grow.

So any treatment should involve parents as well, and this may not suit a private practice setting. This might be a CAMHS setting where they can have that more of a team based approach . But if you have the capacity in private practice or in other settings, to do that, you'll want to be teaching the parent how to regulate their own emotions and to regulate that in the face of the child's emotions as well.

And, if the parent has a history of trauma themselves, they also need to be receiving their own treatment. So something that has come up a lot in literature and interviews has been that parents who have their own trauma, they might also be dissociating and not be able to take on information and strategies that they need to help their child, who is dissociating as well.

And this is completely understandable. Let's take the situation for example, of a parent who has been the victim of domestic abuse. It's completely understandable that if their child comes to them, they might give them frightening or confusing responses. They're trying to survive on their own. So parents need their own support. They need to be taught how to support their child and regulate their own emotions, and this will really help their child to grow and flourish.

[00:33:21] Michael: We do hear the term intergenerational trauma being used more frequently these days, and I guess what you just described there is a good example of how intergenerational trauma can be perpetuated a little bit. So if you do have a, a parent who is dealing with their own stuff, this might be affecting their ability to properly attach with their child. Then the child doesn't have a a, a safe figure in their life, then that might lead to developing dissociative responses instead of other coping strategies. Correct me if I'm wrong in connecting these dots!

[00:34:00] Bronwyn: No, I think that's completely right and it's definitely framing it in a more empathetic way, because you can't ignore the parent child connection. We just need to understand it in a way that is understandable rather than pathologizing them. And I think that's really important. And some people dismiss the concept of intergenerational trauma altogether, but there are clear links in the literature between a parent's trauma and a child's trauma. Um, and how a child presents as well. So, yeah, and I think dissociation can be a really good example of that.

[00:34:31] Michael: So what are the the best tools that a clinician can use to assess for dissociation? And are there any differences between those that you would use for adults versus kids?

[00:34:41] Bronwyn: So yes to differences between kids and adults. And yes, there are a lot of tools. I should say that the way to assess for dissociation in kids is to recognize that it's an ongoing process, not a one-off. So symptoms can change over time and they may only show up in different stages of treatment when, like for example, when you're processing trauma, dissociation might come up.

There are a few indications that you should assess for dissociation, and that is any history of childhood trauma and any attachment injuries. It can also be multiple or changing diagnoses, and that's when you should consider like, is this actually dissociative symptoms.

And for kids, there are questionnaires, um, there's no structured clinical interview for kids with dissociation, there is for adults. Um, for kids, the way that you want to get about assessing dissociation is mostly through indirect methods. So sand tray, art, drawing, those are all really good ways to get at dissociation 'cause it can feel quite hidden and children may not want to talk about dissociation. There may be an element of shame to do with that.

If you do wanna use some questionnaire measures, there are two main ones. Both are available on Novopsych. If you dunno what Novopsych is, it's a large online platform which has a questionnaire assessment instruments you can sign up for a free account and they offer a limited number of uses for free users, and then you have a paid account as well if you wanna increase the amount of questionnaires that you administer.

So the first one for kids, so this is kids under 12 years, it's a caregiver report called the Child Dissociative Checklist. Initially, the research showed that it had good results, psychometrically, but a recent study, which looked comprehensively at all measures of dissociation assessment, found that it had weak reliability and validity. So I think it's a good indication of child dissociative symptoms, but it's not the whole story. So overall , like, don't use these questionnaires in isolation. You wanna be using them in addition to a comprehensive child and parent interview and indirect methods of assessment through sand tray art, and other creative aspects.

The other questionnaire assessment for young people is called the Adolescent Dissociative Experiences Scale. Again, available on Novopsych. This one by contract has excellent psychometrics, so it's quite a good one. Um, this is a self-report tool, it's not diagnostic, but it's a screening tool.

The issue overall with questionnaire assessment instruments for dissociation is that they tend to be over-inclusive, so that means that they measure dissociation and other things, so not just dissociation itself. They can also be under-inclusive in that they don't measure all aspects of dissociation and they rely on self-report, at least with the ADES. And since a big component of dissociation is memory loss, it may not be the best way to gain this information from dissociative folks. So again, it really highlights the importance of interview, observation, multiple observation across different settings. Yeah.

[00:37:51] Michael: Yeah, it sounds like a very complex assessment process.

[00:37:54] Bronwyn: -is a triangulation. You're a bit of a detective, and that's why I recommend overall not doing it on your own. If you're trying to formulate, assess, and treat dissociation on your own, don't do it.

[00:38:03] Michael: Note taken.

 What I'm hearing is that it can take quite a while to identify that dissociation might be happening in a client that you're seeing... that something that requires multiple ob- observations from multiple informants over multiple sessions. There are some screening questionnaires that you could have clients complete, but that's not necessarily going to give you, uh, an answer straight away either. And the process of working with dissociation, and this would apply to working with anyone who has a trauma background, is going to be quite a lot for clinicians to handle. What would you recommend for clinicians to look after themselves whilst working with dissociating clients?

[00:38:49] Bronwyn: Yeah, I think really strong supervision to be able to talk through the emotions as well as the formulation for the client. The emotion that I've experienced mostly working with dissociative clients has been confusion, and that's because I didn't have a good understanding of dissociation. So I found the presentation very confusing. I didn't know what was happening. I think that could have been alleviated with better supervision, um, around that and being able to bring my thoughts and observations to that.

I think the other thing with dissociative clients is to remember that they've often got histories of complex trauma, so that's interpersonal trauma, and that can lead to attachment styles that, I guess the clinical word is disorganized. So the, I guess the non-pathologizing way of put putting it is that it's a push pull kind of relationship and that can be enacted with you as the clinician.

So one moment there may be emotionally attached to you, and you feel like they're really present, and then the other moment they can be extremely mistrustful of you. And they can say, we didn't talk about that because they've forgotten it, or their dissociation has prevented them from remembering it, and that can cause a rupture in the relationship. So that can be very confronting, confusing, frustrating for the clinician, and it'll be really important to talk about your emotions and process that.

The ultimate conclusion is that it's not about you, in the best way possible, it's about what's happening for the client, um, and to realize that they're trying to cope as well as they can with the strategies that they have, and that over time, let's say 12 months, um, this trust can be well embedded in the therapeutic relationship.

[00:40:32] Michael: So it sounds like a slow and steady approach and don't expect results overnight.

[00:40:39] Bronwyn: No, and I think that's how I approached it in the past. I was like doing EMDR therapy and I was giving them the questionnaire and I'd go through it and I'd be like, okay, you've got a bit of dissociation. I didn't really know how to work with it, and I was kind of just like, tick, I've done what I needed to do, and I knew that it wasn't good if it was there for a MDR processing, but I didn't really know how to work with it.

And so how to work with it is the trauma-focused CBT, how we've talked about, but also, your favorite body focused approaches, somatic type approaches, and gradually increasing that window of tolerance through presence, safety, connection, co-regulation, attunement. So all of your therapy skills that you already know about; safety, collaboration, empowerment, all those trauma-informed principles. They all work extremely well with patients who are dissociative.

[00:41:34] Michael: Thank you for this marvelous summary of working with dissociation and especially with kids. I think we could do a whole other podcast on this. I've got three more questions as we wrap up. Number one, are there any myths that you've encountered in the literature or research?

[00:41:51] Bronwyn: Yep. Yeah, so there's truth that I want to share with listeners. The first is that you need to be a trauma expert to work with dissociative clients. You don't, and I think this holds a lot of people back, and I think it's perpetuated in our training as well. So for example, with the ISSTD, which is the Society for Traumatic and Dissociative Studies, you can't access training on dissociation for kids and adolescents unless it's part of a certificate certification, and the advanced part of that as well. So there is barriers to actually gaining and accessing training on dissociation because it's treated like it's a specialist subject.

Through my research and through talking to dissociative individuals, parents and clinicians and reading all the research about it as well, a lot of the skills that clinicians already have are well applicable to dissociative of patients. As I mentioned before, the clinician skills of applying trauma-informed principles, so collaboration, empowerment, respect, reducing hierarchy, trust, safety... they're all paramount and all things that clinicians have been trained to do early on in their training.

The other things that clinicians have in their tool belt are grounding strategies. We usually know a bunch of them to help our clients.

The other thing that clinicians know is that they're usually trained in one sort of trauma approach, which can be helpful for dissociative patients. It just needs to be adapted to have a longer stabilization phase and to be able to work with your clients so that they know that they can trust you to not go too fast and pull them outside their window.

So yeah, I just wanna bust that myth that you need to be extremely expert to work with dissociative clients.

[00:43:34] Michael: So clinicians, you're more capable of working with dissociation than you might think.

[00:43:38] Bronwyn: The other myth that I wanted to bust is that dissociation is always severe. So when people think of dissociation, they tend to jump to Dissociative identity disorder, DID. And DID is the rarer of the dissociative disorders. What is far more common is depersonalization derealization disorder, so that's characterized by feeling disconnected from your body and feeling a sense of unreality, and it usually goes along with dissociative amnesia, so that's far more common and clinicians should focus on really not jumping to the severe end, and instead making sure that they starting point is really amnesia, depersonalization, derealization, and then assessing further if dissociative identities that have their own thoughts, feelings, behaviors exist.

[00:44:26] Michael: That sounds like a, a great approach.

Second last question; if people are curious and want to learn a bit more about how to work with dissociation, what resources would you recommend as a a starting point?

[00:44:38] Bronwyn: What I've come across in Australia is not much, but what I would recommend is Arianne Struik. Sorry, Arianne. If you're listening to this, I've probably butchered your surname. Um, hopefully she won't mind because I'm about to say that I think she has the best training available for Complex Trauma dissociation in Australia, um, in children. Um, and I really like what she's got on offer. She's also written approach called The Sleeping Dogs Method, which looks at barriers to children engaging in trauma processing. And I really like her comprehensive checklist that she has so that we all have a good checklist, don't we, um, therapists. Um, but like for example, she talks about one reason that a child may not be ready for trauma processing is that they're scared of what that will mean for their relationship with their parent, like, will their parent be able to manage increases in like, insomnia or like angry outbursts and stuff like that. Um, so it's really good, I, and I'll check her links to her website in the show notes.

The other resource for dissociation that I highly recommend, and she's been a guest on the podcast, it's Catherine Hayes. Um, so she has an excellent course on dissociation in adults. I found it highly clinically applicable. I felt like as soon as I took it. I understood so much more about dissociation, how to work with it properly in clinical practice. Um, so I think the course is dissociation made simple, but I'll make sure I link to that as well. And I think people can feel quite confident going to these sources, that they're well researched, they're well studied, um, and yeah, I like 'em.

[00:46:08] Michael: It sounds like some fantastic resources for listeners to dive into to get up to speed on the the current workings for dissociation.

[00:46:17] Bronwyn: Yeah.

[00:46:18] Michael: And lucky last , what are your final takeaways that you hope listeners will have from this episode?

[00:46:24] Bronwyn: I hope they're just a bit more informed about what dissociation is and what it looks like. I know we've given a very basic overview. Maybe I've left you more questions than I've answered, but hopefully I've answered a few, and this might be the first introduction that you have with knowledge about dissociation. You might be thinking, oh gosh, is everybody dissociative? And and my answer to that is that you will pick it up more. Since I started learning about dissociation, I've done a mental flashback to all of my clients and I've been like, ah, that was dissociation, that was dissociation. So it really does occur more in clinical practice than you think, and I think it's so helpful to have this frame. Um, so I'd encourage you to take further training in it. I'll pop a link to good books that I recommend as well, if you wanna do some self-study. And just have a read of like one chapter, I think can really make a difference for us.

[00:47:17] Michael: I don't think it's a bad thing. If listeners have more questions at the end of this than they did at the start regarding dissociation, because it is such a complex topic. There is so much, there's so much nuance to it. It interacts with everything.

So if, listeners, if you're feeling that you are, do you have more questions and you are more curious about dissociation, that's a, a good space to be in, and I hope the, the various links that we pop in the show notes are helpful on your dissociation journey.

[00:47:47] Bronwyn: Yeah, and hopefully. When these two papers I've been trying to publish on dissociation are finally published, I'll also link them to, in the show notes. We conducted interviews with adolescents about their experiences of dissociation and how they cope with it, and I hope that that's published sometime soon.

[00:48:02] Michael: Fingers crossed.

[00:48:03] Bronwyn: Well, thanks Michael for interviewing me. I really appreciate it. What's it been like interviewing me?

[00:48:07] Michael: It's been good. It's, it's made me realize just how much there is to dissociation because I felt like we were just like warming up and I'm looking at the timer and we're getting into 40 minutes and knowing that there's so much more stuff to cover, um, we will have to do a part two of dissociation when your studies are published and this project starts to wrap up a bit more. And yeah, we should talk dissociation again.

[00:48:35] Bronwyn: I would love to talk about dissociation again. Thanks again.

So listeners, if you found this episode helpful, please do share it with somebody else. The best way to get the podcast out there is putting it into other people's ears, so have a conversation and make sure you show them the Mental Work podcast. That's a wrap. Thanks for listening to Mental Work. I really appreciate it. I'm Bronwyn Milkins. Have a good one, and catch you next time. Bye.