When we learn how to stop dissociation we often get in contact with DBT skill training. It teaches us how to recognize dissociation early and then use different skills that we chain to help us regulate and return to our window of tolerance.
Theoretically that is a good plan that can work really well. It turns out it is not a panacea though and specifically trauma patients often struggle with DBT in general and the skill training in particular.
DBT skills are meant to be used when we notice that we are dissociating. All the early warning signs we learn to notice and screen ourselves for constantly are signs that we are already dissociating mildly. This knowledge allows us to interrupt the dissociation. It will not reduce how often we start to dissociate. That cannot be influence willingly. The brain stem decides to go into a stress response without asking the neocortex for permission or advice on which stress response to choose. No DBT skill can stop that from happening. It is automatic and involuntary.
When we try to work through our trauma we need to be present for treatment to be effective. That is why dissociating is outlawed and patients are expected to control their stress response. While of course this is important, it is also impossible. The patient doesn’t decide to dissociate. It is not so much a toxic coping strategy like self-harm or drinking as it is a physiological reaction, not unlike reflexes. Many clinics demand that the dissociative patient stops dissociating because that prevents treatment. And the tools offered are DBT Skills. But those can only ever just interrupt dissociation. A patient can only ever do as much as it is humanly possible to stop it, but with this tool the amount of dissociation won’t go down, they won’t build up tolerance, and they won’t get less triggered.
There are two main ways to increase tolerance and reduce the stress that is stuck in out nervous system. One of them is to work though our trauma memories quickly in the hope of a release of all the other symptoms. For that we have to stay present. To be able to do that we need to constantly fight our normal physiological reaction, using hard DBT skills to get through. It is possible to do that, and we have shared our thoughts on it here. This is a very extreme way to approach the problem with a high risk of something going wrong. The drop-out rate for this kind of treatment is high. I think it might be a radical but effective way when the trauma is limited to a few occasions that can be worked through hard and fast. I don’t think this is the right way to go for people with a chronic trauma history. The extreme situations this treatment creates just feed our sense of having to survive over and over again, proving to ourselves that we can do it, but also repeating a trauma pattern.
The other way to increase our window of tolerance is mindfulness. This is part of the original DBT design. But because DBT was not created for highly dissociative trauma patients it doesn’t account for the very limited tolerance we have for feeling our body. Often the mindfulness that is practiced is too difficult, so that patients become aware of themselves for a short moment and get so overwhelmed that they spin back into dissociation. Then the only tool they get handed are DBT skills again. It means that if they are unlucky, all their days will be marked by using DBT skills to interrupt dissociation while being unable to do the things that could improve their window of tolerance to prevent them from dissociating long term. We have personally sat though 40 minute long body scans as part of a DBT program. Our experience is that we can handle a body scan that is about 5 minutes long (and that is with years of practice, coming from a chronically dissociated state). So sadly the right tools are offered, but they are practiced in a way that makes it impossible for chronically dissociative patients to profit from it.
If we could use the concept of titration when learning mindfulness, we could get much better results. Especially for patients with a history of chronic abuse this is the way to go. We first need to expand the window of tolerance a little and feel with our body that we are safe now. That is very different from just constantly shutting down dissociation and could increase our quality of life tremendously.
We regularly hear feedback from complex trauma patients that DBT skills are not working for them. When we look at it from a polyvagal perspective we might understand why. All the intense stimulation we use on ourselves are actually danger cues. If our brain automatically sorts things into the categories ‘safe’ or ‘dangerous’ and we end up with a stress response the moment something is perceived as dangerous, there is no way that the hard DBT skills can get us back into our safe and social system. They are not meant to. They are meant to create a sensory disruption that might get us up the polyvagal ladder one step, from shutdown to flight/fight. That is why we chain skills, to be able to climb the ladder further. That is also why we color-coded our skills and chain them from red/hard DBT skills to yellow to green, with green offering safety cues, to restore our ability for social engagement. That is the theory.
In real life some trauma patients just pick up danger cues everywhere. Even if their shutdown state is interrupted for a moment, and they enter sympathetic arousal, they only perceive a threat they cannot overcome or escape from (the physical sensation of hyperarousal is a danger cue too) and they spin back into dissociation, so they won’t have to feel it.
Some DBT skills are outright trauma triggers or things used by abusers to stop victims from dissociating during the abuse. This is real, especially in more organized abuse, and offering patients these tools for support will only increase their sense of threat. We have to warn every clinic team we work with not to use certain classic skills on us to prevent endless flashbacks.
It is a tricky situation. Patients need to be present for treatment, but they can’t. Instead of forcing more DBT skills on them it would be good to see if there are other techniques that could be beneficial. That could be discrimination so that things won’t be perceived as dangerous anymore. It could be titrated trauma-sensitive yoga or other body work techniques that work with the arousal system directly (eg somatic experiencing) instead of trying to solve this through thinking alone. Mind-approaches are pretty weak when it comes to healing our nervous system. We can learn regulation skills but they don’t change how often we fall into dysregulation. We need new approaches. The usefulness of DBT skills is very limited here.
The way dissociation is often treated in clinics is potentially harmful and creates guilt and shame. It is a standard in many places for the patient to sign a contract where they promise to do everything so they won’t dissociate. Again, that is not possible. We don’t decide when our nervous system perceives things as dangerous and starts dissociation. We are also supposed to reduce our dissociation, but the tools offered for it are only interrupting it, not actually reducing it. It is like fighting windmills if there is no offer for treatment that would actually increase the window of tolerance. Lastly patients are supposed to go find help when they dissociate. That is often an impossibility. Dissociation means that we left the safe and social system behind, where we could successfully go seek for help. Brain scans show that our brain shuts down, so that planned actions are not possible anymore. What is demanded of the patients is unrealistic and often leads to great shame. The contract with the treatment team makes it sound like it should be possible to comply when in reality our abilities to act are limited. Again, it might work for less dissociative people but for those with a very small window of tolerance there is little chance for success. And if all that is ever offered to change that are more DBT skills…
It has always been worrying me that the classic DBT puts controlling behavior over relationships and that patients who were not able to regulate themselves get isolated as a response, to work on figuring out their problem alone. From a polyvagal perspective safe and social contact and secure attachment would be key to help with regulation. Secure attachment reduces dissociation. To the point that you can see the quality of the therapeutic relationship in the amount of dissociation that happens in session. Being left alone is not just a danger cue, it also repeats a trauma pattern. A dysregulated nervous system isn’t really behavior that we can change with the tools of CBT. It won’t be reinforced by giving people attention. The isolation is utterly unnecessary, shameful and untherapeutic. The whole concept is faulty when it comes to trauma and dysregulation. I am endlessly glad to see that more modern concepts like RO-DBT recognized this huge mistake and finally put the relationship above the symptoms, so that patients will experience proper support instead of the company of a sheet of paper with nonsensical questions about controlling an involuntary stress response.
DBT is not trauma therapy. It doesn’t cure dissociation. DBT skills help to control some of it when it is already happening. We need them for that purpose. If this is the only thing that is offered, because a chronically dissociating patient is not stable enough to profit from other elements of DBT beyond mere skill training, it would mean that patients have to live with dissociation for the rest of their life, permanently monitoring themselves to be able to stop it whenever it happens again.
It needs more. Our nervous system needs a chance to heal and build up strength. We need to find a sense of safety in this world. That won’t happen through exposure therapy that is paired with the danger cues of hard DBT skills.
We have some basic DBT on our blog and it has been invaluable when it comes to stopping dissociation. But we can’t stay there, we need to move beyond that to actually heal. And we cannot take the classic DBT program and use that for trauma treatment. It needs some adjustments. It is not even that hard to adapt it to trauma needs, but the way it is currently done is not working from the polyvagal perspective.
Leave a Reply