Should we teach our clients grounding techniques for them to use during reliving?
In short – sometimes! It really depends on whether an individual client is dissociating when they access the trauma memory. If they have a full immersive flashback, or detach and can no longer respond whenever they talk or think about the trauma, it is going to be practically difficult and highly distressing to work on the trauma memories in session. However, if they are able to talk about them and remain aware of their surroundings, you don’t need to spend valuable session time developing grounding strategies with your client. This just delays the most effective parts of trauma-focused therapies. If, as therapists, we find ourselves spending lots of sessions preparing for reliving, it is worth checking if this is really necessary for the client, or if it is our own anxiety or (understandable) reluctance to hear a distressing trauma story which is holding us back.
To assess dissociation, we can ask our clients what usually happens when they have memories of the trauma. Do they lose track of the here and now? Does it feel as if it is happening again or are they aware it is a memory (albeit a vivid one)? We can also observe what happens in session when we talk about the trauma. Typically, in a first session, we ask for a brief account of the trauma. If the client dissociates at this point, we will certainly need to practise some grounding strategies before trying more immersive memory techniques such as imaginal reliving. There are also some handy questionnaires to assess dissociation like the Trait-State Dissociation Questionnaire (available for free on the OxCADAT resources website) and the Dissociative Experiences Scale.
If someone tends to dissociate easily, it is not a reason to abandon work on the trauma memories. In fact, there is no evidence that trauma-focused psychological therapies are any less effective for people scoring highly on measures of dissociation (e.g. Hoeboer, 2020). However, we can take steps to make working with the trauma memories easier for our clients. For many, this will be a brief intervention to help them keep their attention in the here and now while they activate the trauma memories.
Grounding strategies, or ‘reminders of the here and now’, as Ehlers and Clark describe them, aim to reorient attention to the present situation and time. These might be sensory reminders, such as strong smells (smelling salts, essential oils, perfume) or tastes (Airwaves chewing gum, wasabi peas, sour sweets), movements, spoken phrases, items to hold or squeeze, photos or written reminders (e.g. stored on their phone), or other actions e.g. drinking a glass of cold water. Especially for strong dissociation, powerful, attention-grabbing and easily accessible grounding tools are best. It can be helpful to match the sensory modality of the reminder to the strongest sensory feature of any flashback – so use strong smell reminders if the person tends to have olfactory flashbacks, or movement if they tend to freeze. It can be helpful to practise a range of strategies, both within and between sessions, to identify the most effective, as these will differ between people.
Once a client has an effective way to bring their attention back to the here and now, memory work can continue, with the therapist prompting the client to use their grounding strategies if they begin to dissociate. For mild dissociation, imaginal reliving is usually still possible. If dissociation is more severe, it can be helpful to start with less immersive forms of memory work such as constructing timelines, written narratives or bird’s eye view reliving, although it is often possible to progress on to reliving as the memory becomes better processed and dissociation reduces.
Clients with more severe and/or pervasive dissociation may benefit from further intervention. For example, some people experience periods of loss of awareness, or even fainting episodes. If so, we usually begin with some psychoeducation. We often explain this as the mind’s way of coping with overload – if an experience is overwhelming, it can ‘shut down’ to protect us. If this happened at the time of trauma, it may happen again when the memory is triggered, because the shut-down is being re-experienced. An explanation of the ‘fight-flight-freeze’ response can also be helpful (we wrote about this in an earlier FAQ). These discussions seek to normalise dissociation as an understandable and common process. Clients may have negative or even catastrophic beliefs about dissociation (e.g. ‘my brain is damaged’) which we can address using psychoeducation. The ‘6Fs’ model of dissociation (Schauer & Elbert, 2015) can also be a useful heuristic to explain as part of psychoeducation. In brief, it conceptualises ‘shut down’ dissociation as a process which has evolved to protect us from inescapable threat situations.
Sometimes, dissociation is not only a barrier to memory work, but affects a person’s day-to-day life and potentially even puts them at some risk, for example, crossing roads without looking. Diaries can be helpful to better understand triggers to dissociation and to monitor the effectiveness of different grounding strategies. Involving loved ones can be useful to support the person recognise when they are dissociating and help to ground them. Stimulus discrimination is also a valuable technique to work on early in therapy if dissociation is an issue, once triggers have been identified.
There are several training videos about working with dissociation available on the OxCADAT resources website. All the materials on the site are free to access, you just need to register. We also highly recommend this paper by Chessell et al. (2019) about working with dissociation – it focuses specifically on refugees, but we think the contents apply to others too.
Key practice points
· For clients who do not dissociate, there is no need to work on grounding before memory work
· Dissociation can be assessed by asking and observing what happens when the memory is activated, and using a measure
· Memory work is still possible (and effective) for clients who dissociate
· For mild dissociation, some brief work on developing grounding strategies should be enough to progress with imaginal reliving
· Grounding strategies are reminders of the here and now that reorient the attention in the present time and place
· Grounding can be practised in and between sessions to identify the best strategies
· For more severe dissociation, psychoeducation and monitoring of dissociation may be needed, and less immersive forms of memory work used
Chessell, Z. J., Brady, F., Akbar, S., Stevens, A., & Young, K. (2019). A protocol for managing dissociative symptoms in refugee populations. The Cognitive Behaviour Therapist, 12.
Hoeboer, C. M., De Kleine, R. A., Molendijk, M. L., Schoorl, M., Oprel, D. A. C., Mouthaan, J., ... & Van Minnen, A. (2020). Impact of dissociation on the effectiveness of psychotherapy for post-traumatic stress disorder: Meta-analysis. BJPsych Open, 6(3).
Schauer, M., & Elbert, T. (2015). Dissociation following traumatic stress. Zeitschrift für Psychologie/Journal of Psychology.