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Mindfulness
ISSN 1868-8527
Mindfulness
DOI 10.1007/s12671-013-0261-3
Staying Present: Incorporating Mindfulness
into Therapy for Dissociation
Noga Zerubavel & Terri L.Messman-
Moore
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ORIGINAL PAPER
Staying Present: Incorporating Mindfulness
into Therapy for Dissociation
Noga Zerubavel &Terri L. Messman-Moore
#Springer Science+Business Media New York 2013
Abstract Dissociation involves retreating from the experi-
ence of the present moment through various processes, while
mindfulness cultivates the ability to stay in the present mo-
ment. We argue that mindfulness is thus uniquely well suited
for treatment of dissociation. This paper delineates the theo-
retical relationship between mindfulness and dissociation,
discussing how incorporating mindfulness into psychotherapy
can improve outcomes for dissociative clients. Mindfulness
can provide clients with specific techniques for enhancing
prediction of and control over dissociation through building
awareness of dissociative processes and offering a tool for
staying in the present moment. Mindfulness reduces reliance
on avoidance, which in turn diminishes the need for dissoci-
ation. In addition, taking the position of the observer, which is
a key feature of mindfulness, is itself a capability associated
with dissociation. We discuss the application of mindfulness
to three types of dissociative processes: detachment (e.g.,
depersonalization, derealization), absorption (e.g.,
daydreaming, “blanking out”), and compartmentalization
(e.g., amnesia, conversion symptoms). Three mechanisms
underlying the effectiveness of integrating mindfulness into
treatment of dissociation are proposed: (1) the techniques of
mindfulness (e.g., observing, staying present), (2) the
metacognitions of mindfulness (e.g., acceptance, non-
judgment), and (3) the emergent processes of mindfulness
(e.g., reperceiving, dialectical thinking). Challenges to imple-
mentation of mindfulness with dissociative clients are also
explored. Information and recommendations are provided to
guide applications to intervention.
Keywords Mindfulness .Acceptance .Dissociation .
Dialectical behavior therapy .Emotion dysregulation
Introduction
Psychologists have conceptualized dissociation as developing
in order to avoid unacceptable, overwhelming emotions and
knowledge that threaten the psychological and/or physical
survival of the person (Herman 1992; Kluft 1999;Putnam
1989;Steinberg1995). This process, which develops as an
adaptive mechanism for protecting the individual from threats
to psychological and/or physical safety, may become habitual
or chronic. Dissociation is linked to various problematic out-
comes, including impairment in school, work, or interpersonal
relationships, self-injurious behavior, and risk of victimization
(Herman 1992; Putnam 1989). Mindfulness may enable the
development of volitional processes that can afford some of
the psychological safety of dissociation, providing an alterna-
tive to the involuntary nature of dissociation. Given that
dissociation’s maladaptive consequences are related to the
inability to stay present, mindfulness—a practice focused on
experiencing the present moment—offers a uniquely well-
suited intervention.
Mindfulness, a practice rooted in Buddhist principles, has
been increasingly recognized as an effective treatment for a
variety of mental health issues (Brown, Ryan and Creswell
2007; Chambers, Gullone, and Allen 2009;Keng,Smoski,
and Robins 2011; Roemer and Orsillo 2009). Dissociative
clients present with an array of mental health problems, such
as anxiety, panic and agoraphobia, obsessive–compulsive dis-
order (OCD), posttraumatic stress disorder (PTSD), depres-
sion, bipolar disorder, eating disorders, substance abuse,
N. Zerubavel (*)
Department of Psychiatry and Behavioral Sciences,
Duke University Medical Center, Box 3026, Durham,
NC 27710, USA
e-mail: noga.zerubavel@duke.edu
N. Zerubavel :T. L. Messman-Moore
Department of Psychology, Miami University, Oxford,
OH 45056, USA
Mindfulness
DOI 10.1007/s12671-013-0261-3
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borderline personality disorder (BPD), and emotion dysregu-
lation (Holmes et al. 2005; Putnam 1989), which can be
treated effectively with interventions that focus on mindful-
ness. Mindfulness-based interventions, including
Mindfulness-Based Stress Reduction (Kabat-Zinn 1990),
Mindfulness-Based Cognitive Therapy (MBCT; Segal,
Williams, and Teasdale 2002), Dialectical Behavior Therapy
(DBT; Linehan 1993a), and Acceptance and Commitment
Therapy (ACT; Hayes, Strosahl, and Wilson 1999), have
demonstrated some effectiveness in improving coping with
chronic pain (Chiesa and Serretti 2011b); reducing symptoms
of depression (Brown et al. 2007; Chiesa and Serretti 2011a;
Keng et al. 2011) and major depressive episode relapses
(Chiesa and Serretti 2011a;Kengetal.2011); anxiety includ-
ing panic and agoraphobia, OCD, and PTSD (Keng et al.
2011; Roemer and Orsillo 2009); and BPD, including inpa-
tient hospitalization, self-injurious behavior, and suicidal ide-
ation (Keng et al. 2011; Rizvi, Steffel, and Carson-Wong
2013). Mindfulness assists in the development of the ability
to regulate emotions (Arch and Craske 2006;Coffey,
Hartman, and Fredrickson 2010;Farbetal.2010), tolerate
distress (Coffey et al. 2010), and handle interpersonal situa-
tions effectively (Block-Lerner, Adair, Plumb, Rhatigan, and
Orsillo 2007; Wachs and Cordova 2007), improving mental
health in cognitive, affective, and behavioral spheres (Brown
et al. 2007; Roemer and Orsillo 2009).
There is also some empirical support for interventions that
incorporate mindfulness into treatment for trauma and PTSD
(Follette, Palm, and Pearson 2006; Follette and Vijay 2009;
Lee, Zaharlick, and Akers 2009; Walser and Westrup 2007).
When specifically targeting dissociation, trauma experts re-
ported using mindfulness as a top complement to their first-
line interventions; top first-line interventions for dissociation
were education about trauma and emotion regulation inter-
ventions (Cloitre et al. 2011). Although the authors of the
study did not elaborate the specific frameworks of the emotion
regulation interventions, these interventions are often cogni-
tive–behavioral (Hayes et al. 1999; Linehan 1993a,b), expe-
riential (Greenberg 2002), psychodynamic (Fosha 2000), or
integrative (Mennin 2006). In fact, it is also noteworthy that
mindfulness is itself a well-respected emotion regulation in-
tervention (Chambers et al. 2009;HayesandFeldman2004;
Linehan 1993a,b).
Although mindfulness has been integrated into trauma-
focused treatments, particularly treatment for PTSD, its utility
in addressing severe dissociation has only begun to be exam-
ined from a theoretical perspective. Developing awareness of
dissociation and learning to return to the present experience is
an essential aspect of treatment for dissociation (Foa and
Meadows 1998), and mindfulness can facilitate both increased
awareness (i.e., developing the ability to predict and notice
dissociation) and the ability to return to the present (i.e.,
facilitating the ability to control dissociation). Because
mindfulness builds clients’capacity for tolerating and reduc-
ing avoidance of unwanted or uncomfortable emotions or
experiences, therapy that incorporates mindfulness may re-
duce the necessity for dissociation (Baslet and Hill 2011;
Neziroglu and Donnelly 2013). In addition, dissociative de-
tachment and mindfulness both involve the capacity to take
the observer position. This shared feature may be leveraged
therapeutically, making mindfulness techniques accessible
and appealing to clients who habitually dissociate. In contrast
to dissociation, mindfulness can provide volitional access to
the reduced emotional reactivity of the observing ego’s
perspective.
In this paper, we delineate a theoretical framework
outlining the reasons that integrating mindfulness may be
uniquely relevant to and useful for the treatment for dissoci-
ation and provide information to guide clinical applications.
The dearth of research on using mindfulness to treat dissoci-
ation engenders the need for theory to drive research and
clinical work. When research is not yet available, clinicians
treating complex trauma-related problems (e.g., dissociation)
can utilize theory to guide treatment development (Wagner,
Rizvi, and Harned 2007). Experts in mindfulness and trauma-
related disorders have recommended incorporating mindful-
ness into specialized pathology-focused or trauma-focused
approaches (Cloitre et al. 2011; Follette and Vijay 2009). We
will highlight how to practice these techniques, maintain
awareness of the developing mindful metacognitions, and
emphasize the cultivation of emergent processes in the context
of working with severely dissociative clients.
We will first describe dissociation and three specific disso-
ciative processes: detachment, absorption, and compartmen-
talization. In the next section, we define mindfulness and
describe its components: techniques, metacognitions, and the
emergent processes produced through its practice. We then
review the nascent literature that has explored the relationship
between mindfulness and dissociation. Finally, we provide
information about implementing mindfulness in the treatment
of each dissociative process, identifying practical applications
of specific elements of mindfulness that are effective for each
dissociative process (see Table 1).
Dissociation and Dissociative Processes
Dissociation involves the capacity to use disconnection to
achieve psychological safety (Gold and Seibel 2009).
Dissociative symptoms are included in diagnostic criteria for
acute stress disorder, PTSD, BPD, panic attacks, and disso-
ciative disorders (American Psychiatric Association 2013).
They can also occur in the context of mental health problems
including agoraphobia, OCD, depression, bipolar disorder,
and eating disorders (Holmes et al. 2005;Putnam1989;
Simeon 2009; Steinberg 1995). Dissociation takes multiple
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forms and varies inits degree of pervasiveness, frequency, and
severity (Braude 2009). Depending on these qualities, disso-
ciation may differ in whether it is pathological or problematic.
Dissociative phenomena are most often construed as three
distinct processes: detachment, absorption, and compartmen-
talization (Holmes et al. 2005; Steele, Dorahy, van der Hart,
and Nijenhuis 2009; Waller, Putnam, and Carlson 1996),
although other conceptualizations exist as well (Dell 2009).
Detachment refers to an “altered state of consciousness
characterized by a sense of separation (or ‘detachment’)from
certain aspects of everyday experience”such as the body, the
self, or the surrounding world (Holmes et al. 2005, p. 5).
Detachment encompasses experiences of depersonalization
(separation of experiencing ego and observing ego) and dere-
alization (sense of unreality, distortions of time or space;
Simeon 2009). Clients describe detachment as feeling as if
they are in a dream, as if they or things around them are unreal,
or as if they are watching themselves from above (Putnam
1989; Steinberg 1995). Watching oneself from above or out-
side the body involves taking a dissociated observer position.
Absorption refers to experiences of being disconnected
from present moment experience while deeply immersed in
other stimuli (Allen, Console, and Lewis 1999). The field of
attention is narrowly focused and detached from present mo-
ment experience (Allen et al. 1999). When individuals expe-
rience absorption, they describe daydreaming, being im-
mersed in thought or fantasy, or in nothingness (i.e., “spacing
out”). Although some researchers have described absorption
as normal or nonpathological dissociation (Dell 2009; Waller
et al. 1996), others have argued that there is clinical signifi-
cance when frequency or duration is extreme (Braude 2009)
or when the context makes it problematic (e.g., when one is in
danger). Although minimal levels of absorption may be
nonpathological, more chronic and severe presentations may
become a foundation for detachment processes (e.g., deper-
sonalization; Dell 2009) and may disrupt encoding of memory
(Allen et al. 1999). As such, we believe it is important to
address absorption in therapy.
Compartmentalization refers to conditions “characterized
by an inability to bring normally accessible information into
conscious awareness (e.g., dissociative amnesia)”(Holmes
et al. 2005, p. 7). When individuals experience compartmen-
talization, they report conversion symptoms (neurological
symptoms that are unexplained by organic disease and are
best explained through psychological causes), amnesia
(significant memory gaps), and amnesic barriers between
personality states (inability to remember events that occurred
while in another personality state; Holmes et al. 2005;Putnam
1989;Steeleetal.2009;Steinberg1995).
Although detachment, absorption, and compartmentaliza-
tion are distinct phenomena grouped under the term “dissoci-
ation,”a core feature unifies all: dissociation is essentially an
experience of disconnection (Gold and Seibel 2009)—either
from the present moment (absorption), others (derealization
detachment), or the self (depersonalization detachment, com-
partmentalization). Hayes et al. described dissociation as be-
longing to a class of behaviors that function to enable experi-
ential avoidance, maladaptive efforts to escape and avoid
emotions, thoughts, memories, and other private experiences
(Hayes, Wilson, Gifford, Follette, and Strosahl 1996). The
ACT model (Hayes et al. 1999) proposes that mindfulness,
within an acceptance-based framework, provides effective
treatment for experiential avoidance; experts in dissociation
have begun to apply ACT to dissociation (see Baslet and Hill
2011; Neziroglu and Donnelly 2013). Given that mindfulness
teaches skills for staying present and cultivating a sense of
connection to self and others, it makes a particularly fitting
intervention for treating dissociation.
Tab l e 1 Framework for integrating mindfulness into treatment for
dissociation
Type of dissociation Examples Applications of
mindfulness
Detachment: separation
or estrangement
from self, body,
and/or surrounding
world
Depersonalization
Derealization
Mindfulness techniques
Staying present
(participating in
present moment)
Mindful metacognitions
Openness
Willingness
Nonstriving
Nonjudgment
Acceptance
Emergent processes
Reperceiving
Connectedness
Absorption: total
immersion of
attention on a
stimulus or on
nothingness
Daydreaming
Spacing out
Distorted perception
of time
Mindfulness techniques
Intentionally harnessing
attention
Observing/ noticing
Describing
Staying present (present
moment awareness
and participating in
present moment)
Mindful metacognitions
Openness
Willingness
Compartmentalization:
self-fragmentation
and/or somatoform
manifestations of
distress
Separate personality
states
Amnesic barriers
Conversion symptoms
Mindful metacognitions
Openness
Willingness
Compassion
Nonstriving
Nonjudgment
Acceptance
Emergent processes
Reperceiving
Connectedness
Inherent wisdom/values
clarification
Dialectical thinking
Mindfulness
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Mindfulness
Mindfulness has been defined as “the process of intentionally
attending moment by moment with openness and
nonjudgmentalness”(Shapiro, Carlson, Astin, and Freedman
2006, p. 378). It is practiced and applied through both formal
(i.e., meditation) and informal practices (e.g., walking or
eating mindfully). Mindfulness encompasses both techniques
(e.g., intentionally harnessing attention, holding present mo-
ment awareness) and metacognitions (thoughts about emo-
tional and cognitive experience that avoid evaluating, apprais-
ing, or rejecting experience; Brown et al. 2007;Kabat-Zinn
1990). DBT (Linehan 1993a), a well-recognized mindfulness-
based therapy, similarly divides mindfulness skills into “what”
skills (viz., techniques) and “how”skills (viz.,
metacognitions). These processes encourage clients to be-
come curious about internal experience and entertain the
possibility of relating to thoughts and feelings in a new man-
ner. In addition, the integration of mindfulness techniques and
metacognitions produces emergent processes (mechanisms
that are created indirectly through the practice, rather than
directly practiced). We will explain each of these elements
of mindfulness in more detail in the following sections. There
are many theories of mindfulness, unique in certain ways and
similar in others; we draw on the contributions of a range of
theorists (e.g., Baer, Smith and Allen 2004;Bishopetal.2004;
Brown et al. 2007;Hanh1976; Kabat-Zinn 1990;Linehan
1993a; Segal et al. 2002; Shapiro et al. 2006).
The Techniques of Mindfulness The techniques of mindful-
ness include intentional harnessing of attention, staying pres-
ent, observing, and describing. The intentional harnessing of
attention is a concentration skill in which clients purposefully
shift attention; mindfulness skills improve clients’ability to
redirect attention volitionally (Corrigan 2002;Loizzo2009;
Zylowska et al. 2008). Staying present occurs both through
holding present moment awareness (attentional focus on in-
ternal and/or external experience of the present moment) and
through participating in the present moment (engagement in
experience). Observing and describing are impartial in nature.
Brown et al. (2007)stated:“Because mindfulness permits an
immediacy of direct contact with events as they occur, without
the overlay of discriminative, categorical, and habitual
thought, consciousness takes on a clarity and freshness that
permits more flexible, more objectively informed psycholog-
ical and behavioral responses”(p. 212). This concept is
discussed in ACT (Hayes et al. 1999) using the term cognitive
defusion to describe separation between self and thoughts or
the assumption that thoughts are true. Similarly, in MBCT
(Segal et al. 2002), it is highlighted that thoughts are simply
passing mental events, but we often treat them as though they
are reality. It is important to note that the techniques of
mindfulness are practiced rather than attained; the notion of
“achieving”is replaced by “moving toward,”including the
awareness that at different times, one is more or less capable of
using the techniques of mindfulness.
The Metacognitions of Mindfulness A critical aspect that
characterizes mindfulness is the metacognitive approach to
experience, which is non-discriminative (not evaluating or
appraising) and non-conceptual (not applying conceptual
filters or schemas; Brown et al. 2007). This involves clients
having a mindset of openness and finding curiosity about
experiences, even those that are uncomfortable or unwanted.
Clients adopt a mindset of nonjudgment, noticing, and letting
go of evaluations that appraise thoughts, feelings, sensations,
or events as “good”or “bad.”Instead of habitual judgments,
compassion is applied to the self and others (Germer 2009),
cultivating a gentle, forgiving approach that can be therapeutic
for painful emotions (e.g., anger) that many dissociative cli-
ents experience toward themselves and/or others. Mindfulness
is not positive thinking or cognitive reframing (Kabat-Zinn
1990; Linehan 1993a); rather, it is the willingness to stay
present in a nonstriving manner (i.e., a particular outcome is
not sought). Mindful metacognitions are characterized by
acceptance, which involves understanding that things are as
they are (Robins 2002) rather than as one might wish they
were. It is helpful to distinguish acceptance from resignation,
as it is not based in passivity or helplessness, but rather in a
willingness to accept life situations in their current form,
which may then be used to promote change (Segal et al. 2002).
Introducing mindful metacognitions as an element of psy-
chotherapy is based on the Buddhist philosophy that pain
alone is just pain, but when one responds with nonacceptance
and self-judgment, pain then develops into suffering (Linehan
1993a;Robins2002). As it is often the reactions to feelings
rather than the feelings themselves that are most
distressing, having a mindful metacognitive approach pro-
motes the ability to deal with difficult or unwanted internal
experiences without becoming overwhelmed (Brown et al.
2007;Linehan1993a; Roemer and Orsillo 2009). By culti-
vating this metacognitive approach, mindfulness facilitates
change in patterns of emotional reactivity and avoidance
and eases the return to baseline following experiences of
intense affect (Roemer and Orsillo 2009).
Emergent Processes Through regular practice of pairing the
techniques of mindfulness with mindful metacognitions,
meta-mechanisms emerge (Shapiro et al. 2006). These internal
shifts are referred to here as emergent processes because they
emerge from the interaction of other phenomena. Robins
(2002) described emergent processes as having “properties
that arise from the integration of diverse elements, constantly
changing as they affect other things and are affected in turn by
them”(p. 53; see also Kumar 2002). As such, these processes
are not taught directly, but rather arise experientially through
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practice of the components that are taught directly (i.e., the
techniques and metacognitions of mindfulness). Building on
the notion introduced by Shapiro et al. (2006) of reperceiving
as a meta-mechanism, we propose four emergent processes:
reperceiving, inherent wisdom, connectedness, and dialectical
thinking.
The first process that emerges is reperceiving, which is the
de-coupling of the process of consciousness from the content
of mental subject matter (Keng et al. 2011; Shapiro et al.
2006). For example, when reflecting on a conversation, one
switches from thinking about what was said (content) to
noticing that one is thinking about the conversation and ob-
serving how one is thinking about it (process). Although there
are unique aspects of each, this fundamental shift in perspec-
tive has also been called decentering (Bishop et al. 2004;
Brown et al. 2007; Segal et al. 2002), metacognitive insight
(Segal et al. 2002), or cognitive defusion (Hayes et al. 1999).
Reperceiving is a transformation that allows subject to be
converted into object (Shapiro et al. 2006)andmaybring
forth insights such as the impermanence of emotions. By
switching to the observation of mental activities, one becomes
less identified with the content of the mental activity. For
instance, one can observe that a thought is simply a string of
words.
The second process that emerges is becoming connected to
a sense of inherent wisdom. Inherent wisdom is the sense that
an answer emerges, or unfolds, in a manner that is intuitive
and value-driven (Segal et al. 2002). In DBT, this is referred to
as “wise mind”and is described as adding intuitive knowledge
to a balance of rational and emotional input (Linehan 1993a).
When a decision suddenly emerges with clarity from within,
this is an instance of inherent wisdom. Through developing
awareness of inherent wisdom, mindfulness cultivates insight
and value clarification (Brown et al. 2007; Shapiro et al.
2006). Through this process, clients may become increasingly
aware of goals or values that are deeply meaningful. This
clarification of values then serves as a foundation for choosing
behaviors that are congruent with the client’s values and goals
(Shapiro et al. 2006). Individuals who report greater mindful-
ness skills also behave in a manner that is more compatible
with their values and interests (Brown and Ryan 2003).
Inherent wisdom or wise mind may contribute to developing
a stronger sense of internal self-awareness and authenticity
that may be extremely meaningful for chronically dissociative
clients.
The third process that emerges through the practice of
mindfulness is a sense of connectedness. In the mindfulness
literature, this has often been discussed as interconnectedness
among all things (Kabat-Zinn 1990; Linehan 1993a), which
may manifest through a connection to nature, to other indi-
viduals, to groups, or to the universe more broadly.
Connectedness through mindfulness is also discussed as in-
terdependence (Hanh 1976), providing a view in which all
objects or individuals are defined not only by their own
elements, but also by their relationship to other elements,
objects, or other individuals. In such a holistic perspective,
an individual is not only defined as a “self,”but also a person
in existence in relation to others (Robins 2002), thus perme-
ated by the experience of connectedness. In addition, connect-
edness to oneself may be related to a sense of internal whole-
ness that is theorized to become available when the struggle to
eliminate emptiness is suspended (Epstein 1998).
The final emergent process, dialectical thinking, is charac-
terized by “the reconciliation of opposites in a continual
process of synthesis”(Linehan 1993a, p. 19). Rather than
engaging in dichotomous thinking that ascribes to polarities,
dialectical thinking encourages the ability to view both sides
simultaneously. Through dialectical thinking, elements that
appear to be mutually exclusive can be synthesized for more
complete understanding that transcends the limits of the po-
larized perspectives. For example, there is a dialectic between
change and acceptance. On one extreme, one may feel com-
pelled to change and modify the experiences and situations
that are problematic. On the other extreme, one may feel
helpless to change circumstances and identify the important
task as acceptance of this reality. Although these perspectives
are often represented as polarities, through dialectical synthe-
sis, we can integrate the two in the notion that we may work to
change the aspects of our lives that we are able to change,
while at the same time, we must accept the aspects of our lives
that we are unable to change. The concept of dialectical
thinking is related to the focus in ACT on development of
psychological flexibility (Hayes et al. 1999), the ability to
respond in a flexible rather than rule-based manner to stimuli
and events. Below, in the section on “Applications to
Intervention,”we will provide examples of using emergent
processes in the treatment of dissociation.
Mindfulness and Dissociation
There is a relative paucity of literature regarding the use of
mindfulness in treatment for dissociation (Neziroglu and
Donnelly 2013;Wagneretal.2007). Three studies have
provided initial empirical support for using mindfulness-
based intervention to treat dissociation. The first was a DBT
treatment study that demonstrated a reduction in dissociative
symptoms following DBT treatment (Koons et al. 2001). The
second study examined the use of mindfulness in the context
of a sensorimotor psychotherapy group for women with a
history of childhood trauma, reporting significant reductions
in dissociative symptoms (Langmuir, Kirsh, and Classen
2012). The third was a case study in which Baslet and Hill
(2011) suggested the use of ACT to treat conversion and
dissociative disorders, focusing on reducing experiential
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avoidance through development of greater willingness to ex-
perience aversive internal and external experiences. In addi-
tion, we believe mindfulness is likely to be successful as part
of treatment for dissociative clients because it enables the
development of volitional processes that afford psychological
safety, in contrast to the involuntary, passive, and reflexive
nature of dissociation (Allen et al. 1999). It also provides skills
that increase awareness of dissociation. These are meaningful
effects, given that clinical impairment from dissociation is
often related to it being experienced as being involuntary
and outside of consciousness (Dell 2009;Kennerley1996;
Putnam 1989).
One of the most common uses of mindfulness practices in
the dissociation literature is for grounding. The trauma litera-
ture has long recommended using grounding (e.g., attention to
sensory input, an image or object) as a stabilization tool and a
fundamental strategy for preventing or interrupting dissocia-
tion (Boon, Steele, and van der Hart 2011; Gold and Seibel
2009; Kennerley 1996; Najavits 2002). In fact, grounding
exercises have sometimes been labeled “mindfulness prac-
tices.”However, we would argue that although mindfulness
techniques include grounding exercises, mindfulness is more
than grounding. Although the content (i.e., techniques) of
grounding and mindfulness does overlap, the key difference
between mindfulness and grounding is that in mindfulness,
the process aspect (i.e., metacognitions) is equally important:
pairing techniques with a nonjudgmental, accepting, and com-
passionate approach to experience. For instance, a mindful-
ness practice of describing the environment and incorporating
sensory information has a grounding effect on the individual.
Significantly, a mindful metacognitive approach would also
emphasize being non-evaluative, accepting, and compassion-
ate, thus encouraging the client to leave out judgments that
may otherwise sabotage a grounding exercise without mindful
metacognitions. Grounding (and similarly, relaxation exer-
cises) may include a goal of achieving a state of relaxation
(Gold and Seibel 2009); in contrast, mindfulness practice is
specifically nonstriving, and the internal state is observed as it
is (Hanh 1976).
Although the relationship between mindfulness and disso-
ciation has not yet been elaborated fully, two conceptualiza-
tions emerge in the extant literature. One model conceptual-
izes these processes as lying at opposite poles of a continuum
of awareness (i.e., mindfulness as high level of awareness;
dissociation as lack of awareness). According to Walach et al.
(2006), “dissociation seems to be the opposite of mindfulness,
containing symptoms of amnesia, automaticity without con-
scious control and the dissociation of cognitive and emotional
elements”(p. 1546). Similarly, Corrigan (2002) described the
processes as being at opposite ends of a neurobiological
continuum, calling mindfulness “willed and controlled disso-
ciation, applied for a particular purpose, such as emotion
regulation or distress tolerance”(p. 9).
Our conceptualization of the relationship between mind-
fulness and dissociation is consistent with a second perspec-
tive, in which dissociation is characterized by an absence of
mindful awareness (see also Baer, Smith, Hopkins,
Krietemeyer, and Toney 2006; Wagner and Linehan 1998).
Importantly, in this conceptualization, dissociation involves
more than lack of mindfulness, and mindfulness involves
more than not dissociating. They are not opposites, given that
other psychological processes may also involve an absence of
mindfulness (e.g., thought suppression; Baer et al. 2006). In
contrast to the continuum perspective, we do not view mind-
fulness as a more controlled, conscious form of dissociation
(cf. Corrigan 2002); instead, we conceptualize mindfulness
and dissociation as fundamentally distinct psychological pro-
cesses (Williams 2010), linked by specific contrasting dimen-
sions including awareness/lack of awareness, staying present/
detachment, and connectedness/fragmentation. In addition,
mindfulness and dissociation both involve a shared feature:
the observerposition. Indeed, research examining the relation-
ship between mindfulness and absorption demonstrates that
they are distinct processes, perhaps linked through the ability
to take the observer position (Baer et al. 2004).
Applications to Intervention
The framework developed here can be implemented by incor-
porating mindfulness into existing therapeutic models or by
using mindfulness-based treatments (e.g., DBT, ACT). If the
therapist is using a mindfulness-based intervention, we rec-
ommend adding one or two sessions that focus directly on
using mindfulness to address dissociation, including discus-
sions of how mindfulness increases awareness of dissociation,
provides ways to intervene to interrupt dissociation, and may
present an alternative to dissociation. If the therapist is using a
therapeutic approach that does not involve mindfulness, we
recommend dedicating two or three sessions entirely to pro-
viding psychoeducation about mindfulness and conducting in-
session mindfulness practices, with one of these sessions
focusing specifically on using mindfulness to address disso-
ciation. After this foundation is laid, the therapist can set aside
a portion of each session to focus on building mindfulness
skills. It is particularly helpful if these mindfulness practices
can be conducted when the client is experiencing in-session
dissociation. Whether in short-term or long-term psycho-
therapy, dissociative clients are likely to benefit from
introducing mindfulness early on, as the techniques can
function as grounding exercises that may help the client to
remain present.
In this section, we review the theoretical and practical
relevance of mindfulness to the treatment of each dissociative
process, including specific examples of the implementation of
mindfulness in treatment of these key aspects of dissociation.
Mindfulness
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Tab le 1provides an overview of the particular elements of
mindfulness (specific techniques, metacognitions, and emer-
gent processes) that are relevant to each dissociative process.
When providing psychotherapy to dissociative clients, best
practice guidelines rooted in treatment models for complex
trauma and dissociative disorders instruct clinicians to use a
phase-based, sequential treatment process that begins with a
focus on safety, stabilization, and symptom reduction (Cloitre
et al. 2011;ISSTD2011). This reflects the heuristic of first
reducing symptom severity in the interest of stability and
building the client’s capacity for trauma-focused work by
developing emotion regulation and distress tolerance skills
(Cloitre et al. 2011;Linehan1993a). Mindfulness can be a
primary tool for stabilization and continued symptom
reduction.
Using Mindfulness to Reduce Detachment
In both mindfulness (Brown et al. 2007; Kabat-Zinn 1990)
and dissociative detachment (Allen et al. 1999;Simeon2009),
the individual’s consciousness takes the position of an observ-
er. This is a key experiential feature shared by mindfulness
and dissociation, yet it has been largely overlooked that for
dissociative clients, this may make mindfulness a particularly
accessible alternative to dissociation. We propose that mind-
fulness allows dissociative clients to capitalize on the famil-
iarity and safety of the observer position, a perspective that
facilitates reduced emotional reactivity. Leveraging a familiar
coping strategy may enhance the ability of dissociative clients
to engage in mindfulness practice. Dissociative clients who
are emotionally attached to dissociation may find it reassuring
to discuss how mindfulness capitalizes on current coping
strategies by preserving the safety and comfort of the observer
position, while providing a new manner of accessing this
position.
When clients tolerate difficult internal experiences from an
observer position, without extreme emotional reactivity or
self-berating, mindfulness can function as an exposure exer-
cise. That is, when clients withstand distressing emotions in
the context of mindfulness practice, benefits of exposure are
gained (Linehan 1993a;Kengetal.2011; Shapiro et al. 2006).
By enduring aversive internal experiences, the client develops
a sense of mastery and feels more empowered and less vul-
nerable. In addition, clients benefit by having access to the
information that is available in emotional experiences that are
not avoided. The ability to handle awareness and contact with
aversive experiences (e.g., thoughts, feelings) is likely to
reduce clients’reliance on or need for dissociative processes
(Baslet and Hill 2011).
Therapists can describe detachment as an absence of con-
nectedness, either in terms of disconnectedness from the self
(viz., depersonalization) or disconnectedness from others
(viz., derealization). Staying present is a fundamental
intervention for detachment processes, and mindfulness,
which includes both present moment awareness (i.e., atten-
tional focus) and participating in the present moment (i.e.,
engagement), cultivates this ability. One takes an impartial
observer perspective (Brown et al. 2007) while still maintain-
ing engagement and participation in the present moment
(Linehan 1993a). In contrast, dissociative detachment in-
cludes present moment awareness without the sense of partic-
ipating in the present moment. In addition, the emergent
process of connectedness is critical to the sense that one is a
part of what is happening. In-session mindfulness exercises
can devote special attention to developing connectedness by
cultivating compassion and openness toward the object of
observation (e.g., a thought, emotion, or image) and all that
is noticed about it.
Clients who use detachment to avoid emotionally difficult
experiences will benefit from using mindfulness to decrease
avoidance. The mindful metacognitive approach to experience
is essential, because having a nonjudgmental, accepting,
nonstriving attitude is critical to decreasing avoidance.
Reperceiving may also diminish the need for avoidance, given
its ability to reduce emotional reactivity. For instance, if a
client is observing anger, the focus is on noticing the experi-
ence of anger (i.e., process) rather than examining who is to
blame (i.e., content). Another use of mindfulness exercises in
session can be to regulate emotions, particularly to ensure that
dissociative clients leave sessions in a stabilized state
(Kluft 1999). Approaching the end of a particularly distressing
session, the therapist can guide the client through a brief
mindfulness practice. This can serve to end the session with
stabilization, thus affirming that intense emotions can be
safely experienced and contained.
Distinguishing Between Mindful and Dissociated Observer
Positions In dissociative detachment processes, there is a
separation between the experiencing self and the observing
self, while in mindfulness, one might say that the experiencing
self takes the observer position. For the dissociated watcher,
consciousness is external and disconnected (e.g., like
watching a movie; Steele et al. 2009), while for the mindful
watcher, consciousness is internal and connected (e.g., en-
hanced awareness; Shapiro et al. 2006). Therapists can high-
light how to differentiate, as in Linehan’s(1993b) DBT skills
manual: “Remind participants to step back within themselves,
not outside of themselves to observe. Observing is not disso-
ciating.”(p. 67).
For clients who struggle to differentiate mindful and dis-
sociative observer positions, assessing two aspects of their
experience may serve as clarifying indicators: affect and in-
tentionality. Assessing awareness of affective experience may
be beneficial, given that in dissociative processes, affect is
disconnected (e.g., feeling numb, “checked out”), while in
mindfulness, one is aware of and connected to emotions
Mindfulness
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(Michal et al. 2007; Shapiro et al. 2006; Williams 2010). In
contrast to detachment, which is experienced as distancing
and alienating, mindfulness includes the vibrancy and vitality
of connectedness (Michal et al. 2007). Reperceiving may be
confused with distancing or disinterest, but it is different from
detachment because it “engenders a deep knowing and inti-
macy with whatever arises moment by moment”(Shapiro
et al. 2006, p. 379). A dissociative state is either entirely
dissociated (e.g., amnesia) or reflected in dreamlike process-
ing (e.g., derealization; Dell 2009), whereas a mindful state is
fully invested in reality-based processing, connected to sen-
sory experience of the present moment (Hanh 1976; Kabat-
Zinn 1990). Another distinguishing feature to assess is inten-
tionality. For many dissociative clients, the aspect of dissoci-
ation that is most distressing is lack of control. Importantly,
mindfulness provides the client with volitional access to the
reduced reactivity afforded by the observer position without
the cost of restricted awareness and disconnection.
Mindfulness promotes the “conscious regulation of uncon-
scious processes”(Loizzo 2009, p. 189) and is likely to enable
greater conscious regulation of detachment processes, poten-
tially reducing the client’s sense of helplessness regarding
dissociative episodes.
Using Mindfulness to Reduce Absorption
Absorption is characterized by total immersion of attention on
something (e.g., reading, daydreaming) or nothing (e.g., “go-
ing blank”or spacing out) and is often associated with
distorted perception of time, self, or surroundings
(Dell 2009). Absorption can be disconcerting or problematic
for clients because it is often experienced as passive and invol-
untary (Allen et al. 1999), as something that just “happens”(e.g.,
“automatisms”;Dell2009). Thus, we emphasize intentionality
as a concept that distinguishes between mental processes of
mindfulness and dissociation: mindfulness by nature involves
intentional attention, directed with receptiveness toward the
present moment. Mindfulness, when practiced regularly, culti-
vates concentrative abilities (Hanh 1976). Regular practice at
harnessing attention with intention improves attentional capac-
ities (for review, see Brown et al. 2007), even in individuals with
attention problems, such as attention deficit hyperactivity disor-
der (Zylowska et al. 2008). Beyond influences on executive
functioning, attention, and concentration, at a most basic level,
mindfulness improves individuals’capacity to focus attention
on the present moment (Hanh 1976)—a most fitting and appro-
priate alternative to absorption, which essentially removes atten-
tion from present moment experience. In this way, mindfulness
enables staying present.
Noticing attentional drift is a primary task of treatment for
absorption. Becoming aware of dissociation and learning to
return to present experience is a central aspect of treatment for
dissociation (Foa and Meadows 1998). Through developing
awareness that dissociation is occurring, the client is presented
with the opportunity to reclaim attentional resources. It is also
important that the client is not judgmental or self-critical when
noticing that attention has drifted. Instead, the therapist can
stress that it is the nature of the mind to wander, and it is the
task of mindfulness to notice this when it occurs, to harness
attention intentionally (Brown et al. 2007) and return non-
judgmentally to the intended object of attention (e.g., breath, a
candle).
Once the client has noticed that dissociation is occurring,
mindfulness is also central to helping clients to harness and
direct attention intentionally. Clients can practice purposefully
shifting—like a zoom lens—between focused attention to
detail and broad awareness of the larger context (Brown
et al. 2007). By intentionally and consciously directing atten-
tion, holding present moment awareness, and observing with
neutrality (Kabat-Zinn 1990),aclientisbetterabletocon-
sciously direct mental processes that are often unconscious
(Loizzo 2009). If therapy can create a link between awareness
of dissociation and intentional harnessing of attention on the
present moment, mindfulness can be used to counteract dis-
sociation (Boon et al. 2011; Corrigan 2002;Kennerley1996;
Najavits 2002). Clients may benefit from practice with ob-
serving and describing the objects of their attention
(e.g., thoughts, emotions, sensations, images, objects in the
environment).
Staying present is a fundamental aspect of intervention for
absorption, both in terms of present moment awareness (i.e.,
attentional focus) and participating in the present moment
(i.e., engagement). It is facilitated through emotional, cogni-
tive, and behavioral participation in present moment experi-
ence with attentional control. Dissociative clients are likely to
appreciate and enjoy having greater voluntary control over
attention and engagement in present moment experiences, as it
provides them with important skills that generate a sense of
empowerment.
Using Mindfulness to Reduce Compartmentalization
Dissociative compartmentalization processes are character-
ized by experiences of fragmentation, such as conversion
symptoms and amnesic barriers between personality states
(Allen et al. 1999;Holmesetal.2005; Steele et al. 2009).
Compartmentalization symptoms such as hearing voices (e.g.,
commenting on one’s actions; Steinberg 1995) may be im-
proved through mindfulness, given that populations with psy-
chotic symptoms have been helped by taking a mindful
metacognitive stance about the hallucinations rather than
judging oneself for having them (Bach and Hayes 2002).
Given the interactive nature of distress and psychotic symp-
toms, decreasing distress is critical to improving psychotic
and psychotic-like dissociative symptoms. Moreover, com-
partmentalization is often associated with unexplained
Mindfulness
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somatic concerns (Putnam 1989). Such symptoms may im-
prove with mindfulness, given its success as a leading treat-
ment for chronic pain by decreasing maladaptive
metacognitions (e.g., nonacceptance, self-judgment) about
the pain (Brown et al. 2007;Kabat-Zinn1990).
The emergent process of dialectical thinking is particularly
well suited to the treatment of compartmentalization because it
develops the ability to hold different perspectives simulta-
neously. Compartmentalization functions to separate feelings,
thoughts, and/or knowledge to be outside of awareness or in
restricted awareness. Increased ability to tolerate multiple
perspectives simultaneously is apt to reduce the tendency
toward intrusion symptoms from separate personality states
(Baslet and Hill 2011) and may increase co-consciousness, the
ability for the perspectives of multiple personality states to be
present simultaneously. Therapists can also encourage dialec-
tical thinking to emerge through complementary therapeutic
techniques; DBT offers many useful techniques for increasing
tolerance for the duality of dialectics (Linehan 1993a).
Although dissociative compartmentalization may function
more as multiplicity than duality, the techniques are none-
theless applicable. By thinking dialectically, clients in-
crease their capacity to see multiple truths and to replace
an either/or mindset with a both/and mindset. Thinking
dialectically promotes the ability to honor multiple perspec-
tives and is likely to support the development of internal
collaboration among compartmentalized parts of the self. A
therapist must convey both sides of a dialectic effectively in
order to encourage dialectical thinking (Linehan 1993a):
being supportive, yet challenging; cautious, yet curious;
consistent, yet flexible; and gentle, yet firm. Over time,
the therapist’s dialectical style provides a model that helps
the client to think dialectically.
As dialectical thinking increases and separateness and con-
nectedness are no longer polarized opposites, the dissociative
client gains improved access to another emergent process of
mindfulness: the sense of connectedness, both intrapersonally
and interpersonally. As mindfulness enhances the ability to
experience connectedness (Kabat-Zinn 1990), it is well suited
for viewing the fragmented self as internally connected and
increasing connection to others. The therapist can enhance
awareness of such changes through discussion of the inter-
connectedness between parts of the self. Although compart-
mentalization affords safety through creation of barriers, cli-
ents also suffer from effects of these barriers, such as health
problems (e.g., conversion symptoms) or memory gaps
(i.e., amnesic barriers).
The emergent process of inherent wisdom guides the client
to an underlying sense of core, authentic self. It can be
highlighted that this core self underlies all parts of the self.
Reperceiving helps clients to feel less overwhelmed by affect
or experiences; thus, this emergent process is also likely to
reduce the need for compartmentalization, which arises in
order to contain unbearable, overwhelming internal and exter-
nal stimuli. In addition to the emergent processes, mindful
metacognitions (e.g., acceptance, nonjudgment, nonstriving,
willingness, openness, and compassion) increase openness to
experience. Without the need to suppress or repress aspects of
one’s experience, compartmentalization is no longer
necessary.
In sum, mindfulness can provide therapeutic interventions
for detachment, absorption, and compartmentalization pro-
cesses. To use these interventions effectively, it is important
to consider and prepare to address potential challenges and
concerns regarding implementation.
Mindfulness in the Context of Dissociation
There are some important cautionary notes with respect to
introducing and implementing formal mindfulness practice
(i.e., mindfulness meditation) with dissociative clients. The
concerns that we will address are distinct but related: clients
may confuse mindfulness with dissociation, they may disso-
ciate during meditation, they may be attached to dissociation
and reluctant to relinquish dissociative behavior, and they may
have difficulty implementing mindfulness (e.g., regular prac-
tice, modifying metacognitions).
The foremost concern is that clients may confuse mindful-
ness meditation with dissociation (Linehan 1993b). For this
reason, we recommend that therapists prepare clients with
psychoeducation regarding mindfulness and dissociation.
For instance, therapists can leverage the familiarity of the
shared observer position, in conjunction with information
discussed above on how clients can differentiate between
mindful and dissociated states (e.g., connectedness to affect,
volitional shifts of attention).
The second concern is that for some clients, mindfulness
practices may elicit dissociation, perhaps due to the change in
mental state. For example, a client may experience the mindful
state as invoking dissociation, making it difficult to stay present
and participate in the practice. If dissociation occurs during
mindfulness meditation, clients can keep their eyes open during
the practice in order to maintain present moment engagement
and to prevent dissociation (Foa and Meadows 1998;Walser
and Westrup 2007). Similarly, some clients who are trauma
survivors may have flashbacks when they try to meditate
(Walser and Westrup 2007). If the client has a flashback in
session, the therapist can provide present moment reminders
(Foa and Meadows 1998). To counteract dissociation, we en-
courage a focus on grounding as a central aspect of mindfulness
practice. It may be helpful for the client to identify safe anchors
in the therapy room, as well as in rooms at home or at work
(Boon et al. 2011). Using an object such as a rock can facilitate
access to a sense of grounding (Najavits 2002). To identify
mindfulness practices that are comfortable and accessible, it
may be helpful to experiment with different practices, varying
Mindfulness
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the attentional focus each time. Some examples for attentional
focus include breath, each of the five senses, an object, a
sound or sight in the environment, imagery, and an internal
experience such as emotion, a thought, or idea.
The third challenge that may arise is that clients may be
attached to coping through dissociation, making them “reluc-
tant to give up dissociative behavior”(Wagner and Linehan
1998, p. 218). Wagner and Linehan suggested reassuring
clients that the objective is to gain greater control over disso-
ciation, not to abolish the behavior. Mindfulness can be of-
fered as an alternative that permits some of the comforts of
dissociation (e.g., reduced emotional reactivity) without the
costs of habitual dissociation (e.g., disconnection from others;
destructive behaviors). Thus, mindfulness is framed as an
alternative manner of coping with aversive or intense emo-
tions, thoughts, or experiences, and by observing and describ-
ing responses to each mindfulness practice, dissociative cli-
ents are able to access this alternative mode.
Finally, a fourth challenge is that dissociative clients have
often habitually engaged in behaviors that are in stark contrast
to mindfulness techniques, which may result in barriers to
developing a mindfulness practice (e.g., difficulty making time
for meditation, difficulty maintaining compassionate
metacognitions about one’s internal experience). When faced
with these challenges, it is important that the therapist focuses
on the notion of commitment, of setting the intention and
following through on it. Nonetheless, it is also important that
the therapist does not judge the client for not upholding expec-
tations, instead modeling curiosity and openness in exploring
the barriers. In this regard, the therapist must be active in
highlighting the dialectic of change and acceptance: It is ex-
tremely challenging to develop a mindfulness practice and you
should not berate yourself for being deterred by barriers; and at
the same time, if you want to live with less suffering, you will
need to make a commitment and set an intention to invest into
your mental health and well-being. In order to have the ability
to use mindfulness skills in times of great distress and crisis,
clients must practice regularly. Metaphors involving long-term
practice or care are useful, such as: You would never expect to
be an excellent pianist if you only practiced before a recital; it is
through dedication to long-term, consistent care, or practice that
you experience progress. At the same time, you can choose not
to practice piano every day, but still practice three times each
week, and you would see improvements. It is important that we
set standards that are realistic, make commitments to the things
that are important to us, and offer compassionate problem-
solving attitudes to any barriers that arise.
Conclusion
Based on the existing literature on mindfulness and on disso-
ciation, mindfulness skills appear to be a feasible and
potentially beneficial tool in the treatment of dissociation.
This paper provides the theoretical scaffolding that supports
such treatment and presents applications to intervention.
Cultivating mindfulness can address many of the skills deficits
that impair daily living in dissociative clients. Mindfulness
increases clients’ability to predict and control dissociation.
By developing greater awareness, clients can learn to notice
when they are dissociating, a critical foundation for treating
dissociation. Mindfulness provides clients with techniques
that are useful for counteracting dissociation by increasing
awareness of dissociation, intentionally harnessing attention,
and providing tools for staying present. In addition, the
metacognitive approach to experience contributes to im-
proved emotion regulation and reduced emotional reactivity.
Finally, the emergent processes, such as reperceiving and
dialectical thinking, encourage cognitive flexibility. Taken
together, these effects of mindfulness can reduce the need
for reliance on avoidance processes, and dissociative symp-
toms may subside in the context of greater capacity to tolerate
aversive experiences. Mindfulness and dissociation share the
use of an observer position, and building on this shared feature
capitalizes on current dissociative coping strategies, while also
offering a markedly distinct coping strategy that is volitional
and both maintains and enhances connectedness. Although
some challenges may arise in applying mindfulness to disso-
ciation, psychoeducation and skillful intervention are likely to
address the challenges successfully. Mindfulness can provide
a liberating and empowering alternative mode of coping for
dissociative clients.
Acknowledgments The authors wish to express our appreciation to
“Madison,”the client who inspired this work; her excitement and enthu-
siasm over mindfulness fed our curiosity to gain a deeper understanding
of the relationship between mindfulness and dissociation. We would also
like to thank Frank Putnam for his consultation regarding that case; his
input was invaluable in discussing the case assessment, treatment plan,
and the model that was used. The authors also appreciate the insightful
recommendations made by M. Zachary Rosenthal, Clive Robins, Lisa
Smith Kilpela, and Andréa Hobkirk. We appreciate the helpful sugges-
tions made by the editor and reviewers.
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