What it means to be a dissociation friendly provider
I’ve been reflecting a lot on the moniker of “trauma-informed” and wanting be really specific about what that means and how it shows up in my work. As a pelvic health provider, there are so many reasons why a client might be experiencing some level of dissociation in our work together. Whether that be related to gender dysphoria, sexual trauma, or religious upbringing, many folks come to see me who are disconnected from their pelvis.
Tune into your hands and try to feel them. You might find that there’s a vast array of sensation that emerges. That’s because the brain's sensory map for your hands is quite large (and seems to be larger for folks like violinists #yayneuroplasticity). The sensory map of your pelvic floor is verrrry small. For many folks, trying to tune into this small muscle group can feel hazy, fuzzy, less specific. Add in a history of trauma and chronic pain, and this map in your brain becomes even more smudged.
So what does it mean to be a dissociation-friendly provider? We know there’s a high correlation between sexual trauma and pelvic pain, yet most of the interventions taught in traditional pelvic rehab curriculums assume that it’s safe for the client to connect with their body, as well as receive manual therapy. Although I’ve always seen consent for internal work highly emphasized in these teaching environments, I’ve found throughout my clinical experience that consent needs to be a much more present part of a client’s whole rehab experience. So what does that look like?
Identifying if someone is experiencing dissociative symptoms
Most folks don’t use clinical words to describe their experiences. I have many clients that tell me about their dissociation using that word specifically, and I have other clients who use other words, like feeling numb or disconnected. I try not to ascribe the word “dissociation” to a person’s experience, but rather provide some education on dissociation as a common trauma response and see if that resonates with them.
Many times when working with someone, I start to get curious if they’re moving towards dissociation if they start to get suddenly very sleepy, if they close their eyes, or if they start talking a lot and intellectualizing their experience. These aren’t necessarily indicators that someone’s dissociating, (i.e. someone might close their eyes because they’re trying to focus or relax) but something to track throughout a session.
Use education as validation
Many people experience shame around their dissociation, so I like to provide nervous system education as a form of validating their experience. One of the first things I usually say is that dissociation is an ADAPTIVE COPING RESPONSE, so we can’t change it by shaming ourselves out of it or by forcing ourselves into a more embodied state. We have to work with it collaboratively.
Provide Options
Breathwork, restorative exercise, and manual therapy can all contribute to dissociation. So if someone is experiencing dissociation, I like to give 2-3 options for alternative interventions. It helps to be really concrete, without overburdening the person with too many choices to consider. At this point, instead of focusing on interoceptive or felt sense-based ideas, I offer things related to nervous system settling that relate either to visually orienting to the environment, connecting the body to another object (tactile-based exteroception), sensing into gravity, or sensing into the distal extremities (especially feet).
Be mindful of facilitator vs fix it mentality
I think working with dissociation as a pelvic health provider is a great opportunity to challenge our “helper” identities as clinicians. If you start to have thoughts like “this person is going to think this session is pointless” or “are these interventions even relevant to this person’s goals” (even if you know in your evidence-based and client-centered heart that they are), then it’s possible you need to challenge some of your beliefs around how you think you’re supposed to perform as a clinician. I think for rehab clinicians, because our work tends to be more concrete than say psychotherapy, we can place ourselves in boxes in terms of how our work should look. I think this limits creativity, takes energy and agency away from you as a clinician, and saps confidence. Ask yourself: Am I trying to “fix” this person’s experience, or am I trying to collaborate with them to make their experience more easeful? Notice how each of those approaches live in your body.
Embrace divergent treatment plans rather than linear approaches
This is connected to the above point, but I think it’s really important to let go of how we think a session is “supposed” to look. We tell our clients that healing is not linear all the time, but how can we grant ourselves the permission to “go off course” a bit, for the sake of establishing trust between you and the client, and between the client and themselves? Rather than always prioritizing moving towards the person’s goals at all cost, what if we allowed ourselves the flexibility to prioritize that person’s moment-to-moment needs, knowing that they’re always changing? This helps establish consent between client and clinician as a more active process, rather than only using it as a tool when connected to internal work.
Dissociation is common, normal, and part of our bodies’ natural wisdom. If you feel confused and nervous about acknowledging when dissociation is happening in your clinic, then I highly suggest connecting to folks with more training or expertise around this topic.
