Mindfulness (2015) 6:303–314

DOI 10.1007/s12671-013-0261-3

ORIGINAL PAPER

Staying Present: Incorporating Mindfulness

into Therapy for Dissociation
Noga Zerubavel & Terri L. Messman-Moore

Published online: 21 November 2013

# Springer Science+Business Media New York 2013

Abstract Dissociation involves retreating from the experi- explored. Information and recommendations are provided to
ence of the present moment through various processes, while guide applications to intervention.
mindfulness cultivates the ability to stay in the present mo-
ment. We argue that mindfulness is thus uniquely well suited Keywords Mindfulness . Acceptance . Dissociation .
for treatment of dissociation. This paper delineates the theo- Dialectical behavior therapy . Emotion dysregulation
retical relationship between mindfulness and dissociation,
discussing how incorporating mindfulness into psychotherapy
can improve outcomes for dissociative clients. Mindfulness Introduction
can provide clients with specific techniques for enhancing
prediction of and control over dissociation through building Psychologists have conceptualized dissociation as developing
awareness of dissociative processes and offering a tool for in order to avoid unacceptable, overwhelming emotions and
staying in the present moment. Mindfulness reduces reliance knowledge that threaten the psychological and/or physical
on avoidance, which in turn diminishes the need for dissoci- survival of the person (Herman 1992; Kluft 1999; Putnam
ation. In addition, taking the position of the observer, which is 1989; Steinberg 1995). This process, which develops as an
a key feature of mindfulness, is itself a capability associated adaptive mechanism for protecting the individual from threats
with dissociation. We discuss the application of mindfulness to psychological and/or physical safety, may become habitual
to three types of dissociative processes: detachment (e.g., or chronic. Dissociation is linked to various problematic out-
depersonalization, derealization), absorption (e.g., comes, including impairment in school, work, or interpersonal
daydreaming, “blanking out”), and compartmentalization relationships, self-injurious behavior, and risk of victimization
(e.g., amnesia, conversion symptoms). Three mechanisms (Herman 1992; Putnam 1989). Mindfulness may enable the
underlying the effectiveness of integrating mindfulness into development of volitional processes that can afford some of
treatment of dissociation are proposed: (1) the techniques of the psychological safety of dissociation, providing an alterna-
mindfulness (e.g., observing, staying present), (2) the tive to the involuntary nature of dissociation. Given that
metacognitions of mindfulness (e.g., acceptance, non- dissociation’s maladaptive consequences are related to the
judgment), and (3) the emergent processes of mindfulness inability to stay present, mindfulness—a practice focused on
(e.g., reperceiving, dialectical thinking). Challenges to imple- experiencing the present moment—offers a uniquely well-
mentation of mindfulness with dissociative clients are also suited intervention.
Mindfulness, a practice rooted in Buddhist principles, has
been increasingly recognized as an effective treatment for a
N. Zerubavel (*)
variety of mental health issues (Brown, Ryan and Creswell
Department of Psychiatry and Behavioral Sciences,
Duke University Medical Center, Box 3026, Durham, 2007; Chambers, Gullone, and Allen 2009; Keng, Smoski,
NC 27710, USA and Robins 2011; Roemer and Orsillo 2009). Dissociative
e-mail: [email protected] clients present with an array of mental health problems, such
N. Zerubavel : T. L. Messman-Moore
as anxiety, panic and agoraphobia, obsessive–compulsive dis-
Department of Psychology, Miami University, Oxford, order (OCD), posttraumatic stress disorder (PTSD), depres-
OH 45056, USA sion, bipolar disorder, eating disorders, substance abuse,
304 Mindfulness (2015) 6:303–314

borderline personality disorder (BPD), and emotion dysregu- mindfulness builds clients’ capacity for tolerating and reduc-
lation (Holmes et al. 2005; Putnam 1989), which can be ing avoidance of unwanted or uncomfortable emotions or
treated effectively with interventions that focus on mindful- experiences, therapy that incorporates mindfulness may re-
ness. Mindfulness-based interventions, including duce the necessity for dissociation (Baslet and Hill 2011;
Mindfulness-Based Stress Reduction (Kabat-Zinn 1990), Neziroglu and Donnelly 2013). In addition, dissociative de-
Mindfulness-Based Cognitive Therapy (MBCT; Segal, tachment and mindfulness both involve the capacity to take
Williams, and Teasdale 2002), Dialectical Behavior Therapy the observer position. This shared feature may be leveraged
(DBT; Linehan 1993a), and Acceptance and Commitment therapeutically, making mindfulness techniques accessible
Therapy (ACT; Hayes, Strosahl, and Wilson 1999), have and appealing to clients who habitually dissociate. In contrast
demonstrated some effectiveness in improving coping with to dissociation, mindfulness can provide volitional access to
chronic pain (Chiesa and Serretti 2011b); reducing symptoms the reduced emotional reactivity of the observing ego’s
of depression (Brown et al. 2007; Chiesa and Serretti 2011a; perspective.
Keng et al. 2011) and major depressive episode relapses In this paper, we delineate a theoretical framework
(Chiesa and Serretti 2011a; Keng et al. 2011); anxiety includ- outlining the reasons that integrating mindfulness may be
ing panic and agoraphobia, OCD, and PTSD (Keng et al. uniquely relevant to and useful for the treatment for dissoci-
2011; Roemer and Orsillo 2009); and BPD, including inpa- ation and provide information to guide clinical applications.
tient hospitalization, self-injurious behavior, and suicidal ide- The dearth of research on using mindfulness to treat dissoci-
ation (Keng et al. 2011; Rizvi, Steffel, and Carson-Wong ation engenders the need for theory to drive research and
2013). Mindfulness assists in the development of the ability clinical work. When research is not yet available, clinicians
to regulate emotions (Arch and Craske 2006; Coffey, treating complex trauma-related problems (e.g., dissociation)
Hartman, and Fredrickson 2010; Farb et al. 2010), tolerate can utilize theory to guide treatment development (Wagner,
distress (Coffey et al. 2010), and handle interpersonal situa- Rizvi, and Harned 2007). Experts in mindfulness and trauma-
tions effectively (Block-Lerner, Adair, Plumb, Rhatigan, and related disorders have recommended incorporating mindful-
Orsillo 2007; Wachs and Cordova 2007), improving mental ness into specialized pathology-focused or trauma-focused
health in cognitive, affective, and behavioral spheres (Brown approaches (Cloitre et al. 2011; Follette and Vijay 2009). We
et al. 2007; Roemer and Orsillo 2009). will highlight how to practice these techniques, maintain
There is also some empirical support for interventions that awareness of the developing mindful metacognitions, and
incorporate mindfulness into treatment for trauma and PTSD emphasize the cultivation of emergent processes in the context
(Follette, Palm, and Pearson 2006; Follette and Vijay 2009; of working with severely dissociative clients.
Lee, Zaharlick, and Akers 2009; Walser and Westrup 2007). We will first describe dissociation and three specific disso-
When specifically targeting dissociation, trauma experts re- ciative processes: detachment, absorption, and compartmen-
ported using mindfulness as a top complement to their first- talization. In the next section, we define mindfulness and
line interventions; top first-line interventions for dissociation describe its components: techniques, metacognitions, and the
were education about trauma and emotion regulation inter- emergent processes produced through its practice. We then
ventions (Cloitre et al. 2011). Although the authors of the review the nascent literature that has explored the relationship
study did not elaborate the specific frameworks of the emotion between mindfulness and dissociation. Finally, we provide
regulation interventions, these interventions are often cogni- information about implementing mindfulness in the treatment
tive–behavioral (Hayes et al. 1999; Linehan 1993a, b), expe- of each dissociative process, identifying practical applications
riential (Greenberg 2002), psychodynamic (Fosha 2000), or of specific elements of mindfulness that are effective for each
integrative (Mennin 2006). In fact, it is also noteworthy that dissociative process (see Table 1).
mindfulness is itself a well-respected emotion regulation in-
tervention (Chambers et al. 2009; Hayes and Feldman 2004;
Linehan 1993a, b). Dissociation and Dissociative Processes
Although mindfulness has been integrated into trauma-
focused treatments, particularly treatment for PTSD, its utility Dissociation involves the capacity to use disconnection to
in addressing severe dissociation has only begun to be exam- achieve psychological safety (Gold and Seibel 2009).
ined from a theoretical perspective. Developing awareness of Dissociative symptoms are included in diagnostic criteria for
dissociation and learning to return to the present experience is acute stress disorder, PTSD, BPD, panic attacks, and disso-
an essential aspect of treatment for dissociation (Foa and ciative disorders (American Psychiatric Association 2013).
Meadows 1998), and mindfulness can facilitate both increased They can also occur in the context of mental health problems
awareness (i.e., developing the ability to predict and notice including agoraphobia, OCD, depression, bipolar disorder,
dissociation) and the ability to return to the present (i.e., and eating disorders (Holmes et al. 2005; Putnam 1989;
facilitating the ability to control dissociation). Because Simeon 2009; Steinberg 1995). Dissociation takes multiple
Mindfulness (2015) 6:303–314 305

Table 1 Framework for integrating mindfulness into treatment for Simeon 2009). Clients describe detachment as feeling as if
dissociation
they are in a dream, as if they or things around them are unreal,
Type of dissociation Examples Applications of or as if they are watching themselves from above (Putnam
mindfulness
1989; Steinberg 1995). Watching oneself from above or out-
Detachment: separation Depersonalization Mindfulness techniques side the body involves taking a dissociated observer position.
or estrangement Derealization Staying present Absorption refers to experiences of being disconnected
from self, body, (participating in
and/or surrounding present moment) from present moment experience while deeply immersed in
world
Mindful metacognitions other stimuli (Allen, Console, and Lewis 1999). The field of
Openness attention is narrowly focused and detached from present mo-
Willingness ment experience (Allen et al. 1999). When individuals expe-
Nonstriving
rience absorption, they describe daydreaming, being im-
Nonjudgment
Acceptance
mersed in thought or fantasy, or in nothingness (i.e., “spacing
Emergent processes out”). Although some researchers have described absorption
Reperceiving as normal or nonpathological dissociation (Dell 2009; Waller
Connectedness et al. 1996), others have argued that there is clinical signifi-
Absorption: total Daydreaming Mindfulness techniques cance when frequency or duration is extreme (Braude 2009)
immersion of Spacing out Intentionally harnessing or when the context makes it problematic (e.g., when one is in
attention on a Distorted perception attention
stimulus or on of time danger). Although minimal levels of absorption may be
nothingness Observing/noticing
nonpathological, more chronic and severe presentations may
Describing
Staying present (present become a foundation for detachment processes (e.g., deper-
moment awareness sonalization; Dell 2009) and may disrupt encoding of memory
and participating in
present moment) (Allen et al. 1999). As such, we believe it is important to
Mindful metacognitions address absorption in therapy.
Openness Compartmentalization refers to conditions “characterized
Willingness by an inability to bring normally accessible information into
Compartmentalization: Separate personality Mindful metacognitions conscious awareness (e.g., dissociative amnesia)” (Holmes
self-fragmentation states Openness et al. 2005, p. 7). When individuals experience compartmen-
and/or somatoform Amnesic barriers
manifestations of Conversion symptoms Willingness talization, they report conversion symptoms (neurological
distress Compassion symptoms that are unexplained by organic disease and are
Nonstriving
Nonjudgment
best explained through psychological causes), amnesia
Acceptance (significant memory gaps), and amnesic barriers between
Emergent processes personality states (inability to remember events that occurred
Reperceiving while in another personality state; Holmes et al. 2005; Putnam
Connectedness 1989; Steele et al. 2009; Steinberg 1995).
Inherent wisdom/values Although detachment, absorption, and compartmentaliza-
clarification
Dialectical thinking 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
forms and varies in its degree of pervasiveness, frequency, and from the present moment (absorption), others (derealization
severity (Braude 2009). Depending on these qualities, disso- detachment), or the self (depersonalization detachment, com-
ciation may differ in whether it is pathological or problematic. partmentalization). Hayes et al. described dissociation as be-
Dissociative phenomena are most often construed as three longing to a class of behaviors that function to enable experi-
distinct processes: detachment, absorption, and compartmen- ential avoidance, maladaptive efforts to escape and avoid
talization (Holmes et al. 2005; Steele, Dorahy, van der Hart, emotions, thoughts, memories, and other private experiences
and Nijenhuis 2009; Waller, Putnam, and Carlson 1996), (Hayes, Wilson, Gifford, Follette, and Strosahl 1996). The
although other conceptualizations exist as well (Dell 2009). ACT model (Hayes et al. 1999) proposes that mindfulness,
Detachment refers to an “altered state of consciousness within an acceptance-based framework, provides effective
characterized by a sense of separation (or ‘detachment’) from treatment for experiential avoidance; experts in dissociation
certain aspects of everyday experience” such as the body, the have begun to apply ACT to dissociation (see Baslet and Hill
self, or the surrounding world (Holmes et al. 2005, p. 5). 2011; Neziroglu and Donnelly 2013). Given that mindfulness
Detachment encompasses experiences of depersonalization teaches skills for staying present and cultivating a sense of
(separation of experiencing ego and observing ego) and dere- connection to self and others, it makes a particularly fitting
alization (sense of unreality, distortions of time or space; intervention for treating dissociation.
306 Mindfulness (2015) 6:303–314

Mindfulness “achieving” is replaced by “moving toward,” including the

awareness that at different times, one is more or less capable of
Mindfulness has been defined as “the process of intentionally using the techniques of mindfulness.
attending moment by moment with openness and
nonjudgmentalness” (Shapiro, Carlson, Astin, and Freedman The Metacognitions of Mindfulness A critical aspect that
2006, p. 378). It is practiced and applied through both formal characterizes mindfulness is the metacognitive approach to
(i.e., meditation) and informal practices (e.g., walking or experience, which is non-discriminative (not evaluating or
eating mindfully). Mindfulness encompasses both techniques appraising) and non-conceptual (not applying conceptual
(e.g., intentionally harnessing attention, holding present mo- filters or schemas; Brown et al. 2007). This involves clients
ment awareness) and metacognitions (thoughts about emo- having a mindset of openness and finding curiosity about
tional and cognitive experience that avoid evaluating, apprais- experiences, even those that are uncomfortable or unwanted.
ing, or rejecting experience; Brown et al. 2007; Kabat-Zinn Clients adopt a mindset of nonjudgment, noticing, and letting
1990). DBT (Linehan 1993a), a well-recognized mindfulness- go of evaluations that appraise thoughts, feelings, sensations,
based therapy, similarly divides mindfulness skills into “what” or events as “good” or “bad.” Instead of habitual judgments,
skills (viz., techniques) and “how” skills (viz., compassion is applied to the self and others (Germer 2009),
metacognitions). These processes encourage clients to be- cultivating a gentle, forgiving approach that can be therapeutic
come curious about internal experience and entertain the for painful emotions (e.g., anger) that many dissociative cli-
possibility of relating to thoughts and feelings in a new man- ents experience toward themselves and/or others. Mindfulness
ner. In addition, the integration of mindfulness techniques and is not positive thinking or cognitive reframing (Kabat-Zinn
metacognitions produces emergent processes (mechanisms 1990; Linehan 1993a); rather, it is the willingness to stay
that are created indirectly through the practice, rather than present in a nonstriving manner (i.e., a particular outcome is
directly practiced). We will explain each of these elements not sought). Mindful metacognitions are characterized by
of mindfulness in more detail in the following sections. There acceptance, which involves understanding that things are as
are many theories of mindfulness, unique in certain ways and they are (Robins 2002) rather than as one might wish they
similar in others; we draw on the contributions of a range of were. It is helpful to distinguish acceptance from resignation,
theorists (e.g., Baer, Smith and Allen 2004; Bishop et al. 2004; as it is not based in passivity or helplessness, but rather in a
Brown et al. 2007; Hanh 1976; Kabat-Zinn 1990; Linehan willingness to accept life situations in their current form,
1993a; Segal et al. 2002; Shapiro et al. 2006). which may then be used to promote change (Segal et al. 2002).
Introducing mindful metacognitions as an element of psy-
The Techniques of Mindfulness The techniques of mindful- chotherapy is based on the Buddhist philosophy that pain
ness include intentional harnessing of attention, staying pres- alone is just pain, but when one responds with nonacceptance
ent, observing, and describing. The intentional harnessing of and self-judgment, pain then develops into suffering (Linehan
attention is a concentration skill in which clients purposefully 1993a; Robins 2002). As it is often the reactions to feelings
shift attention; mindfulness skills improve clients’ ability to rather than the feelings themselves that are most
redirect attention volitionally (Corrigan 2002; Loizzo 2009; distressing, having a mindful metacognitive approach pro-
Zylowska et al. 2008). Staying present occurs both through motes the ability to deal with difficult or unwanted internal
holding present moment awareness (attentional focus on in- experiences without becoming overwhelmed (Brown et al.
ternal and/or external experience of the present moment) and 2007; Linehan 1993a; Roemer and Orsillo 2009). By culti-
through participating in the present moment (engagement in vating this metacognitive approach, mindfulness facilitates
experience). Observing and describing are impartial in nature. change in patterns of emotional reactivity and avoidance
Brown et al. (2007) stated: “Because mindfulness permits an and eases the return to baseline following experiences of
immediacy of direct contact with events as they occur, without intense affect (Roemer and Orsillo 2009).
the overlay of discriminative, categorical, and habitual
thought, consciousness takes on a clarity and freshness that Emergent Processes Through regular practice of pairing the
permits more flexible, more objectively informed psycholog- techniques of mindfulness with mindful metacognitions,
ical and behavioral responses” (p. 212). This concept is meta-mechanisms emerge (Shapiro et al. 2006). These internal
discussed in ACT (Hayes et al. 1999) using the term cognitive shifts are referred to here as emergent processes because they
defusion to describe separation between self and thoughts or emerge from the interaction of other phenomena. Robins
the assumption that thoughts are true. Similarly, in MBCT (2002) described emergent processes as having “properties
(Segal et al. 2002), it is highlighted that thoughts are simply that arise from the integration of diverse elements, constantly
passing mental events, but we often treat them as though they changing as they affect other things and are affected in turn by
are reality. It is important to note that the techniques of them” (p. 53; see also Kumar 2002). As such, these processes
mindfulness are practiced rather than attained; the notion of are not taught directly, but rather arise experientially through
Mindfulness (2015) 6:303–314 307

practice of the components that are taught directly (i.e., the objects or individuals are defined not only by their own
techniques and metacognitions of mindfulness). Building on elements, but also by their relationship to other elements,
the notion introduced by Shapiro et al. (2006) of reperceiving objects, or other individuals. In such a holistic perspective,
as a meta-mechanism, we propose four emergent processes: an individual is not only defined as a “self,” but also a person
reperceiving, inherent wisdom, connectedness, and dialectical in existence in relation to others (Robins 2002), thus perme-
thinking. ated by the experience of connectedness. In addition, connect-
The first process that emerges is reperceiving, which is the edness to oneself may be related to a sense of internal whole-
de-coupling of the process of consciousness from the content ness that is theorized to become available when the struggle to
of mental subject matter (Keng et al. 2011; Shapiro et al. eliminate emptiness is suspended (Epstein 1998).
2006). For example, when reflecting on a conversation, one The final emergent process, dialectical thinking, is charac-
switches from thinking about what was said (content) to terized by “the reconciliation of opposites in a continual
noticing that one is thinking about the conversation and ob- process of synthesis” (Linehan 1993a, p. 19). Rather than
serving how one is thinking about it (process). Although there engaging in dichotomous thinking that ascribes to polarities,
are unique aspects of each, this fundamental shift in perspec- dialectical thinking encourages the ability to view both sides
tive has also been called decentering (Bishop et al. 2004; simultaneously. Through dialectical thinking, elements that
Brown et al. 2007; Segal et al. 2002), metacognitive insight appear to be mutually exclusive can be synthesized for more
(Segal et al. 2002), or cognitive defusion (Hayes et al. 1999). complete understanding that transcends the limits of the po-
Reperceiving is a transformation that allows subject to be larized perspectives. For example, there is a dialectic between
converted into object (Shapiro et al. 2006) and may bring change and acceptance. On one extreme, one may feel com-
forth insights such as the impermanence of emotions. By pelled to change and modify the experiences and situations
switching to the observation of mental activities, one becomes that are problematic. On the other extreme, one may feel
less identified with the content of the mental activity. For helpless to change circumstances and identify the important
instance, one can observe that a thought is simply a string of task as acceptance of this reality. Although these perspectives
words. are often represented as polarities, through dialectical synthe-
The second process that emerges is becoming connected to sis, we can integrate the two in the notion that we may work to
a sense of inherent wisdom. Inherent wisdom is the sense that change the aspects of our lives that we are able to change,
an answer emerges, or unfolds, in a manner that is intuitive while at the same time, we must accept the aspects of our lives
and value-driven (Segal et al. 2002). In DBT, this is referred to that we are unable to change. The concept of dialectical
as “wise mind” and is described as adding intuitive knowledge thinking is related to the focus in ACT on development of
to a balance of rational and emotional input (Linehan 1993a). psychological flexibility (Hayes et al. 1999), the ability to
When a decision suddenly emerges with clarity from within, respond in a flexible rather than rule-based manner to stimuli
this is an instance of inherent wisdom. Through developing and events. Below, in the section on “Applications to
awareness of inherent wisdom, mindfulness cultivates insight Intervention,” we will provide examples of using emergent
and value clarification (Brown et al. 2007; Shapiro et al. processes in the treatment of dissociation.
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 Mindfulness and Dissociation
(Shapiro et al. 2006). Individuals who report greater mindful-
ness skills also behave in a manner that is more compatible There is a relative paucity of literature regarding the use of
with their values and interests (Brown and Ryan 2003). mindfulness in treatment for dissociation (Neziroglu and
Inherent wisdom or wise mind may contribute to developing Donnelly 2013; Wagner et al. 2007). Three studies have
a stronger sense of internal self-awareness and authenticity provided initial empirical support for using mindfulness-
that may be extremely meaningful for chronically dissociative based intervention to treat dissociation. The first was a DBT
clients. treatment study that demonstrated a reduction in dissociative
The third process that emerges through the practice of symptoms following DBT treatment (Koons et al. 2001). The
mindfulness is a sense of connectedness. In the mindfulness second study examined the use of mindfulness in the context
literature, this has often been discussed as interconnectedness of a sensorimotor psychotherapy group for women with a
among all things (Kabat-Zinn 1990; Linehan 1993a), which history of childhood trauma, reporting significant reductions
may manifest through a connection to nature, to other indi- in dissociative symptoms (Langmuir, Kirsh, and Classen
viduals, to groups, or to the universe more broadly. 2012). The third was a case study in which Baslet and Hill
Connectedness through mindfulness is also discussed as in- (2011) suggested the use of ACT to treat conversion and
terdependence (Hanh 1976), providing a view in which all dissociative disorders, focusing on reducing experiential
308 Mindfulness (2015) 6:303–314

avoidance through development of greater willingness to ex- Our conceptualization of the relationship between mind-
perience aversive internal and external experiences. In addi- fulness and dissociation is consistent with a second perspec-
tion, we believe mindfulness is likely to be successful as part tive, in which dissociation is characterized by an absence of
of treatment for dissociative clients because it enables the mindful awareness (see also Baer, Smith, Hopkins,
development of volitional processes that afford psychological Krietemeyer, and Toney 2006; Wagner and Linehan 1998).
safety, in contrast to the involuntary, passive, and reflexive Importantly, in this conceptualization, dissociation involves
nature of dissociation (Allen et al. 1999). It also provides skills more than lack of mindfulness, and mindfulness involves
that increase awareness of dissociation. These are meaningful more than not dissociating. They are not opposites, given that
effects, given that clinical impairment from dissociation is other psychological processes may also involve an absence of
often related to it being experienced as being involuntary mindfulness (e.g., thought suppression; Baer et al. 2006). In
and outside of consciousness (Dell 2009; Kennerley 1996; contrast to the continuum perspective, we do not view mind-
Putnam 1989). fulness as a more controlled, conscious form of dissociation
One of the most common uses of mindfulness practices in (cf. Corrigan 2002); instead, we conceptualize mindfulness
the dissociation literature is for grounding. The trauma litera- and dissociation as fundamentally distinct psychological pro-
ture has long recommended using grounding (e.g., attention to cesses (Williams 2010), linked by specific contrasting dimen-
sensory input, an image or object) as a stabilization tool and a sions including awareness/lack of awareness, staying present/
fundamental strategy for preventing or interrupting dissocia- detachment, and connectedness/fragmentation. In addition,
tion (Boon, Steele, and van der Hart 2011; Gold and Seibel mindfulness and dissociation both involve a shared feature:
2009; Kennerley 1996; Najavits 2002). In fact, grounding the observer position. Indeed, research examining the relation-
exercises have sometimes been labeled “mindfulness prac- ship between mindfulness and absorption demonstrates that
tices.” However, we would argue that although mindfulness they are distinct processes, perhaps linked through the ability
techniques include grounding exercises, mindfulness is more to take the observer position (Baer et al. 2004).
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, Applications to Intervention
the process aspect (i.e., metacognitions) is equally important:
pairing techniques with a nonjudgmental, accepting, and com- The framework developed here can be implemented by incor-
passionate approach to experience. For instance, a mindful- porating mindfulness into existing therapeutic models or by
ness practice of describing the environment and incorporating using mindfulness-based treatments (e.g., DBT, ACT). If the
sensory information has a grounding effect on the individual. therapist is using a mindfulness-based intervention, we rec-
Significantly, a mindful metacognitive approach would also ommend adding one or two sessions that focus directly on
emphasize being non-evaluative, accepting, and compassion- using mindfulness to address dissociation, including discus-
ate, thus encouraging the client to leave out judgments that sions of how mindfulness increases awareness of dissociation,
may otherwise sabotage a grounding exercise without mindful provides ways to intervene to interrupt dissociation, and may
metacognitions. Grounding (and similarly, relaxation exer- present an alternative to dissociation. If the therapist is using a
cises) may include a goal of achieving a state of relaxation therapeutic approach that does not involve mindfulness, we
(Gold and Seibel 2009); in contrast, mindfulness practice is recommend dedicating two or three sessions entirely to pro-
specifically nonstriving, and the internal state is observed as it viding psychoeducation about mindfulness and conducting in-
is (Hanh 1976). session mindfulness practices, with one of these sessions
Although the relationship between mindfulness and disso- focusing specifically on using mindfulness to address disso-
ciation has not yet been elaborated fully, two conceptualiza- ciation. After this foundation is laid, the therapist can set aside
tions emerge in the extant literature. One model conceptual- a portion of each session to focus on building mindfulness
izes these processes as lying at opposite poles of a continuum skills. It is particularly helpful if these mindfulness practices
of awareness (i.e., mindfulness as high level of awareness; can be conducted when the client is experiencing in-session
dissociation as lack of awareness). According to Walach et al. dissociation. Whether in short-term or long-term psycho-
(2006), “dissociation seems to be the opposite of mindfulness, therapy, dissociative clients are likely to benefit from
containing symptoms of amnesia, automaticity without con- introducing mindfulness early on, as the techniques can
scious control and the dissociation of cognitive and emotional function as grounding exercises that may help the client to
elements” (p. 1546). Similarly, Corrigan (2002) described the remain present.
processes as being at opposite ends of a neurobiological In this section, we review the theoretical and practical
continuum, calling mindfulness “willed and controlled disso- relevance of mindfulness to the treatment of each dissociative
ciation, applied for a particular purpose, such as emotion process, including specific examples of the implementation of
regulation or distress tolerance” (p. 9). mindfulness in treatment of these key aspects of dissociation.
Mindfulness (2015) 6:303–314 309

Table 1 provides an overview of the particular elements of intervention for detachment processes, and mindfulness,
mindfulness (specific techniques, metacognitions, and emer- which includes both present moment awareness (i.e., atten-
gent processes) that are relevant to each dissociative process. tional focus) and participating in the present moment (i.e.,
When providing psychotherapy to dissociative clients, best engagement), cultivates this ability. One takes an impartial
practice guidelines rooted in treatment models for complex observer perspective (Brown et al. 2007) while still maintain-
trauma and dissociative disorders instruct clinicians to use a ing engagement and participation in the present moment
phase-based, sequential treatment process that begins with a (Linehan 1993a). In contrast, dissociative detachment in-
focus on safety, stabilization, and symptom reduction (Cloitre cludes present moment awareness without the sense of partic-
et al. 2011; ISSTD 2011). This reflects the heuristic of first ipating in the present moment. In addition, the emergent
reducing symptom severity in the interest of stability and process of connectedness is critical to the sense that one is a
building the client’s capacity for trauma-focused work by part of what is happening. In-session mindfulness exercises
developing emotion regulation and distress tolerance skills can devote special attention to developing connectedness by
(Cloitre et al. 2011; Linehan 1993a). Mindfulness can be a cultivating compassion and openness toward the object of
primary tool for stabilization and continued symptom observation (e.g., a thought, emotion, or image) and all that
reduction. is noticed about it.
Clients who use detachment to avoid emotionally difficult
Using Mindfulness to Reduce Detachment experiences will benefit from using mindfulness to decrease
avoidance. The mindful metacognitive approach to experience
In both mindfulness (Brown et al. 2007; Kabat-Zinn 1990) is essential, because having a nonjudgmental, accepting,
and dissociative detachment (Allen et al. 1999; Simeon 2009), nonstriving attitude is critical to decreasing avoidance.
the individual’s consciousness takes the position of an observ- Reperceiving may also diminish the need for avoidance, given
er. This is a key experiential feature shared by mindfulness its ability to reduce emotional reactivity. For instance, if a
and dissociation, yet it has been largely overlooked that for client is observing anger, the focus is on noticing the experi-
dissociative clients, this may make mindfulness a particularly ence of anger (i.e., process) rather than examining who is to
accessible alternative to dissociation. We propose that mind- blame (i.e., content). Another use of mindfulness exercises in
fulness allows dissociative clients to capitalize on the famil- session can be to regulate emotions, particularly to ensure that
iarity and safety of the observer position, a perspective that dissociative clients leave sessions in a stabilized state
facilitates reduced emotional reactivity. Leveraging a familiar (Kluft 1999). Approaching the end of a particularly distressing
coping strategy may enhance the ability of dissociative clients session, the therapist can guide the client through a brief
to engage in mindfulness practice. Dissociative clients who mindfulness practice. This can serve to end the session with
are emotionally attached to dissociation may find it reassuring stabilization, thus affirming that intense emotions can be
to discuss how mindfulness capitalizes on current coping safely experienced and contained.
strategies by preserving the safety and comfort of the observer
position, while providing a new manner of accessing this Distinguishing Between Mindful and Dissociated Observer
position. Positions In dissociative detachment processes, there is a
When clients tolerate difficult internal experiences from an separation between the experiencing self and the observing
observer position, without extreme emotional reactivity or self, while in mindfulness, one might say that the experiencing
self-berating, mindfulness can function as an exposure exer- self takes the observer position. For the dissociated watcher,
cise. That is, when clients withstand distressing emotions in consciousness is external and disconnected (e.g., like
the context of mindfulness practice, benefits of exposure are watching a movie; Steele et al. 2009), while for the mindful
gained (Linehan 1993a; Keng et al. 2011; Shapiro et al. 2006). watcher, consciousness is internal and connected (e.g., en-
By enduring aversive internal experiences, the client develops hanced awareness; Shapiro et al. 2006). Therapists can high-
a sense of mastery and feels more empowered and less vul- light how to differentiate, as in Linehan’s (1993b) DBT skills
nerable. In addition, clients benefit by having access to the manual: “Remind participants to step back within themselves,
information that is available in emotional experiences that are not outside of themselves to observe. Observing is not disso-
not avoided. The ability to handle awareness and contact with ciating.” (p. 67).
aversive experiences (e.g., thoughts, feelings) is likely to For clients who struggle to differentiate mindful and dis-
reduce clients’ reliance on or need for dissociative processes sociative observer positions, assessing two aspects of their
(Baslet and Hill 2011). experience may serve as clarifying indicators: affect and in-
Therapists can describe detachment as an absence of con- tentionality. Assessing awareness of affective experience may
nectedness, either in terms of disconnectedness from the self be beneficial, given that in dissociative processes, affect is
(viz., depersonalization) or disconnectedness from others disconnected (e.g., feeling numb, “checked out”), while in
(viz., derealization). Staying present is a fundamental mindfulness, one is aware of and connected to emotions
310 Mindfulness (2015) 6:303–314

(Michal et al. 2007; Shapiro et al. 2006; Williams 2010). In awareness that dissociation is occurring, the client is presented
contrast to detachment, which is experienced as distancing with the opportunity to reclaim attentional resources. It is also
and alienating, mindfulness includes the vibrancy and vitality important that the client is not judgmental or self-critical when
of connectedness (Michal et al. 2007). Reperceiving may be noticing that attention has drifted. Instead, the therapist can
confused with distancing or disinterest, but it is different from stress that it is the nature of the mind to wander, and it is the
detachment because it “engenders a deep knowing and inti- task of mindfulness to notice this when it occurs, to harness
macy with whatever arises moment by moment” (Shapiro attention intentionally (Brown et al. 2007) and return non-
et al. 2006, p. 379). A dissociative state is either entirely judgmentally to the intended object of attention (e.g., breath, a
dissociated (e.g., amnesia) or reflected in dreamlike process- candle).
ing (e.g., derealization; Dell 2009), whereas a mindful state is Once the client has noticed that dissociation is occurring,
fully invested in reality-based processing, connected to sen- mindfulness is also central to helping clients to harness and
sory experience of the present moment (Hanh 1976; Kabat- direct attention intentionally. Clients can practice purposefully
Zinn 1990). Another distinguishing feature to assess is inten- shifting—like a zoom lens—between focused attention to
tionality. For many dissociative clients, the aspect of dissoci- detail and broad awareness of the larger context (Brown
ation that is most distressing is lack of control. Importantly, et al. 2007). By intentionally and consciously directing atten-
mindfulness provides the client with volitional access to the tion, holding present moment awareness, and observing with
reduced reactivity afforded by the observer position without neutrality (Kabat-Zinn 1990), a client is better able to con-
the cost of restricted awareness and disconnection. sciously direct mental processes that are often unconscious
Mindfulness promotes the “conscious regulation of uncon- (Loizzo 2009). If therapy can create a link between awareness
scious processes” (Loizzo 2009, p. 189) and is likely to enable of dissociation and intentional harnessing of attention on the
greater conscious regulation of detachment processes, poten- present moment, mindfulness can be used to counteract dis-
tially reducing the client’s sense of helplessness regarding sociation (Boon et al. 2011; Corrigan 2002; Kennerley 1996;
dissociative episodes. Najavits 2002). Clients may benefit from practice with ob-
serving and describing the objects of their attention
Using Mindfulness to Reduce Absorption (e.g., thoughts, emotions, sensations, images, objects in the
environment).
Absorption is characterized by total immersion of attention on Staying present is a fundamental aspect of intervention for
something (e.g., reading, daydreaming) or nothing (e.g., “go- absorption, both in terms of present moment awareness (i.e.,
ing blank” or spacing out) and is often associated with attentional focus) and participating in the present moment
distorted perception of time, self, or surroundings (i.e., engagement). It is facilitated through emotional, cogni-
(Dell 2009). Absorption can be disconcerting or problematic tive, and behavioral participation in present moment experi-
for clients because it is often experienced as passive and invol- ence with attentional control. Dissociative clients are likely to
untary (Allen et al. 1999), as something that just “happens” (e.g., appreciate and enjoy having greater voluntary control over
“automatisms”; Dell 2009). Thus, we emphasize intentionality attention and engagement in present moment experiences, as it
as a concept that distinguishes between mental processes of provides them with important skills that generate a sense of
mindfulness and dissociation: mindfulness by nature involves empowerment.
intentional attention, directed with receptiveness toward the
present moment. Mindfulness, when practiced regularly, culti- Using Mindfulness to Reduce Compartmentalization
vates concentrative abilities (Hanh 1976). Regular practice at
harnessing attention with intention improves attentional capac- Dissociative compartmentalization processes are character-
ities (for review, see Brown et al. 2007), even in individuals with ized by experiences of fragmentation, such as conversion
attention problems, such as attention deficit hyperactivity disor- symptoms and amnesic barriers between personality states
der (Zylowska et al. 2008). Beyond influences on executive (Allen et al. 1999; Holmes et al. 2005; Steele et al. 2009).
functioning, attention, and concentration, at a most basic level, Compartmentalization symptoms such as hearing voices (e.g.,
mindfulness improves individuals’ capacity to focus attention commenting on one’s actions; Steinberg 1995) may be im-
on the present moment (Hanh 1976)—a most fitting and appro- proved through mindfulness, given that populations with psy-
priate alternative to absorption, which essentially removes atten- chotic symptoms have been helped by taking a mindful
tion from present moment experience. In this way, mindfulness metacognitive stance about the hallucinations rather than
enables staying present. judging oneself for having them (Bach and Hayes 2002).
Noticing attentional drift is a primary task of treatment for Given the interactive nature of distress and psychotic symp-
absorption. Becoming aware of dissociation and learning to toms, decreasing distress is critical to improving psychotic
return to present experience is a central aspect of treatment for and psychotic-like dissociative symptoms. Moreover, com-
dissociation (Foa and Meadows 1998). Through developing partmentalization is often associated with unexplained
Mindfulness (2015) 6:303–314 311

somatic concerns (Putnam 1989). Such symptoms may im- order to contain unbearable, overwhelming internal and exter-
prove with mindfulness, given its success as a leading treat- nal stimuli. In addition to the emergent processes, mindful
ment for chronic pain by decreasing maladaptive metacognitions (e.g., acceptance, nonjudgment, nonstriving,
metacognitions (e.g., nonacceptance, self-judgment) about willingness, openness, and compassion) increase openness to
the pain (Brown et al. 2007; Kabat-Zinn 1990). experience. Without the need to suppress or repress aspects of
The emergent process of dialectical thinking is particularly one’s experience, compartmentalization is no longer
well suited to the treatment of compartmentalization because it necessary.
develops the ability to hold different perspectives simulta- In sum, mindfulness can provide therapeutic interventions
neously. Compartmentalization functions to separate feelings, for detachment, absorption, and compartmentalization pro-
thoughts, and/or knowledge to be outside of awareness or in cesses. To use these interventions effectively, it is important
restricted awareness. Increased ability to tolerate multiple to consider and prepare to address potential challenges and
perspectives simultaneously is apt to reduce the tendency concerns regarding implementation.
toward intrusion symptoms from separate personality states
(Baslet and Hill 2011) and may increase co-consciousness, the Mindfulness in the Context of Dissociation
ability for the perspectives of multiple personality states to be
present simultaneously. Therapists can also encourage dialec- There are some important cautionary notes with respect to
tical thinking to emerge through complementary therapeutic introducing and implementing formal mindfulness practice
techniques; DBT offers many useful techniques for increasing (i.e., mindfulness meditation) with dissociative clients. The
tolerance for the duality of dialectics (Linehan 1993a). concerns that we will address are distinct but related: clients
Although dissociative compartmentalization may function may confuse mindfulness with dissociation, they may disso-
more as multiplicity than duality, the techniques are none- ciate during meditation, they may be attached to dissociation
theless applicable. By thinking dialectically, clients in- and reluctant to relinquish dissociative behavior, and they may
crease their capacity to see multiple truths and to replace have difficulty implementing mindfulness (e.g., regular prac-
an either/or mindset with a both/and mindset. Thinking tice, modifying metacognitions).
dialectically promotes the ability to honor multiple perspec- The foremost concern is that clients may confuse mindful-
tives and is likely to support the development of internal ness meditation with dissociation (Linehan 1993b). For this
collaboration among compartmentalized parts of the self. A reason, we recommend that therapists prepare clients with
therapist must convey both sides of a dialectic effectively in psychoeducation regarding mindfulness and dissociation.
order to encourage dialectical thinking (Linehan 1993a): For instance, therapists can leverage the familiarity of the
being supportive, yet challenging; cautious, yet curious; shared observer position, in conjunction with information
consistent, yet flexible; and gentle, yet firm. Over time, discussed above on how clients can differentiate between
the therapist’s dialectical style provides a model that helps mindful and dissociated states (e.g., connectedness to affect,
the client to think dialectically. volitional shifts of attention).
As dialectical thinking increases and separateness and con- The second concern is that for some clients, mindfulness
nectedness are no longer polarized opposites, the dissociative practices may elicit dissociation, perhaps due to the change in
client gains improved access to another emergent process of mental state. For example, a client may experience the mindful
mindfulness: the sense of connectedness, both intrapersonally state as invoking dissociation, making it difficult to stay present
and interpersonally. As mindfulness enhances the ability to and participate in the practice. If dissociation occurs during
experience connectedness (Kabat-Zinn 1990), it is well suited mindfulness meditation, clients can keep their eyes open during
for viewing the fragmented self as internally connected and the practice in order to maintain present moment engagement
increasing connection to others. The therapist can enhance and to prevent dissociation (Foa and Meadows 1998; Walser
awareness of such changes through discussion of the inter- and Westrup 2007). Similarly, some clients who are trauma
connectedness between parts of the self. Although compart- survivors may have flashbacks when they try to meditate
mentalization affords safety through creation of barriers, cli- (Walser and Westrup 2007). If the client has a flashback in
ents also suffer from effects of these barriers, such as health session, the therapist can provide present moment reminders
problems (e.g., conversion symptoms) or memory gaps (Foa and Meadows 1998). To counteract dissociation, we en-
(i.e., amnesic barriers). courage a focus on grounding as a central aspect of mindfulness
The emergent process of inherent wisdom guides the client practice. It may be helpful for the client to identify safe anchors
to an underlying sense of core, authentic self. It can be in the therapy room, as well as in rooms at home or at work
highlighted that this core self underlies all parts of the self. (Boon et al. 2011). Using an object such as a rock can facilitate
Reperceiving helps clients to feel less overwhelmed by affect access to a sense of grounding (Najavits 2002). To identify
or experiences; thus, this emergent process is also likely to mindfulness practices that are comfortable and accessible, it
reduce the need for compartmentalization, which arises in may be helpful to experiment with different practices, varying
312 Mindfulness (2015) 6:303–314

the attentional focus each time. Some examples for attentional potentially beneficial tool in the treatment of dissociation.
focus include breath, each of the five senses, an object, a This paper provides the theoretical scaffolding that supports
sound or sight in the environment, imagery, and an internal such treatment and presents applications to intervention.
experience such as emotion, a thought, or idea. Cultivating mindfulness can address many of the skills deficits
The third challenge that may arise is that clients may be that impair daily living in dissociative clients. Mindfulness
attached to coping through dissociation, making them “reluc- increases clients’ ability to predict and control dissociation.
tant to give up dissociative behavior” (Wagner and Linehan By developing greater awareness, clients can learn to notice
1998, p. 218). Wagner and Linehan suggested reassuring when they are dissociating, a critical foundation for treating
clients that the objective is to gain greater control over disso- dissociation. Mindfulness provides clients with techniques
ciation, not to abolish the behavior. Mindfulness can be of- that are useful for counteracting dissociation by increasing
fered as an alternative that permits some of the comforts of awareness of dissociation, intentionally harnessing attention,
dissociation (e.g., reduced emotional reactivity) without the and providing tools for staying present. In addition, the
costs of habitual dissociation (e.g., disconnection from others; metacognitive approach to experience contributes to im-
destructive behaviors). Thus, mindfulness is framed as an proved emotion regulation and reduced emotional reactivity.
alternative manner of coping with aversive or intense emo- Finally, the emergent processes, such as reperceiving and
tions, thoughts, or experiences, and by observing and describ- dialectical thinking, encourage cognitive flexibility. Taken
ing responses to each mindfulness practice, dissociative cli- together, these effects of mindfulness can reduce the need
ents are able to access this alternative mode. for reliance on avoidance processes, and dissociative symp-
Finally, a fourth challenge is that dissociative clients have toms may subside in the context of greater capacity to tolerate
often habitually engaged in behaviors that are in stark contrast aversive experiences. Mindfulness and dissociation share the
to mindfulness techniques, which may result in barriers to use of an observer position, and building on this shared feature
developing a mindfulness practice (e.g., difficulty making time capitalizes on current dissociative coping strategies, while also
for meditation, difficulty maintaining compassionate offering a markedly distinct coping strategy that is volitional
metacognitions about one’s internal experience). When faced and both maintains and enhances connectedness. Although
with these challenges, it is important that the therapist focuses some challenges may arise in applying mindfulness to disso-
on the notion of commitment, of setting the intention and ciation, psychoeducation and skillful intervention are likely to
following through on it. Nonetheless, it is also important that address the challenges successfully. Mindfulness can provide
the therapist does not judge the client for not upholding expec- a liberating and empowering alternative mode of coping for
tations, instead modeling curiosity and openness in exploring dissociative clients.
the barriers. In this regard, the therapist must be active in
highlighting the dialectic of change and acceptance: It is ex- Acknowledgments The authors wish to express our appreciation to
“Madison,” the client who inspired this work; her excitement and enthu-
tremely challenging to develop a mindfulness practice and you
siasm over mindfulness fed our curiosity to gain a deeper understanding
should not berate yourself for being deterred by barriers; and at of the relationship between mindfulness and dissociation. We would also
the same time, if you want to live with less suffering, you will like to thank Frank Putnam for his consultation regarding that case; his
need to make a commitment and set an intention to invest into input was invaluable in discussing the case assessment, treatment plan,
and the model that was used. The authors also appreciate the insightful
your mental health and well-being. In order to have the ability
recommendations made by M. Zachary Rosenthal, Clive Robins, Lisa
to use mindfulness skills in times of great distress and crisis, Smith Kilpela, and Andréa Hobkirk. We appreciate the helpful sugges-
clients must practice regularly. Metaphors involving long-term tions made by the editor and reviewers.
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
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