Dissociation Worksheet (PDF)

• Be aware of these common signs and symptoms of Dissociation in your loved ones

• The individual looks like they are gradually spacing out
• They are staring blankly somewhere without awareness of their surroundings
• Signs indicate their mind is completely blank and unresponsive to stimuli around them
• They are acting like they are in another world by themselves
• Eyes appear glazed
• They are unresponsive to your presence

• Immediately begin the Grounding Technique:

1. Use gestures or physical movements to get them to make eye contact with you
2. Remind them about their dissociation symptoms and how you observed those just now, Try to get them to acknowledge their current state. Bring them to the present moment.
3. Ask them questions about who they are, where they are and what's the date and time.
4. No use grounding techniques such as: name 5 things you see and hear around you, Name 5 pet animals, Name 2 things in the room that are red etc  (with time you will know which works best for them)
5. Give them something they can get physically involved in for grounding such as: a strong smell, cold water to their face and hands, a sweet or sour candy to chew on etc

• Once they seem to be back to a conscious state, remind them to utilise the cognitive coping strategies that they have learned in therapy to deal with the uncomfortable state of their thoughts and feelings.

• Take note of the following things to provide to the therapist in the next session:

1. Signs and symptoms you noticed.
2. When did they occur including details of the situation prior to it.
3. How was their response to the grounding technique used.
4. How their response to the cognitive coping strategies used.

Reference

Kennerley H. (1996). Cognitive therapy of dissociative symptoms associated with trauma. The British journal of clinical psychology, 35(3), 325–340. https://doi.org/10.1111/j.2044-8260.1996.tb01188.x

You can download more Mental Health worksheets here.

Please note: There may be a more up-to-date and editable version of this worksheet available here which may be more suitable to present to clients if you are a therapist or to use in a classroom as a teacher or guidance counsellor.