Psychological Trauma: Theory, Research,

Practice, and Policy

Dissociation-Informed Assessment: Process-Related Guidance
Nicholas A. Pierorazio, Bethany L. Brand, and Julie Goldenson
Online First Publication, July 10, 2025. https://dx.doi.org/10.1037/tra0001997

CITATION
Pierorazio, N. A., Brand, B. L., & Goldenson, J. (2025). Dissociation-informed assessment: Process-related
guidance. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication.
https://dx.doi.org/10.1037/tra0001997
 Psychological Trauma:
Theory, Research, Practice, and Policy
© 2025 American Psychological Association
ISSN: 1942-9681 https://doi.org/10.1037/tra0001997

Dissociation-Informed Assessment: Process-Related Guidance

Nicholas A. Pierorazio1, Bethany L. Brand2, and Julie Goldenson3
1
Department of Psychology, University of Massachusetts Boston
2
Department of Psychology, Towson University
3
Department of Applied Psychology and Human Development, Ontario Institute for Studies in Education, University of Toronto

Objective: There is a lack of training about how to recognize, assess, and treat trauma-related dissociation—a
phenomenon that is prevalent in individuals with histories of complex trauma. This lack of training can cause
mental health professionals to overlook dissociation, which can lead to underdetection, misdiagnosis, and
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

possible prolonged suffering and misdirected treatment. Professionals seeking to improve their capacity to
This document is copyrighted by the American Psychological Association or one of its allied publishers.

work effectively with clients with dissociation may face a paucity of training opportunities, particularly with
respect to assessing trauma-related dissociation. Method: This article provides process-level guidance for
helpfully engaging clients who experience trauma-related dissociation, recognizing persistent dissociation, and
noticing and managing dissociation as it arises during assessment. Results: We emphasize the mental health
professional’s stance. We also review a variety of methods to detect and assess trauma-related dissociation,
including behavioral observations and process-oriented questions and reflections, highlighting the complexity
of dissociation-informed assessments, not only in treatment settings but also when these assessments are
required for third-party evaluations. Conclusions: We make a case for the vital importance of considering
process-related issues not only in the treatment of dissociation but also in assessment. We argue that for best
clinical assessment and treatment, training should emphasize collaborative rapport-building, professional
reflexivity, and cultural responsiveness.

Clinical Impact Statement

Trauma-informed assessment across settings entails being responsive to trauma-related dissociation. In
this article, we provide process-level guidance for dissociation-informed assessment. We emphasize the
mental health professional’s stance that can improve dissociation assessment: prioritizing rapport and a
collaborative relationship; reflexivity; and cultural responsiveness. We provide guidance for how
professionals can assess trauma and dissociation at the process level, such as attending to behavioral
observations and asking process-oriented questions, also noting how they can manage dissociation that
occurs during the assessment.

Keywords: trauma, dissociation, trauma-related dissociation, assessment, process

The fifth edition, text revision of the Diagnostic and Statistical field endorse the view that it is a complex phenomenon, which also
Manual of Mental Disorders defined dissociation as a “disruption includes:
of and/or discontinuity in the normal integration of consciousness,
Emotional numbing, heightened self-observation, changes in body
memory, identity, emotion, perception, body representation, motor
experience, distortions in the experiencing of time and space, changes in
control, and behavior” (American Psychiatric Association [APA],
the feeling of agency, feelings of having the mind empty of thoughts,
2022, p. 329). Dissociation phenomenologically exists on a con-
memories and/or images, and an inability to focus and sustain attention.
tinuum, ranging from normative experiences, such as absorption, to (Sierra & Berrios, 2000, p. 154)
complex experiences, as in dissociative disorders (DDs). Deperso-
nalization is a cornerstone experience in trauma-related dissociation. Derealization (i.e., disconnection from one’s environment) and
It is defined somewhat simply in the fifth edition, text revision of amnesia outside of normal forgetting are also typical dissociative
the Diagnostic and Statistical Manual of Mental Disorders as ex- symptoms (APA, 2022; Brand, 2024; Simeon & Putnam, 2022).
periences of unreality and detachment; however, researchers in the Complex dissociation, or dissociative symptomatology, is more

review and editing. Bethany L. Brand played a supporting role in writing–

Paul Frewen served as action editor. original draft and an equal role in conceptualization and writing–review and
Nicholas A. Pierorazio https://orcid.org/0000-0002-2462-9212 editing. Julie Goldenson played a supporting role in conceptualization and
Bethany L. Brand https://orcid.org/0000-0003-0377-2770 writing–original draft and an equal role in writing–review and editing.
Julie Goldenson https://orcid.org/0000-0003-0021-5186 Correspondence concerning this article should be addressed to Nicholas
None of the authors have any conflicts of interest to disclose. A. Pierorazio, Department of Psychology, University of Massachusetts
Nicholas A. Pierorazio played a lead role in project administration and Boston, 100 Morrissey Boulevard, Boston, MA 02125, United States.
writing–original draft and an equal role in conceptualization and writing– Email: [email protected]

1
 2 PIERORAZIO, BRAND, AND GOLDENSON

prevalent than most mental health professionals realize. Simeon could receive medications and therapy that do not ameliorate their
and Putnam (2022) found that, in a United States representative condition. Such treatment may lead to unnecessary side effects and
adult survey, the prevalence of complex dissociation was 4.1%. prolonged suffering. Neglecting to assess for dissociation may be
Dissociative identity disorder (DID) is considered the most viewed as failing to meet the standard of care (Boyer et al., 2022;
complex dissociative disorder and is defined in the fifth edition, Brand et al., 2014). Dissociation-informed assessment is crucial to
text revision of the Diagnostic and Statistical Manual of Mental maximize professionals’ ability to be responsive to clients’ needs
Disorders as the existence of two or more distinct self-states as and to minimize harm across settings.
well as amnesia for autobiographical information, including Although trauma-related dissociation is prevalent (Simeon &
trauma, everyday information, and/or details about oneself (APA, Putnam, 2022), and adequate assessment and care are necessary,
2022). The gold standard interview for assessing dissociation and individuals with dissociation are often provided treatment that does
dissociative disorders, the Semistructured Clinical Interview for not address dissociation due to clinicians’ lack of understanding
Dissociative Symptoms and Disorders (Steinberg, 2023), has evolved about the phenomenon (Bailey & Brown, 2020; Brand, 2024; Nester
a research-based definition of DID over time to also include symptoms et al., 2022). There is a lack of training about how to identify, assess,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

of amnesia, depersonalization, derealization, identity confusion, and and treat trauma-related dissociation (Kumar et al., 2022). This lack
This document is copyrighted by the American Psychological Association or one of its allied publishers.

identity alteration (Brand, 2024; Steinberg, 2023). Johnson et al. of systematic training in dissociation creates a public health concern
(2006) found the 1-year prevalence of DID was 1.5%, higher than rates due to a dearth of clinicians who can effectively assess and treat
of schizophrenia (APA, 2022). dissociative individuals (Boyer et al., 2022). Dissociative in-
The focus of this article is on assessing trauma-related dividuals reported having difficulty accessing clinicians who have
dissociation—that is, complex dissociation resulting from a had training in assessing and treating trauma-related dissociation
trauma history. Dissociation is associated with antecedent trauma (Nester et al., 2022). In a study by Nester et al. (2022), 27.54% of
(Dalenberg et al., 2012; Hyland et al., 2020), and it should be individuals with DDs reported having been challenged and/or
contextualized as such. Dissociation is particularly prevalent in disbelieved by professionals about the veracity of reports of their
individuals with complex childhood trauma, such as child mal- history of experiences of traumatic events and/or dissociation.
treatment and abuse (Hyland et al., 2020). A convincing body of Dissociative individuals have reported feeling shamed and stig-
research supports that complex dissociation is a trauma-related matized by some clinicians’ comments about dissociation (e.g.,
phenomenon (Brand, 2024; Dalenberg et al., 2012); it often Nester et al., 2022; Pierorazio et al., 2024). Fearing disbelief and
occurs alongside posttraumatic stress disorder. Complex disso- stigmatizing comments from mental health care providers may
ciation is often chronic and traitlike, as in DDs, while peritraumatic cause dissociative individuals to feel mistrust during assessment
dissociation is transient and occurs due to recent stress or traumatic (Nester et al., 2022; Pierorazio et al., 2024); this experience may be
events (reviewed in Brand, 2024). Given the complexities of dis- particularly salient for dissociative clients who often have already
sociation and its link to trauma, trauma-informed care, including experienced invalidation, betrayal or broken trust, and harm in
assessment, should also be dissociation-informed. relationships with caregivers, as well as a lack of protection from
society. Being invalidated and harmed by the professionals who are
The Importance of the Assessment of supposed to understand and treat individuals can be understood as a
type of institutional betrayal, and institutional betrayal trauma has
Trauma-Related Dissociation
been associated with dissociative symptoms (Smith & Freyd, 2017).
Adequate assessment is necessary in psychotherapy settings, Moral injury, or “a sense of one’s moral or ethical code being
forensic contexts, and beyond. Assessment can helpfully guide case violated,” has also been associated with dissociation (Lathan et al.,
conceptualization and allow for responsive treatment in mental 2023, p. 692), suggesting that moral injury, posttraumatic stress
health care settings. In forensic contexts, adequate assessment is responses, and dissociation are closely related nuances to consider in
crucial because it can affect psycholegal outcomes. In this article, we a dissociation-informed assessment. Thus, it is important to mini-
refer to mental health professionals across contexts as “professionals.” mize institutional harm, betrayal, moral injury, and other trauma
We refer to the assessee as the “client”; however, there are a number stemming from the mental health care system.
of instances in which that assessee is not technically the client of the Given the lack of systematic training on trauma-related dissocia-
evaluator and may be seen at the request of a third party to answer tion, professionals may feel unsure how to assess and be responsive
particular questions (e.g., a first responder’s fitness for duty, miti- to this phenomenon (Brand, 2024). Here, we provide guidance for
gation for criminal justice involved individuals). dissociation-informed assessment.
Adequate assessment of trauma-related dissociation is especially
pressing because failing to detect dissociation may lead to misdi- Process-Level Guidance for Assessing Trauma-Related
agnosis, improper care, and even retraumatization. For example,
Dissociation
dissociation and DDs are often misdiagnosed as psychotic or bipolar
symptoms or disorders (Hall, 2024). Of note, individuals with DID Thoughtful clinical assessment can be the bedrock for responsive
tend to display more first-rank symptoms than those with schizo- treatment and is particularly important when treating complex
phrenia (Kluft, 1987), which may contribute to misdiagnosis. Also, psychological phenomena such as trauma-related dissociation.
given the nature of dissociation itself, it can be difficult for dis- Assessment is not simply based on objective outcomes but also
sociative individuals to describe their symptoms and emotional evolves from a series of contextual processes that holistically build
states (Brand, 2024; Pierorazio et al., 2024), which could contribute an understanding of the client, co-created by the client and the
to misdiagnosis, such as misdiagnosing a dissociative individual as professional. In other words, assessment is not simply based on
alexithymic (Vatanparast et al., 2024). If misdiagnosed, individuals content; it also includes processes. Like treatment, assessment is a
 PROCESSES OF ASSESSING TRAUMA-RELATED DISSOCIATION 3

dynamic relational interaction (Goldenson & Gutheil, 2023). empowerment for the client (Brand, 2024; Finn & Tonsager, 1997).
Understanding and leveraging these processes of co-constructing The client should be actively empowered to give voice to their
meaning with clients can supplement the content of the assessment, internal experiences from the beginning (Evans & Finn, 2017; Finn &
such as data from instruments. Given that assessment takes place in Tonsager, 1997). In addition to sharing their psychosocial experi-
a relational context, knowing how to be attuned to trauma-related ences, the professional can also let the client know that the assessment
experiences and potentially implicit processes that become apparent process may be experienced as intrusive and invite them to voice their
during assessment is important. This is particularly true for clients experiences if questions feel poorly phrased, hurtful, or potentially
who have experienced interpersonal trauma and may have adapted to offensive. They should also be given choice, including shaping the
it by avoiding discussing trauma and potentially perplexing symp- reasons for the assessment, if possible (Evans & Finn, 2017; Finn &
toms, such as dissociation. While a full discussion is beyond the scope Tonsager, 1997). For example, a client may be referred for assessment
of this article, there is a wealth of writing in the contemporary for clarification about whether their voice hearing and thought
relational psychodynamic treatment literature about working with blocking is due to trauma-related dissociation or a psychotic
dissociation and multiple self-states (see Bromberg, 1998, 2006, disorder, yet the client may prefer to better understand why they
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

2011; Chefetz, 2015). However, most of the guidance around feel intense surges of anger during which they lose the ability to
This document is copyrighted by the American Psychological Association or one of its allied publishers.

assessing trauma-related dissociation focuses on what to do or control their behavior (note: this could be due to passive influence
administer rather than how to effectively engage clients moment- phenomena; Brand, 2024). Trauma- and dissociation-informed
to-moment. Becoming attuned to processes of assessment, such as assessment considers the client’s experience to be a crucial source
building a working alliance (or other common factors; Dalenberg, of data about the impact of trauma. Assessment done in this manner
2014), can function to improve assessment practice across settings will yield the most useful information about the individual’s
(Goldenson & Bailey, 2024; Goldenson et al., 2022). Attending to strengths, challenges, and life circumstances.
the process has the potential to improve professionals’ under- Assessment conducted in this manner has been referred to as
standings of their clients’ experiences and, as a result, generate both “listening and intervention” (Brand, 2024, p. 72), with the
more accurate assessment results and effective treatment. client feeling supported in sharing their reactions to the assessment
Guidance at the process level can help professionals manage as- process as well as their traumatic experiences. Being encouraged to
sessments, as well as notice trauma-related experiences and par- notice and share one’s internal experiences while discussing their
ticularly dissociation as they occur and intervene, if needed. lives can be a powerful intervention if a collaborative relationship
Recognizing dissociation and knowing how to respond to it during with rapport has been established. The client’s sense of control and
assessment creates greater competence for professionals and a safety should be supported. For example, they can be encouraged
more validating experience for clients. to ask for breaks when needed. While some assessments (e.g.,
forensic evaluations) might require professionals to delve deeply
The Mental Health Professional’s Stance into potentially traumatic content, providing clients with choices
about the timing and depth of inquiry related to traumatic events as
A professional’s interpersonal stance should be prioritized when much as possible may increase clients’ sense of safety. Choices
assessing trauma-related dissociation as the professional’s stance such as these may increase the individual’s sense of agency and
influences the assessment. Next, we review three domains regarding avoid triggering the feeling of being trapped or “forced” to par-
this stance as it relates to dissociation-informed assessment: (1) ticipate in the assessment, feelings which may be reminiscent of
Prioritizing Rapport and a Collaborative Relationship, (2) Reflexivity, prior trauma and could even precipitate a flashback (Brand, 2024;
and (3) Cultural Responsiveness. Brown, 2008).
As the professional bears witness to clients’ difficulties and
A Stance of Prioritizing Rapport and a Collaborative strengths, the client may feel increasingly validated and open to
sharing their experiences. By helping the client make sense of their
Relationship
reactions to trauma, the assessment process can be organizing, rather
Traumatic events and abusive relationships can be disorganizing than disorganizing. The client can feel validated if the professional
and terrifying to endure. Consider how daunting it could be for a listens openly and conveys empathy through the assessment pro-
traumatized person to meet a professional who essentially is a stranger cess. If the client feels safe, this can support them in giving voice to
asking them about the most awful life experiences they have had, experiences that may have been shaming and overwhelming. In a
experiences which they may be almost unable to bear thinking about supportive environment that fosters reflection, clients who have a
due to their distress. Also consider the shame of describing having tendency to avoid discussing their experiences may feel encouraged
been demeaned, violated, and/or threatened with death. to be more curious about themselves and develop self-compassion
A collaborative assessment approach can diminish service users’ as they recognize that their maladaptive patterns may be adaptations
understandable fear of thinking and talking about trauma and dis- to trauma (Brand, 2024).
sociation. Historically, psychologists assumed the role of “expert”
when conducting assessments such that they were often conducted
A Stance of Reflexivity
in a detached, supposedly neutral manner. But detachment is not
neutral (Brown, 2008). Rather, it is often experienced as cold and Professionals should adopt a reflexive stance when considering
judgmental, especially if the client has experienced harm by others. trauma-related dissociation in assessment. Reflexivity entails an
Instead of this potentially dehumanizing style of assessment, ongoing process wherein professionals turn inward to reflect on
assessment for trauma and dissociation should be collaborative with themselves and their own experiences and understand how those
the professional actively working to develop rapport with and subjectivities influence one’s work (Wilkinson, 1988). Reflexivity is
 4 PIERORAZIO, BRAND, AND GOLDENSON

often a stance taken in research, though we also believe it to be a Given the complexities of culture as they relate to dissociation, a
helpful framework for assessment. Cimbora and Krishnamurthy culturally responsive stance requires an active process of cultural
(2018) discussed “psychometrics of the self” (p. 29), explaining that contextualization of all assessment data. For example, it can be
an assessor ultimately is the instrument through which data gets typical for dissociative individuals who grew up religious to have
filtered. A professional’s subjectivities (e.g., identities, experiences, religion- or spirituality-based conceptualizations of their dissocia-
and emotional reactions) may influence the process of dissociation- tion, particularly if this was how their dissociative experiences have
informed assessment (Brand, 2024; Dalenberg, 2000; Goldenson & been explained to them. In a qualitative study on the impact of
Gutheil, 2023). culture on dissociation and treatment, one participant stated: “My
It is important for professionals to adopt a reflexive stance to work religious background marked [my dissociation] as me being a
toward an understanding of how their subjectivities may influence prophet hearing God and me being possessed by demons” (Pierorazio
the process of dissociation-informed assessment. A reflexive stance et al., 2023, p. 4). One professional working with this client may
not only requires acknowledgment that one’s subjectivities can assume that the experience is psychosis, while a culturally responsive
influence assessment but also reflection on how and perhaps why. professional would inquire further about dissociation. Being cul-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

For instance, a professional who has a strong emotional reaction, turally responsive in the assessment of trauma-related dissociation
This document is copyrighted by the American Psychological Association or one of its allied publishers.

such as fear, to clients potentially dissociating can turn inward and requires being open to seeing and hearing such dissociation and being
consider the etiology of these reactions, how these reactions willing to consider and respond to dissociation rather than defaulting
influenced the process, and how to work through these reactions to to more common assumptions even when dissociation is possible.
more effectively work with clients who dissociate. Through reflexive Trauma-related dissociation is not a rare “exception,” as is too often
self-engagement, this professional may realize that they felt fear believed in dominant psychological discourses (Hall, 2024; Pierorazio
engaging with the client’s potential dissociation due to their reluc- et al., 2023, 2025).
tance to hear about trauma-related experiences or manage dissociation To fully contextualize a client’s potential dissociation, as well as
because of their personal emotional wounds, for example (Goldenson trauma, professionals should inquire about clients’ range of
& Gutheil, 2023). Importantly, this professional can leverage their identities and experiences (e.g., race, ethnicity, gender, sexual
reflexivity to ensure they attend to their reactions via supervision, orientation, and religion). Culturally responsive professionals also
consultation, or personal therapy. Doing so can help these profes- inquire about traumatic and stressful experiences related to
sionals course-correct so they can follow up on trauma and disso- oppression, such as discrimination, identity-based rejection, and
ciation. Professionals may also find that, by reflexively connecting to hate crimes, among others. Useful ways to ask about these potentially
and managing their own emotional reactions, they are able to be more challenging topics can be found in Brand and Pierorazio’s (2023)
empathically understanding of the client (Dalenberg, 2014; Pierorazio trauma- and dissociation-informed diagnostic interview outline.
et al., 2025). Professionals can also notice their gaps in knowledge Directly asking about these oppression-based experiences can provide
about dissociation and seek education or consultation as needed. valuable information about stigma-based stress and promote rela-
Therefore, a reflexive approach to dissociation-informed assessment tional safety in discussing these experiences (Brand & Pierorazio,
may result in improved assessment processes. 2023; Williams et al., 2018).
Practicing cultural responsiveness in sessions with clients with
trauma-related dissociation often entails acknowledging power dif-
A Stance of Cultural Responsiveness ferentials in the relationship and attempting to reduce them as much as
possible (Goldenson, 2025). As noted previously, reflexive practice is
Cultural responsiveness is essential in assessment, as clients’ important to understand one’s own cultural blind spots and as-
cultures influence our understanding of their problems, strengths, sumptions, which may lead to a richer understanding of the client’s
and their own understanding of their experiences (Hays, 2022). lived experiences. Reflexivity can support addressing power dynamics
Culture, including axes of privilege, power, and oppression, in- and cultural variables in the assessment relationship. In turn, pro-
fluences how a person may experience trauma and its sequelae fessionals should continue to understand cultural responsiveness as a
(Brand & Brown, 2022; Brown, 2008; Pierorazio et al., 2023). It is process-oriented stance rather than an end goal. Cultural respon-
vital for professionals to appreciate clients’ layered culturally siveness in dissociation-informed assessment is active and requires
laden experiences and intersecting identities. Culturally responsive continual work on the part of the professional.
assessment is essential given the ways that dissociation is socially
entwined and often catalyzed by oppression-based experiences and
A Note on Using Screeners and Clinical Interviews
marginalization, such as a person’s trans experience dominating
their mental health journey and maintaining their dissociation due There are available dissociation screening tools and clinical in-
to stigma and threats of possible violence (Pierorazio et al., 2023). terviews to potentially include in a battery reviewed elsewhere (e.g.,
Considering cultural variables also involves noting that clients’ Brand, 2024). Here, we focus on process-level considerations for
dissociation may have gone unseen in the context of societal their administration. It is important that professionals attend to
stigma (Nester et al., 2022; Pierorazio et al., 2023). Culturally processes relevant to administering measures in order to prioritize
laden trauma, even if not “technically” considered Criterion A rapport and gain relevant data.
trauma, can also lead to dissociative responses (e.g., Gómez, One domain that professionals can be responsive to is a client’s
2019). Further, there is often cross-cultural variability in disso- reactions to completing screeners and interviews. In keeping with
ciation, such as possession phenomena in particularly non-Western trauma-informed principles related to safety and choice (Harris &
cultures (APA, 2022). Fallot, 2001), self-report measures need to be used with sensitivity.
 PROCESSES OF ASSESSING TRAUMA-RELATED DISSOCIATION 5

Professionals might introduce measures by saying something in This said, some individuals may feel slowed down or thwarted when
keeping with: prompted to discuss trauma at a headline level. Thus, it is important
to be responsive to clients by consistently checking in with them
Filling out a questionnaire, about experiences you may or may not have,
about their experiences and needs throughout the assessment, pri-
helps me learn about you so I can better plan our work together. If you
oritizing those needs where possible.
don’t feel comfortable answering a question, you can leave it blank.
Please feel free to ask questions and if any notable feelings come up,
please let me know. We can stop at any time. Attending to Behavioral Observations
While nondissociative clients may have minor reactions to com- Many dissociative symptoms are internal experiences which are
pleting these tools or interviews (e.g., feeling items were mildly not observable. For example, clients may feel dizzy or see them-
strange), some dissociative clients may have stronger reactions. For selves during the interview as if they are watching a movie of
instance, they may have a positive response and feel seen when the themselves (i.e., depersonalization) or they may perceive the pro-
assessment process helps them find language for their often neb- fessional as if they are sitting very far away or the office is “foggy”
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

ulous dissociative experiences. On the other hand, individuals who (i.e., derealization; Brand, 2024; Pierorazio et al., 2024). They may
This document is copyrighted by the American Psychological Association or one of its allied publishers.

relied on dissociation as a covert defense for survival and maintain hear voices of dissociative self-states having multiple conversations.
it may feel “found out” and react with surprise, anxiety, shame, These experiences are not visible, yet they are crucial to know about
defensiveness, and/or potentially by becoming more dissociated during assessment (Loewenstein, 1991).
(Perry, 2012). Some individuals may have mixed positive and However, there are often observable signs that might indicate
negative reactions. It is useful for professionals to pay attention to dissociation, although careful query and differential diagnosis must
the client’s reactions to these instruments and seek to understand be thoroughly considered because it is possible that other factors
them. By understanding these reactions, a professional may develop such as anxiety, psychosis, attention deficit hyperactivity disorder,
a deeper, more nuanced conceptualization of the client’s trauma, brain injury, and more may cause symptoms that seem to be dis-
dissociation, and related problems. These moments can be leveraged sociation and vice versa. To clarify if dissociation is causing memory
to process clients’ experiences related to dissociation, perhaps with gaps, for example, rather than a neurological problem, one can
language that they did not have before. observe carefully over time to determine if there is a pattern to what
Clients with trauma-related dissociation may have similarly seems to be amnesic gaps. The possibility of trauma-related disso-
strong reactions to questions about traumatic events or dynamics, ciation causing gaps in memory becomes more likely if the gaps only
which may come up during interviews, screening instruments, or occur when the client talks about an abusive relationship, especially if
structured assessments (Nester et al., 2024). It can be helpful to the gaps occur along with other behaviors suggestive of possible
discuss trauma at a headline-level (as if it were a newspaper or blog; dissociation (Brand, 2024). For instance, if a client loses awareness of
Loewenstein, 2006), refraining from flooding clients with details of having just told the clinician about having been raped in childhood,
their story related to experiences leading to posttraumatic distress and if the clinician observed an abrupt change in the client’s style such
while still ascertaining main themes and salience (Brand, 2024). that they shifted from sounding calm and sophisticated, to speaking in
Operating at this headline-level allows for relationship building and a halting, childlike voice while appearing to be suddenly afraid, the
evaluation of safety before over-telling of trauma details in assess- client may have shifted to a dissociative self-state.
ment (Loewenstein, 2006). Generally, it is helpful to understand the While dissociation is a distinct phenomenon, it can co-occur
type of trauma (e.g., childhood sexual abuse, neglect), the approxi- when people experience altered states of arousal. Professionals
mate ages of the client during the trauma periods, as well as should also watch for signs of hyper- and hypoarousal, as well as
relationships to abusers, if applicable (e.g., parent, peer; Brand & what seems to trigger shifts in arousal. Signs of hyperarousal like in
Pierorazio, 2023). Loewenstein (2006) used the following phrasing posttraumatic stress disorder include shaking, hyperventilating, and
to illustrate how a professional may prompt a client to discuss trauma a flushed face. Signs of dissociation or hypoarousal include barely
at a headline-level: breathing, fixed staring, pallor, and collapsed posture. The following
behaviors may indicate dissociation (Armstrong, 2002): (a) fluc-
You know how there is the big, big headline on the first page [of a tuations in activity level, affect, developmental presentation (e.g.,
newspaper] Then, under that, there’s a headline in somewhat smaller shifting from an adult presentation to a fearful, childlike presentation),
type, and then another one in a little smaller type, then finally the story.
or somatic symptoms (e.g., sudden onset of a headache); (b) emotional
Then the story might continue onto page 12 and onto page 14 and so on
reactions such as a pronounced fearful reaction, emotional over-
and so on. All you need to talk about today is the first two levels of
headline, maybe the third. You don’t need to go into the details of the
whelm, rocking, leg shaking, and/or reports of emotional numbness;
story. … (p. 308) (c) being unresponsive such as having a “far away” look and not
responding to the assessor or staring in a blank, fixed way while not
At points when clients may go on to discuss trauma details and moving for a significant period of time; (d) possible amnesia such as
appear to become overwhelmed, it may be advantageous for the actively denying something they have already reported or sudden
professional to kindly remind them that they have the agency to inability to recall a major aspect of experience; and (e) possible
pause disclosure as they wish, reiterating that the information is evidence of dissociative interference such as hiding gestures (e.g.,
important but that it is an option to get into the details of trauma hiding their face under their hair), eye movements (e.g., eye roll that is
when they have coping skills to deal with the increased distress so pronounced that little of the pupil shows, rapid blinking), clearing
related to facing those details (Brand et al., 2022). Working at a gestures (e.g., shaking their head as if to stop certain thoughts), or
headline-level can minimize the risk of flooding and dissociation reports of going “blank” or thoughts being “taken.” If the clinician
while maximizing data quality, rapport, and client empowerment. observes any of these behaviors, particularly when they occur
 6 PIERORAZIO, BRAND, AND GOLDENSON

frequently, it is recommended that additional assessment is pursued with these cases, it can be helpful to provide reflections wondering whether
self-report screening measures such as the Dissociative Experiences all self-states feel the same (using the client’s language for their self-
Scale (Carlson & Putnam, 1993) and validated semistructured interviews states) and to invite all self-states to participate. It may be useful to
such as the Semistructured Clinical Interview for Dissociative prompt clients to check inside with all self-states when indicated.
Symptoms and Disorders (Steinberg, 2023). Note that for individuals who report having dissociative self-states,
or when that is a possibility, it can be helpful to ask if they feel like
they experience different emotions, and if so, could they allow
Employing Process-Oriented Questions and Reflections themselves to share their experience of different emotions.
In addition to semistructured and structured assessment techni- Comments such as “different ways of being me” or “different parts
ques and behavioral observations, process-oriented questions and of my brain” may be references to self-states, although the client
open reflections can improve dissociation-informed assessment. might not recognize this. It may be useful to explain that all
Exploratory process-oriented questions and reflections can open the emotions or states (or whatever their word choice is) are important.
dialogue beyond the surface content of clients’ words (Brand et al., Welcoming all aspects of a client supports developing a full
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

2022; Perry, 2012; Westra & Di Bartolomeo, 2024). For instance, if understanding of the client, especially in cases where there appears
This document is copyrighted by the American Psychological Association or one of its allied publishers.

a client continually changes the subject in response to being asked to be dissociation-related internal conflict.
about their relationship with their caregivers, it may be prudent to
call attention to this and “wonder aloud” whether it feels challenging Managing and Leveraging a Client’s Dissociation in
to discuss these relationships and, if this is correct, learn more about Assessment Sessions
those relationships, as well as a potential trauma history and dis-
sociation. Such process-level inquiry can also highlight dissociative Clients with trauma-related dissociation may dissociate in ses-
processes in the session, providing a window for supporting and sions, including psychotherapy sessions, routine assessments, or
further understanding the client. For example, a professional may other evaluative settings. They may do so for several reasons,
openly ask a client who is silently “staring off into space” what is including trauma-reminders, feeling “too much” when confronting
going on for them while being curious about dissociation, rather their pain (Brand et al., 2022), and more. Clients often have dif-
than simply assuming they are disengaged (although that could also ficulty noticing their dissociative experiences as they occur (Brand
be the case). Such process-level questions can be helpful for et al., 2022). Therefore, clients may need support with noticing their
working through obstacles in rapport, which may then deepen the dissociation in sessions, such as asking clients to reflect on their in-
client’s openness to disclose and engage in assessment. the-moment experiences (Brand, 2024; Brand et al., 2022).
Clients often struggle with explaining their dissociative experiences. Professionals could help the client to notice and describe their
Process-level questions and reflections can be helpful to support them dissociation by directing them to their body and what they are
in finding language for these experiences. Some dissociative clients feeling physically, although this needs to be done sensitively as
tend to discuss their dissociative experiences in metaphorical or surviving trauma via dissociation may have required disconnecting
symbolic terms, rather than concrete terms (Pierorazio et al., 2024). from their bodily sensations (Pierorazio et al., 2024); thus, asking
For example, individuals with dissociative self-states may describe them to pay attention to sensations that may signal dissociation can
passive influence that occurs when one self-state is not in control of sometimes lead to increased dissociation. If the professional is asking
behavior, yet is aware of what is going on; they may say something about in-the-moment dissociation and the client seems defensive,
like, “I feel like I’m in the back seat of the car, so I can see where I am disconnected, or unusually reactive, respectfully calling attention to
going but I can’t control the car.” It can be helpful to note clients’ this and asking if they can tolerate discussing what is going on for
potential difficulty with discussing their dissociative experiences with them may be effective. One might say, “I’ve noticed you’ve been
them as an act of validation and rapport-building. To ease this dif- staring off. How connected do you feel right now to being here?”
ficulty, one may prompt clients for metaphorical explanations of their After noticing dissociation in sessions, clients can be supported by
experiences to improve assessment (Pierorazio et al., 2024). For grounding in the present. This can be done through the professional
instance, a professional may say: orienting them to the present (e.g., “It’s [current year]. We’re in
[location of session].”) and leading them through anchoring in the
I’m noticing that you seem to be having a bit of trouble finding the present (e.g., using their senses to describe in detail what they see,
words to describe your experiences. Some people have an easier time
hear, feel). Some clients may have the skills to independently practice
when they compare these experiences to an image or something like
that. Do you have anything like that coming to mind?
grounding, but others may not. We refer the readers to Brand et al.
(2022) for further guidance about helping a client get more grounded.
In nonforensic settings, it may be helpful to provide examples to Helping clients get grounded improves clinical assessment quality,
help the client verbalize their experiences (e.g., feeling as if they are such as improving narrative coherence (Holbæk et al., 2024), and
in a painting; Pierorazio et al., 2024). Dissociative clients may also their experience of the assessment process.
come into the assessment already discussing their experiences When the client becomes grounded after dissociating, it can be
highly abstractly (Pierorazio et al., 2024), so professionals should helpful to inquire about, reflect on, and explore the experience of
become attuned to metaphor in the assessment process. Holding dissociation with the client. For instance, professionals may ask: “It
dissociation as a possibility when clients use metaphor, and engaging seemed like you just went away for a moment. What was going on
this at a process-level, can be important for understanding their for you?” Clients may then provide valuable insight to support the
experiences and building the relationship. assessment. They may say: “I don’t remember. I feel weird, and my
For individuals with potential dissociative self-states, there is often hands and feet feel numb. Last thing I remember you asked me about
internal ambivalence about the assessment process (Brand, 2024). In my home life growing up. The next thing I know, I’m here.” Then,
 PROCESSES OF ASSESSING TRAUMA-RELATED DISSOCIATION 7

the professional may need to follow up to learn if there was training about collaborative rapport-building, reflexivity, and cul-
something about discussing the client’s childhood home life that felt tural responsiveness, as well as noticing in-session dissociation and
distressing or triggering. Also, is depersonalization typical, in what using process-oriented questions, can similarly allow for applicable
other contexts does it occur, and how long does it last? To what learning. For instance, engaging in role plays where one person acts
extent, if any, does this person experience amnesia? Professionals as a potentially dissociative client and another acts as the profes-
should consider whether to invite the client to complete dissociation sional can allow trainees to hone their dissociation-informed stance
screeners and/or interviews that assess the severity, frequency, and and skills in engaging processes for positive assessment outcomes.
nature of dissociation. There is a wealth of information that can be Trainees can practice helping clients become grounded, asking
garnered by supporting clients with noticing and processing in- process-oriented questions when their mock-client begins to “dis-
session dissociation. There may be benefit in processing how it felt sociate.” As professionals progress through training, they can apply
for the client to name experiences of dissociation that they may process-centered principles with clients in practice. Process-oriented
rarely discuss—for example, if this helped them feel seen or elicited training can be built into graduate curricula like assessment courses,
shame. If negative emotions were evoked, naming and processing practica, and continuing education. Such education can be supple-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

this could assuage concerns, emphasize positive regard, and be mented by specialized training in specific assessment instruments,
This document is copyrighted by the American Psychological Association or one of its allied publishers.

corrective. such as the Semi-Structured Clinical Interview for Dissociative

Of note, though, some types of assessment such as forensic or Symptoms and Disorders (Steinberg, 2023), contributing to a holistic,
third-party evaluations are intended to answer particular questions dissociation-informed professional.
and not be therapeutic. In these circumstances, therapeutic inquiry
or direct interventions like grounding would extend beyond the
boundaries of third-party referrals or the evaluator’s role. That said, Conclusions
even in these cases, it is possible that dissociation can be explored at
Assessment that is trauma-informed must also be dissociation-
a process-level to understand here and now reactions (Pierorazio
informed. However, there is a lack of training in assessing trauma-
et al., 2025), as well as to enhance the formulation. Behaviors and
related dissociation. Process-oriented considerations are often
reactions that unfold during assessments can be vital to an eva-
sidelined. While assessment settings vary (e.g., forensic evaluations
luator’s understanding of the person being assessed and can aid in
are not intended to be therapeutic) and require a tailored approach,
rendering accurate formulations. For example, if the evaluee appears
being sensitive to process and responsive to trauma-related disso-
to be having a reaction to an interview question (e.g., becoming
ciation consistently bears relevance, even in nontreatment settings
quiet and staring blankly), it could be appropriate to inquire into the
(Brand, 2024; Goldenson et al., 2022). Professionals should inte-
here and now experience of the interviewee to better understand this
grate these process-oriented considerations with their standardized
reaction (e.g., “Are you comfortable telling me what was happening
assessments, as possible. It is our hope that the guidance included in
for you in that moment?”). While some measures require a stan-
this article provides professionals with a practical, process-oriented
dardized administration, Armstrong (2012) spoke to the possible
path toward becoming responsive to trauma-related dissociation
benefit of process-level inquiry after a measure is administered in
during assessment.
service of developing a deeper understanding of the person and their
struggles and strengths. For example, a dissociative client of the
second author did poorly on arithmetic intellectual subtests despite
doing well on other subtests. Follow-up processing revealed that her References
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1781(00)00100-1 Williams, M. T., Metzger, I. W., Leins, C., & DeLapp, C. (2018). Assessing
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institutional betrayal linked to health and dissociation. Journal of Received September 22, 2024
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10.1080/10926771.2017.1322654 Accepted June 6, 2025 ▪