Clinical Reflections

Listening in the Space between Us: Dissociative Attunement as a Therapeutic Tool

Our world is filled with vibration. Everything on/in the planet resonates at some frequency, from the slowest and lowest (infrasound) to the highest frequencies (ultrasonic) which cannot be perceived by the human ear. Some frequencies that we humans cannot hear are still perceived by the human body. In her TED talk, ‘How to Truly Listen’, profoundly deaf percussionist, Evelyn Glennie describes that to truly listen we must use our bodies as resonating chambers. But, even when we do not knowingly use our bodies to listen, we are always resonating chambers. Whether we actively listen or not, we are knowing information that is transmitted in ways beyond cognitive and body language. In essence, we are always listening and always knowing in a felt sense (Gendlin, 1978). When we learn about therapeutic techniques for healing pain and suffering in individuals traumatized during childhood, we do not necessarily nourish our full capacity to listen, nor do we always recognize information that is perceived through intuition. Intuition is often dismissed as lacking objectivity, certainly not evidence-based ‘science’. However, intuition can also be understood as a function of entrainment and synchronization. Entrainment happens when an external rhythm causes rhythms within one’s brain and body to synchronize with that external rhythm. Clayton, Sager & Will (2004, p.3) describe this:

Entrainment describes a process whereby two rhythmic processes interact with each other in such a way that they adjust towards and eventually ‘lock in’ to a common phase and/or periodicity… The tendency for rhythmic processes or oscillations to adjust in order to match other rhythms has been described in a wide variety of systems and over a wide range of time scales (i.e., periodicities): from fireflies illuminating in synchrony, through human individuals adjusting their speech rhythms to match each other in conversation, to sleep-wake cycles synchronizing to the 24-hour cycle of light and dark. Examples have been claimed from the fast frequency oscillations of brain waves to periods extending over many years, and in organisms from the simplest to the most complex as well as in the behaviour of inorganic materials and systems.

William McNeill (1995) described how rigorous preparation for military service involves entraining the soldiers to step together in time, what he called muscular bonding. When pacemaker cells in the heart and single motor neuron cells in the brain are entrained to pulse in synchrony these cells demonstrate self-sustaining oscillations. They beat to a rhythm that is self-generated and facilitate systems that are self-organizing (Pikovsky, Rosenblum, & Kurths, 2001).

Synchronization is a bi-directional force in which two or more bodies influence each other rhythmically. If I am playing music with someone else and I gradually slow the tempo, this may well cause the other musician to slow down. However, they could just as well influence me to speed up. The rhythmic attunement is bidirectional. 

Our understanding of entrainment and synchronization is informed by the advancement of non-linear systems theory, which introduces us to the concept of self-organization (Guastello & Liebovitch, 2009). We become who we are through interactions both with the outside world and within our bodies. This is true for individuals as well as groups. When an athletic team is entrained, they play a better game. When a quartet of musicians is entrained their performance can feel magical.

I came to understand more about the experience of entrainment while studying middle eastern frame drumming. The concept of dissociative attunement emerged from my experience of entrainment while drumming polyrhythms with other drummers. As a western-trained musician, my brain wanted to read music on the page and play it as it is written. At first, sitting in the circle of drummers, without the guidance of written notes, enveloped in the sounds of complex rhythms around me, I felt confused. Actually, I felt like my fingers would not follow the signals from my brain. Each session of drumming would begin with this feeling of disconnection within my own body and within the group. And then, after several minutes something else would happen. I stopped ‘thinking’, my breath would steady, and my hands would play the rhythms that matched exactly with the group.

After many months of drumming, I noticed similarities between my introduction to polyrhythms and my process as a psychotherapist. Like reading a page of music, my professional training taught me to think about symptoms, and to think about concepts like transference, countertransference, and projective identification. I could use these concepts as smart and sophisticated ideas, but transference and countertransference too easily can become reified feeling states. While we are capable of listening as an integrated, resonant body, I felt like my education was getting in the way.

About a year after I started to study frame drumming, I wrote a paper, published in the Journal of Trauma and Dissociation, entitled ‘Being in Rhythm: Dissociative Attunement in Therapeutic Process’ (Hopenwasser, 2008). In this paper I introduced the concept of dissociative attunement, which emerged from the awareness that I was using the parts of my self trained as a musician informed by my psychiatrist and psychotherapist skills. I described attuned therapists as micro-tonal tuning forks. This means that when we sit repeatedly in the same space (including cyberspace) with a patient or client, in some ways we become entrained. We resonate with them both physically and psychologically. Through this resonance we know things that are not necessarily communicated by a narrative story.

I have written other papers and a book chapter, as well as had many conversations with colleagues exploring this concept of dissociative attunement. It’s not easy to explain without using language that many find challenging – the language of complex systems science and philosophy as it pertains to both human neuronal networks as well as a larger ecosphere. In this brief article I am describing the clinical experience of dissociative attunement without all the other explanation. At the end I’ll list some references for anyone who wants to learn more.

In that first paper I wrote about a patient* Marina, with whom I repeatedly made the ‘mistake’ of triggering shame. It was easy to explain this as a misattunement. But it made no sense to me that I would repeat this mistake over and over. Ultimately, I realized this was not a misattunement. On the contrary, I was attuned with self-states that were dissociated – effectively I was speaking to parts of her that were not present in the session. I was feeling connection with self-states not in the room. In this connection I was also experiencing shame.

Marina had had a painful rupture in a previous treatment. The former therapist was skilled and seasoned, but struggled to understand their repeated negative interactions and ultimately felt she just could not work with her. Once I realized that I was attuned to shamed and perpetrator self-states it became possible for me to better understand my own feelings in the sessions and consequently to better regulate my own reactions to her. In my understanding of our attunement as dissociative I recognized a greater degree of dissociation in my patient than was immediately apparent and ultimately this recognition facilitated a positive outcome. Feelings of shame are inevitably encountered by most children, and perhaps some animals. But in relationally traumatized individuals, it has been my experience that shame can be like a forever chemical. Even when dissipated by good therapy it remains as body memory and in dissociative individuals, vulnerable to activation. (For extensive discussion of shame in relationally traumatized individuals see the work of Benau (2022) and Badouk Epstein (2022)).

In this case, with Marina, her dissociative adaptation was more subtle than my other patients with dissociative identity disorder. This required me to notice the rhythm of our encounters with mindful attention. My attunement with her dissociated feeling states was less obvious and easily misunderstood.

Dissociative attunement happens. We don’t get taught to be attuned. If we start to teach ourselves to truly listen, then we might also be teaching ourselves to recognize attunement. On the way to understanding this I have found helpful the concept of ‘implicit relational knowing’ and the ‘two-person unconscious’ (Lyons-Ruth, 1998, 1999). But psychoanalytic learning did not help me to understand moments of meeting with dissociated self-states. And, as described above, my more psychoanalytic thinking led me to mis-understand clinical moments. Studying the writing of Bromberg (1996, 2001) who facilitated profoundly important awareness of dissociation in psychoanalytic treatment, gave me the nudge to go one step further. Bromberg never wrote specifically about dissociative identity disorder. My own training was more medical management of this presentation, with lots of guidance from the cohort of clinicians who first wrote the ISSTD guidelines. As a psychotherapist and clinician who struggled with the social determinants of diagnosis, feeling outside of the ‘academy’ was both lonely and liberating. My own study of the philosophy of embodied cognition (Maturana and Varela, 1987) followed by the teachings of somatic therapists (Levine, 1997; Ogden, 2006; Fisher, 2017) cleared the path for thinking differently (Sander, 2002). 

When I talk about the concept of dissociative attunement, I am transforming a passive knowing of information into a mindful awareness that is an essential tool in the therapeutic healing process. In our therapeutic work with individuals who manifest the lived experience of dissociative self-states, over time we are attuning in subtle ways with these different self-states. We receive information that is both verbal and embodied, but also, in ways that sometimes feel disembodied. Here is one example:

Ingrid was a very successful attorney, highly regarded within her community and known to be generous, ethical and philanthropic. She was also severely obese and a compulsive binge eater. She had had decades of treatment by eating disorder specialists – repetitive treatments to structure and manage her eating. Some of those therapies also recognized her history of severe emotional mistreatment in childhood. However, when we began our work, she was actively binging every day and she was shocked when I used the word abuse to describe her childhood experience. For a few years I discouraged talking much about food in our sessions, knowing that Ingrid in my office was not the self-state binging at home in the evening. We occasionally did some EMDR with early childhood memories and ultimately, she steadily lost weight until she was no longer dangerously obese. But it was in a single session in my office that I understood something about her she had never told me. I found myself thinking about an Indian woman, Phoolan Devi, known as ‘the Bandit Queen’. The story of Phoolan Devi is complicated, and controversial, yet her story essentially reveals how harmful and/or risky behavior can be a means to preserve self-integrity. A therapist having associations during psychotherapy sessions is not unusual and can be incredibly useful. But when I impulsively blurted out to Ingrid that she is a bandit, her whole body relaxed, she smiled wryly and said, “I have to tell you something – sometimes I steal candy from stores.” Ingrid also suffered with compulsive shoplifting, stealing items she could well afford to buy. I was not surprised by this, as shoplifting is sometimes seen in those dysregulated by early childhood abuse, along with binge eating. After this session, we were able to explore in depth the experience of dissociation while inside a store, the compulsive need to steal food, and the way in which this exemplified a dissociative self-state. My association to the Bandit Queen arose from an attunement with Ingrid, to what felt like an attunement with a dissociated self-state that she did not even know needed to be brought into the room.   

A few years after this session with Ingrid, I read an article about the Default Mode Network and the sense of self in traumatized individuals (Lanius et al. 2020). The Default Mode Network consists of a constellation of mid-line regions in the brain that contribute to self-referential processing. Lanius and others have been investigating the ways in which early trauma and dissociation impact on the development of connections in the default mode network. In this particular article they present a clinical case of a woman who described how shoplifting created a sense of agency, facilitating the feeling of being in her body and being in the world. 

My intuitive knowing of Ingrid the bandit emerged from the flow of information within a complex interpersonal relationship. The recognition that all systems are interconnected, that information flows in what can be called non-linear ways, is essential to our therapeutic work. We are individual complex systems embedded within larger complex systems, or more simply put, within an ecosystem. When we limit our understanding of the psychotherapeutic process to concepts like transference and countertransference, we are simply missing an opportunity to listen to dissociated information that does not fit neatly into our intellectual understanding.            

In our work with dissociated self-states, we are challenged to recognize felt sense that is not easily able to be explained. I have written about my long-term work with a woman who revealed “parts” to a previous therapist after many years of treatment. This patient, Francesca, felt loved and nurtured by her therapist, but both agreed that she needed specialized treatment, and a transition was made that was supportive to her ongoing therapy. For the first years of our work together, Francesca would sit slouched in a chair that swiveled, facing the wall and revealing only the top of the back of her head. I was forbidden to look at her, but I could get a glimpse of her face as she entered the office, or if she switched into a part that could tolerate eye contact. This went on for a very long time. Yet we developed a strong therapeutic relationship, and I came to ‘know’ her despite the lack of facial cues. In this treatment relationship I also came to understand that there was a dissociative attunement happening, and if I listened carefully to what I was feeling with her it would guide me in the process. Francesca taught me a great deal about knowing and not knowing about early trauma. We used crayons and markers for some communication, but even when we sat in silence, sometimes I could ‘feel’ which part was present. She taught me to let her know when I felt overwhelmed, to warn her when I felt impatient (she could be very provocative at times). This allowed her to anticipate my inconsistencies, which helped her to manage anxiety. From these encounters I realized that dissociative attunement goes both ways. While I was ‘knowing’ things about her that she did not directly tell me, she was ‘knowing’ things about me too! (Hopenwasser 2008, 2015).

Dissociative attunement can impact clinicians in subtle ways. Sometimes the more attuned I feel with dissociated self-states the more difficult it is to write a coherent note. Too much is happening at once. This can cause fatigue and at times a feeling of incompetency. How ironic. Sometimes, the more that I am knowing, the less I understand. We have no non-linear equations for psychotherapeutic discourse. While information flows horizontally between individuals in present time it also flows vertically, from generation to generation: ‘[T]he felt sense of trauma resonates through generations’ (Hopenwasser 2018). In the therapy process, I find it useful to name this flow of dissociated information as dissociative attunement. Others may choose different words. Most importantly, I remain mindful that rhythms are the threads that weave the fabric of connection.

*I use the term patient because my professional identity is deeply informed by my medical training and practice.  

Want to Learn more?

For those of you interested in hearing Karen present on this topic, she will be conducting a workshop on Saturday 21 October at ISSTD’s virtual annual conference entitled Dissociative Attunement: Being in Rhythm With Individuals Experiencing Complex PTSD. A link to conference registration is here.


Badouk Epstein, O. (2022). Shame Matters: Attachment and Relational Perspectives for Psychotherapists. Routledge.

Benau, K. (2022). Shame, Pride, and Relational Trauma: Concepts and Psychotherapy. Routledge.

Bromberg, P. (1996) Standing in the Spaces: The Multiplicity Of Self And The Psychoanalytic Relationship. Contemporary Psychoanalysis 32:509-535

Bromberg, P. (2001) Standing in the Spaces: Essays on Clinical Process, Trauma and Dissociation. Routledge.

Clayton, M. R. L., Sager, R. & Will, U. (2005). In time with the music: The concept of entrainment and its significance for ethnomusicology. European Meetings in Ethnomusicology,11 (ESEM Counterpoint, 1), (pp. 3-75).

Fisher, J. (2017) Healing the Fragmented Selves of Trauma Survivors. Routledge.

Gendlin, E. (1978). Focusing.  Everest House.

Gendlin, E. (1997). Experiencing and the creation of meaning: A philosophical and psychological approach to the subjective. Free Press of Glencoe.

Guastello, S. J., & Liebovitch, L. S. (2009). Introduction to nonlinear dynamics and complexity. In S. J. Guastello, M. Koopmans, & D. Pincus (Eds.), Chaos and complexity in psychology: The theory of nonlinear dynamical systems (pp. 1–40). University Press.

Hopenwasser K. (2008). Being in rhythm: Dissociative attunement in therapeutic process. Journal of Trauma & Dissociation, 9(3), 349–367. ttps://

Hopenwasser, K. (2018). Bearing the unbearable: Meditations on Being in Rhythm, (Revised).  Attachment: New Directions in psychotherapy and Relational Psychoanalysis,12: 48–55.

Hopenwasser, K. (2016).  Dissociative Attunement in a Resonant World. In Howell L, Izkowitz S, (Eds). The Dissociative Mind in Psychoanalysis, Routledge, pp. 175-186.

Hopenwasser, K. (2018). The Rhythm of Resilience: A deep ecology of entangled relationality. In Salberg, J. and Grand, S. (Eds.) The Wounds of History: Repair and Resilience in the Transgenerational Transmission of Trauma, (pp. 60-76) Routledge.

Levine, P. (1997). Waking the Tiger. Berkeley, CA: North Atlantic Books

Lanius, R.A., Terpou, B.A., McKinnon, M.C., (2020). The sense of self in the aftermath of trauma: Lessons from the default mode network in posttraumatic stress disorder. European Journal of Psychotraumatology, 11(1), 1807703, DOI: 10.1080/20008198.2020.1807703

Lyons-Ruth, K. (1998). Implicit relational knowing: Its role in development and psychoanalytic treatment. Infant Mental Health Journal, 19(3): 282–289.<282::AID-IMHJ3>3.0.CO;2-O

Lyons-Ruth, K. (1999). The two‐person unconscious: Intersubjective dialogue, enactive relational representation, and the emergence of new forms of relational organization. Psychoanalytic Inquiry, 19: 576-617.

Maturana, H.R. and Varela, F.J. (1987). The Tree of Knowledge: The biological roots of human understanding. Shambhala.

McNeill, W. (1995). Keeping together in time: Dance and drill in human history. Harvard University Press.

Ogden, P., Minton, K., & Pain, C. (2006). Trauma and the body: A sensorimotor approach to psychotherapy. Norton.

Pikovsky, A., Rosenblum, M., & Kurths, J. (2001). Synchronization: A universal concept in nonlinear sciences. Cambridge University Press.

Sander, L. W. (2002). Thinking differently: Principles of process in living systems and the specificity of being known. Psychoanalytic Dialogues, 12(1), 11–42