Working with structural dissociation can be critical in the treatment of severe or prolonged trauma . . .
. . . but it’s often difficult to detect.
According to Janina Fisher, PhD, structural dissociation is commonly underdiagnosed, or it’s misdiagnosed as a personality disorder. And when left undetected, it could lead to ineffective treatments that stall progress.
So in the infographic below, we’ve laid out three warning signs of structural dissociation.
Have a look.
Click the image to enlarge
Janina Fisher, PhD describes three explicit signs, or red flags, that can help you detect structural dissociation.
1.Paradox and ContradictionThe first red flag is when a client’s actions seem to contradict their desires.
This can be a signal that their attachment system is attempting to reach out for comfort while in the same moment their defense system is trying to protect them.
Examples:
- Your client alternately idealizes and devalues you as a therapist.
- Your client reports a certain phobia, but engages in actions that are counterphobic.
- Your client reports feelings of shame, but also acts superior to others.
2.Terminal AmbivalenceThe second red flag is when clients struggle to make decisions or won’t follow through on the decisions they have made.
This may look like self-sabotage, but this “stuckness” is actually the result of an inner struggle between the client’s desire and a part that’s afraid to take a step forward or be visible to others.
Examples:
- Your client struggles equally with decisions big and small – like where to attend college or where to go for dinner.
- Your client completes an assignment or task but is afraid to talk about it or show the results.
3.Somatic IndicatorsThe third red flag is when clients report bodily reactions that are unexpected or differ from the norm.
Dissociation can help clients disconnect their mind from bodily sensations – like pain during a traumatic event. But it can also disconnect them from other bodily experiences, like the effects of medications.
Examples:
- Your client reports that prescribed medications have no effect, or the opposite effect.
- A medication that is normally activating puts your client to sleep.
According to Janina, when a client is stuck with various treatments proving ineffective, and the client has a history of turbulent relationships with therapists, this is a likely indicator of structural dissociation.
(If you’re sharing this infographic, please attribute it to NICABM. We put a lot of work into creating these resources for you. Thanks!)
If you’d like to print a copy, you can use one of these links:
You can get more strategies like this one in the Advanced Master Program on the Treatment of Trauma.
The experts look at how dissociation plays out in the brain and nervous system, and how you can overcome some of the challenges of working with dissociation.
You’ll hear from Bessel van der Kolk, MD; Peter Levine, PhD; Pat Ogden, PhD; Stephen Porges, PhD; Janina Fisher, PhD; and other leaders in the field.
Now we’d like to hear your takeaways from this infographic. Please let us know in the comments below.
If you found this helpful, here are a few more resources you might be interested in:
[Infographic] Working with Structural Dissociation
A Three-Step Approach to Treating Trauma-Related Dissociation
I wonder if you might make a simple change to the language used. Would it be possible to change ‘warning signs’ to ‘indicators’ and ‘red flag’ to ‘cue’? I think the language we use can go a long way to destigmatising.
I really agree with this comment as someone seeking out treatment for this issue. Language used can indicate how I’m seen or going to be treated. But overall appreciate the work!
I’ve now finished the series. I found the final bonus (#6) with Kathy Steele very helpful. It closely follows a case I’ve been involved with for the last 12 years. In my case, the situation is quite different because the “client” is not in therapy and was my former partner. It’s interesting to see how my former partner has built a life that provides elements of revelation and coping. I hope she will one day come to the resolution that Kathy Steele’s client has. This situation is especially interesting to me because many people who could use therapy don’t get it, can’t find it, or don’t want it. The question is, how can we help these people as outsiders, even in serious cases such as the one I’m involved with? Another aspect that I wrestle with is how helpful are these coping mechanisms? We know that DID itself is a coping mechanism that is more about safety than progress. In my therapy (that is, therapy for myself) it’s been pointed out that my coping mechanisms have been more about prolonging hope than fostering change. These hopeful attitudes can be a kind of behavioral scar formation that creates protection, but forestalls change. I have yet to find that question answered.
I know from my personal experience, that hope has always been a big part in my trauma response. What I don’t know , because I haven’t had diagnosis or therapy yet, is whether it was a lack of hope that triggered trauma responses. If I’d still had hope and I could have got away, then I believe that would have meant change. So to me trauma responses allowed me to function where there was no foreseen hope in my normal part, had I not lost hope as a child, would I have been able to seek help from a teacher for example and get the protection (change) I needed. I think it depends on the time frame in the traumatic period / periods and the age of the child. What I don’t understand is, we can pull ourselves out for a bit as adults, but how do we stop going back if our trauma is ongoing?
And when I say stop going back, I mean stop having trauma response. Because dealing with trauma without trauma response is very very scary.
“Working with a Client with Mild Dissociation–A Case Study (bonus 5),” another great interview. The camera work in the video is screwed up, which isn’t professional, but that has no effect on the content. It’s great to hear Bethany Brand talk about hypnosis, as that’s my main modality. I’m aware of hypnosis in all my client sessions, but I usually reserve classic hypnotic induction for special times and special purposes, as Dr. Brand does. I would add to what she says by mentioning that if the client can help you create a hypnotically empowered, positive state, then you can use this as a foundation for a transformation of almost any kind. And you can do this with both severely and mildly dissociated clients.
“Working with a Client with Mild Dissociation–A Case Study (bonus 4)” finally gets to the meat of these issues. This is what I have come here for. I don’t understand why this session is called “mild’ because it’s full blown and horrific. But its emphasis is right what I’m looking for. I always draw out people’s parts, and find this even more important with those people who claim they don’t have any. For example, I have a client who’s successful in all regards, but is reticent in committing to having a family. When I finally connected with his injured child, we had our first break in what was otherwise his completely and successfully managed life. What I’m struggling with myself, as I mentioned before, is how to deal with a manifestly destructive and dishonest part. So far, I have found no guidance. I suspect I will continue to follow my intuition, which usually leads me in the right direction, but sometimes more quickly than I’d like. I think the key lies in managing my counter-transference. I’m working on how to do that without sacrificing authenticity.
Very interesting to listen to Stephen Porges. His polyvagal theory is now being recognized as a metaphor, not an explanation. My neurologist friends say “polyvagal theory” makes no physiological sense. But Porges’ description of trauma release sounds similar to that of Peter Levine. It is becoming evident to me that Porges is really a layering of a nervous system fiction on top of Levine’s sympathetic and autonomic nervous system model. Only at the end of the video does Porges make some reference to the vagus nerve, and it doesn’t add anything to Levine’s model. As a neurophysiologist myself, I could never understand how Porges’ theory gained adherent. I’ll be interested to learn if he can play the metaphore into something more substantive.
I found the short video on dissociation in couples therapy to be disappointing. Janina Fisher talks about bringing attention to couples parts, but this is more about conflict than disconnection, and it does not resolve these conflicts. I struggle with what to do when I identify a violent and destructive part. Some advocate attempting to “talk it down,” but I’m uncomfortable with giving it any power. As a result, I’ve lost several clients who refuse not to do violence. Jenine advocates a conciliatory approach, but I take a harder line. I feel that first the violence must stop. This is where the rubber meets the road, and this gentle talk about clarifying the part’s confused purposes does not address what to do when a part’s intention is both clear and destructive.
I’ve now watched the 3rd video in the series, and the 1st bonus video. I found Usha Tummala-Narra and Kelly Wilson’s insights interesting. In the 1st bonus I noticed, and this is probably true throughout, that the audio for Ruth’s segment was poorly produced. It is shrill, and the treble is too high. This is because the room in which it was recorded has too many perpendicular, undamped walls. You can fix this in post production by lowering the high frequencies, and during recording by erecting some stiff and absorbant walls, placed behind the microphone, that are not parallel to any other walls in the room.
Richard Edge — I’m a 100% Disabled Combat Veteran with spine & brain injuries causing emotional disregulation — mixed with severe full body nervous system damage. I can wholeheartedly agree this program depicts my Trauma responses the last 24 years. I live in what you describe as dissociated states frequently since my parachute accident — I can’t help it. my body responds to external triggers due to damage. it’s difficult to manage without accommodations & equally barely noticeable if accommodations are respected.
It is really good to see the difference between dissociation as opposed to structural.
I am seeing clear signs of this in one of my clients, but I’m thinking that she has moved more into parts than just dissociation. I can definately see her protector part & superior self & a little 6yo who is unable to speak because the protector is extremely vigilant.
it’s so interesting how the protector part sniggers behind hand when I call them out in what they are doing, almost like they are pleased they are being recognised. But this protector part is so strong that the core part is not aware of how volatile they are in social interactions & blames others for attacking them. I can definately see this is attachment mechanism seeking friends but attacks them the 1st glimpse of threat so their very desire for relationship is self sabbotaged…
it’s very very complex working with them!!
I’m getting great clarity in approach to working more effectively with them.
I really wish I could some way to help my husband. He will allow no help for himself and he is doing ok but bad. I can tell you this in layman’s views but a well researched and valid laymen. He had an extremely emotionally traumatic event he initially disassociated from and then some kind of personality break happened and developed multiple personality problems but internal monalogue and self perception problems with an inability to self regulate and identify internal issues and does not feel pain unless he accepts it and can disassociate at will I can see a complete change in entire self and personality through eyes. Lots of other issues but he has a complex IED kind of lifelong problem and a desire for complete perfectionist behavior which results in excelling greatly in work environment complete moral behavior as in he is defender to the weak and will protect at all costs will recklessly stand in front of any and all danger for anyone weaker. Has a moral high ground and tries to stay perfect so he can’t be corrected or wrong and he always knows everything not in a narcissistic reason but with self pride in hard work and being the leading source, but will take criticism and correction beautifully but usually works all problems intensely so no one ever sees weakness in him, he will get it right most times hisself he wants to look like the best but I swear it’s not narcissistic. So much more, but something changed, his personally inside is trying to come out and he fears it but he feels like weakness let’s it out and he thinks he found a way to weaken him, and his emotional disregulatiin is worse. He needs help but I can’t get him to take it. He is completely medication free and his adopted parents never helped him really and had a medication free life. He lived this way alone but it was a hard life.
Hi
It would be really helpful to have this for children so that anyone who is in a position to observe children can spot red flags. For example early educationalists, Doctors, teachers etc. If we generate awareness of dissociative symptoms whilst infants and child’s minds are still developing we may just catch it early enough to avoid this in adulthood. We have DID and it’s our mission to help spread the word so that little children are supported and appropriate interventions made available
Thank you for the overview. Very Clearly articulated, well organized, and intriguing. I look forward to additional workshop training!
No
Very informative,reminding me of myself.I’ve rejected therapist once.I thought she was just a bookworm
with no life experiences, I was very wrong, she was the best therapist I’ve ever had. Thankyou
well now this is interesting. as a person with developmental Trauma, I am more and more confused.
I have had so many diagnoses and types of treatment. my latest was ADHD. although a very small dose of Ritalin works ( 2.5 mg 2xa day) to motivate and keep me somewhat focused, I don’t believe its the full version.
Your info graph seems to show me that I can have all three of those responses.
I love your programs and have purchased a fair amount of them because there really is no qualified professionals in my area and our Canadian Mental Health system is a farce. If you are not Medication Compliant, then they do not want to care for you. You have to Pay over 120$ an hour and with Childhood Brain Developmental Trauma, it makes it difficult to even hold a job or a relationship never mind a paycheque that would accommodate that kind of wage for long term treatments.
So, thank you for more info and something else to ponder on how to work this thru on my onw.
Namaste and keep up the wonderful work.
Here I found an excellent explanation for ratdiness: Someone who has to be on time for an appointment decides to engage in another task just minuts before he/she needs to leave the house for that appointment…
Great insight, research, awareness. Thank you for sharing knowledge
Excellent
Thank you, great information!
I’m sure the infographic isn’t discounting neuroplasticity or quantum brain functions. It merely describes the dissociative state common to traumatised patients. I would say it’s often seen in personality disorders, such as BPD, even though the infographic sees it as distinct from these. I’m unsure why you want to call it ‘troubled egoic personality’. That seems a needless complication which may not help in treatment.
Agree, with the replies to original comment.
Thank you 🙏
Re: your infographic, it’s important to recognize somatic indicators as only one potential – we are still learning about genetics and the microbiome, and how they affect absorption and detoxification of medications.
As someone who talked about odd reactions to many medications for years (even so called regular medications such as acetaminophen) I breathed a sigh of relief to have had genetic testing and found some pathways were not working correctly. I knew they weren’t psychological, but to have proof for physicians and other professionals was validating.
Other than that caution, a fantastic resource, thank you.
I think part of it is that people who have pre-verbal or early trauma tend to manifest it as bodily symptoms (somatic manifestations) and emotions. There can also be an Alexithymia component.
I think these are great infographics you have been posting the last few days, thank you!
However, they suggest a binary system when actually the dynamics are usually much more complex. From an Ego State psychology perspective (the various kinds of parts work, from Psychosynthesis to Gestalt, Voice Dialogue, Internal Family System etc), everyone is a bundle of conflicting stake holders and habits that we try to lead and manage in a sensible way. In this view, dissociation is simply a period when the stress of an internal conflict overwhelms the self-management skills. Nando Raynolds, MA LPC
Thank you for this.
Hello, My Mum is 94. She married during the Second World War in Egypt to an English Navy Officer. My late Father.
He turned out to be a violent sadistic husband and Father. I am one of 4 siblings. We were 5 but at the age of 64 my brother took his own life. My memories of my Mum, from early childhood onwards are of a person who was never there. Physically yes but mentally unavailable. But she survived. I feel so guilty for her terrible life, but continue to try to make it up to her.
Mine lost out to chronic anxiety then like nothing. Called it paranoia schiz.
I fear Alzheimer’s losses.
Just sharing helps.
Thanks. Helpful with the examples.
Now I understand why, when I was in a dissociative state, alcohol had little to no effect on me! Makes perfect sense now! Thanks for that!
Also, I’ve been dealing with dissociation my whole life and I didn’t even notice the term ‘red flag’ used in the infographic — I actually had to give it another good look to find the words, so in answer to is the term offensive or triggering, I would say not — at least in my humble opinion.
Hi Kate,
I’m curious about this too! I have similar issues, including a mast cell condition, and have similarly had good results with somatic practices, therapy etc.
It’s fair to say that some of us are biologically (even genetically +/or epigenetically) primed to respond to life’s challenges more intensely than others. So we are predisposed to developing embodied trauma (including somatic dissociation as one option) as an adaptive response to our overwhelm.
I’d say if “somatic dissociation” per se gives you a framework for better understanding your psycho-physiology, then it’s relevant.
But it may be possible to experience yours & my symptoms simply as medical issues to be managed–issues which are related in some way to embodied trauma, and which are mitigated by body-mind/somatic therapies.
BTW, these “warning signs” in the infographic are behaviors that might also be associated with BPD (or ADD, in the case of being calmed by stimulants). I wonder if the lecture will explore reevaluating these conditions as being the result of embodied trauma…?
Instead of “BPD”, I should’ve specified that I meant “borderline personality disorder”
Thank you for sharing this is an interesting concept. I am looking forward to the next session of the Advanced Master Program On the Treatment of Trauma.
Your infographics are terrific! Always informative and concise, well illustrated. Thank you for providing them.
I am one of those rare blind counselors in the world, and while I love your webinars and videos I’ve never been able to access and benefit from your info-graphics. Would it be possible for you to add alt-text to them, or otherwise find non-visual ways of conveying the information so that I can use them, too? Thanks.
Hello Anneliese,
That is really impressive and important: the work you do. Congratulations!
Eventhough I think you make a very important point, and I am sure the a.n.c.a.b.m. will take it on, if you would like, and you think it would be helpfull to you in the meantime, I could read the infographics aloud for you, discribing them, in mp3-files and email them to you.
If you think that could help you out just now, please send me an email to:
onlijn@freeler.nl
All the best,
Lijn, Amsterdam, the Netherlands
Sorry, I meant to say: n.i.c.a.b.m
National Institute for the Clinical Application of Behavioral Medicine
Hi Anneliese,
Thanks for bringing this to our attention!
We have made this infographic more accessible and added a text version under the image version.
Thanks for bringing this to our attention and we hope this improves your experience as well as others!
These infographics (this and others received in last few days) are really clarifying and useful . Much appreciated.
I hadn’t made the ‘red flag’ association till it was pointed out in the comments. But as it raises a red flag for some people and looks like it would be easy enough to delete those 2 words while leaving the meaning the same, would it be possible to do that and resend new edit?
Here’s hoping!
‘Red flag’ could be a triggering term because it is often applied in psychology to criminals & domestically violent offenders who display behaviour connected with the three stages of ‘The Cycle of Abuse’ pattern.
With all due respect, the term is far more generic than you suggest. It’s been used for at least 2 centuries, pre-dating psychology by a very long time. Do you have any studies or anecdotes about this being offensive? I’m curious about what your comment is based on.
Does the term ‘red flag’ not come from mail boxes? The postal worker would raise the red flag on the box to let the resident know there was mail so they wouldn’t have to walk to the end of the driveway to check. As such, a ‘red flag’ is simply an indicator that there is something warranting further investigation. The ‘mail’ in the box could be good, bad, inconsequential, a mix thereof…
Brad, I think the image comes from something like car racing where, if there is something amiss on the track, a red flag is brought out to ask everyone to slow down and proceed more cautiously than they have been until now. There is something similar used during fire season in CA and also on beaches when rip tides and other conditions need extra care from those using the forest or beaches and water. It is meant to keep everyone and everything safe through increased caution. As Chris Hagen noted, the symbol is far more generic than sometimes perceived.
Love this graphic, makes so much sense. It’s a powerful way to acknowledge the conflicting patterns clients experience with trauma rather than automatically attributing it to PD. Thank you! Britta Neinast, LCSW
Such an interesting infographic from Janina Fisher’s work. Simple, yet clearly impactful red flags that would surely cause ambivalence for a client within the therapy process…the ‘stuckness’ is almost palpable in those examples.
The language in this infographic and the way it represents the client who has structural dissociation is disrespectful in my view. The term red flag is a really horrible way to describe complex struggles, emotions, and coping mechanisms that a person may be showing. Where is the empathy, the compassion, and the understanding?
I think it’s just an easy & brief way of explaining it in an infographic, that’s all. Not meant to be disrespectful. Jen.
It works for me
I don’t hear the term as disrespectful at all, Liz. It is a red flag for the caregiver, not the client, and is meant to raise the caregiver’s awareness that something important and potentially dangerous for the client’s well-being and future progress may be being missed or misinterpreted. I suspect there are more than a few patients/clients out there who, if handed a small red flag upon entering the treatment space, and asked to feel free to raise it gently — or, if it feels right, to wave it madly whenever the caregiver misses something important or steps too heavily or quickly on(to) holy ground — might really love the image and recognize the compassion that stands behind it. Might be helpful in assisting some clients to signal where they are within their own widow of tolerance too even as it invites eventually putting things into words for the practitioner.
oops, window of tolerance, not widow!!!