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
Adapted from Janina Fisher, PhD
Structural dissociation is often overlooked, underdiagnosed, or misdiagnosed as a personality disorder – all of which can be key reasons that a client’s progress stalls, or treatments prove to be ineffective.
So how can we more effectively recognize structural dissociation?
Janina Fisher, PhD describes three explicit signs, or red flags, that can help you detect structural dissociation.
- 1.Paradox and Contradiction
- 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.
The 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:
- 2.Terminal Ambivalence
- 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.
The 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:
- 3.Somatic Indicators
- Your client reports that prescribed medications have no effect, or the opposite effect.
- A medication that is normally activating puts your client to sleep.
The 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:
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:
This week in the Advanced Master Program on the Treatment of Trauma, we’ll be looking at expert strategies to identify and treat dissociation (even when it’s subtle).
It’s free to watch – you just have to sign up here.
In the session, we’ll 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.
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 do not buy into structural dissociation theory maybe with a TBI , shear injury or a severing of corpus C but even in those rare cases of the occurrence trust me the brain is plastic , compensates and communicates .
The brain cells are all connected ( both particles and waves)so this just doesn’t resonate. Ego is a tricky bugger the three “warning signs” for SD are a description of a troubled egoic personality. Paradoxical , ambivalence and being not in their body (totally mind identified) is just someone in the grip of ego.
All people with inferiority complexes behave like they are superior .
All egos are personality disorders ( haha).
This SD label may be used as an excuse when in difficult personalities one cannot find the source of ( childhood)trauma and/or the persons mind conditioning.
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.
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.
What is structural dissociation? I feel like I suffer from some of these but don’t consider myself traumatized.
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!
Hi Curiuos about this.
I was very ill with lots of integrated bodily trauma. I also had so much agitation I have Severe mast cell activation syndrome.
The anxiety and trauma activating my immune system severely to attack. This led to medications and food being extremely difficult to tolerate as I would react very badly to them. Dropping my blood pressure etc as the foods and the meds were seen as a threat.
I’m curious what category would that fit into. ? Somatic dissociation?
By the way after lots of hypnotherapy Constelation therapy and shamanic drumming as well as regular therapy. I am much much better.
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”
‘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…
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
Oh yes thank you Liz, for speaking up & out re this, my friends & I who are all compkex trauma survivor peer support activists were just ranting in our own community re this, its outrageously disrespectful & arroggantly condescending imo 😱🥺😫