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[Infographic] – Three Warning Signs of Structural Dissociation

35 Comments

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

Title: Three Warning Signs of Structural Dissociation 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 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: 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 Ambivalence 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: 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 Indicators 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: 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.

Click here for the text-only version of the infographic
Title: Three Warning Signs of Structural DissociationAdapted from Janina Fisher, PhDStructural 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 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:

  • Full color
  • Print friendly

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

Working with Dissociation

 

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Related Posts: Healing Trauma, Infographics, Trauma, Trauma Therapy

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35 Comments

  1. Anonymous, Another Field, GB says

    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

    Reply
  2. Maureen Wagner, Other, Novato, CA, USA says

    Thank you for the overview. Very Clearly articulated, well organized, and intriguing. I look forward to additional workshop training!

    Reply
    • no no, Coach, AF says

      No

      Reply
  3. Pamela Peyton, Other, Memphis, TN, USA says

    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

    Reply
  4. Suzanne Bigras, Another Field, CA says

    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.

    Reply
  5. Yael Mailiniak, Medicine, IL says

    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…

    Reply
  6. Kate Starr, Another Field, AU says

    Great insight, research, awareness. Thank you for sharing knowledge

    Reply
  7. Carol Kilp, Other, CA says

    Excellent

    Reply
  8. Sheila Murray, Counseling, Choteau, MT, USA says

    Thank you, great information!

    Reply
  9. S DW, Coach, ZA says

    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.

    Reply
    • Anonymous says

      Agree, with the replies to original comment.

      Reply
  10. Carol Kilp, Other, CA says

    Thank you 🙏

    Reply
  11. A S, Other, CA says

    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.

    Reply
  12. Nando Raynolds, Psychotherapy, Talent, OR, USA says

    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

    Reply
    • Rachelle Maxwell, Health Education, GB says

      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.

      Reply
      • Anne Ober, Hamilton, VA, USA says

        Mine lost out to chronic anxiety then like nothing. Called it paranoia schiz.
        I fear Alzheimer’s losses.
        Just sharing helps.

        Reply
  13. Anonymous says

    Thanks. Helpful with the examples.

    Reply
  14. Steffany Caldwell, Another Field, CA says

    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.

    Reply
  15. Delia Garigan, Coach, USA says

    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…?

    Reply
    • Delia Garigan, Coach, USA says

      Instead of “BPD”, I should’ve specified that I meant “borderline personality disorder”

      Reply
  16. Patricia Fairclough, Counseling, GB says

    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.

    Reply
  17. Chris Hagen MSW RSW, Psychotherapy, CA says

    Your infographics are terrific! Always informative and concise, well illustrated. Thank you for providing them.

    Reply
  18. Anneliese Knop, Counseling, Huntsville, AL, USA says

    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.

    Reply
    • Lijn Schutte, Teacher, NL says

      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

      Reply
      • Lijn Schutte, Teacher, NL says

        Sorry, I meant to say: n.i.c.a.b.m
        National Institute for the Clinical Application of Behavioral Medicine

        Reply
    • NICABM Staff, CT, USA says

      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!

      Reply
  19. Mary O'Neill, Psychotherapy, IE says

    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!

    Reply
  20. Jussara Arundel, Student, AU says

    ‘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.

    Reply
    • Chris Hagen MSW RSW says

      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.

      Reply
      • Brad Bergman, Other, CA says

        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…

        Reply
  21. Britta Neinast, Social Work, South Bend, IN, USA says

    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

    Reply
  22. Jennifer Marsh, Student, AU says

    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.

    Reply
  23. Liz Hargraves, Teacher, NZ says

    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?

    Reply
    • Jennifer Marsh, Student, AU says

      I think it’s just an easy & brief way of explaining it in an infographic, that’s all. Not meant to be disrespectful. Jen.

      Reply
      • Michael Nixon, Student, NZ says

        It works for me

        Reply

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