Healing the fragemented selves of trauma survivors: overcoming internal self-alienation by Janina Fisher
Written for:
- Therapist who treat trauma-related problems like cPTSD, BPD, eating disorders, addiction, chronic suicidality and self-harming behaviors or dissociative disorders, including simple cases of DID but mostly OSDD
- people who have any of these problems based on childhood trauma or insecure attachment.
Special focus:
- working with ‘parts’
- healing attachment wounds
- ‘integrating’ mild structural dissociation through acceptance and care
- neurobiology and connections to body work
- the modern paradigm for treating complex trauma
What it is not:
- a proper guide to treating DID
- a concept that will work for more complex DID systems
- exposure therapy
- about RA/MC topics
Language: It is not the hardest thing I’ve ever read, but it needs an extended vocabulary. Non-native english speakers might have to look up words more often.
Book: Examples are mostly dialogues between T and clients that don’t go into any trauma details. I didn’t find it triggering. The theoretical foundation of this work is followed by structured tools. The price seems sensible.
Overview
Chapter 1: the neurobiological concept of structural dissociation is explained, with a focus on left brain-right brain differences (parts that are better with language and logic and everyday life and parts who remember thing exactly in a more emotional and nonverbal way). There is a solid list of signs of structural dissociation in patients that every therapist should know.
Chapter 2 explains why during TraumaTime it was adaptive to get used to being in stress responses. ‘Parts’ are introduced as trauma-responses that were established in the past and that can be triggered now. All trauma memories and responses are attributed to a ‘part’. So when there is something trauma-related coming up, it gets treated as a different ‘part’. The desidentificaction gives the part who manages everyday life some space for orientation and regulation.
Chapter 3 describes a major paradigm shift. Trauma patterns become adaptive resources for survival. Coping behaviors are no longer stigmatized. We move away from the idea that exposure therapy and having a complete narrative is necessary. The focus is on offering a space to experience safety and co-regulation while only working on ‘pathogenic kernels’, pacing the patient and offering grounding interventions instead of being a silent witness. Reactions are explained instead of just showing empathy. Working with the concept of parts and the body opens chances for integration that were not possible with old-fashioned trauma treatment. I think that every trauma T should read at least this chapter and get familiar with the paradigm shift that is happening. This is the future of trauma therapy for cPTSD.
Chapter 4 is diving deep into understanding structural dissociation and parts. They are divided into the different survival responses like attachment cry/cry for help, flight, fight, freeze and submit and going on with normal life. Misdiagnoses of these parts as other disorders are explained. We learn more about mapping an inner landscape and desidentification with ‘parts’ through mindfulness to help us manage the situation. The goal is acceptance and in that, integration.
Chapter 5: here it is all about changing our relationship to our disowned parts, finding compassion and understanding their role in the past and how to support them today. Internal attachment is placed over attachment to outside people. Goals in therapy are to ‘un-blend’ from other parts so work within the system becomes possible. There are details on how to solve problems where several parts trigger each other and create a knot of problems. (More)
Chapter 6: we learn about attachment in trauma and how to explain the different dynamics using the ‘parts’ language. Especially the pushing and pulling that is usually diagnosed as ‘borderline’ is explained in detail as an interaction between parts and it makes so. much. sense. Working with this could improve the therapy for BPD tremendously. It also explains all the attachment issues we will see in DID.
Chapter 7: addiction and sef-harming or chronically suicidal behavior is explained, why and how it is serving us and how different parts might be engaged. It can make the client look treatment-resistant when really it is structural dissociation. Another paradigm shift, from considering these issues as destruction seeking towards realizing that in truth they are relief-seeking. TIST is shortly introduced as a treatment concept that looks very promising.
Chapter 8: Fisher takes a deep dive into using her concept of survival response-driven ‘parts’ to treat DID and subforms. She offers help with diagnosing DID including how to interweave questions from the SCID-D into a conversation when the client is not stable enough to go through the rather long test.
The T works with the going on with normal life part to reduce the chaos and reach the parts stuck in survival responses. Many classic problems are covered with tools and examples.
Chapter 9: the clients resources are emphasized as skills to make sure the adult perspective is kept and the dysfunctional patterns of ‘parts’ are not encouraged. We find interventions from body work here as well as more instructions on how to communicate with the goal of building connection.
Chapter 10 has lots of practical examples how to manage different situations and integrate parts to become a team. There are step by step tools to foster connection and communicate through the body for a felt sense of safety and protection to ‘earn’ secure attachment.
Chapter 11: we learn about integration of trauma memories through the integration (not fusion) of parts and how to make use of our structural dissociation when it is needed. A deeper dive into earned secure attachment explains why these new experiences are healing the attachment wound of trauma without the need for exposure therapy.
After reading
I have deeply mixed feelings about this book. It seems to me that it is brilliant and lacking at the same time. Let me explain.
I would recommend this book and technique for the treatment of cPTSD and BPD without hesitation. It addresses the problem of structural dissociation in attachment and regulation where trauma-oriented DBT simply fails.
The paradigm shift, seeing trauma symptoms as a problem of structural dissociation instead of calling it other things, is so desperately needed I wish that everyone who treats traumatized people, no matter their official diagnosis, would read chapter 1-7, simply to get a proper understanding of what is even happening. This book offers both the theory and the tools for communication to help us move towards a stable life that is not hijacked by trauma responses all the time. It is especially good for people who experience a lot of emotional flashbacks without there necessarily being clear memories attached to it.
The problems start when the structural dissociation is more severe and the exact same tools are used to treat DID. I felt deeply disturbed how the theory was not adapted at all to accommodate the fact that parts in DID are more than ‘parts’ in cPTSD.
In DID, parts have autonomy, their own first person perspective, their likes and dislikes, wishes, talents, needs in the present etc. What was dissociated contains considerably more of the personality than the trauma fragments that are addressed in this theory. IFS had this big issue when used for the treatment of DID and Fisher didn’t solve that when she adapted it for trauma treatment. DID parts are more than the ‘parts’ described here.
DID parts are not limited to one survival response. Nor are they a survival response that somehow got stuck in the past. Some might tend towards a certain response more than towards others, but they can have different responses depending on the situation, just like any person. The tool for solving a knot of responses still works, but it has to be analyzed for the specific situation and the pattern might change.
DID parts are not limited to being emotional or stuck in trauma. They do have access to the prefrontal cortex and logical thinking, some are better at it than the hosts. It is not true that the host has to teach all DID parts everything because they can’t learn things about the present themselves.
DID parts are often able to be grounded in the present and use their own grounding skills to regulate themselves. At least those who are not too young. Littles often need the support of a care-taking part, but others do well on their own once they learned how. Pretending that only the host can help them can sound condescending. (More about action systems)
DID parts have problems beyond trauma. There will be disagreements and conflicts over how to live life, how to spend time or money etc. That will happen no matter how oriented they are in the present, it is the natural result of different DID parts sharing one life and body. It means that treatment has to go beyond what is described in this book.
DID systems are not always set up with one host. Some have several hosts, some have a whole team to manage the going on with normal life, some have no host at all. The approach that is introduced here fits best for systems with one high-functioning host and a limited number of other parts who are only active when triggered. It won’t work for polyfragmented systems or RA/MC survivors or systems that don’t fit the model. This book is not a thorough guide for treating all of DID. Its main focus is attachment and it is good at that.
DID systems are sometimes managed by the host, but often not by the host alone. The technique in this book heavily builds on the host who has to carry the full weight of the system. Many DID systems have their own helpers or care-taking parts. It doesn’t make sense to put it all on the host when there are parts whose specific job it is to be an attachment partner for younger parts. The idea of working only through the host will fail in DID. At best we get stuck, at worst the host gets traumatized and loses the ability to cope with life. It looks like the goal is to stop switching altogether. The host supports vulnerable part and receives support from protectors, but they are always doing everything. That is often not the way systems want to live their life.
Hosts in DID systems are more than going on with normal life parts. They have flashbacks, they struggle with emotions, they can have their own toxic coping strategies. It is not all other parts. In DID we know quite well what belongs to ‘us’ and what belongs to other DID parts. Because the definitions for ‘parts’ in this technique and DID parts are not the same, there will be major confusion when we get told that our emotions aren’t really our emotions. It feels like gaslighting and leads to a rupture with a T who suggests this. I see the need for a desidentification with strong emotions, but it cannot be done by calling the experience another part. It needs a different word. The word part already has a definition, our parts are distinct and consistent and more than a survival response. Call it shadows or wounded places or flashback or just the name of the stress response that is experienced, but allow hosts to have their own feelings and experiences. If we are taught it is all other parts, that is when we will develop a deep sense of being just a shell. The ‘unblending’ tool in this book needs to be changed considerably to make it work for a DID host.
DID systems don’t just struggle with ‘blending’. Passive influence is one topic we need to learn to manage, the other are the dissociative barriers that separate us so completely that we have amnesia but don’t know a thing about some parts and can’t even reach them to communicate. We already have too much desidentification. Again, it needs more than this technique to treat DID successfully.
Definitions of words in this book are confusing. It is not just that the definition of ‘parts’ does not match DID parts, other words that are commonly used in DID therapy are used in a different context with a different meaning (like ‘blending’ for passive influence or revolving door for mere switching). It is necessary to talk about the definitions of what we are trying to address here and make sure to agree on what it is supposed to mean. It drove me nuts to see established terms used with a different definition.
This book is all about acceptance, earning secure attachment and collboration. Child parts get grounded in the present and the new experiences are supposed to stop their trauma responses. I have Littles who are well oriented and attached and their flashbacks haven’t stopped. It makes me believe that it will need more than this approach to process the trauma.
Whoever longs for fusion, not just cooperation, will need something different too.
I guess this technique can be helpful in the stabilization phase of DID treatment, when it is properly adapted, but it won’t go far beyond that. Presentification is covered, identification and personification are not. Fisher makes it sound like this book is about treating DID but it is limited and in very few places, concerning DID, it is plain wrong.
My most interesting observation is that while the theory isn’t matching DID in these places, the actual tools are still helpful. Some need to be changed, like the unblending tool. Others, like the mapping log or especially the body work interventions will absolutely work for DID parts. A T who tries to explain DID with the survival response concept will probably confuse a DID patient, sooner or later. But when we are only introduced to the tools and exercises they will automatically make sense, given we have some contact with our parts. I would suggest not to talk too much and to just try the intervention. I truly believe that Fisher is treating DID successfully with these tools, even with flaws in the theory.
This is a lot of talk about why the theory isn’t perfect for DID and I know it can make the whole book look like it is no good. I actually think that huge parts of the book are close to brilliant and much much needed. The chapters that explain attachment problems, addiction and chronic suicidality are amazing and it will help trauma survivors to understand themselves, especially when they feel stuck in their own therapy or they were told that they are ‘untreatable’. If you can borrow this book and read only chapters 1-7 I would recommend you do it. If you have DID I would advise you not to read chapter 8 about DID and beyond because it could be very upsetting.
Those of you with cPTSD or BPD could benefit a lot from working with this technique. Therapists who work with this approach need to listen carefully to what their clients are experiencing and make sure to use their vocabulary and definitions and adapt tools where needed. We can’t ignore the work with parts when treating cPTSD and all this is a good foundation to start with.
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