[âUnlike traditional models of treatment, the assumption in neurobiologically informed trauma treatment is that clients are just as likely to be dysregulated by therapy than to feel âsafe,â more likely to come to therapy with limitations imposed by trauma-related hypo- or hyperarousal, sensitivity to triggering, and some degree of structural dissociation. The most complex regulating challenges are posed by clients with dissociative disorders and more severe structural dissociation (see Chapter 8 on Treatment Challenges: Dissociative Systems and Disorders).
Tessa came to her first therapy session with a very sophisticated question, âHow does one deal with the effects of attachment trauma in personal relationships?â But as she talked about her new dating relationship, it became increasingly clear that she was describing structural dissociation: âI really like him, but when weâre together, I start feeling very ambivalent. I begin questioning: should I have come on this date? Should I let him hold my hand? What if he becomes sexual?â
The picture she described suggested conflicts between several parts: a part that liked him and longed to be his girlfriend, a part that pulled away and began questioning as soon as things got closer, a part that wanted sex, and a part disgusted and frightened by the thought. âSo I keep my distance when weâre out taking a walk, but then I get home to an empty apartment, and I feel a longing for him, and I wish Iâd let him take my hand. I hate thisâI canât think about anything else at home, but then I get ambivalent in his presence.â
ME: âOf course itâs a battle âŚâ I knew that validating the normality of her internal conflicts would help her feel understood. âHow could it not be? This is what relational trauma leaves as a legacy: the terrible longing when youâre not together and a âyuck, donât get too closeâ feeling in his presence.â The âof courseâ is said with conviction but also a softness and sadness. âHow could it not be?â is said with a smile that normalizes and lightens it. âTerrible longingâ conveys the yearning in its tone; âyuckâ is equally spoken with conviction but also toughness. Both are expressed as if each is entirely normal and to be expected.
 âWhat generally happens next?â I ask.
TESSA: âI donât know ⌠I try to be honest about my ambivalence but at the same time, heâs all I ever think about ⌠Usually, these guys stop returning my texts and emails, and I donât know why, so I get very upset and keep texting to explain myself. And then I get brushed off. He isnât ready for commitment either, heâll say. But whatâs the âeitherâ? What makes him think Iâm not ready for commitment?â [Note that she is out of touch in this moment with the part of her that speaks openly to her dates about feeling ambivalent.]
ME: [Again, I mirror her words so she can hear herself better:] âSo the ambivalent part discourages him, and then the part that yearns for connection encourages himâthe guy must get very, very confused!â [Laughs softly.]
TESSA: âWhy do you keep talking to me like Iâm some multiple personality?â she suddenly says in a new gruff, irritated tone.
I use an authoritative but empathic tone: âBecause I can hear both sides in your story, Tessa. Both sides of you are there. This is what happens when we have relational trauma when weâre young: a battle starts up inside whenever we might possibly, maybe get close to someone.â [The last few words are said with a tone of regret or sadness.]
If clients like Tessa are willing to embrace the structural dissociation model, learn to consciously and voluntarily âsplit offâ the intense affects and assign them to younger, more vulnerable parts, they can achieve the necessary mindful distance to feel some relief without having to resort to denial or disconnection. Only when they are able to âseeâ the parts in these paradoxical responses will they be able to begin healing their wounds.â]
janina fisher, from healing the fragmented selves of trauma survivors: overcoming internal self-alienation, 2017