539. Dissociation is a normal human experience, but when it's outside of normal limits, it can be dysregulating. In this episode, Dr. Monica Johnson and Alexandra Mejia look at the signs of structural dissociation, the importance of building a baseline of coping skills, and the need for trauma-informed, integrated therapy (like DBT and somatic work) for long-term healing.
539. Dissociation is a normal human experience, but when it's outside of normal limits, it can be dysregulating. In this episode, Dr. Monica Johnson and Alexandra Mejia look at the signs of structural dissociation, the importance of building a baseline of coping skills, and the need for trauma-informed, integrated therapy (like DBT and somatic work) for long-term healing.
Learn more about Sasha at her practice, MindfulInsightsMHC.
Find a transcript here.
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[Computer-generated transcript]
Dr. Monica Johnson: I am so happy to have Sasha with us today to talk about structural dissociation. This may be a topic that you haven't heard about before, but I'm sure you've heard about dissociation because it's been something that I've been seeing more and more in the mental health community. So I am so pleased to present our guest today.
Sasha, can you please give people an introduction to who you are?
Alexandra Mejia: Absolutely. Thank you so much, Monica. Alexandra Mejia, everybody calls me Sasha. I run a private practice. It's a teaching private practice that specializes in working with complex trauma, dissociation, and personality disorders, which, believe it or not, that whole group really does kind of go together hand in hand. And I specialize in working with structural dissociation as a model to help reintegrate pieces of my clients' personalities.
Dr. Monica Johnson: Mm-hmm.
Alexandra Mejia: A whole.
Dr. Monica Johnson: Yeah. And before we get into the structural dissociation part, can you just give us a general kind of working definition of dissociation as a starting point?
Alexandra Mejia: Absolutely. Dissociation is actually a biological tool that we all have, and we all use it in situations. And it can span from something as mundane as daydreaming or highway hypnosis to dissociative identity disorder, where you have these very strong dissociative parts that experience memory loss when they're activated.
So there's a great spectrum, and in the middle of that spectrum, , is where a lot of the trauma is—right where we might feel like we can't connect with our own bodies or we feel like things are foggy around us and unreal. Or possibly even have pieces of memory missing from our day-to-day, right? So we might have left our keys somewhere, and then they show up somewhere else, and we're like, how?
When did I move them? Type of.
Dr. Monica Johnson: Yeah.
Alexandra Mejia: Yeah.
Dr. Monica Johnson: How does structural dissociation start to relate to this?
Alexandra Mejia: So structural dissociation occurs when there is a trauma history or a lot of what we call toxic stress throughout childhood. And, you know, our developmental period, , toxic stress can become complex trauma over time, , if there's nothing secure in the child's life throughout their childhood.
And so what happens is a toxic stress period occurs, and part of your personality dissociates from you to help you survive that time period. So if, let's say, this child's toxic stress is that the parents are always fighting every day—they're fighting, fighting, fighting—and the dissociative part might have the child's guard up so that hearing that doesn't impact them as much, right? So that numbness is actually a part trying to protect that child that then later in life snowballs into something that is very dysregulating or not helpful in adulthood.
Dr. Monica Johnson: Right. And with the dissociated part, what should they be looking for? Should it be something like numbness if someone was trying to figure out if they had dissociated parts?
Alexandra Mejia: So there's, in the structural association model, five different parts that you can keep an eye out for. The general sense is that when triggering happens, there's a switch that's kind of flipped in you, right? So you'll go from 0 to 60 or 60 to 0 right away, right? So you might be in a situation, you're out with a friend, and the friend says something that you know is innocuous to anybody else, but for you, it might trigger a neural network in your brain that's traumatic, taking you back to that time period. And all of a sudden, you're in tears.
Dr. Monica Johnson: Yeah.
Alexandra Mejia: And maybe you're speaking with a baby voice, and you're like, "Why did you say that?" So it's
evident. It's like a very switchy type of thing that happens, and I see this happen in sessions a lot where a client will come in and they'll be themselves, and then all of a sudden I ask a particular question, and they're just like, "Why would you ask me that?" Ah, you know, like really like just almost like a different person is in front of me. And for people that are trying to identify this in themselves, it's sometimes hard because they might not see themselves. So it's good to ask people around you, "Do you ever see this in me?"
Dr. Monica Johnson: When you say, "See this in me," kind of that personality switch that you're talking about, or kind of like the emotional liability of going from like zero to 60 or 60 to zero.
Alexandra Mejia: Yeah. So it's almost like, you know, during a conversation when I get upset, does it kind of seem like I'm a different person?
Dr. Monica Johnson: Mm, sure. Yeah. You alluded to there being kind of five different categories. Can you say more about those?
Alexandra Mejia: Yeah, absolutely. So there's, and they're all based on trauma responses or fight-flight responses type of things, right? So we have the fight parts, which are combative either to ourselves or to others. So these parts might say things like, "They're trying to hurt you," or "They're out to get you," or you're, "I'm bad," or "I should be ashamed of myself," or "I'm wrong." It's all because of me, right? So these are kind of the fight parts. Then there are flight parts, which can be those parts that might possibly dissociate to get away from situations. They might be suicidal because they're trying to get away from all their problems, right? Running away, hiding, things of that nature, those kinds of behaviors. Then we have our freeze parts. These are the parts that make us just quiet, silent—a lot of dissociative features here as well in terms of you just kind of freeze up like a deer in the headlights, right? Your boss comes into your office, and you're all of a sudden just like myself, right? Type of thing. We have our submit parts, lots of Ss, lots of Fs—not Ss, lots of Fs. Then we have the submit parts, which are those people pleasers, right? So we're submitting to protect ourselves.
So if it's a child, they might just do whatever to, , not get in trouble or not get hit or not get yelled at, right? So the submit part might come home and do all of the cleaning and anything they could think of just to make sure they don't get yelled at. , their mom comes home, "Oh, look, I did all of this and all of that." "What do you need me to do? Something else, type of thing. Right?"
Dr. Monica Johnson: Mm-hmm.
Alexandra Mejia: And then we have the cry for help parts. These are the most vulnerable parts. , they're usually very young parts, and the behaviors are crying, reaching out, , you know, overly being concerned about people not liking them, things of that nature.
Dr. Monica Johnson: And with these different parts, because they're aligned with survival responses, I'm assuming that a person may not see themselves in all five of the categories, that there may be like one or two that they're more strongly aligned with.
Alexandra Mejia: It is possible. Yes. And on the flip side, it's also possible that they'll have multiple parts in some of the categories.
Dr. Monica Johnson: Mm-hmm.
Alexandra Mejia: I had clients with three fight parts, two submit parts, right, a freeze part, and so on and so forth. So there's really no limitation of how these parts can present.
Dr. Monica Johnson: Mm-hmm.
Alexandra Mejia: On the amount of toxic stress and complex trauma that they've experienced.
Dr. Monica Johnson: Mm-hmm. Are there, I know you've mentioned trauma and also personality disorders. Are there any other diagnoses that you normally see as it relates to structural dissociation?
Alexandra Mejia: Depersonalization-derealization disorder fits into this dissociative fugue, dissociative identity disorder, what we know as DD, NOS, which is dissociative disorder not otherwise specified. So all of these dissociative disorders tend to be in the realm of structural dissociation, so a lot of the time they present without PTSD symptoms.
Dr. Monica Johnson: Mm-hmm.
Alexandra Mejia: Right. So, and another thing is they're often confused with psychotic disorders because there's a lot of internal talk, internal talk that sounds different from the person themselves.
Dr. Monica Johnson: Well, I'm assuming if you have a highly critical voice inside your head, it may sound different from you or may be someone's voice that you recognize, that represents that critical voice.
Alexandra Mejia: Yes, absolutely. I've had a lot of clients who are like, "Oh yeah, that's my mom's voice in my head," or "my sister's voice in my head," or "my dad's voice." Yeah. Or like an ex, even if the trauma came from a prior romantic relationship. Yeah.
Dr. Monica Johnson: So if I have an awareness that I have these parts, because I know you mentioned that you may have a patient with like three fight parts and two submit parts, is the goal just to amputate all of these parts and get rid of them?
Alexandra Mejia: No, no. It's actually the opposite. The goal is to reintegrate the parts to create a sense of wholeness within you. And that's not as easy as it sounds, probably, right? Because
Dr. Monica Johnson: Oh, it sounds pretty hard. So.
Alexandra Mejia: 'Cause you're now just working with the whole, right? A lot of you go to therapy and you're working on your whole self, right? To heal you from depression or anxiety, right? But here you're possibly working with 5, 10, 15, or 20 different parts, and you're trying to integrate them all into the one client that's in front of you, if that makes sense.
Dr. Monica Johnson: Yeah. How does the person, I don't know, distinguish between the part and the whole? Is there a way for them to tap into that?
Alexandra Mejia: Yeah, absolutely. And you can use language from different therapeutic modalities, right? You can use DBT language, saying when you're in Wise Mind, that is your true self.
Dr. Monica Johnson: Mm-hmm.
Alexandra Mejia:: You can use trauma language saying, you know, being in the window of tolerance, right? That's your true self. Because when we are triggered, we're either going into the sympathetic fight-flight or into the parasympathetic shutdown mode, right? So we're going to be outside of that window of tolerance or the wise mind state. If we're talking about mentalization language, we're mentalizing effectively, right?
We're in an effective mentalization state. So, depending on what language you want to use or how you want to look at it, it is the idea of feeling grounded, present in the moment, and being able to feel your emotions and rationalize at the same time. See all different angles of the story, different perspectives, rather than just kind of a one-track mind.
Dr. Monica Johnson: Spoken to a couple of times that, and you brought up the language of the window of tolerance specifically, and you've described kind of hyperarousal versus hypoarousal. Do you have any suggestions for either one of those extremes?
Alexandra Mejia: Like skills to use?
Dr. Monica Johnson: Yes. Skills? Yeah. Yeah.
Alexandra Mejia:: Oh, absolutely. I mean, any grounding skills from any modality you want to pull from DBT or RO-DBT are really good for either of these, right? So when we're grounding ourselves, we're literally just feeling our feet on the ground or touching something or connecting with something that's real in the world. So that we can bring ourselves into that window of tolerance again, calm our emotions or increase our energy so that we can be present again. And so the basic grounding exercise would be to just plant your feet on the ground, whether you're sitting or standing. If you feel comfortable, close your eyes and just focus on the sensations of the bottoms of your feet, the tops of your feet, noticing anything wrapping the feet, and just engaging with those sensations so you come back into your body and back into the present moment.
Dr. Monica Johnson: I'm gonna assume that a lot of people maybe struggle with meditation or grounding. Would you suggest anything as a starting place for them? You know, 'cause sometimes it can be difficult, especially for longer spans of time, to do this sort of thing. Or maybe you're confused even on just how to do it.
Like, you know, in terms of are there groups that you would suggest, or YouTube channels or anything that could maybe be an extra tool?
Alexandra Mejia: Yeah, absolutely. There are so many mindfulness groups out there. My own practice is starting a therapeutic Sangha, which is a meditation community that helps you kind of practice more regularly and connect with others who are practicing. They have so many videos, from really brief videos that just help you learn to follow your own breath to, you know, just reaching out to a therapist who does mindfulness work and having them train you in sessions.
Dr. Monica Johnson: Yeah, I like what you said about the Sangha because so many patients describe feeling alone in their situation. Having a group setting where you can know that maybe people have similar experiences as you, and you're learning the same sorts of things, can hopefully allow you to be vulnerable together and grow together.
Sounds like it can be a healing experience on multiple levels.
Alexandra Mejia: Yeah, it absolutely can. I mean, community nowadays is hard to find sometimes, especially in big cities.
Dr. Monica Johnson: Mm-hmm.
Alexandra Mejia:: You'd think there'd be so much community in big cities, but everybody's like alpha themselves in their own nowadays, and it's hard.
Dr. Monica Johnson: Mm-hmm. Yeah. And are there any things related to hyperarousal that you would suggest? Because I know that when I go back and I'm telling people about structural association and we talk about hyperarousal, some people get so flooded and overwhelmed that the numb side of things can feel like a relief, just not being able to feel.
But when you're fully hit with that full impact of emotion, it can really drive people into the ground, so to speak.
Alexandra Mejia: Yeah. And this is really up to the therapist to lead the sessions in an effective way. It's not recommended to just straight jump into structural dissociation or any type of trauma work right off the bat, right? You're done with intake. Let's do trauma work. Like that doesn't— You have to learn the meditations, the coping skills, the relaxation skills, the breathing skills.
All of that needs to be done prior to starting this work because it is so easy to get triggered. I've had clients bawling and having panic attacks during intake, just briefly being exposed to a traumatic memory. Imagine just jumping in there right away. That's only gonna re-traumatize the person.
And that's also why, you know, it's to do this kind of work for yourself as like a self-help thing, but it's not recommended because you are not gonna know when you're necessarily ready to move on to that work. Are you gonna have the, you know, the motivation to practice all of these skills and know when you're like, "Yeah, I have enough skills to go and do this and not re-traumatize myself," if that makes sense?
Dr. Monica Johnson: Well, and what you said about being ready is like a curious thing because sometimes, , people will say like, being ready means that I'm not triggered by my trauma, so I'm ready to approach the trauma, and I'm kind of like, wait, that's not really how that works or what that means. Being ready may just mean that I have the necessary kind of spaciousness or capacity that I've built up with my therapist to be able to approach this and use skills when I do feel myself starting to get triggered.
Alexandra Mejia: Yeah, and it's important to reiterate that triggering can be dissociative, not energizing. Right? So, like, triggering can shut you down; you can feel so triggered that you are always shut down and don't even realize it. Right? I have several clients I'm working with who are in session and kind of just very numbed out, never cried a day, and are, you know, working through their careers together. Never really, they're talking about a friend being murdered as though it's what they had for lunch yesterday. That's not readiness; that's numbness. Right? That's dissociation in and of itself.
Dr. Monica Johnson: For sure. You've talked about the skill of the therapist, and part of what I'm picking up on what you're saying is you need a therapist with a high level of skill and understanding of these things. But I'm also picking up that this can be longer-term work. This is maybe not something you're gonna show up for three months and then we're done.
Alexandra Mejia:Yeah. Yeah. And this is, you know, something that you might be doing post-EMDR even, right? Like, you'll work through EMDR to really process some of that memory. But the structural dissociation might still be present, so you might continue that work into your structural dissociation to really bring everything together.
Dr. Monica Johnson: I mean, one of the reasons why I am an integrated therapist is exactly what you've been talking about, is that you kind of have to be a Swiss Army knife so that you can tailor the experience to the person that you're working with. And so sometimes if we are a therapist that's trained in one modality, we tend to lean into that
one, where we may kind of start to have a one-size-fits-all approach, sometimes with things that are a lot more complicated and nuanced. You know, I have certain modalities that, like, basically they're in everything that I do foundationally. I would say DBT is like that for me, but then, you know, it may be DBT and EMDR and IFS for this person over here; it may be DBT and cognitive processing therapy or prolonged exposure for this person over here.
Based on their traumatic experiences, their PTSD, and their symptomatology that is showing up, you really have to tailor it to what you see coming up in real time.
Alexandra Mejia: Absolutely. A hundred percent. And my practice also kind of structures within DBT and mentalization and then builds around depending on the client's needs. With dissociative clients, whether they have trauma like PTSD-type trauma or personality disorders with dissociative features, there has to be a baseline that we start with. Because again, we're not going to go into the trauma work right away. So what do we do first? We build the baseline for the client to stand on their own two feet when they're exploring the trauma in whatever method we choose to. Does that make sense? Does that make sense?
Dr. Monica Johnson: Oh yeah. Yeah, yeah, yeah. Well, you've definitely convinced me. I really want to ask, if people are looking to do this kind of work, where can they find you? You know, you mentioned the SGA, it sounds like you're also seeing individual patients. Please give us all of the information.
Alexandra Mejia: Sure. Yeah, I have a website, InsightsMHC as in “Mental Health Counseling” dot com. I have a group practice; it's a teaching practice. All of my clinicians are trained in DBT and RODBT and mentalization. Those are our groundwork, right? As well as structural association and sensory motor psychotherapy. This is the integrative work that we do as a staple. Our clinical residents, who are the students that we work with, offer lower-fee sessions for people who are uninsured or underinsured or have high deductibles or whatever. I have a couple of other clinicians that work with me, all trained in these modalities.
You can find us on Facebook as Mindfulness with Sasha and on Instagram as Mindful Sasha. Yeah, I don't know if I missed anything yet. Oh, we're also now offering ketamine-assisted psychotherapy via myself. I am offering that in group format as well as individually. I'm available to do it in person in Connecticut, 'cause that is where I am based. But I'm also offering it virtually in New York, Vermont, Delaware, and Florida.
Dr. Monica Johnson: I just want to say thank you so much for sharing your expertise with us. Um, I'm sure there are some listeners that are going to resonate with what you are talking about today and now know that their experience is not strange; they are struggling with dissociated parts, and it would be very helpful for them to potentially seek services from someone like you.
And just so that everyone knows, because we are using terms like mentalization-based therapy and sensory motor therapy, these are all different types of evidence-based practices for trauma that address trauma at the cognitive level, the behavioral level, and also somatic therapies—everything across the board. And I think that's the, you know, when we talk about being integrated, being able to have treatments that can meet a person where they are makes a huge difference.
Alexandra Mejia: And I just want to add for all the folks listening who are relating to this: There's nothing wrong with you, right? Dissociation is a normal part of everybody's experience. Surgeons dissociate during their surgeries so that they can get through their surgeries. Athletes dissociate when they are at their peak performance, musicians dissociate on stage to just, you know, keep it moving and focus. So there's nothing wrong with you. Your brain and body are doing exactly what they were built to do, and the stigma around it can be quite painful and often prevents people from seeking help. So I just wanted to add that in there as well.
Dr. Monica Johnson: For sure. I'm always talking to patients about the idea of within normal limits; it's like everybody dissociates, and when it's within normal limits, it's not an issue. You are here because it's outside of normal limits and it's getting in the way of you being your full self and having the experience of life that you want to have.
Alexandra Mejia: Yeah, absolutely.
Dr. Monica Johnson: Again, thank you so much. I enjoyed this conversation, and everyone, please choose whether you visit the practice or visit the Instagram. Please hit up one of those links and get some more information about structural dissociation.
Alexandra Mejia: Thank you so much, Monica.