Being Mindful of Mindfulness –Why Physios May Benefit From Understanding Dissociation:

Dissociation is a contentious issue, even within the psychological community.
That said, it may represent a missing link in how we understand physical health and rehabilitation.

At its most basic level, dissociation means disconnection.

It is most commonly discussed in the context of overwhelming anxiety and complex trauma. More recently, research has begun to explore dissociative traits in relation to neurodivergent masking and chronic nervous system load.¹

In my own practice, dissociation most often shows up in people who appear stuck in a freeze response — playing dead.
This is the nervous system’s last option when a threat feels too overwhelming to outrun or fight.

What might this look like in a physio setting?

Often, it’s not obvious.

People may find it extremely difficult to connect with parts of their body, particularly in the presence of pain, a sense of numbness (not in a reduced-sensation-on-neuro-exam way), or when asked to slow down or be still they may say things like:

“Focusing on my breathing makes me feel more panicky,”

while simultaneously tolerating moderate to very firm pressure and responding with:

“You can go harder — I can barely feel that.”

They may struggle with small, specific movements. A classic example is lumbopelvic dissociation or scapular protraction and retraction.
No matter how the movement is cued, they are unable to find a fluid transition between anterior and posterior pelvic tilt, or between scapular protraction and retraction, without compensating elsewhere (often by bending the elbows).

There may also be an emotional response to slowing down — tears when resting, when exploring baseline breathing patterns, or during small, mindful movements.

A broader context

In parts of Europe, FND, FSS, and dissociative conditions sit under the same diagnostic umbrella ².

With recent studies suggesting dissociative traits may be present in around 10% of the population, ³ it raises the question of whether we are seeing this far more frequently than the extreme presentations of FND/FSS or DID — just in subtler, less recognisable forms.

Why this matters in physio

How do we expect to create meaningful physical change if there is a fundamental disconnect between mind and body?

Physiotherapy relies on the mind’s influence over movement. Remove voluntary muscle control, interoceptive awareness, or cognitive understanding, and any change we create is likely to be short-lived.

This becomes particularly relevant when working with complex presentations.

The uncomfortable questions

What does this mean for DVA patients, many of whom present with significant complexity but only have funding for short sessions?

How do we shift the perspective from:

twice-weekly physio — manual therapy and heat packs

to something that may actually support longer-term change?

And perhaps more uncomfortably:
Is this even a shift our industry wants to make, when consistent funding models (including schemes like DVA) are what keep many private practices financially viable?

References:

^1. Campey, T., Gillies, J., Kate, M. A. (2025). Unmasking the Self: Investigating Dissociative Symptoms and their Relationship to Camouflaging in a Clinical Population with High Autistic Traits. Presented at ISSTD International Conference. Sourced from: https://www.notion.so/Unmasking-the-Self-Investigating-Dissociative-Symptoms-and-their-Relationship-to-Camouflaging-in-a--2935f5e4dd7080fd9ff1c06d19195001

^2. Cullinane, D. P., Durfee, A., Fleming, N., Barry, D. S. (2025). Functional neurological disorder and related conditions in healthcare provider education: A scoping review of teaching strategies and outcomes, Journal of Psychosomatic Research,192. https://doi.org/10.1016/j.jpsychores.2025.112102.
(https://www.sciencedirect.com/science/article/pii/S0022399925000662)

^3. Kate, M. A., Hopwood, T., & Jamieson, G. (2020). The prevalence of Dissociative Disorders and dissociative experiences in college populations: a meta-analysis of 98 studies. Journal of trauma & dissociation : the official journal of the International Society for the Study of Dissociation (ISSD), 21(1), 16–61. https://doi.org/10.1080/15299732.2019.1647915

**Edited with AI