For Clinicians
Start using the TSD framework with your clients today
The 5-Minute TSD Guide
Recognize Survival Mode
Look for signs: hypervigilance, numbing, anger/fight response, shutdown, relationship patterns
Validate the Protection
"Your nervous system learned this to keep you safe. It's not broken—it's protective."
Ask the Key Question
"Are you in actual danger RIGHT NOW, or is your system reacting to an old threat?"
The Three Assessment Questions
"Who feels in charge of your life right now?"
Assesses Core Self vs. Survival Self governance
"Where do you feel that in your body?"
Connects cognitive experience to somatic reality
"Does this remind you of anything from your past?"
Links present-tense reaction to historical threat
Clinical Assessment Toolkit
TSD Screening Questions (Use in Intake)
"When did you first notice these symptoms? What was happening in your life at that time?"
→ Look for trauma, loss, threat onset
"Do you feel like YOU having emotions, or like something happening TO you?"
→ Assesses Altered Sovereignty (Criterion 1)
"Where in your body do you feel [anxiety/depression/rage]?"
→ Connects to Somatic Dominion (Criterion 3)
"Are you in actual danger right now, or is your nervous system reacting to an old threat?"
→ Identifies Temporal Collapse (Criterion 4)
"Do your emotions come in waves, or feel trapped/frozen in your body?"
→ Assesses Neurobiological Recalibration (Criterion 2)
For "Bipolar" Presentations - Critical Questions
• "How long do your 'manic' episodes last?" (hours/days = TSD; weeks = bipolar)
• "Do mood shifts feel random or reactive to triggers?" (reactive = TSD; random = bipolar)
• "Do medications help?" (no response = consider TSD)
• "Trauma history?" (if yes + above patterns = strong TSD indicator)
Sovereignty-Focused Therapy Protocol
Phase 1: Provisional Government (Sessions 1-8)
Establish therapeutic alliance, co-regulation, psychoeducation using Internal Kingdom model
Modalities: Somatic resourcing, pendulation, psychoeducation
Goal: Client understands Core Self vs. Survival Self
Key intervention: "Your nervous system is doing exactly what it was trained to do. It's not broken—it's protective."
Phase 2: Constitutional Convention (Sessions 9-24)
IFS, Somatic Experiencing, parts work to dialogue with Survival Self
Modalities: IFS (parts work), SE (somatic completion), EMDR (if appropriate)
Goal: Survival Self unburdening, discharge trapped activation
Key intervention: "What is this part protecting you from? Let's help it know the threat has passed."
Phase 3: Sovereignty Restoration (Sessions 25+)
Core Self restoration, flexible governance, Survival Self as advisor
Modalities: Integration work, relapse prevention, life visioning
Goal: PostTSD (Integration) state achieved
Key marker: Client says "I feel like myself again" or "I'm in charge now"
First-Line Modalities: Somatic Experiencing®, Internal Family Systems (IFS), Sensorimotor Psychotherapy, Neurofeedback. Pharmacotherapy as bridge (not cure) to reduce autonomic intensity while doing the work.
Billing Codes & Documentation
Primary Diagnosis Code
309.89 (F43.9) - Other Reactions to Severe Stress
Use for TSD. This is the closest current DSM-5 code. In documentation, specify: "Trauma and Stressor-Related Disorder, presenting with [Altered Sovereignty/Oscillating Survival States/etc.]"
Documentation tip: Use TSD language in clinical notes while using F43.9 for insurance. Example: "Client presents with F43.9, manifesting as Survival Self governance with hyper-arousal oscillation."
Differential Diagnosis
If considering F31.9 (Bipolar, Unspecified): Complete bipolar-TSD assessment first
If presenting with "personality disorder" features: Consider TSD with specific Survival Constitution (Abandoned Monarchy, Fortress City-State, etc.)
If "treatment-resistant PTSD": Likely TSD (Active) - Survival Self still governing
Progress Note Template
S: Client reports [hyper/hypo-arousal symptoms]. Identifies [triggering event].
O: Presents with [somatic signs]. Survival Self activation observed.
A: F43.9 (TSD, Active). Survival Self governance maintained. Core Self accessibility: [low/moderate/high].
P: Continue [SE/IFS/etc.]. Focus on [somatic discharge/parts work/sovereignty restoration]. Next session: [date].
Clinical Case Example (Composite)
Initial Presentation
Sarah, 34, referred for "Bipolar Disorder, Unspecified" (F31.9). 3 hospitalizations for "mania," 2 suicide attempts during "depressive episodes." On lithium, quetiapine, lamotrigine. "Treatment-resistant." Therapist focused on mood tracking and medication compliance.
TSD Assessment Reveals
- • Trauma history: Severe emotional neglect ages 4-12, mother with untreated mental illness (unpredictable), father absent
- • Pattern: When alone = terror (depressive shutdown). When connection available = frantic energy to secure it ("manic" pursuit)
- • Altered Sovereignty: "I don't control my moods, they control me"
- • Somatic Dominion: "The crash after mania feels like my body is dying. Depression isn't sadness—it's a physical weight."
- • Temporal Collapse: Manic episodes involve fantasies of "finally being chosen." Depressive = reliving childhood aloneness.
Reframe & Treatment
New diagnosis: 309.89 (TSD, Active) with Oscillating Survival States, Abandoned Monarchy Features
Phase 1: Provisional Government - therapist as stable presence, co-regulation
Phase 2: IFS to work with "Manic Protector" (trying to secure connection) and "Depressed Exile" (the abandoned child)
Phase 3: Somatic completion of "reaching for mother" gesture that was never completed
Outcome: Medications gradually reduced. Mood stability without polypharmacy. PostTSD (Integration) achieved after 18 months.
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