Trauma and DID therapists commonly agree on working with a 3-phase-model. It describes an order in which to do work for the best, fastest and safest results. In an attempt to keep articles short we will share about the different phases in separate articles.
The 3 phases are
- Stabilization
- Trauma work
- Integration
Here is what you are supposed to be working on in phase 1
- get an overview of your problems
- find words for your treatment goals
- connect with your T well enough to work together
- get all the medical checks done (it’s important for good diagnostics to do brain scans and the like to make sure your symptoms are not caused by a physical problem)
- learn about your diagnoses, trauma, dissociation, DID and co-morbid disorders
- put together a safety plan
- put together a network of helpers
- reduce crisis and chaos in life
- learn how to be safe (outside) and feel safe (inside)/ safe place
- learn about the polyvagal ladder/ the window of tolerance
- learn about physical warning signs for hyper/hypoarousal
- learn skills for the body and mind to regulate yourself
- reduce symptoms (dissociation, depression, anxiety, substance abuse, self-harming behavior eating disorders, PTSD symptoms etc)
- learn containment for traumatic memories
- learn how to stop flashbacks
- realize that there is a difference between internal and external reality
- learn to discriminate
- learn to be more mindful and present/ use orientation&grounding/ anchors
- have safe and positive experiences in the present
- explore what brings you joy/ increase quality of life
- explore your talents/gifts and unique traits/ self-esteem
- learn how to identify emotions
- learn how to manage different emotions ( like anger, guilt, shame, sadness etc)
- learn breathing exercises
- improve body awareness
- reduce avoidance
- Improve self-care
- learn how to eat regularly and healthy
- improve sleep
- learn how to balance work/action and relaxation
- improve ability to focus and change focus when needed
- improve functioning in daily life
- learn life skills like managing your housework, finances and shopping, doctors appointments etc
- learn how to manage your time (keep track of it, plan, organize, prioritize etc)
- find stability/routine in self-regulation and daily life
- carefully expand your window of tolerance
- improve relational skills
- learn how to set boundaries
- improve ability to stand up for yourself
- overcome a victim mentality
- experience that vulnerability can be safe with your T
- learn how to make sense of your experiences
- ….
So far all of these points are Phase 1 work for cPTSD therapy in general, they just get more complex when you have DID because you have to include the whole system. You have to learn all these things together. It needs all of you to make you a stable system.
The following points are specific for DID and need to be kept in mind at all times
- accept that you have „others“
- overcome the fear of interacting with your parts
- map your system and get to know each other
- get better at communicating and cooperating with each other
- find compassion for yourself and your other parts
- reduce uncontrolled switching
- improve co-consciousness
- reduce amnesia/blackouts
- ….
This is a lot of work. It takes years, so don’t feel bad if don’t know all of this already.
During stabilization there is no trauma work happening. You can share things that come up with your T, but they would usually help you to contain it instead of working through it. You cannot skip learning self-regulation skills and hope to get through exposure therapy without harm.
We also want to emphasize the importance of learning how to enjoy life in the present. Chances are that you have little experience with that. Don’t skip finding out about it. You need to build a life that has as many positive elements as possible as a counter balance for all the terrible things in the past. We cannot recommend starting trauma work before having other, better, experiences to remind you of the good aspects of life. It is not all trauma!
Most of what we write about on this blog is phase 1 work. Most of it can be learned without a T, if you can’t find or afford one. It is hard work but if it has to happen you can make it happen!
When it comes to phase 2 you need to work with a therapist to avoid hurting yourself.
We really hope that we can encourage you to be thorough with stabilization. It is the foundation you build on. With a solid foundation all your future work will be easier.
(The list above is an adapted version of one published in „Treating trauma-related dissociation“ by Steele, Boon, van der Hart. If you are a T we recommend reading the whole book. If you are a patient this will not serve you much.)
Thanks for pointing out that being grounded in the present is a good way to start the healing process from trauma. My husband and I recently adopted a 13-year-old girl who apparently has had a traumatic experience that she isn’t comfortable sharing with us right now. Perhaps making her talk with a trauma therapy counselor can make her more comfortable in dealing with it.
you probably can’t ‘make her’, but I think it is a good idea to offer trauma therapy. Children and youth benefit from resolving trauma early. It spares them from developing more severe problems later in life.
As parents the best thing you can do is offer a normal life that is predictable and free of any form of violence. The more stability you can offer the easier it will be to integrate traumatic memory and return to a normal life. In that way you can do a huge job that is parallel to trauma therapy and just as important.
I know that your site is a goldmine, but I feel like the kid in class who doesn’t have a clue, while all the other kids are nodding their heads.
PVT says that we need to move through activation in order to reach safety and calm, but traumatised people often can’t handle that activation, so they’re not going to be able to climb the ladder.
To be focusing on building stabilisation first seems to completely contradict the polyvagal model, because safety is allegedly on the other side of all this activation.
It’s like being asked to cross a frothy river to get to a boat, in order to cross the river…
That is why stabilization is often the longest phase and people tend to revisit topics. The first round of ’safety‘ isn’t even meant to create a felt sense of safety. It is just to remove danger and create action plans to limit dangerous behavior and crisis. Even in bodywork that works closely with the polyvagal ladder you will see therapists build up resources which are typical on this list, to give people sometimes to orient towards. In a way, you build a small boat to reach the bigger boat that reaches the big boat.
Thank you for responding. I hope you don’t mind me asking for a bit of clarification as I’m obviously missing something very obvious. I’ve read around this subject a lot and it still completely baffles me.
The polyvagal theory seems like a total paradox.
According to PVT we can’t reach a calm state until we’ve moved through fight/flight – climbing up the ladder. This is presented as being a strict, predictable order.
But every time I try and learn about PVT and how it relates to trauma, I read that the first priority should always be getting regulated and stable. How can that be if I first need to process these stored fight/flight responses in order to reach calm and stable, to be able to climb the ladder? I feel like I’m reading Kafka! I’m totally baffled.
PVT is a bodywork concept that doesn’t always fit into the framework of other therapy. It also just explains a fragment of what is needed. In this case, you can neatly fit it into phase 2 and how trauma resolution works. There you actually do have to work through the ladder of activation to create integration.
It does not come up like that in everyday life for most people with ptsd because the body is not literally in a stress response at all times. While a memory is stuck and can get activated quickly, the body does regulate to a certain extent. PVT wouldn’t be applied unless there is a flashback.
For some people stress responses feel more chronic. We covered that in articles about getting out of chronic dissociation. That is a framework that is not usually included in the talking therapy context. The 3 phases as they are presented belong to talk therapy. It often doesn’t do these second kind of patients justice because the chronic states don’t get addressed. I think your confusion might be based on mixing frameworks that weren’t meant to include the other.
Talk therapy doesn’t promise closure and stability until after phase 2. Before that you work with a ‘good enough’ state of being stabilized, not stable. It is a different approach that makes sense for these kinds of techniques. It just doesn’t neatly fit into pvt.
Thanks again. What really gets me is how someone (in theory, not in practice) could get to a ‘good enough’ state if they simultaneously don’t have the capacity to climb the ladder, through the intense activation which got them traumatised in the first place. It’s like they’d be skipping a step and reaching straight up to ventral to grab little bits of safety. In terms of the ladder analogy that makes no sense to me.
To my mind, using a ladder analogy, the only way to ventral safety is back through their trauma response. If there’s another way to get some safety online I don’t see how this fits with the model.
Another reason I get confused is because I myself am in the second category. I came out of a deep freeze a few years ago and it completely freaked me out. I went into parasympathetic, and it felt completely alien. I wasn’t expecting it at all.
Your site is really great for filling in the gaps here. I just wish I could get a better handle on the theory as I see contradictions all over the place, and I see people praising PVT for its application across the board, in cPTSD and more regular PTSD. I just wonder what I’m missing.
there might come a time when it’s better to just try it and see for yourself instead of trying to wrap your mind around it from a distance.
I feared you might say that
🙂