The concept behind trauma processing is usually to bring up the traumatic memory in a controlled setting, use an intervention to break up the fixed way in which it got stuck and then support the brain in re-organizing the memory in a new and more connected/integrated way. That is why you will find the term ‘re-processing’ in the description of trauma therapy techniques. The first attempt of integrating the memory was not successful and now we try again.
Trauma integration in regular PTSD
In regular PTSD, we would go through the trauma story that is mostly remembered and the main goal is to realize, that it is not happening anymore. We survived, it is in the past and there is no threat to our life anymore. We tap into the emotions and beliefs of the situation that got stuck, process them and build new connections to other emotions and beliefs about the events. We will have a stress response and emotional reactions and a sense of relief when we realize on a deeper level that we survived and we are safe now. Milder symptoms of depersonalization and derealization dissolve in this process as we are re-connecting to our experience. While this is really hard, it is also not extremely complex.
The effects of structural dissociation
When we are working with structural dissociation, there will be more gaps in our memory and the knowledge of what happened can be spread over different parts. Worse, the thoughts, emotions and body sensations of the situation might be stored with different parts. We don’t start with a whole experience that we can process, we have to put it together first. The way structural dissociation works, it also separates experiences into opposing extremes. So we can get puzzle pieces that don’t seem to fit together at all at first glance.
(Partial) amnesia can lead to the conviction that nothing ever happened. We struggle to grasp that trauma is even part of our life’s story. Once we do know we have a trauma history, derealization makes everything seem like a dream or something that wasn’t actually that bad. It all feels alien and unreal. It has a structural element to it in the way dissociative barriers keep us from experiencing the memory as real.
We will also face the typical sense of ‘not-me’ when it comes to the memory. While some parts know that this happened to them, other cannot. To them, it feels like it happened to a stranger and they have nothing to do with it. It feels like someone else’s memory is intruding on them and making their life a nightmare. This structural depersonalization is a useful defense and it is also a version of failed integration and one of the reasons why the memory stays stuck.
In addition to that, we have the typical problem that some parts are not aware that the trauma is not happening right now. They might constantly re-experience it as a present reality. Processing is made harder because other parts only know the world today and are unaware of the past. There is a great divide between past-parts and present-parts who don’t share the same perception of reality. They live in multiple realities that all feel like they are happening right now.
The integrative mental actions to resolve these issues are Synthesis, Realization, Personification and Presentification.
Trauma processing with DID
What happens when we use our regular trauma therapy tools with a system of parts who live with this structural dissociation that prevents integration? Without any specific preparation, we will probably just trigger a lot of reactions while we don’t even have access to all of the experience for re-processing. People report uncontrolled switches, flooding, crisis. We cannot ignore the structural dissociation because it is a major element of how our trauma is stored and stuck. It is not just the memory that is not integrated. Our mind fragmented the experiences and built barriers around them to keep them firmly separated.The weird diagnostic criteria for DID that describe an invisible inner structure instead of a list of symptoms matter because we have to work with this inner structure to make any improvements. That is not just true for everyday life, it matters in trauma processing too. Our approach will always have to be rooted in integrative actions. Without them, there is no re-processing.
Beyond the regular trauma processing techniques
It is possible to use established trauma processing techniques with DID but they don’t make up the majority of the work and the emphasis of the inner processes will be different. Before we try re-processing memories, we need to build bridges across the dissociative barriers. Without preparing these new inner connections, the challenge of integrating experiences would be too big. And building these new connections will already do some of the integrative work that is needed. In a way, working on these integrative actions might be the bigger part of the trauma integration in DID and any kind of re-processing we add just improves our results and helps us to manage the last hurdles.
Synthesis
After we build up inner relationships and regulation skills, we can gently explore memories by putting together the puzzle pieces that are spread across different parts. All parts who hold on to elements of the experience (memories, emotions, thoughts, body sensations) add their part of the story so we can understand the full picture. This can happen as a form of story-telling where parts join in and that is framed and guided by a therapist. Sometimes dissociative people will put big chunks of the puzzle together by themselves. The museum exercise is meant to help with that. Having guidance is helpful because therapists can ask about pieces of experience that are obviously missing from their perspective. We might not remember that things like a body sensation would make sense in the scene when we are chronically numb or that there should be emotions when we as a part never feel any. It is easier to miss pieces that we are unaware of because of the dissociation when we do this alone. This would usually happen before we try to process a memory. Sometimes new fragments of experience show up during processing but we should know what we are looking at as much as possible to avoid overwhelm.
Realization
DID stabilization comes with a longer process of accepting that there is more to us than the ‘I’ that we experience in a first-person perspective. The parts who know nothing about trauma are challenged to accept that it still happened. We can come to the realization that the others are real and that their memories are real when we build relationships and therefore connections between parts. Once there is more trust and the ability to regulate ourselves and help with co-regulation, we might experiment with Sharing. We first listen to what other parts have to say and when we can cope with that, we can share more of our experiences and realize that these do feel real when they are shared. They still feel alien when we just hear about it but once we connect, we experience it too. The key to realization lies in connection. We cannot do it alone and in our mind because we are so smart. Realization is an experience. It usually knocks us flat on our ass because we didn’t expect it to be like that. Trauma processing techniques will intensify this experience but it can be prepared well in advance so that it won’t be utterly overwhelming.
Personification
Understanding that we are one person with many parts who survived a traumatizing childhood is incredibly hard. We can achieve some level of personification when we put together the puzzle pieces and realize that these are all aspects of the same experience. The same thing happened to everyone and we spread the knowing and not-knowing of it across many parts. It is possible to grasp the logic of it all and that really helps to motivate us to cooperate. But the actual realization of this truth is an experience that goes beyond logic. It is a moment of recognition when we look at younger parts and suddenly know that ‘this is me’. It is not someone else. This is me. I don’t think that it can be fully achieved before and unless the memory is re-processed. Otherwise it would be too devastating to know that. That means that there is an integrative process after memory re-processing where more integrative actions are needed that target the personality and not just the memory. In my experience, it can sometimes happen during trauma processing and it often happens in the period after trauma processing when we re-organize how we make sense of everything.
Presentification
Parts don’t have to be stuck in trauma scenes until we process a memory. It sometimes needs endless patience but we can work on connecting them to the present reality through our senses. That means that they need to connect to the body today to use these senses. We can gently ask them to look through our eyes more often and see what is really happening around us. We can figure out what sensory stimulation they enjoy and offer that to help them have positive experiences through the senses. And we can tell them about today, the things that have happened since TraumaTime, what has changed, who we are today and who the people around us are. Grounding a part in the present reality is one of the most important things we can do for them during the stabilization phase. It allows them to compare that reality to TraumaTime and find a sense of safety with what is happening today. It can take a long time and so much patience, but the good news is that it is plain old Orientation & Grounding combined with reality checking and not something completely new. Trauma processing will make it feel more real but the majority of the work can happen beforehand and often must happen beforehand to make processing possible. We can rescue parts who know nothing about the outside world but it is very challenging because of the active re-experiencing that is going on. Working with grounded parts will make everything in life easier, including trauma processing. They will have occasional flashbacks but they won’t live in a permanent flashback anymore. A therapist can sometimes be the first person who guides a fronting trauma part through orientation. Other times, it’s our own parts who constantly offer connection with the outside world by inviting them to use the senses with them in co-consciousness. Have I mentioned how much patience this needs… Parts tend to forget new experiences because they don’t easily integrate with their old ones. Eventually, it will stick. Creating this new connection to the present reality is a huge part of what is usually achieved in memory processing and needs to be a main focus.
Integration
So how does the integration process really work? We put in a lot of effort that is focused on integrative actions. That will build different kinds of bridges across different kinds of dissociation. We cover the fragmentation of our memory, the separation from the present reality and the alienation from ourselves and our history as much as we can. Building these connections is a structurally integrative process. Our integration does not start with trauma processing. All this is already a form of re-processing, just not memory re-processing specifically. We are shaking up the internal structures that separate our experience of ourselves and create new inner connections. That doesn’t fully integrate a memory but it does move us towards more integration of our personality and experience. And then we tackle the memory with these new connections in place. That makes it possible to shake the memory up safely and re-process more of it. While we do that, we will notice improvement in our ‘structural integration’ as well. Memory processing is just more of the same elements of integration we already practiced and it deepens the experiences. And then once the memory is not blocking further integration, we keep going. A processing session is an event that acts as a catalyst for a longer process. It comes with fresh experiences that will change how we see things. And it also needs more time to integrate these revelations and make sense of them. We have the 3 phase model of stabilization, memory work and integration because they are all parts of the process that is needed.
Lessons
It is a fallacy of trauma therapy to think of memory processing as the big and important part of therapy when all parts of the process are crucial. When we are working with DID, it makes more sense to focus on integrative actions across all phases. We need a bit of structural integration to even get to the memory and it does more for our process than we might assume. During memory processing, we keep an eye on integrative actions to get the most out of it. Sharing across dissociative barriers is probably the more important part of the process than whatever else we do with therapy techniques. Without that, the intervention will fall flat. After I process a memory I always reflect about the amount of integration that was achieved during the session and what is left for another day.
For some parts, memory processing might not even be needed because the integrative actions changed enough of their inner experience to just leave it that way. It did the important things. There is a certain level of re-processing that is already happening when we puzzle together memories or get parts oriented in the present reality. Therapy techniques for DID should put an emphasis on integrative actions. These are the useful interventions that make a difference. We can sometimes get distracted by inner relationship dynamics and discussions about how to live life today that will endlessly repeat themselves. Team meetings and negotiations on how to live life can always only be one part of our therapy process if we want to recover. We have to work on integrative actions if we want to improve beyond that stage. Even ‘healthy multiplicity’ needs integrative actions to relief suffering.
An example for DID therapy that focuses on integrative actions is Nijenhuis’ ‘Enactive Trauma Therapy’. You can read about that in ‘The Trinity of Trauma: Enactive Trauma Therapy’. Nijenhuis is a pain to read and brilliantly entertaining when teaching live. If you can, get a recording.