The Reason for phase-oriented Treatment

 

The recommended way to do trauma treatment is in 3 phases. They have been called by slightly different names over the decades but the goal of the phases never changed. First there is stabilization, then a form of processing and finally a phase of reintegration and adapting to the changes. The phases are not strictly separated and in reality there is always a slight shifting between neighboring phases but the general order is important. We can’t skip steps to move ahead. If that was possible nobody would bother doing prior steps and the whole concept wouldn’t exist. Therapists are not so short on clients that they need to add artificial steps. Phased treatment is needed for safe and successful treatment that preserves human dignity without unnecessary risks or brutality. The more severe the traumatization the more important it is to stick to the proper order.

 

The memory is not the problem

When we are new to trauma treatment we intuitively think that everything would be fixed if the flashbacks stopped. But trauma is not just a memory. It includes our ability to regulate ourselves, the harmful ways we cope with overwhelm, how we manage vehement emotion, how it influences our relationships etc. Even a single trauma later in life cannot safely be processed without learning a minimum of Grounding, Containment, the ability to restore a sense of safety and the most basic stress regulation like breathing exercises. For mono trauma, a short stabilization phase is ok because there isn’t so much stabilizing to do. It is still needed in some form because managing traumatic stress does not belong to the regular skill-set anyone grows up with and we need some extra tools.

People who come to this website usually don’t just have a mono trauma. They have a lifetime of trauma that is layered to the point that it is impossible to grasp it all. The memories are not our main problems. We might not even remember them because they are dissociated. We suffer from extreme dysregulation, unbearable emotions, high levels of dissociation, a fragmentation within our sense of self, chronic suicidality, a whole bunch of unhealthy coping behaviors like self-harm, addictions, disordered eating etc that in themselves could kill us, struggles with relationships and overall extreme experiences. If we tried to ignore all that and ‘just process the trauma’ it would explode in our face. All of this is the trauma. The memory is just one aspect of it.

 

What happens without stabilization

There have been attempts to process memories without doing any stabilization first so we know the different scenarios of what can happen:

People pull up the memory and then they can’t contain it. They get flooded, can’t find their way out of re-experiencing and they get retraumatized.

Sometimes they try to look at memories but then they dissociate so hard that it is impossible to continue. Some people slip right into crisis and need to get hospitalized because they lose it.

In other cases people force themselves to remember and it seems manageable but once they are at home they get flooded with emotions, memories or inner voices that are so terrible that they attempt suicide, self-harm, relapse or increase whatever kind of unhealthy coping they have. Because of a lack of other options they have to use more maladaptive coping to reduce the surge of symptoms but the effects on their life are devastating.

Some people develop amnesia for the processing session. The mind removes it from awareness. In severe cases they might split off a new part to hold the experience.

With DID it is possible for unknown parts to come up, flood the whole system and destroy every cooperation that existed because dissociative barriers need to be raised to protect from the memory.

That’s not therapeutic, it is a nightmare.

And when we look at the list of what we are supposed to learn in phase 1 we can see that all of it is meant to give us the tools and skill that make it possible to be safe and avoid these kinds of escalations. Phase 1 teaches us how to manage our inner experience without losing control.

 

 

How phase 1 prepares for phase 2

Among the first things we will learn is Grounding, which helps us to connect to reality, notice that nothing bad is happening right now and which keeps us oriented, even when the inner experience is extremely difficult or when we start to dissociate. We will learn different mindfulness skills to help us with grounding. This is the foundation of regulation. We need to be able to pull ourselves out of the memory and into the present to be able to safely look at the memory at all. Work becomes impossible when we dissociate. The brain shuts down and is incapable of processing. That is why we need to learn how to notice dissociation and how to get grounded again.

We will learn more techniques for coping with extreme emotions, stress and symptoms. That way we can reduce our use of harmful coping and replace it with safer strategies. That will make our everyday life more stable and it is also a preparation for when we look at memories. When we finish a processing session and we return home there is less risk of unmanageable chaos to unfold because we learned how to manage difficult situations. We can stay safe. This includes ways to manage suicidal feelings.

Some of the tools we will learn will be about gaining control over memories when they come up. We learn how to stop re-experiencing, how to tell apart what is past and what is present and how to contain the memory, how to safely put it away for later. That allows us to handle difficult material without getting overwhelmed.

To increase our overall capacity for processing we learn better self-care and build up resources that create a counterbalance to all the painful things. We need some good experiences in life to remind us that it is worth the struggle.

On top of these things we might have to learn basic things about managing everyday life, simply because we never got a chance to learn them at home. We can’t try to process trauma while our normal life is on fire because we can’t organize daily tasks. There might also have to be some work to set safe boundaries with people or otherwise make changes in relationships to get the support we need and protect us from all the ways other people can make our life worse. Nobody needs that while also trying to process trauma. There might be individual challenges that need our attention, too.

When we are dealing with (p)DID we need to make sure we don’t run into new and isolated parts during processing. That is why we map our system as best we can, and then work on communication and cooperation. Most techniques for processing need us to be co-conscious. There are some that don’t but they aren’t getting used that often anymore. What we don’t want is parts that interfere with or sabotage processing sessions. That is why we need to find an agreement regarding processing first.

Our current life will benefit from all these efforts and then it is also needed for processing. We are not trying to ignore the memories, even if some parts might be scared that that’s the plan.

The things we learn in the stabilization phase are a direct preparation for processing. It is not a waste of time. You wouldn’t try to reach the north pole in your jeans and flip flops either. The rule of thumb is that you stabilize until you are stabilized. There is no specific time frame. When we are not stabilized yet the tasks we need to focus on are all centered around symptom management and regulation. It is exactly what we are supposed to do at that time and nothing else.

 

 

When the path ends here

Sometimes this is all that we get. We learn how to be safe, how to cope with stress, how to regulate ourselves, how to stop flashbacks quickly and contain the memory and how to have a life with more and more nice moments. It happens a lot when we run out of ways to finance therapy. Good stabilization needs time and I don’t know of a single healthcare system in the world that is prepared to give people that amount of time. It is impossible to walk ourselves through processing alone and a lack of access to therapy might end our journey here. In some cases we might not get stable enough for processing, a catch 22 that sucks. We can’t just move into Phase 2 because it would be a disaster waiting to happen but we also can’t make more progress without processing. No easy solutions here.

Being stabilized is not the same as being stable. We will still have our flashbacks sometimes and we will still experience pain. But we can get really good at recovering from it, to the point where it can take us only moments to breathe, contain and move on. A stabilized life can be a good life and all the nice things we can add as a counterbalance make it better.

Some people are actually satisfied with this and decide not to dive into trauma memories. Processing is costly and if our life isn’t a constant crisis because the triggers are too numerous then it could be ok to just leave it as it is. When there are younger parts we need to make sure that they are grounded in the present and not stuck in memory and that they are ok with this. But generally speaking, there is nothing that forces us to move into processing. It is hard. Gut wrenchingly hard. When we decide to stick with being stabilized we do that knowing that we will have to work on staying stabilized our whole life. We are not stable. Whenever we get triggered we need to put in extra work to recover from that and to build our stabilization back up. It is a valid choice. Life can be ok enough with this strategy.

 

 

The goal is not processing

Why isn’t stabilization enough? Couldn’t we just all stop there and make the best of our situation? The truth is that triggers limit how far we can get with stabilization. We learn how to regulate but we cannot prevent dysregulation through triggers from happening. The nightmares and flashbacks will have an impact on our life and for many people it is so big that it is worth the effort of processing memories so that they can get integrated. Integration of memories means that they will become like every other memory. They won’t go away and they can still cause a certain amount of emotion but they won’t create the same kind of disruption in our life that happens when we get overwhelmed. No stress response, flashback experience or flooding. When it comes up we know that it is from the past and over. Processing is not a miracle solution that takes away our memories but it can serve us in a way that stabilization can’t when it comes to integration. It is an important tool.

Processing takes up so much space in our minds because it is ‘the big event’ we are working towards in phase 1. It’s the scary thing that will save us from ourselves, right? In reality, the sole purpose of phase 2 is to bring us to the place beyond. It is the vehicle that gets us past the trauma memory but the true goal of our journey is recovery and a new life. We need to remember that when we are doing phase 2 work. It is not done for its own sake or because therapists say that this is what trauma therapy is all about. It is done because we want stability and not just stabilization and to get there, we need to integrate at least some of the trauma. It is ok to leave the less disruptive scenes as they are. People like us cannot possibly process everything that happened in detail. There is a calculation of risk and effort vs benefits that we will have to make.

 

 

Phase 3 as a continuation of Phase 1

The weird thing about phase 3 is that we will re-visit many of our stabilization topics, just on a different level. We continue the work that we couldn’t finish because of the numerous disruptions. But it will feel different because we have changed. When we face a stressful situation we will experience a lot more emotions that try to guide our behavior instead of stress responses. It means that we will need less of our stress regulation tools and a whole new level of skill when it comes to managing differentiated emotions. There has never been a chance to learn that before because these emotions were out of reach. The way we experience life has changed and we need to adapt our coping skills accordingly.

When we have DID, we will notice that it was the overwhelm that comes with the trauma memories that kept us apart. We couldn’t come closer to each other because the trauma wouldn’t let us. We will have the freedom to make an actual choice on how to continue now because finally there is the option to remove the barriers. Without that option there never was a choice and our perspective on fusion might have changed significantly while we helped each other process the trauma. Phase 3 is when we can reflect and re-organize our system, adapting to the changes.

When it comes to the broader context of our life, we are leaving our role as a mentally ill person and that will have an effect on all our relationships. There will be a lot more talking than we have ever done and the way we take responsibility and express ourselves will be different. There is new room for needs, wishes and dreams.

In a way, we have to adapt to our new life and our old life has to adapt to the new Us. It is a huge challenge that should not be underestimated. There is a tendency to leave therapy after processing because all the ‘real work’ is done and its not. Creating a life that is so unlike anything we have ever had before is going to be hard. Really hard. It often costs people their closest relationships when they start to blossom and unfold. It is wise to stay in therapy, even when the topics have changed completely. We need to move away from this weird idea that processing is trauma therapy. It is just one aspect of trauma therapy. It is super hard but it might not be the hardest and it is really just one step in a much longer journey. All techniques for processing trauma need to be embedded into a broader concept and that concept should come in 3 phases. There is no use in seeing someone who only knows a processing tool but doesn’t know about all the work that has to surround it. If their only tool is a hammer, someone will get hurt.

 

 

Blurry lines

The separation into phases is not as strict as it might seem. This is a model after all and models rarely hold up to real life. We need to start with stabilization, there is no responsible way around that. When we experience so many disruptions that we cannot get anywhere with our efforts, a skilled trauma therapist will weave in some fragmented processing. It doesn’t target the core of memories and instead just tries to reduce some of the triggers surrounding the traumatic event. Small bits of processing can be enough to give us some space so we can continue with stabilization.

Whenever we process something in phase 2 we will notice some element of change and the need to adapt to it. We do a bit of phase 3 work every time and ideally we will notice the difference in our life, even if there is still more to process. We will also have to take breaks and tap into stablizating again to find solid ground. It is a treatment error to have one session of processing after the other for an extended period. The processing phase consists of some processing and a lot of stabilizing in between. We need time to recover to avoid getting lost in depression and suicidality. Processing cannot be all that we are doing. It is too difficult and defeats the purpose. We are meant to integrate the trauma, not just get exposed to it endlessly. Integration needs time. There will be a constant back and forth between phases at this point and that is how it is meant to be.

It is not rare for new memories to come up when we are in phase 3. Our life is finally safe enough and we have the capacity for it. It is not a sign of weakness or failure, just a confirmation of our progress. We might have to step back into processing a couple of times even when we are mostly done and busy building our new life.

 

 

This is roughly how phased treatment is supposed to look like. If your Ts do something that is radically different, you need to find out why. There is a tendency towards short or non-existent stabilization phases spread by people who over-emphasize processing. Those are usually techniques that are not recommended for severe trauma with lots of dissociation or comorbidities and that are clearly contra-indicated for people with structural dissociation. As a rule of thumb, if someone tells a client with complex trauma that stabilization is not needed, unusual or outdated, you should run. They are going to throw you into the water unprepared and just hope that you will learn to swim. You won’t. It is irresponsible, non therapeutic and often injuring human dignity, which is a form of reenactment of trauma. The majority of trauma specialists agree that it is not good practice. There are very good reasons for phased treatment. It is the result of decades of treatment efforts and collective wisdom.

 

 

 

Sources and Resources

You can read more about phased treatment for complex trauma in both ‘ The body keeps the score’ by Bessel van der Kolk and ‘Trauma and Recovery’ by Judith Herman and more about phased treatment for DID in the ISSTD Treatment Guidelines or ‘Treating trauma-related dissociation’ by Steele, Boon and van der Hart

Here is an overview over the topics that the stabilization phase should cover and here you can find more about processing and how to know you are ready for it.

If you need to work on stabilization alone because there is no access to trauma therapy then this workbook book and this one could help you.