This article is the conclusion of a series, published in editions 4.2 and 5.1 of Multiple Parts, about the phase-oriented approach to treating complex trauma.
Much has been written about the work in therapy in stages I and II of the phase-oriented approach to treating trauma, but less so about the third stage. The work in phase III aims to consolidate the gains acquired in the early stages and to apply these to everyday life in order to develop ‘a life worth living’. To recap, the three phases follow a standard pattern, described in various ways:
- Safety and stabilisation
- Processing traumatic memories
- Consolidation, integration and reconnection—resolution and recovery.
As Courtois and Ford put it (2012, p.142):
The three phase treatment model for complex trauma is designed to give the therapist a road map of treatment tasks that are sequenced and approached in a hierarchical way.
Phase I establishes a solid foundation of relationship-building and affect regulation to ensure a sufficiently safe treatment frame, providing the basis for all future work. Phase II confronts some of the direct symptoms and manifestations of trauma, working to process traumatic memories and address the body’s automatic, neurobiologically-oversensitised responses. Phase III then works to draw together the gains and insights, the emotional regulation, the increased self-confidence and sense of relational security acquired during the first two phases, and establishes a platform for life post-therapy. Whereas Phase II in particular tends to be backward-looking, the focus of Phase III is definitely forwards, directing energies which had previously been expended coping with the symptoms of trauma towards building a new and fulfilling future.
Phase III work is seen by many as the culmination of the therapeutic work, but some clinicians instead view this integrative phas as being interwoven throughout the entire process, with gains from the first two phases being applied to daily living at every step of the way. Babette Rothschild (2010, p.60) says:
…for any trauma therapy to be successful, integration—both in phase I and phase II—must build bridges to relevant points in the current life of the survivor. For example, if one of the trauma elements was being isolated, being unable to talk with anyone, a major integrative step might be helping the client to talk with selected friends and family members about what happened.
In many respects, phase III work resembles ‘normal’ psychotherapy: it is where many non-dissociative, non-traumatised people begin their work. But dissociative clients also have an essential foundation to lay in phases I and II, which, due to their childhood experiences, may at the start of therapy be non-existent: building their capacity to trust and establishing a working alliance with the therapist; learning to manage intrusive trauma-related symptoms such as flashbacks and body memories; developing co-consciousness and co-operation within the dissociative personality system; and developing affect-regulation skills which allow them to feel and express emotion without either using dissociation and avoidance as a blocking mechanism, or becoming hyperaroused and distressed.
Clients may naturally progress to phase III work: when they are no longer unduly affected by memories of trauma, when they have at least a rudimentary and coherent narrative for their personal life, and when they are able to reflect through mentalisation upon their experiences. If the goal of therapy is simply to reduce symptoms, however, some clients may not wish to progress to phase III work at all. They may feel that they have achieved enough at the end of phase II, or even phase I, or their access to therapy may be curtailed. However, great rewards lie in store for those who push through into the third phase and begin to establish the kind of life that they may always have wanted but previously had not thought was possible.
Rather than focusing on stabilising and reducing symptoms, or processing traumatic memory, therefore, the third phase of work covers a range of issues common to many people entering therapy, for example:
- addressing core beliefs and making meaning
- learning life skills
- establishing new blueprints for both the self and relationships with others
- developing support systems outside of therapy
- increasing independence
- negotiating peer relationships
- exploring issues of intimacy and sexuality
- parenting skills and issues
- career and vocational choices
- improving physical health
- pursuing potential prosecutions against abusers if desired and if possible
- developing a ‘survivor mission’
- existential and spiritual questions
- potential integration/fusion of alternate personalities
- dealing with endings, and moving on from therapy.
As has been emphasised in previous articles, progress through the three phases is rarely linear, moving efficiently from phase I through phase II and finally into phase III. Again in the words of Courtois and Ford (2012, p.XV):
The three phases are not neatly subdivided but tend to overlap, and treatment tasks may need to be repeated numerous times before emotions, beliefs, and cognitions are sufficiently reprocessed and integrated.
A client may therefore move repeatedly from phase III work back to phase II or even phase I, repeatedly covering old ground and reinforcing previously acquired skills. Challenges and skills that had been faced or learned in earlier phases may reappear in phase III. This should not be seen as a ‘failure’, either by the therapist or the client. In fact, it signifies the contrary: that the client is able to revisit past topics from a different, higher vantage point, and is integrating what he or she has previously known with this new, wider perspective. At many points during phase II work, for example, the client will need to return to working on issues of safety and stabilisation, and emotional regulation skills will need to be strengthened to cope with the higher levels of distress accompanying more profoundly traumatic memory. The same is true of phase III work: very often the client, in pulling together a number of threads to integrate traumatic material into his or her autobiographical narrative, will need to revisit further traumatic material in order to gain a more holistic viewpoint or mentalising stance.
Phase III provides a focus for all the work in therapy that has already taken place, to establish and integrate into daily life the therapeutic gains and the resilience that has been developed. As James Chu puts it:
I am convinced that insights in therapy are only the beginning, and the roots of self-esteem and a positive self-image are in actually doing things in life. Summoning up the courage to reach out and connect with others, going to work reliably, following through with an exercise program, and engaging in recreational activities are some examples of types of functioning that begin to instil new positive ways of thinking about oneself to replace the old negative ones (e.g. “friendly”, “productive”, “fit”, “fun-loving”). Over time, healthy functioning in all domains—relational, vocational, educational, and recreational — leads to self-esteem and a positive self-identity. (2011, p.128)
Conflicts of the three phase approach
Many conflicts emerge in the midst of phase III work. As the client is less assaulted by unwanted feelings, flashbacks and body memories, so new energy arises. This energy can be directed towards building a future, with a wealth of possibilities in both relational and vocational domains. But it can also lead to the emergence of conflicts: does the client want to be well, or does the idea of engaging in ‘normal’ life feel too terrifying? Some dissociative survivors took on the sick role and/or the child role, or that of a submissive victim, as their only means of surviving, and it served them well. It was adaptive during the abuse: compliance and submission limited the duration or extent the abuse, to get it ‘over and done with’ more quickly. But it becomes problematic in a new, non-abusive environment, where instead as adults we are expected to demonstrate assertiveness, make choices, and actively defend ourselves. This can be terrifying for many survivors. Stepping into a new role, not as victim or child, but as autonomous adult, carries with it not just the difficulties of adjusting to a role never before experienced, but can also carry the traumatic reminders and injunctions, embedded in procedural memory, that it is dangerous to step up and make choices, to be independent and not to hide in the shadows. It is therefore important that clients are helped to reassess the role they have played in life, frame it in terms of survival necessity, but then be empowered to take on the most adaptive role for their current and future circumstances.
Some survivors lack basic life skills, having focused purely on survival until this point, and cannot imagine being well enough to hold down a job and live without support from mental health or other professional services. For some, ‘stable multiplicity’ is their informed choice for the future. However, many others do want to move away from their label and their place in society as being perceived as ‘mentally ill’, and phase III work can focus on building the necessary resources to facilitate this: skills such as assertiveness, planning, and relationship-building, coupled perhaps with vocational or career training/re-training. Previously, a great deal of energy has been used simply surviving and managing the discontinuities and ‘glitches’ of a dissociative mind. With increased co-consciousness and control of switching, this energy can now be redirected towards managing the demands of family/relationships and career/vocation, without the safety net of welfare benefits or mental health services. Therapy should not therefore be terminated soon after the main chunk of phase II work, but plenty of time should be allocated to working through the challenges of phase III in order to prevent a later relapse: it is all too easy for daily life pressures to mount up for a client who has spent all their life just surviving trauma and the resultant dissociation, and feels ill-prepared to tackle ‘normal’ life at the end of it.
Social pressures too can keep clients in the role of ‘victim’: these include therapy itself, when the therapist is invested in the work and the individual relationship to such an extent that they are consciously or unconsciously unwilling for the client to gain independence and move beyond therapy. In many scenarios the power dynamics of abuse can be unwittingly replayed as the therapist, the ‘expert’ who holds all the knowledge and all the power, takes a one-up role of superiority over the client. To an extent this is unavoidable, but it is important that the therapist remains aware of it and of the potential for abuse. The therapist should not foster a belief that the client is dependent on the therapy and the therapist, but should instead imbue them with a belief in themselves as an equal human being who has suffered (and survived!) extensive trauma and so who is a resilient and resourceful human being. The mindset of ‘victim’, ‘inferior’ and ‘powerless’ can be particularly resistant to change, and so it is essential that the therapist does not reinforce it in any way.
Within a therapeutic setting where they are being encouraged to grow and gain independence, the client must also co-operate with this process if they are to see real transformation. They must be willing, with help, to leave their victimhood behind. James Chu (2011, p.128) says:
Late phase therapy involves consolidation of gains, achieving a more solid and stable sense of self, and increasing skills in creating healthy interactions with the external world. The resolution of the all-encompassing and overwhelming past events reduces patients’ inevitable narcissistic preoccupation with their symptoms and difficulties, and allows them to have more appreciation of others as separate individuals. Moreover, an empowered sense of self leads patients to have increased confidence in their abilities to participate successfully in interpersonal relationships and other activities in ways that previously eluded them.
This echoes one of the central paradigms of Judith Lewis Herman, in her seminal book Trauma and Recovery (1994), who talks about the third phase in terms of ‘reconnection’. She argues that trauma separates people from people—it disconnects. Part of recovery, therefore, is to encourage reconnection. For dissociative survivors who have been used to living life through the lens of multiple parts of the personality, it can be a challenge to begin to relate to others in a non-traumatised way: as an adult, as a peer, not requiring care or over-solicitously providing it, and with a consistent, integrated, narrative memory for day-to-day events. This should not be underestimated: for someone with polyfragmentation of the personality, it is a whole new challenge to remain consistently ‘one’ and engage with others on the basis of a new sense of identity—as someone who was traumatised but is now living ‘beyond trauma’—rather than the previous roles of ‘patient’, ‘victim’, ‘mental health service user’, even ‘survivor’. Understandably, therefore, some clients will find it difficult to fully embrace this final stage of moving on because it represents entirely new territory and they may feel that they have no map or guide for it. A large part of phase III work therefore can consist of adjusting to this new identity and life, and developing the self-esteem and positive self-identity, as well as the life skills and understanding of social ‘rules’, to be able to function healthily in these challenging new domains.
Without a focus solely on survival, phase III provides space for many previously unfaced feelings to emerge. It is not surprising that this stage is so often accompanied by a great deal of grief: for lost opportunities, and for the burden of symptoms that so frequently prevent a survivor from experiencing positive physical health, family life, career success and enjoyment of life. It is not surprising that many clients struggle with this phase of the work, as the full force of their feelings —anger, rage, resentment, hatred, outrage, indignation, amongst many others—are experienced and felt, perhaps for the first time. The injustice of all their losses may be keenly felt, and it can take some time to process these feelings adequately so that a new life can be established, rather than sabotaged because of the ungrieved losses of their traumatised past. Elizabeth Howell (2011, p.183) says:
As patients shift their focus from their traumatic pasts to their current lives, many core beliefs emerge and need to be re-examined. These may include such things as continuing to feel and believe that one is worthless, continuing to believe that comfortable intimacy is not possible, facing existing unhappy relationships and work problems, as well as learning some of the “blueprints” for adult life for the first time. Perhaps even more painfully, these core issues also include facing the narcissistic personality structure that is often the residue of the dissociative personality structure (Howell, 2003; Schwartz, 1994, 2000). As Kluft has frequently said, following work on the problems posed by DID, patients increasingly must deal with the everyday problems of “unitary personality disorder”.
It can be challenging for many survivors to realise that day-to-day difficulties exist for all people, not just people who like them have been traumatised, and that having experienced atrocities in childhood does not preclude further tragedies in adult life. One of the many sequelae of childhood traumatisation is a significant increase in risk for long-term physical disease, in particular some cancers, autoimmune disorders, heart disease and diabetes. It can feel like a double whammy to have experienced trauma in childhood and then, even upon processing the trauma in therapy, to be faced with physical health battles. But this nevertheless is the statistical reality, and so an important emphasis in phase III work is on developing, or redeveloping, good physical health, especially when the client has previously coped with the pressure of unprocessed trauma through alcohol or drug abuse, eating disorders, a sedentary lifestyle rooted in a physical freeze response, smoking, or a generally inadequate diet.
Having processed and metabolised much of the trauma in phase II work, many survivors begin in phase III to experience their inner worlds—the dissociative parts of the personality—in different ways. With a reduced need for segregation of memories and feelings, parts of the personality often spontaneously ‘fuse’. Some clinicians favour the use of ‘fusion rituals’ to encourage the removal of dissociative and amnesic barriers between parts of the personality, often using visualisation or imagery. However, many survivors feel deeply uncomfortable with this. Many express their fear that ‘integration’ equals ‘death’, and it may require repeated explanations that parts of the personality cannot ‘die’ or cease to exist, and that fusion or integration means that the dissociative client is in touch with more of themselves, rather than being so disconnected and subjectively experiencing themselves as different identities. The ISSTD Guidelines (2011) explain this well:
Fusion rituals are useful when, as a result of psychotherapeutic work, separateness no longer serves any meaningful function for the patient’s intrapsychic and environmental adaptation. At this point, if the patient is no longer narcissistically invested in maintaining the particular separateness, fusion is ready to occur. However, clinicians should not attempt to press for fusion before the patient is clinically ready for this. Premature attempts at fusion may cause significant distress for the DID patient, or, alternatively, a superficial compliance wherein the alternate identities in question attempt to please the therapist by seeming to disappear. Premature fusion attempts can also occur when the therapist and patient collude to avoid particularly difficult therapy material.
The clinical literature suggests that the best long-term outcomes are associated with higher levels of integration or fusion of parts of the personality, although it is generally accepted that clients may redissociate at later points when under extreme stress, even if they present in day-to-day life as fully ‘integrated’. Integration does not imply the absence of ‘parts’: rather, integration refers to an overall process of connecting and associating previously disconnected (dissociated) mental processes. Richard Kluft (1993a, p.109) defines integration as:
an ongoing process of undoing all aspects of dissociative dividedness that begins long before there is any reduction in the number or distinctness of the identities, persists through their fusion, and continues at a deeper level even after the identities have blended into one. It denotes an ongoing process.
Meanwhile, fusion is defined in the ISSTD Guidelines (2011) as
the point in time when two or more alternate personalities experience themselves as joining together with a complete loss of subjective separateness.
The Guidelines go on to elaborate many of the factors that preclude some survivors from either pursuing or achieving integration of all their personality states:
- chronic and serious situational stress
- avoidance of unresolved, extremely painful life issues, including traumatic memories
- lack of financial resources for treatment
- comorbid medical disorders
- advanced age
- significant unremitting DSM Axis I and/or Axis II comorbidities
- and/or significant narcissistic investment in the alternate identities and/or DID itself.
It is therefore reasonable for the client to set their own therapeutic goals and the extent to which they desire to achieve ‘stable multiplicity’ or push further forwards into complete fusion and integration. But it is equally important that clients and therapists alike realise that a new, ‘post-post-traumatic’ (Spring, 2015) world is possible. In Judith Lewis Herman’s words (1994, p.196):
Having come to terms with the traumatic past, the survivor faces the task of creating a future. She has mourned the old self that the trauma destroyed; now she must develop a new self. Her relationships have been tested and forever changed by the trauma; now she must develop new relationships. The old beliefs that gave meaning to her life have been challenged; now she must find anew a sustaining faith. These are the tasks of the third stage of recovery. In accomplishing this work, the survivor reclaims her world.
This is the challenge, and the reward, of phase III: reclaiming the world. The client can discover, or rediscover, aspirations and ambitions. Although there is much mourning to be done for what has, irrevocably, been lost, nevertheless the ultimate purpose of mourning is to clear the ground for new crops to be sown. This phase III work helps the survivor see that, although he or she has been a victim, revictimisation is not a certainty and skills can be learned to protect against it; safe relationships can be nurtured whilst building boundaries to protect against unsafe relationships. In effective phase III work, the client learns from the past—learns that abuse is never a child’s fault, but also learns to live free of abuse through the choices that they can make now as an adult. In Judith Lewis Herman’s words (1994, p.199):
The survivor is free to examine aspects of her own personality or behaviour that rendered her vulnerable to exploitation only after it has been clearly established that the perpetrator alone is responsible for the crime.
Phase III work, although daunting and difficult, does open the door to a brave, new world.