The three phase approach: part one – safety and stabilisation
EXPERTS OR SKILLED HUMAN BEINGS?
Over the last few years, it has become very clear to me how difficult it is for so many people with complex trauma histories to find anyone willing to provide therapy to them. Many therapists haven’t heard of dissociative identity disorder or feel that working with trauma is beyond their competence. Those are valid reasons, but it leaves many trauma survivors with nowhere to turn. It is my firm belief that trauma survivors don’t need ‘experts’ to work with them, but solid, safe and skilled human beings. If the therapist has a core sense of integrity, with a foundation of quality counselling training, then the skills can (and should) be learned.
The clinical consensus is that work with complex trauma clients is different to standard therapeutic work, that treatment is generally lengthy, and that there will be numerous challenges to the work and to the therapeutic alliance. Having a clear roadmap for the work is therefore essential and can be found in the concept of the ‘three-phase approach’, a way of working with complex trauma that is now generally considered to be the safest, most ethical and most effective approach. But what actually is it, what does each phase consist of, and why is there a need for ‘phased’ work at all?
WHY THE NEED FOR PHASED WORK?
James Chu in his excellent book Rebuilding Shattered Lives (2011) talks about the issues that were encountered by therapists in the 1980s and early 1990s when working with clients with a history of complex trauma. In attempting to help them work through their childhood trauma, some of these clients were unintentionally harmed rather than helped. There was too often a premature emphasis on the trauma itself before the client had the skills and grounding necessary to face it. Later clinical opinion established that for people to process their trauma successfully, they would first need to build a ‘secure base’ with the therapist and develop grounding and other skills to manage their intolerable feelings.
Judith Lewis Herman, in her pioneering book Trauma and Recovery (1997) introduced the concept of a three-phase approach, building on foundations laid over a century previously by the ‘father of dissociation’ Pierre Janet. A wealth of clinical literature has followed and this phased approach is now the bedrock of the Guidelines for Treating Dissociative Identity Disorder in Adults (2011), which was issued by the International Society for the Study of Trauma and Dissociation (ISSTD).
REMEMBERING IS NOT RECOVERING
Trauma represents a serious threat to life or physical integrity, and as such it makes sense for the body to protect itself by preparing for future similar traumatic events. As a result, the brain is rewired to be hyper-aware of possible risk, and the body is geared up to respond instantly. At the same time, the brain attempts to avoid situations and people which are a ‘match’ for the previous trauma. Together, these symptoms represent post-traumatic stress disorder (PTSD): avoidance of stimuli reminiscent of the trauma, and a ready-to-run state of bodily hyperarousal. The survival-based ‘back brain’ dominates, ready to protect the body at a millisecond’s notice, while the learning, thinking, reflecting ‘front brain’ is muted. But in order to process past trauma effectively, the reverse needs to be true: the ‘back brain’ needs to be muted and the reflective ‘front brain’ brought online.
For therapy to succeed, these issues must be addressed. If they are not, bringing the trauma back to mind will merely set off the back brain’s alarm system; the front brain will be switched off; and the trauma will be re-experienced but not processed.
Much of the work that took place in the 1980s and 1990s was based on the assumption that ‘remembering is recovering’: that the act of recalling traumatic events to mind in the presence of a validating other would be sufficiently cathartic to bring about healing. But this has proved not to be the case – at least, not consistently. Remembering can instead be retraumatising. Unprocessed trauma is relived through flashbacks and symptoms, including ‘body memories.’ By contrast, trauma that has been ‘metabolised’ crystallises as a distinct, narrative event – albeit a previously overwhelming and life-threatening one – which happened at some point in the past but is no longer happening now. For this to happen, the front brain needs to be online and remain so rather than being deactivated by the back-brain alarm.
Few complex trauma clients enter therapy with the emotional regulation skills needed to turn on the front brain and turn off the back brain. But these skills can be learned in the context of a safe, boundaried, therapeutic relationship which acts a ‘secure base’ for exploring past trauma, and then gaining mastery over its symptoms. This preparatory work is the essence of the initial stage in the three-phase approach and focuses on safety and stabilisation in the context of the emerging therapeutic alliance. The second stage moves on to processing the trauma, and the third stage builds on these gains to develop a new life free from the disruptive impacts of that trauma. Each stage is hierarchical, building from one level to the next.
THE THREE PHASES OF REBUILDING A HOUSE
A useful metaphor to understand this sequence is that of rebuilding a damaged property, for example a house that has been hit by mortar fire. In the first stage, the property has to be made secure – fences erected around the building site, any crumbling ceilings or walls properly attended to. Necessary tools and machinery are brought on site and the right personnel engaged. Plans are drawn up for the work. Only once the site is secure does the phase 2 work of demolition take place. Gradually, in a way that does not risk the site, the rubble is cleared away. Parts of the property that were buried are rediscovered and attended to. The impact of the mortar shells is assessed. When the building site is cleared of debris, the remodelling work of Phase 3 can begin. Some walls may need to be knocked down; others are replastered. Some areas are redesigned from scratch; others are repaired. Walls are painted, flooring laid, and eventually a new life begins in earnest.
THE PHASES ARE DYNAMIC, NOT LINEAR
Whilst helpful as a metaphor, the reality for any building site, as for any therapy, is that life rarely proceeds in a steady, predictable sequence of events. So the three-phase approach is essentially dynamic in nature, rather than linear. Sometimes rubble needs to be cleared away in order to make the site safe, rather than the other way around. Sometimes areas of the building can be inhabited before the rest of the building is completed. Often, the work of demolition leads to further safety issues which were previously hidden, and new scaffolding must be erected before any further work can be completed.
Similarly, in therapy, after the initial foundation of safety and stabilisation is established, there will often be a need to return to this stage. This can happen both over a period of time and even within an individual session. A key question to ask might be: is there sufficient safety for this next stage of work to proceed? Or do we need more scaffolding? Moving fluidly backwards and forwards between the stages is not a sign of failure, but of flexibility. Gains that have already been made in phase 1 work are never lost, but sometimes they need to be reinforced.
PHASE ONE IS MEASURED IN SKILLS, NOT TIME
Joan Turkus, quoted in Treatment of Complex Trauma (2012) by Christine Courtois and Julian Ford, talks about phase 1 work being ‘measured in skills, not in time’. Indeed, some clients may never move beyond phase 1, and this is not a therapeutic failure. They may lack the resources, internally and externally, to engage in trauma-processing work, but they can still move from a dangerous, semi-derelict building to one that is reasonably safe and habitable, and the value of this should not be underestimated. The three-phase approach also makes it clear that even short-term work with complex trauma clients can be productive, as the development of safety and stabilisation provides immediate short-term gains as well as establishing a foundation for the possibility of more long-term trauma-focused work in the future.
The focus of phase 1 work, and the focus of this first article in the series, involves four key areas: establishing a ‘secure base’ in therapy; developing safety; increasing stabilisation; and building skills and knowledge.
1. ESTABLISHING A SECURE BASE IN THERAPY
Christine Courtois (2012) says, ‘The therapy relationship is the therapy.’ The client may have suffered unrelenting abuse, betrayal, degradation, humiliation, coercion and manipulation. The therapist is, or should be, safe, non-abusive, non-judgemental, attentive and emotionally balanced. This contrast for the client is often deeply impactful. And so this safe setting – perhaps the client’s first safe setting – allows an opportunity to begin to trust and to learn to manage feelings within a ‘window of tolerance’, to build skills that were previously unattainable without such support. It is a new relational template that is non-coercive and de-shaming, encouraging the development of new ‘internal working models’ and a prototype for relationships in the outside world.
But the therapeutic relationship will uncover a host of issues: trust, fear of abandonment, fear of coercion, dependency needs, and learned helplessness, amongst many others. The therapeutic alliance is challenged on many levels and in many ways. Courtois and Ford (2012) propose five essential conditions of trauma-informed therapy in phase 1: safety, trustworthiness, choice, collaboration and empowerment.
Is the therapy safe? Is the therapist safe? Is the client physically safe both in and around the building where the therapy takes place, and is he or she safe in the therapist’s office? Is the client’s privacy safe – is there appropriate confidentiality? Is the work safe to engage in? Bearing in mind the client’s vulnerabilities and other life stresses, is it paced appropriately, and does it have the right focus at the right times?
The therapist cannot assume that the client has the basic ability to trust. Demanding or expecting trust from someone who has been multiply betrayed and abused could have further negative impacts. Trust takes time to build, and the client can be encouraged to test the therapist out and ‘look for the evidence’. This is an important element of recovery as many people with complex trauma histories have become distrustful of their internal ‘radar’ – people who should have been trustworthy in the past have not been, and so the radar is turned off altogether. Trust is then based on closing the eyes and jumping: frequently offered to people who do not deserve it, and withheld from those who do. In addressing this, the client can be encouraged by the therapist to weigh up actual evidence – have I ever hurt you? do I do what I say I’m going to do? have I ever actually abandoned you? have I consistently told the truth? – and to realign their internal radar based on that information. It is an essential component in phase 1 work, because there will be many times during phase 2 work that the client needs to lean back on their trust in the therapist and, if it has not by then been established, the work will inevitably falter.
To have been chronically victimised is to have been without choice. In many settings of abuse, ‘choice’ has been manipulated in order to blame-shift onto the victim, leaving them feeling responsible for what was no choice at all. The therapy should include as much choice as is practicable. It is a considerable achievement for the client to have chosen to enter therapy, and, where they have done so, to choose to work with this particular therapist. Therapy can build on those strengths and facilitate small but significant choices: which chair to sit in, how far to position it from the therapist, how to use the session, what to say or not to say. Recovery from trauma involves regaining the ability to choose and building relationships with people who respect our choices, as we respect theirs.
It can be a shock for the client to realise that the therapist is not there to tell them what to think, what to do, or how to feel, but that they are coming alongside them in a co-created, collaborative relationship. Many clients will resist this, fearing perhaps that it is a ‘trick’. The therapist can help by remaining consistent within the relationship, swinging to neither extreme of abandoning or rescuing, and encouraging the client to take an active role in the relationship.
In what ways might the therapeutic setting continue to disempower the client? Is their chair lower than the therapist’s, leaving them feeling vulnerable and exposed? Does the therapist jump in to rescue them from their distress rather than empowering them and educating them to be able to manage and modulate their feelings for themselves? In what way can the client be empowered to be assertive both within the therapeutic relationship and outside it, such as in abusive relationships, oppressive work situations or unreasonable living conditions? The therapeutic relationship is the nursery for an empowered self.
2. INCREASING SAFETY
To be traumatised is to be unsafe. Therefore, in order to recover from trauma, the survivor must begin to establish at least some degree of safety in their life, and to be able to feel safe. Only in safety do we grow and develop, so it is a prerequisite for change. How is safety developed?
A. ASSESS CURRENT RISK
In the first instance, the therapist can help the client to assess the current level of risk in their life and identify any specific dangers. It is possible that the client, who is so used to feeling and being unsafe, has not yet realised that they can be safe. Furthermore, many traumatised clients are under-aware of real risks and dangers in their current life, and over-aware of perceived risks from the past. So they may feel at risk from a stranger with a beard because he reminds them of their abuser, even though he poses no actual risk, but be oblivious to the risks they are posing to themselves in terms of (for example) self-injury.
B. DISTINGUISH BETWEEN EXTERNAL AND INTERNAL RISKS
There may be a number of credible risks in the external environment, such as abusive relationships, ongoing harmful interactions with past (or even current) abusers; community violence, crime, and so on. The client may be so used to these risks that they do not take them seriously, but the therapist can help the client to figure out what practical steps can be taken to mitigate these risks. Knee-jerk reactions are rarely, however, helpful: attempting to leave a domestic violence situation without proper planning and support, for example, could just escalate the risk.
Most danger faced by trauma clients, however, tends to come from internal sources, from behaviours resulting from or intending to cope with post-traumatic symptoms. Self-harm and suicidality are very real threats to a person’s safety, as is dissociative fugue. With a dissociative identity disorder (DID) client, the therapist needs to begin to build an alliance with the different parts of the personality, as many of the risks to the client can result from internal conflicts and diametrically opposed survival strategies. For example, one traumatised part may attempt to feel safe by developing a relationship with the therapist, while another part of the personality may attempt to feel safe by creating distance from the therapist, whom they do not yet trust. That conflict may be externalised in contradictory or potentially harmful behaviours. It is therefore a high priority for the therapist to encourage the client to begin to attempt to communicate internally and try to begin to bring all the dissociated parts of themselves into agreement on staying safe. This is easier said than done but can be facilitated if the client understands the critical importance of safety to the therapeutic process and how phase 2 cannot be attempted without sufficient safety being in place.
As well as risks from self-destructive behaviour, some consideration should be given to threats to physical health due to issues such as eating disorders and chronic insomnia. As well as being a risk factor for developing type 2 diabetes and being exacerbated by binge eating or poor diet, chronic insomnia can heighten risks while driving, engaging machinery (for example at work) or any kind of activity where concentration is required in an otherwise dangerous setting. Although the client may dismiss it as ‘normal’, focusing on sleeping patterns, improving ‘sleep hygiene’ and, if necessary, acquiring appropriate short-term medication can have a positive knock-on effect into numerous areas of the client’s life.
C. DEVELOP AWARENESS OF RISK
When dissociation has been used repeatedly as a survival mechanism in the face of threat, the client will be less able to be consciously aware of further threats in the future. ‘Triggers’, which are in effect warning signs of impending trauma (however wrongly attributed), initiate a cascade of responses resulting in the survival-based, instinctive ‘back brain’ taking over, and the mindful, rational, ‘front brain’ shutting down. A trauma survivor may therefore be less aware than others of even obvious risks, because the automatic responses of dissociation have kicked in. This prohibits planning for the future. What appears blindingly obvious to the therapist in terms of risk should not be assumed to have been noted or considered by the client.
The therapist should not therefore take responsibility for the client’s safety but can help them on a regular basis to bring to mind aspects of safety and danger that they are habitually dissociating from. The client ultimately is responsible for their own safety and needs to exercise this responsibility appropriately, and to the extent of their capacity, if the therapy is to be safe enough – both for the client and the therapist – to proceed.
D. NOTICE HOW THE CLIENT PUTS THEMSELVES AT RISK, AND WHY
Traumatised clients put themselves at risk in a number of ways for a number of reasons. Firstly, they may be habituated to danger. The therapist’s insistence that they attend to matters of safety can be surprising, disconcerting, and even confusing – it is possible that no one has ever previously shown concern for their safety. Putting themselves at risk may also act as a kind of attachment cry, a way of attracting attention. It is less shaming if this is understood by both therapist and client in terms of its survival value. The therapist can then work to help the client express their attachment cry in a different way – the client may never have been able to ask for help directly before, and so continues to do it obliquely until he or she receives ‘permission’ to express it differently.
The client may also put themselves at risk because of their core beliefs around their value and worth, and as an expression of their hopelessness for a positive future. Rather than assuming that danger and harm are inevitable, the therapist can help the client to think through the pros and cons of their unsafe, and safe, behaviours, so that they can start to make conscious, deliberate choices rather than acting out of instinctual and early attachment-based drives.
E. DEVELOP A SAFETY PLAN
The culmination of these issues can be a ‘safety plan’, a consolidation of all the ways in which the client is unsafe or puts themselves at risk, and specific steps that they agree to take to improve their safety. Putting things in black and white can help to keep the issues clear in the client’s mind, rather than dissociative processes causing them to slip out of view. It also provides a constant reference point for the future if and when further challenges to safety arise.
3. WORK AT STABILISATION
Stabilisation is required when symptoms do not pose a direct threat to safety but are disruptive, both to the client’s life generally and to the work of therapy specifically. These symptoms are often intertwined or overlapping and might include physiological hyperarousal and the inability to relax, chronic insomnia, overpowering shame, overworking or depression. Anything that severely constricts the client’s ‘window of tolerance’ needs to be addressed so that the client is best prepared for the potentially gruelling work of processing trauma. At the same time, positives need to be built in: activities or attitudes which build resilience, foster self-care or are soothing and containing. For example, one trauma survivor benefited enormously from cordoning off part of a room in her house where she could retreat to when feeling overwhelmed. Other members of the household were primed to allow her some privacy when she entered her ‘safe space’. Just knowing that it was there and could be entered when needed helped reduce her anxiety and provided a ready means of down-regulating when stressed. Other people report the efficacy of creating imaginal ‘safe spaces.’
A. WORK ON THE BASIS OF ‘MARGINAL GAINS’
A series of small steps – ‘marginal gains’ – can add up to a big change over time. An extra half hour of sleep each night, slightly calmer emotions, keeping on top of household chores, more physical energy from a daily short walk – these can all widen the ‘window of tolerance’ as well as giving the client a sense of triumph. Big changes don’t happen overnight but are the result of a thousand small changes over a season.
B. IDENTIFY WHAT TAKES THE CLIENT OUT OF THE ‘WINDOW OF TOLERANCE’
The ‘window of tolerance’ is a concept used by many leading clinicians nowadays, albeit under various names. It suggests that feelings usually exist within a normal range (see graph) but at times things will happen to spike feelings up out of the ‘window of tolerance’ at the top (into hyperarousal) or to plummet feelings down through the bottom (into hypoarousal). This is true for everyone – not just trauma survivors or people with mental health problems – and that in itself is very empowering and de-shaming. The therapist can help the client to start considering the following kinds of questions in order to build their self-awareness and help them develop strategies for managing their feelings:
- What does it feel like to be hyperaroused? What sensations are there in your body? What thoughts go through your mind? What feelings do you have?
- Similarly, what does it feel like to be hypoaroused?
- What sort of things lead you to be hyper/hypo-aroused? Are there particular stressors? People? Situations?
- What kinds of things bring you down from hyperarousal, or bring you up from hypoarousal?
By beginning to be conscious of stressors, and aware of the body sensations associated with hypo/hyperarousal, the client can learn to put in place specific strategies for managing their feelings when they do spike or plummet.
C. DEVELOP SOME EMOTIONAL REGULATION SKILLS
Many techniques and approaches are available which can help clients to manage their feelings, and a very helpful book in this regard is Coping with Trauma-Related Dissociation by Suzette Boon, Kathy Steele and Onno van der Hart. Focusing and mindfulness help not only with stabilisation but also with the mentalising work of phase 2, and the daily practice required can provide structure for clients who have stopped being able to work or whose lives have become out-of-control with the chaos of overwhelming symptoms.
One trauma survivor reports:
One of my biggest shifts was when I began to learn to breathe. It sounds silly – everyone can breathe. But I didn’t realise that I used to breathe so fast and so shallowly, especially when I was stressed. I learned some mindfulness techniques about focusing on my breathing just for a minute at a time and I started doing it several times a day. I practised breathing from my tummy and focusing on the breath all the way up from my diaphragm, up through my chest, my throat, into my nose and out through my nostrils.
Then the same going back in again, noticing how the air filled my lungs, and breathing deep into my belly. I did it slowly, deliberately. I could do it when I was in the queue at the supermarket, when I was driving, when I was washing up. It felt safe to do because I didn’t have to close my eyes. It became quite fun to try to focus just on my breathing for 30 or 60 seconds. And over time I’ve really noticed the difference. Because I’ve practised it when I’m not stressed, I can use it when I do get stressed too.
The first thing I tell myself when I realise that I’m getting out of my window of tolerance is to breathe. Wherever I am, whatever I’m doing, I just stop and focus on my breathing for a few seconds. Beforehand I would just get upset really easily and fly off the handle even at little things like not being able to find a parking space or stuff that my kids were doing. Now I feel like I’ve got a tool, something I can use when I’m stressed, and it helps. It doesn’t solve everything, but it does help.
4. BUILDING SKILLS AND KNOWLEDGE
The average dissociative client will have little or possibly no prior knowledge of trauma, the role of the autonomic nervous system, dissociation, or the ‘window of tolerance’. Many clients also have had relatively few opportunities to learn skills for maintaining safety, regulating themselves and their emotions, and negotiating relationships. Psychoeducation in all of these areas can help normalise their experiences as well as equipping them for the rest of their lives.
A. BUILD ON STRENGTHS
Trauma survivors often have very negative views of themselves. They invariably have core beliefs that they are pathetic, weak, incompetent and bad, and that their symptoms are proof that they are crazy. In phase 1 work, these self-assessments can be challenged, and replaced instead with a new focus on the client’s strengths and resiliency. They have after all survived atrocious trauma as children with no support. Far from being weak, the client’s survival is evidence of their strength. Far from being pathetic, they are admirable in their willingness to engage in therapy.
B. REFRAME SYMPTOMS
In addition, the client’s symptoms are not evidence of ‘madness’ but are entirely logical and can be reframed instead as their best attempts to survive trauma. Therapy can help to address the underlying trauma as well as the symptoms and adaptations that it has caused. This reframing may be welcomed by the client, but equally may also be resisted. It may feel too good to be true, or an attempt at grooming. Regardless of the response, however, the therapist can continue to gently and sensitively reinforce the new frame, mirroring to the client their appreciation for their strengths and their compassion for their suffering.
C. EDUCATE ABOUT TRAUMA
As well as dissociation being a normal response to trauma, and the freeze response as an inherent part of dissociation, the client can be encouraged to see that they are no longer powerless and that they can overcome the learned helplessness of chronic victimisation. Having hope for the first time that they are ‘normal’ and have nothing to be ashamed of, that other people also have similar symptoms, and some have successfully overcome them, can be tremendously empowering.
D. ‘JUST NOTICE’
The client can also begin to learn, sometimes for the first time, that their feelings are separate from their thoughts, and that both their feelings and their thoughts are sometimes not in sync with reality. Sometimes their feelings and their thoughts lead to impulses, strong desires to act in a certain way, but they can learn that they are able to control their impulses and notice that they are ‘just’ impulses – they are not commandments to act. Being able to separate out thoughts from feelings from sensations from impulses from beliefs from actions equips them to do the hard work of ‘mentalising’ required in phase 2 trauma processing work.
E. BUILD LIFE SKILLS
Alongside these skills and knowledge base, phase 1 can also be used to educate and equip the client with other areas of competence such as assertiveness, problem-solving and decision-making. The client can be encouraged to develop the skills needed to erect appropriate boundaries with people, to say no, to clearly articulate their needs, and to be able to distinguish between ‘safe’ and ‘unsafe’ people. This work in many ways is ongoing right through to phase 3.
The three-phase treatment plan makes sense at a number of levels and phase 1 can be readily adapted to be used in short-term work. Even six to twelve sessions can be useful in building skills and knowledge, addressing issues of safety and stabilisation and building a therapeutic alliance that will act as a template for a ‘secure base’ in future relationships. In the next part, I will look at the phase 2 work of processing trauma and how all of the skills developed in phase 1 are essential if clients are to gain mastery over the trauma that haunts them.