The three phase approach: part two – treating trauma
THE NEED FOR A DIFFERENT APPROACH
Historically, survivors of complex trauma and abuse were encouraged to ‘talk about’ their trauma, in the belief that ‘catharsis’ or ‘abreaction’ would in and of itself solve their difficulties. However, many dissociative survivors became destabilised when they attempted to do so, resulting in rapid switching, fugue states, intense distress, self-harm and suicidality. Bessel van der Kolk and Judith Lewis Herman, among others, pioneered new approaches to treating trauma in the 1990s, with a fresh understanding that talking about trauma resulted in many survivors feeling overpowered and overwhelmed – the same effect that the trauma had had on them originally. As Bessel van der Kolk first showed in 1994, ‘trauma lives non-verbally in the body and the brain’ and traumatic memory is not confined to images and narrative, but also comprises intrusive emotions, sensory phenomena, automatic arousal and physical actions and reactions. Treating trauma therefore had to take a more holistic approach.
The typical response for a trauma survivor when recounting their past is bodily dysregulation: either hyper-arousal in terms of hyperventilation, shaking, crying, agitation, pounding heart, tense muscles, etc.; or the collapsed state of helpless dread and shame of hypo-arousal. This bi-phasic response is typical of many trauma survivors – in van der Kolk’s words: ‘They see and feel only their trauma, or they see and feel nothing at all.’ In these states of dysregulation, survivors find it difficult to think and almost impossible to ‘process’ – to mentalise, and ‘metabolise’ their trauma, and without their thinking ‘front brain’ online, little processing is possible. The trauma is recounted and relived, but nothing changes. It is vital therefore to be able to manage the physical response of distress in response to recalled trauma, so that recounting it is not retraumatising but transformative. Van der Kolk says:
Healing from trauma is really about rearranging your relationship to your physical self. If you really want to help a traumatised person, you have to work with core physiological states, and then the mind will start changing … if clinicians can help people not become so aroused that they shut down physiologically, they’ll be able to process the trauma themselves. Therapists must help people regulate their affective states.
The ‘all-or-nothing’ bi-phasic trauma response can be seen clearly in the dissociative survivor who swings between the Apparently Normal Personality (ANP) who is emotionally flat and avoids all reminders of the trauma, and the Emotional Personality (EP) who is immersed in the trauma, with accompanying states of bodily distress and dysregulation. One of the biggest challenges in trauma work is holding a middle road, in Dan Siegel’s terms, between ‘rigidity’ and ‘chaos’ – specifically the rigidity of avoidance, where the client is unwilling to engage with traumatic material at all, and the ‘chaos’ of hyper- and hypo-arousal, where the client is flooded and overwhelmed by their automatic responses to it. The therapist needs to help the client to stay ‘grounded’, within a ‘window of tolerance’ where they can both think and feel, whilst still being willing to engage with traumatic material rather than continuing to cope through avoidance.
THE ESSENCE OF PHASE 2 WORK
Phase 2 is the aspect of trauma therapy that is most geared towards facing and resolving the intrusive traumatic memories that plague a trauma survivor’s life and manifest in forms such as flashbacks, physiological dysregulation, avoidance, numbing and re-experiencing. But phase 2 work is not a case of ‘going after memories’, hunting them down and then ‘remembering’ them. The aim is not recall that leads to emotional flooding. In fact, phase 2 work is much more concerned with memory resolution than memory recall. It is more about being able to forget, rather than being able to remember.
This phase of work is not meant simply to be cathartic – the trauma has to be metabolised so that the survivor changes their relationship with it, not just merely expressing feelings about it. Nor should it be destabilising – it is not meant to cause heightened distress that feels out of control and is thus retraumatising. And therapy during this phase 1 is not intended simply as a supportive discussion around ‘bad things that happened’, ending in an exhortation to ‘move on’ or ‘forgive and forget’: this phase of work should result in a change in the survivor’s automatic responses to traumatic reminders at an implicit-memory, bodily-response level, not just an intellectualised discussion, and certainly not one that is in any way coercive in terms of instructing the client how they should think and feel about certain events.
Nor is phase 2 work the grand ‘centrepiece’ of trauma recovery work, the Holy Grail that phase 1 work was merely a preparation for. All three phases of the three-phase approach are equally important, and all represent the ‘real’ work: just as the survivor is attempting to integrate the various aspects of their identity, personality and history into one coherent whole, so the therapy itself should be seen not as different ‘parts’ but as an inter-related and inter-dependent series of steps which all build towards the client being able to move forwards in their life, in touch with all the different facets of themselves, with their past connected into their present, and where they can make choices freely and consciously rather than being forever dysregulated by the trauma of the past.
THE MAIN TASKS OF PHASE 2
In the first instance in this phase of therapeutic work, the client begins to create an explicitly-remembered narrative account of what happened to them, breaking the injunction to never tell, and sharing their burdens and shameful secrets with a compassionate and understanding other. Forming a narrative may only be possible to a certain degree, depending on levels of amnesia, and should always be held lightly in terms of its provable historical accuracy. Although ‘remembering is not recovery’ and the creation of a narrative (however incomplete) is not essential to recovery, it is nevertheless vitally important to many dissociative survivors’ sense of self-identity, who can find their amnesia and disjointed sense of autobiography both frustrating and shameful. Creating some sense of verbal narrative of their life can help many survivors come to terms with what has happened to them and to reframe their coping behaviours not as dysfunction and disorder but instead as valiant attempts to manage unbearable suffering. If traumatic events are held out of mind (dissociated), it can be difficult for a survivor to understand why they act, feel, believe and react the way they do. Survivors often find it easier to feel compassion towards themselves for their struggles when they can bring to mind some of the things which caused those struggles – but while that traumatic material is dissociated, the logical conclusion that they come to instead is, ‘There’s no reason for me to be like this or struggle so badly, so I must just be inherently pathetic and evil.’
Secondly, trauma processing involves disrupting survivors’ automatic responses to the trauma. When faced with a traumatic reminder, a survivor will often instinctively respond by dissociating (in the sense of switching to another part of the personality or entering a trance state); by automatically engaging a fight/flight/freeze response; or by feeling a cascade of emotions which build towards a sense of overwhelm and catastrophe. While they continue to respond like this automatically, survivors feel out of control of their bodies, their emotions and their memories. It is little wonder that they spend so much energy trying to avoid all reminders of the trauma when those are the consequences! But if they can gradually learn to take control of these automatic reactions, and for these responses to be disrupted, they can gradually begin to feel more confident that they have the resources they need to be able to face their trauma and that it will not continue to control them.
This aspect of trauma processing is therefore predominantly concerned with ‘affect regulation’ (managing feelings). Survivors can learn that traumatic distress hijacks the mind, and that the body responds as in an emergency, but that there are ways of learning to thwart this hijacking. They learn that they can do something to calm their pounding heart and jerky breathing, and that they do not need to remain victims of their bodies’ responses. Over time this builds their confidence to be able to face increasingly distressing material, knowing that they have the capacity to manage their reactions to that distress rather than being overwhelmed by it.
Thirdly, and overlapping into phase 3 work, the client begins to make meaning out of what happened and begins to address some of the no-longer-helpful beliefs that have developed as a result of the trauma (for example, ‘I am worthless’, ‘I am powerless and weak’, ‘I deserve bad things’). Understanding some of the family dynamics and ‘systems’ that were in place during childhood, for example those which meant that it was never safe to express a different opinion (although it is now) or required perfection (but adulthood allows for mistakes) or meant that others’ feelings are more important than your own (your mother will survive even though she is upset with you) – this can all help survivors move out of unhealthy relational dynamics into more self-caring, mutually respectful, healthy relationships.
It can be deeply liberating for a survivor to recognise that they were manipulated by their abusers as part of the grooming process to believe that the abuse was their fault, that they deserved it, and that they were worthless: the survivor can then begin to challenge these core assumptions that they have held all these years and begin to choose what they believe about themselves now rather than their self-worth being determined by someone who caused them harm.
Part of the work of traumatic processing therefore involves ‘mentalising’: not just recalling traumatic incidents to mind but standing back from them and reflectively considering the dynamics and reality of those situations, in a way that was not possible as a child. But reconsidering these events is impossible unless the trauma is first brought back to mind.
Survivors often feel very apprehensive about the work of phase 2. After all, they have lived their lives with complex mental and emotional mechanisms in place to ensure that this overwhelming traumatic material remains out of mind, and now the suggestion in therapy is that they discard those defences and face the unfaceable! Often it is only when they realise that they can no longer keep it fully out of mind – that it intrudes too often, day or night, in flashbacks, in nightmares, in unexplained pain and other physical symptoms – that they come to a place of realising that they need to face this stuff in order to be able to deal with it. However, it is important that they realise that ‘facing the trauma’ does not mean being retraumatised and overwhelmed all over again. It means gradually approaching it, considering a sliver of it, being supported in it, and then ‘metabolising’ it – changing their relationship to this trauma so that it no longer holds power over them.
The presence of a supportive other during this process cannot be overstated. So much of the abuse was experienced with an intense sense of aloneness, and many clients’ biggest fears is that they will have to face the echoes of this trauma once again, alone, and without support. Suggestions to journal or deal with some of this stuff whilst alone, during the week outside the therapy room, can often be met with great resistance: the fear is of being alone with this trauma once again, and being retraumatised again by the isolation.
Clients often have greater confidence in facing this material when there is a reasonable guarantee that the therapist will be there to help them deal with it, for as long as it takes. Consequently, threats to the stability of therapy, such as coming to the end of funding, impending holidays or prolonged absences, or relational ruptures with the therapist, can understandably increase a client’s unwillingness to work on phase 2 material, and this should be respected and reframed not as resistance but in fact as self-preservation and the survival instinct: the client’s inherent wisdom knows when it feels safe enough to proceed with this work.
As Courtois and Ford put it:
Avoidance may begin and continue as a conscious form of coping, but it often becomes habitual, automatic and out of consciousness and control. As such it can be labelled ‘behavioural dissociation’.
Avoidance has been a dissociative survivor’s only or main strategy for dealing with the distress of overwhelming trauma, believing perhaps that if they can just keep the avoidance going, then everything will be ok. However, seeking help in therapy usually indicates that the avoidance is no longer a satisfactory or sufficient coping mechanism and that some if not all symptoms cannot be managed through avoidance and denial alone.
Often based on prior experiences of uncontrolled reliving and reexperiencing of the trauma, without support and outside their ‘window of tolerance’, many survivors feel that ‘remembering’ will make things worse. Effective trauma processing, by contrast, takes place when a client can remain inside a ‘window of tolerance’, where they have neither ‘flipped out’ (hyper-arousal) or ‘zoned out’ (hypo-arousal) and where they can be reflective about what they are remembering and experiencing. They can therefore remain present and personified during the remembering (‘I am still me and I am remembering being me as a child when these awful things happened’).
They can also gradually learn to actively manage their own states of bodily arousal (emotional distress expressed physically such as a pounding heart, shaking, crying) with support and assistance from the therapist, so that they are neither flooded nor destabilised by focusing their attention on their traumatic past. The aim is to think about the trauma whilst standing back from it, and to integrate all the different facets of their experience such as their feelings, their beliefs, their memories and their sensations. By doing so they come to understand the memory as ‘something that happened’ and ‘something that happened to me’ rather than disclaiming ownership of it (‘It happened to another part of me’ or ‘It didn’t happen at all – I’m making it all up’) and experiencing it as a past event, not as something that is happening right here, right now.
Avoidance has been a very successful and creative strategy in a client’s life and should not be dismissed or disparaged. The client will need to continue to choose to ‘avoid’ the traumatic content for large portions of their week in between therapy sessions. The key therefore is not to discard avoidance as a strategy, but to choose when to use it in an appropriate manner, and to be sufficiently in control of it (rather than being controlled it) so that traumatic material can be confronted purposefully at the right times. Rather than all-or-nothing, the client can be helped to understand that they can choose when to avoid, and when not to avoid, and so take charge of the focus of their mind. Mindfulness meditation can be helpful in learning this skill of taking control of one’s thoughts and mental focus: see for example Daniel Siegel’s book Mindsight.
A key consideration for clients to make is whether facing the trauma in stages, as part of a structured process, with the support of a therapist and in a way that is titrated to prevent overwhelm, is preferable to being confronted by the trauma at unexpected and inconvenient times. The main focus to this work then is an attitude of intentionality: ‘Let’s face this trauma now, recalling it where possible to mind, feeling the feelings associated with, disrupting the automatic responses to it, changing where necessary the unhelpful beliefs that it engendered, so that we can take control of it rather than being controlled by it.’
By saying, ‘Let’s look at this now,’ the client also implies, ‘Let’s not look at this at another time.’ That inherent belief, that the client can gain control over the trauma rather than being controlled by it, is a first essential steppingstone towards recovery. The survivor gradually learns to manage and control their affective states of distress – the times when they become deeply upset and overwhelmed by bodily sensations of distress and the fight/flight/freeze response, resulting in either manic attempts to self-soothe using self-harm, or zoning out with dissociation into a ‘not me, not here’ state of avoidance. So the basis of processing trauma is therefore learning to manage the feelings that it evokes, and the associated states of bodily arousal – it is not simply all about ‘facing the trauma’ which, as Richard Kluft described, can feel like ‘a guided tour of his or her personal hell without anaesthesia.’
READINESS TO ENGAGE IN PHASE 2 WORK
Not everyone is suited to phase 2 work. Babette Rothschild says:
Work in this phase 1s vital to the recovery of a good portion of trauma survivors. However, it will not be indicated or even helpful for another portion of survivors.
There are a number of contraindications, for example:
- insufficient safety in current life situation (e.g. domestic violence or ongoing victimisation)
- inadequate inner resources
- lack of emotional regulation skills
- maladaptive coping strategies such as unremitting substance dependence or self-harm
- lack of time in the therapy (e.g. because the sessions are time-limited)
- lack of attachment security in the therapeutic relationship
- psychiatric inpatient status
- current, ongoing police investigation or criminal proceedings (as either victim or perpetrator)
- uncontrolled switching between parts of the personality and ambivalence amongst them towards the work, or a lack of internal cooperation and collaboration.
It is also important that the therapist has the resources and feels sufficiently skilled and supported (e.g. with specialist supervision) to undertake this work, and that they can commit to the process, which may take a considerable period of time.
Clients’ readiness to proceed to phase 2 work would be signalled by a variety of factors, for example:
- having sufficient safety in their current-day life situation
- having personal circumstances that allow for the intensity of work in this phase, for example settled and suitable accommodation, no pressing demands such as a new-born baby, and financial stability to be able to continue to afford the therapy where it is paid for
- a ‘good enough’ relationship with the therapist that has previously demonstrated successful repair from ruptures
- an understanding of the work’s nature of phase 2 and a willingness to engage with it
- a range of affect regulation skills and a commitment to employing them
- good social and professional support such as GP, partner, children, employer
- a sufficiently robust ‘contract’ between therapist and client which includes contingencies for the heightened pressure on the relationship during phase 2, and an awareness of the forms that pressure will take
- established and respected boundaries within the therapeutic frame
- some ability to pay attention to internal physiological states and to be able to regulate them through techniques such as controlled breathing, oscillating attention and sensory grounding
- a general sense of having sufficient resilience to able to take the work to a deeper level.
Moving into phase 2 work is not a ‘once only’ decision: the nature of phase-oriented work is that while the three stages are sequential, it is not a linear process, and there is often movement between each of those phases over a particular month or term’s work, as well as even within a single session. For example, a typical session might consist of an opening phase of stabilisation and grounding and reconnecting with the therapist, followed by a segment focused on phase 2 trauma processing; and finishing either with more safety and stabilisation work if needed, or reflective meaning-making and integrating of information typical of phase 3. Similarly, it is important to prepare for holidays and breaks from the therapy not by leaving phase 2 work ‘hanging in the air’ but by pacing it appropriately.
It is important that the client does not feel coerced or pressured to proceed to phase 2 work, and that they make an informed decision, being aware of the nature of the work, and coming to their own place of motivation and commitment to it. Some clients will choose not to engage in phase 2 work, and this should not be seen as a therapeutic failure but as responding to individual needs and circumstances. However, it is important to recognise the potency of avoidance as a coping mechanism and to gently challenge clients to move forwards, if ready, into phase 2 work rather than colluding with their avoidance.
EFFECTIVE PHASE 2 WORK
These are some indicators of effective phase 2 work:
- the ‘social engagement system’ of the client is maximised – he or she is able to stay connected and in touch with the therapist during the work
- defences such as denial and minimisation are reduced
- traumatic material is faced rather than avoided, and processed rather than being merely re-lived
- the client can remain physiologically settled enough to both think and feel during the sessions – the client remains neither hyper-aroused nor hypo-aroused, but in a ‘window of tolerance’
- the client shows an increasing ability to integrate different facets of the trauma (e.g. memories, emotions, beliefs), and hold complexity rather than splitting (all good / all bad; all-or-nothing)
- the client demonstrates personification – ‘I am me and this happened to me’ – and presentification – ‘I am here, and it is not happening to me right here, right now; I am remembering a past event’
- the client shows dual awareness: an ability to focus their mind on the ‘there-and-then’ whilst also in touch with the ‘here-and-now’
- increased choice and control over what is remembered and when
- decreased dissociative and amnesic barriers between parts of the personality, without destabilisation and flooding
- awareness of the body (in Bessel van der Kolk’s words: ‘The moment you’re not feeling your body, you’re gone, because the body really is the engine of aliveness, of thought. As long as people don’t feel their bodies, we’re wasting our time and theirs trying to do talking psychotherapy.’)
- transforming maladaptive behaviours into adaptive ones (such as reducing trauma-
related conditioned responses of fight, flight or freeze without falling into further avoidance and dissociation; practising self-soothing rather than self-harm)
- willingness to ‘experiment’ and thoughtfully consider a variety of scenarios or possibilities, rather than being stuck in either rigidity or chaos
- flexibility in pausing the trauma narrative when hyper- or hypo-arousal becomes too marked and re-establishing equilibrium before continuing with the narrative
- an ability to direct attention to the what happened as well as the sense of how it felt and what it meant
- successful disruption of automatic bodily responses and states of distress at reminders of the trauma – gaining mastery over the reflexive symptoms of trauma and becoming desensitised to them, as manifested in life outside the therapy room.
Phase 2 work in the treatment of trauma builds on the foundations of the first phase of developing safety and stabilisation and, using that safe platform, begins to address some of the dissociated trauma that previously has been too overwhelming to be able to face and has therefore been kept out of mind. As survivors grow in their ability to regulate their physiological arousal in response to reminders of the trauma, so they can begin to face this trauma and neutralise it, by bringing it into mind and disrupting their automatic, procedurally-learned responses to it.
Staying within a ‘window of tolerance’ where they can both think and feel, the survivor learns to be in control of their body and mind, directing their attention to the trauma when they want to, to process and metabolise it, and avoiding it when that is also adaptive, for example whilst at work or play. Over time it therefore loses its power and becomes part of their narrative history, something that happened in the past, rather than recurring in the present, and something that happened to them, rather than to a ‘not-me’ part of the self.
By bringing traumatic incidents to mind, survivors can then begin to think about the meaning they have made of them, viewing them and reappraising them through adult eyes, and changing some of the unhelpful beliefs and cognitions that they have held regarding them. This leads on then into the work of phase 3 of trauma treatment, which focuses on integrating both the trauma and the self into a new, coherent whole, and developing or rebuilding a new life free from the overwhelming effects of trauma.