Structural-dissociation-informed therapy

1. Introduction

Version followed: the phase-oriented treatment of structural dissociation set out by Steele, van der Hart & Nijenhuis (2005) and The Haunted Self (van der Hart, Nijenhuis & Steele, 2006). Practical detail comes from the authors' later papers: imagery (van der Hart, 2012), EMDR adaptations (van der Hart et al., 2013, 2014) and traumatic-memory work (van der Hart, Steele & Nijenhuis, 2017). The relational and parts-work emphasis follows Treating Trauma-Related Dissociation (Steele, Boon & van der Hart, 2017); only its table of contents and introduction are drawn on. Where the 1993 synthesis paper (pre-ANP/EP terminology) adds procedure, it is named.

What it is. This is not a single manualised therapy. It is a theory, the theory of structural dissociation of the personality (TSDP), plus the phase-oriented treatment model its authors derive from it, drawing on Pierre Janet's psychology of action. The attribution to Onno van der Hart (Netherlands), Ellert Nijenhuis (Netherlands) and Kathy Steele (Atlanta, USA) is confirmed. Suzette Boon is a co-author of the skills manual (2011) and the 2017 clinical text. It is sometimes listed under humanistic/experiential parts work, but its authors describe it as an integrative, relational and Janetian trauma model [source: Steele et al. 2005; Haunted Self publisher description].

Core idea of change. Chronic traumatisation leaves the personality divided between parts that function in daily life ('apparently normal parts', ANPs) and parts fixed in 'trauma time' and in defensive action systems ('emotional parts', EPs). In this model, dissociation is first a deficit of integrative capacity and only secondarily a coping strategy. It is kept in place by a set of trauma-related phobias: of inner experience, of parts, of traumatic memory, and later of normal life, change and intimacy. Change comes from four things:

raising integrative capacity (Janet's 'mental efficiency' or 'mental level');
overcoming these phobias step by step, in a set order;
synthesising traumatic memory across parts;
realising it, which means owning it as one's own (personification) and grasping that it is over while living in the present (presentification).

When this is done, structural dissociation is no longer needed and parts can integrate [source: Steele et al. 2005; van der Hart et al. 2017].

Scope. The model distinguishes three levels:

Primary structural dissociation: one ANP and one EP (simple PTSD).
Secondary: one ANP and several EPs (complex PTSD, trauma-related borderline personality disorder, DDNOS/OSDD).
Tertiary: several ANPs and several EPs (DID).

The full phase model was written mainly for secondary and tertiary dissociation [source: Steele et al. 2005].

Terminology note. The 2017 book reports that the authors disagree about the ANP/EP terms, and it mostly says 'dissociative parts' instead. Steele's current (2026) teaching speaks of the 'adult self' and of parts by type (child, adolescent, hostile and others) [source: Desclée preview of the 2017 book; ESTD 2026 flyer]. This guide uses ANP/EP where the cited source does.

2. Framework

Overall shape. There are three phases. In practice they are recursive, a spiral in which the client returns to Phase 1 whenever capacity drops: 'Safety first' [source: Steele et al. 2005; van der Hart et al. 2014]. Steele now presents stabilisation as 'a major feature of treatment' in its own right, not just a gateway to memory work [source: ESTD 2026 flyer].

Format. Individual outpatient psychotherapy, built on the therapeutic relationship. Some patients need supportive care, case management or quick access to hospital instead of insight-oriented outpatient work [source: Desclée preview]. Phase 2 can use extended sessions, but only to titrate material more slowly, never to intensify it [source: van der Hart et al. 2017]. For EMDR-trained therapists, Kluft's 'rule of thirds' gives a session structure:

first third: the ANP works on here-and-now issues;
second third: processing;
final third: closure, with the ANP back in executive control [source: van der Hart et al. 2014].

Duration. No fixed session count is given [uncertain]. Treatment of complex dissociative disorders runs for years. In one published case, three years of Phase 1 work on phobic avoidance came before any synthesis, and integration was completed at five years [source: van der Hart et al. 2017]. The authors cite Kluft's suggestion that integration should be stable for 27 months before it is considered secure [source: Steele et al. 2005].

Phobias treated in each phase [source: Steele et al. 2005]:

Phase 1: (1) phobia of attachment and attachment loss with the therapist, worked mainly with the ANP; (2) phobia of mental contents, meaning trauma-derived mental actions; (3) phobia of dissociative parts, ANPs first and then EPs.
Phase 2: (4) phobias tied to insecure attachment to the perpetrator; (5) phobia of attachment and attachment loss with the therapist, now in EPs; (6) phobia of traumatic memory, the 'core' phobia.
Phase 3: (7) phobia of normal life; (8) phobia of healthy risk-taking and change; (9) phobia of intimacy, worked emotional first, then physical, then sexual. The phobia of fusion is also addressed here [source: van der Hart et al. 2014].

The phobias of mental contents and of parts come back throughout treatment. Phase 3 phobias are touched on throughout but become the main work only in Phase 3.

Phase 1: Symptom reduction and stabilisation

Goals: safety; less self-destructive behaviour; better daily functioning; a stronger ANP (more reflective and regulated, with more energy); tolerance of inner experience; growing empathy and cooperation among parts. Traumatic memory content is not shared yet [source: Steele et al. 2005; van der Hart 2012].
Main work: relationship; psychoeducation; regulation and grounding skills; daily structure and energy management; containment and safe-place imagery; inner communication and a meeting place; early attention to aggressive and perpetrator-imitating parts.
Criteria for moving to Phase 2 [source: Steele et al. 2005; van der Hart et al. 2017]:
- the ANP(s) and key EPs function adequately in the present;
- there is a reasonably stable collaborative relationship;
- the client can mentalise and regulate arousal and tolerate inner experience;
- there is some inner empathy and cooperation among parts;
- the client gives informed consent to starting Phase 2.
Contraindications to Phase 2:
- ongoing abuse;
- ongoing substance misuse or self-destructive behaviour;
- acute life crises or periods that need extra energy;
- pregnancy;
- old age or serious or terminal illness;
- psychosis;
- severe characterological problems;
- uncontrolled switching;
- the therapist being the client's only attachment figure [source: van der Hart et al. 2014, 2017].
The authors call for strict adherence: the lower the integrative capacity, the slower the work and the more often the client returns to Phase 1.

Phase 2: Treatment of traumatic memories

Goals: synthesis of traumatic memory shared among the relevant parts, then realisation (personification and presentification), so that the memory becomes a narrative the person tells from the present, without reliving it or depersonalising [source: van der Hart et al. 2014, 2017].
Stages:
1. Preparation, which may take several sessions.
2. Guided synthesis: rapid, or fractionated across sessions.
3. Guided realisation: long and process-oriented. Retrieval is 'merely the beginning' [source: Steele et al. 2005].
Moving to Phase 3: integrative capacity is sufficient and the phobia of traumatic memory is no longer in the foreground. The shift often happens spontaneously, as the client starts to bring up Phase 3 concerns [source: Steele et al. 2005].

Phase 3: Personality integration and rehabilitation

Goals:
- fusion or integration of parts;
- grief for what was lost;
- a balanced life (work, play, rest, relationships) and activation of neglected action systems;
- tolerance of healthy risk, change and intimacy;
- relapse prevention and termination [source: Steele et al. 2005; van der Hart et al. 2014].
Ending: the first apparent fusion is often not the last. Termination work addresses the client's fear of detaching from the therapist and the therapist's own countertransference [source: Steele et al. 2005; van der Hart et al. 2014].

Assessment. Assess for dissociative parts early: parts that are missed can become active in the middle of treatment and lead to panic, self-harm or decompensation [source: van der Hart et al. 2013]. The 2017 book gives three chapters to assessment, formulation and treatment planning, which are not drawn on here. Specific instruments are not specified here [uncertain].

3. Guiding principles

Sources: Steele et al. 2005; van der Hart 2012; van der Hart et al. 2013, 2014, 2017; Steele et al. 2017 introduction.

Safety first. Deal with self-harm, suicidality, substance use, violence and ongoing abuse before anything else.
Raise integrative capacity before doing trauma work. Improve the quality and quantity of adaptive action in daily life before any memory is shared.
Treat the phobias in sequence. Start with avoidance of the therapist, of inner experience and of parts; address memory phobias only later.
Respect the client's need for their phobias. Avoidance is protective. Do not strip it away; reduce it in graded steps.
Relationship as backbone. Relational ways of being with the client are 'the backbone of treatment' (translated from the Spanish edition). The relationship is itself an intervention: it should be collaborative, not a rescue.
Dyadic regulation first, then self-regulation. Regulate the client's arousal together in session, then model and teach the client to do it alone.
Stay within the window of tolerance. Slow down or stop when the client moves toward hyperarousal or hypoarousal.
Work with all parts, as one person. Every part belongs to the same personality and is responsible to and for the others. Do not side with or 'babysit' a single part.
ANP first. Begin with the most adult, daily-life parts. Reach EPs through the ANP before addressing them directly.
Every part once served survival. This includes perpetrator-imitating and self-harming parts. Explain these protective functions to the parts themselves.
EPs live in 'trauma time'. Repeat orientation to the present often.
The therapist is a consultant. Help the client build their own inner solutions and skills, not dependence on you.
Your words act as suggestions. Watch your phrasing so you do not create threatening images. The way you introduce a technique can decide whether parts accept it.
Introduce techniques gradually and get all parts' agreement. Check that parts agree, ask whether the client already has a solution, offer an option, and deal with objections. Skipping this step can cause adverse reactions later.
Individualise. Published imagery is 'sources of inspiration'. Build on the client's own images.
Synthesis is not abreaction. Uncontrolled emotional discharge is rejected. Share only the 'pathogenic kernels'.
'Less, rather than more, is the safest way' [source: van der Hart et al. 2014]. Short, controlled, manageable doses are better than too much.
Realisation, not retrieval, is the goal. Recovering a memory is only the beginning. The work is owning it and knowing it is over.
Expect a recursive spiral. Plan for returns to earlier phases.
Look after your own integration. Watch for enmeshment versus distancing, rescue fantasies, counter-phobic fascination with memories, and collusion with avoidance.
Resistance is phobic avoidance and is co-created [source: Sheppard Pratt workshop description]. Explore what the client finds intolerable instead of pushing past it.
Do not set the client against the perpetrator. Explore all the conflicting loyalties among parts without taking sides [source: van der Hart et al. 2014].
Specialised methods need specialised training. Use hypnosis and EMDR in this population only if you are trained for chronic trauma and dissociation.

4. Intervention inventory

The interventions are grouped by the phase where each is mainly used. Many are reused whenever treatment spirals back to an earlier phase. All example language is illustrative unless a source is cited. Imagery techniques are drawn from van der Hart (2012), who notes there are no empirical data on imagery in any phase.

A. Phase 1 and ongoing: safety, relationship, capacity

4.1 Safety assessment and resolving unsafe behaviour

Purpose / when: From the first session onward, and whenever self-harm, suicidality, substance use, violence, risky behaviour or ongoing abuse is present. 'Safety first' comes before all other work [source: Steele et al. 2005]. The 2017 book has a chapter on resolving unsafe behaviours, which is not drawn on here [uncertain].
Steps:
1. Carry out standard suicide and self-harm risk assessment, and repeat it [synthesis: current standard practice].
2. Ask which part or parts drive the behaviour. Ask what the urge protects against or tries to solve. Unsafe behaviours often work as 'substitute actions' when a more adaptive action is not available [source: Steele et al. 2005].
3. Agree a safety plan with the ANP that the relevant parts also accept. Include lethal-means counselling: safe storage, or removal of means by a trusted person [synthesis].
4. Negotiate less harmful ways for the protective part to reach its goal [source: van der Hart et al. 2013].
5. Plan crisis contacts. For parts in acute pain, use safe-place and rest imagery (4.14).
6. If abuse is ongoing, support protection first. Memory work is contraindicated while it continues [source: van der Hart et al. 2014].
Example language (illustrative): 'Some part of you is very determined to cut tonight. Before we talk about stopping it, I'd like to understand what that part is trying to do for you. Can everyone inside listen while we find out?'
Watch for: An agreement made by the ANP alone that another part breaks. The 2014 paper describes an EP that broke a 'not-harming' contract. When that happens, explore the source of the pressure behind the breach, which may be a perpetrator-imitating part, and do not simply renew the contract. You know it is working when there are fewer unsafe acts and parts start telling you about urges before they act on them.

4.2 Building the collaborative therapeutic relationship (phobia of attachment and attachment loss)

Purpose / when: This is the first phobia treated in Phase 1 (with the ANP). In Phase 2 it is treated again with EPs. The relationship is the medium for all other work [source: Steele et al. 2005; Steele et al. 2017].
Steps:
1. Keep a predictable frame: consistent times, boundaries and responses [source: van der Hart et al. 1993].
2. Expect the client to alternate between seeking attachment and defending against it (clinging versus avoidance or hostility). Respond calmly, with curiosity and consistency, without becoming defensive or enmeshed [source: van der Hart et al. 2013].
3. Do not encourage too much attachment too fast. Do not feed rescue fantasies, which can grow as the alliance grows [source: Steele et al. 2005].
4. Name the alternation openly, and help the client see that the opposing pulls belong to different parts or needs.
5. Build collaboration around shared goals. The therapist acts as a consultant, not a rescuer [source: van der Hart 2012; Steele et al. 2017 TOC, ch. 4].
Example language (illustrative): 'Last week you felt close to me, and today part of you seems to want to keep a distance. Both make sense to me. Can we be curious together about what feels risky about being close?'
Watch for: Push-pull cycles, testing of the therapist, sudden absences, and the therapist being drawn into rescuing or withdrawing. It is working when the client can tolerate both closeness and separations, such as breaks and holidays, without crisis.

4.3 Psychoeducation about trauma, parts and 'trauma time'

Purpose / when: Early in treatment, then repeated often. Psychoeducation lowers shame and fear of parts and gives the client a shared map.
Steps:
1. Explain dissociation as a division of the personality that once helped survival. Explain daily-life parts and parts stuck in the trauma.
2. Explain that each part had a survival function, including hostile and self-harming parts [source: van der Hart et al. 2013].
3. Explain that EPs live in 'trauma time' and cannot tell past from present. Repeat this often [source: van der Hart et al. 2013].
4. Explain triggers, and the difference between having a feeling and acting on it [source: Steele et al. 2005].
5. Make sure all parts can 'listen in' while you explain.
Example language (illustrative): 'The parts of you that feel terrified right now are reacting as if it is still happening back then. Your adult self knows it is 2026 and you are safe in this room. Part of our work is helping those parts know that too.'
Watch for: The ANP intellectualising, or hearing 'parts' as proof of being 'crazy'. Some parts may object to being described. It is working when the client starts using the concepts to make sense of switches and triggers.

4.4 Arousal regulation within the window of tolerance (dyadic, then self-regulation)

Purpose / when: In every session. Keep processing within tolerable arousal, and teach the client to notice and correct hyperarousal and hypoarousal [source: Steele et al. 2005; van der Hart et al. 2014].
Steps:
1. Track signs of arousal: breathing, posture, gaze, speech, numbness, spacing out.
2. When arousal rises or the client starts to shut down, stop the topic and regulate together. Slow down, orient to the room, and use your voice.
3. Name what you noticed, and teach the client to notice the early signs themselves.
4. Gradually hand regulation over to the client's own skills (4.5).
Example language (illustrative): 'I notice your voice getting quieter and your eyes drifting. Let's pause the story. Can you feel your feet on the floor and tell me three things you can see in this room?'
Watch for: Hypoarousal can look like calm. It is working when the client signals earlier and recovers faster within the session.

4.5 Grounding, presentification and time orientation

Purpose / when: To strengthen dual attention and present-orientation for the ANP and EPs. Use it whenever a part is in 'trauma time' [source: van der Hart et al. 2013; Steele et al. 2005].
Steps:
1. Teach grounding through the senses and the body. Expressive movement and mindfulness can be added [source: Steele et al. 2005].
2. For an EP, ask whether it knows the current year, that the client is now an adult, and that the danger is over.
3. Use concrete cues: a ring, today's newspaper, a diary or agenda, the therapist's office [source: van der Hart et al. 2013].
4. Have the ANP show the EP the present, for example by looking through the ANP's eyes.
5. EMDR option: pair present-orientation cues with short, slow sets of bilateral stimulation. Stop if negative material emerges, then explore and ground [source: van der Hart et al. 2013].
Example language (illustrative): 'I'd like the part who is frightened to look through your eyes for a moment. What year is on that calendar? Whose hands are these, a child's or a grown woman's?'
Watch for: EPs that are afraid of the present, for example because being 'here' means feeling the losses. It is working when the EP calms down, can say it is an adult body, and can communicate with other parts.

4.6 Self-soothing, relaxation, mindfulness and expressive movement

Purpose / when: Phase 1 skills to tolerate affect and reduce substitute actions [source: Steele et al. 2005].
Steps:
1. Choose one skill at a time and practise it in session while arousal is low.
2. Check whether any part finds the skill threatening. For example, relaxation can feel dangerous to vigilant parts.
3. Assign brief daily practice, then review it.
4. Adapt the skill to parts. For example, child parts may prefer comforting objects or movement.
Example language (illustrative): 'Is there any part inside that feels uneasy about relaxing? Let's find a version that every part can agree to try for one minute.'
Watch for: Paradoxical anxiety when relaxing. If it appears, use a shorter, eyes-open, active version.

4.7 Structuring daily life and managing energy (raising mental efficiency)

Purpose / when: To raise integrative capacity, which is the model's core aim in Phase 1 [source: Steele et al. 2005; van der Hart et al. 2017].
Steps:
1. Review sleep, rest, eating, work, play and relationships [source: van der Hart et al. 2013].
2. Build a daily structure with realistic tasks and rest breaks.
3. Ask the ANP and other parts to agree on daily schedules. The inner meeting place (4.15) can be used for an agenda in the morning and a review in the evening [source: van der Hart 2012].
4. Count completed actions as progress. Reduce demands that drain energy.
Example language (illustrative): 'Let's look at your week like an energy budget. Where does energy leak, and which part needs what in order for Tuesday to work?'
Watch for: An ANP that overworks as a form of avoidance, and EPs that fear the ANP getting stronger. One EP warned against giving the ANP more energy [source: van der Hart et al. 2013].

4.8 Overcoming the phobia of mental contents (trauma-derived mental actions)

Purpose / when: In Phase 1, and again whenever needed. Use it when the client avoids feelings, sensations, thoughts or wishes [source: Steele et al. 2005; Haunted Self ch. 15 title].
Steps:
1. Help the client notice inner experience without judging it.
2. Identify and reduce self-conscious emotions about inner experience, such as shame, fear and disgust [source: van der Hart et al. 2013].
3. Expose the client to inner experience in graded steps: small amounts, inside the window of tolerance, with the therapist present.
4. Separate feelings from actions ('feeling rage is not hurting someone').
5. Address reflexive beliefs such as 'If I start to feel, I'll go crazy' [source: van der Hart et al. 2017].
Example language (illustrative): 'Can you let yourself notice just a little of that sadness, maybe 5 percent, while you stay here with me, and then we'll set it aside?'
Watch for: Switching or numbing as a way to escape the feeling. It is working when the client can name feelings and stay present with them for longer.

4.9 Ideomotor finger signalling

Purpose / when: In Phase 1. It gives parts that cannot or will not speak a way to communicate, for example yes, no and stop [source: Steele et al. 2005].
Steps:
1. Agree with the client, and with parts listening in, which finger means yes, which means no, and which means stop or 'I don't want to answer'.
2. Ask simple, non-threatening questions about agreement and safety.
3. Use a stop signal in all later work. A finger-lift can also signal 'I'm drifting' during processing [source: van der Hart et al. 2014].
4. Formal hypnotic use requires training [source: Steele et al. 2005] [uncertain: the exact procedure is not detailed].
Example language (illustrative): 'If any part inside wants us to stop, it can lift that finger and we will stop. No explanation needed.'
Watch for: Ambiguous signals. Treat any doubt as a 'no'.

4.10 Overcoming the phobia of dissociative parts: graduated contact, ANP first, 'talking through'

Purpose / when: In Phase 1 and onward. Reduces the ANP's avoidance of, or hostility toward, EPs, and the parts' avoidance of each other [source: Steele et al. 2005; van der Hart et al. 2013; Haunted Self ch. 16 title].
Steps:
1. Explore the client's fears of parts with empathy, working from the least to the most frightening.
2. Start with ANPs. With tertiary dissociation (several ANPs), build communication among the ANPs first.
3. Reach EPs through the ANP before addressing them directly. Ask the ANP to relay a question ('talking through') while other parts listen. Speak to the whole system ('talking to') [source: Steele et al. 2005; van der Hart et al. 2013].
4. Ask what each part needs to feel safer. Help the ANP respond to those needs in a balanced way.
5. Introduce parts to each other gradually, without sharing trauma content in Phase 1 [source: Steele et al. 2005].
6. Address the client's avoidance of a part while explaining that part's protective role.
Example language (illustrative): 'Could you ask inside, and just listen for whatever comes back, whether the part who screams at night would be willing to let us know what she needs to feel a little safer? Nobody has to come out.'
Watch for: Engaging EPs too early, which can drive the ANP into avoidance [source: Steele et al. 2005]. Watch also for the therapist favouring one part. It is working when the ANP can show curiosity or empathy toward parts and parts start cooperating.

4.11 'Loving Eyes' and other EMDR-assisted Phase 1 procedures (EMDR-trained clinicians only)

Purpose / when: To use bilateral stimulation (BLS) to soften the phobia of parts and to strengthen inner empathy [source: van der Hart et al. 2013, citing Knipe].
Steps:
1. Loving Eyes: The ANP looks with care at a child EP it has been avoiding. Add BLS, then process the beliefs and feelings that come up.
2. Targeting blockages: If the ANP cannot feel empathy for a hostile EP, have it notice the body sensation of that block. Apply short, slow sets. Stop if distress rises. Once the ANP is more open, propose dialogue with the EP.
3. Temporary blending: With psychoeducation, a part briefly 'borrows' a capacity that another part holds, such as assertiveness.
4. Resource installation: First get the whole system's agreement. Extend resources (safety, attachment, strength, adaptive coping, present orientation) to EPs, not only to the ANP.
Example language (illustrative): 'As you look at that little girl, just notice what happens inside you... Let's go with that.'
Watch for: Resources that trigger EPs, such as an EP fearing that a stronger ANP will defeat it. Address the phobia of parts before strengthening the ANP. Stop BLS if decompensation, unreported somatic distress or threatening voices appear [source: van der Hart et al. 2013].

4.12 Containment imagery (vault or container)

Purpose / when: In Phase 1, and between Phase 2 sessions. Traumatic material that intrudes is put away until it can be integrated [source: van der Hart 2012; Steele et al. 2005].
Steps:
1. Have the client create an imagined container, such as a safe, bank vault, steel box, pillbox, computer file or video.
2. Optionally add a lock with two keys, one held by the client and one by the therapist. The material stays locked until both agree to open it in Phase 2.
3. Practise putting a small intrusive image away, and check the client's distress before and after.
4. Separate healthy pacing from avoidance: the container postpones work, it does not erase it [source: van der Hart et al. 2013].
Example language (illustrative): 'Whatever doesn't need to be with you this week can go into the vault, and we'll decide together when to open it.'
Watch for: Parts that refuse because they need to be heard, and leakage of material. Watch also for the container becoming a way to avoid work indefinitely.

4.13 Inner safe places for parts

Purpose / when: To protect vulnerable EPs from triggers outside and from other parts inside, and to let parts withdraw before a threat they can predict [source: van der Hart 2012].
Steps:
1. First check that all parts agree with the procedure and the image [source: van der Hart et al. 2013].
2. The ANP develops a safe place together with each EP. Parts may share a place or have their own. Use the client's own images; the therapist may offer examples such as a hidden cabin or an island.
3. Add protection as needed, for example an inner soundproof wall.
4. Rehearse moving parts there before predictable stressors and during sensitive discussions, such as choosing a Phase 2 target.
5. Adapt creatively to fears. For example, a part with claustrophobia can be helped to enter at its own pace [source: van der Hart 2012, case 'Etty'].
Example language (illustrative): 'Before we talk about the anniversary, would the younger parts like to go to their place, where they can't hear us, and the ANP will let them know when it's quiet again?'
Watch for: Hostile parts that sabotage the safe place, for example by experiencing it as an escape from their control. Watch also for the word 'safe' itself acting as a trigger. Use other words ('quiet place') or protective imagery instead [source: van der Hart et al. 2013].

4.14 Rest imagery for parts in acute pain or with impulses

Purpose / when: In crises, to prevent admission, suicide attempts, self-injury or acting out when parts are overwhelmed [source: van der Hart 2012, citing Kluft].
Steps:
1. An ANP agrees to stay in charge of daily affairs.
2. Suggest that the parts in pain go to their safe places.
3. Invite them to rest and drift toward sleep, undisturbed until the next session.
4. Confirm a crisis plan and the next contact.
Example language (illustrative): 'Those parts who are hurting most tonight can go to their resting place and stay there quietly until we meet on Thursday, while your adult self takes care of tomorrow.'
Watch for: This is not a substitute for risk assessment and crisis care when risk is high [synthesis]. It is working when the ANP stays in executive control between sessions.

4.15 Imaginary protective gear

Purpose / when: To prepare for a demanding situation that could reactivate EPs, such as an angry person or overwhelming emotions in others [source: van der Hart 2012, citing Boon et al. 2011].
Steps:
1. Invite the client to imagine a store with protective devices: suits, armour, cloaks.
2. The client chooses protection. Different parts may choose different gear.
3. Once the client feels protected and calm, rehearse the stressful situation in imagination while staying in that calm state.
4. The client 'wears' the gear in real life when needed.
Example language (illustrative): 'What would you choose to wear into that meeting so his anger doesn't get through to the little ones?'
Watch for: Imagery that becomes a way to avoid needed assertive action [synthesis].

4.16 Inner meeting place (Fraser's dissociative table technique)

Purpose / when: To build inner cooperation, negotiate goals and make shared decisions [source: van der Hart 2012, citing Fraser 2003; van der Hart et al. 2013].
Steps:
1. Help the parts create a table and chairs in a safe room. Some clients prefer another space at first, because rooms can feel unsafe.
2. Optionally provide hiding places, such as a cloth over the table or dark niches, so child parts can listen without being seen.
3. Add imaginary microphones or spotlights to support respectful turn-taking.
4. Ask the parts who is best suited to chair, so that every part gets a turn. Optionally appoint a 'secretary' to record decisions.
5. Begin with business-like agendas, such as daily plans and practical decisions, and only later move to emotional sharing.
6. The therapist stays a consultant, especially to the chair part.
Example language (illustrative): 'Who would be the best chair for today's meeting? The question on the agenda is whether you go to your sister's on Sunday.'
Watch for: Parts that dominate or stay silent, and new parts appearing. Check the meeting place when processing gets blocked [source: van der Hart et al. 2014].

4.17 Inner community building (imaginary house)

Purpose / when: To combine the meeting room, safe places and container into one larger inner structure that supports inclusion and teamwork [source: van der Hart 2012].
Steps:
1. Help the client imagine a house or similar structure.
2. Include a meeting room, safe rooms for parts, rooms for specific needs (for example, carers staying with child parts), and a storage place for memories nearby.
3. Encourage parts to visit each other and to decide who needs protection during sensitive discussions.
Example language (illustrative): 'Is there a room in the house where the caretaking part could stay with the little one tonight?'
Watch for: Elaborating the structure as a substitute for real cooperation [synthesis].

4.18 Inner source of wisdom

Purpose / when: For stuck decisions with serious consequences, such as starting Phase 2, leaving hospital or ending a relationship. It builds autonomy and reduces maladaptive dependence [source: van der Hart 2012].
Steps:
1. Invite the client to imagine the path to an inner place where a source of wisdom resides.
2. Approach it with respect.
3. Parts consult it with their question.
4. Process the answer together in session.
Example language (illustrative): 'Take whatever path leads you to that place of wisdom inside, and bring the question of whether now is the time to begin memory work.'
Watch for: The therapist handing all responsibility over to the imagery. The source explicitly warns against this.

B. Working with specific parts and relational processes (Phase 1 and beyond)

The 2017 book has a chapter on each of these topics: child parts, shame, angry and hostile parts, perpetrator-imitating parts, dependency and resistance. Those chapters are not drawn on here. The steps below come from the cited papers, with gaps marked.

4.19 Working with child parts

Purpose / when: Child EPs often hold neediness, fear and attachment longing. The ANP or other parts may despise or avoid them [source: van der Hart et al. 2013; Steele et al. 2017 TOC ch. 14].
Steps:
1. Orient the child part to the present and to the adult body (4.5).
2. Help the ANP, or a caretaking part, take responsibility for the child part's needs. The therapist should not become the child part's primary carer, the 'babysitter' trap [source: van der Hart et al. 2013].
3. Provide safe or quiet places and caretaking imagery, such as carers staying with child parts [source: van der Hart 2012].
4. Explain to hostile parts why the child part behaved as it did. In one case, a fight part came to see that a child part's surrender had prevented a more lethal outcome [source: van der Hart et al. 2013].
5. Celebrate small steps across the system. In one published example, parts applauded a five-year-old part who had stopped bedwetting [source: van der Hart 2012].
Example language (illustrative): 'Who inside is grown-up enough to sit with the little one when she wakes up scared at night?'
Watch for: Child parts demanding contact with the therapist outside sessions, and the therapist's own pull to rescue. Steele's current teaching adapts ego-state approaches such as IFS for this population [source: ESTD 2026 flyer]; the details are uncertain.

4.20 Working with angry, fight and hostile parts

Purpose / when: Early in Phase 1. Aggressive or persecutory EPs can sabotage treatment and threaten safety [source: Steele et al. 2005].
Steps:
1. Address these parts early, through the ANP where possible.
2. Acknowledge the part's protective function and its strength. Do not try to get rid of it.
3. Explore what the part fears would happen if it relaxed its control.
4. Work through the ANP's blocked empathy toward the part (4.11 for EMDR-trained clinicians).
5. Negotiate less destructive ways for it to protect the system.
6. In Phase 2, work with fight parts before relying on them to protect the system with empathy [source: Steele et al. 2005].
Example language (illustrative): 'You've worked very hard to keep everyone from getting hurt again. I'm not here to fight you. I want to know what you're guarding against.'
Watch for: Threatening inner voices, retaliation after sessions, and the therapist feeling intimidated or allying against the part. It is working when the part's energy shifts from attack to protection.

4.21 Working with perpetrator-imitating parts

Purpose / when: Some EPs imitate abusers. They reject or punish needy EPs and 'wimpy' ANPs [source: van der Hart et al. 2017]. Give them special attention before and during any memory processing [source: van der Hart et al. 2014].
Steps:
1. Acknowledge the part's protective origins. Imitating the perpetrator was a way to survive.
2. Help the ANP tell apart the real abuser and the inner part that resembles them [source: van der Hart et al. 2013].
3. Explore the approach-avoidance conflict this creates within a secure alliance [source: van der Hart et al. 2017].
4. Negotiate other ways of solving problems.
5. Gently orient the part to the present. Such parts may believe they are the perpetrator, or that they are not part of the person [uncertain: this is inferred from the general 'trauma time' principle; the specific technique is not in the cited papers].
Example language (illustrative): 'You sound a lot like him, and I think you learned to sound like that to keep everyone alive. You're part of her, and you've been protecting her in the only way you knew.'
Watch for: The ANP treating the part as the actual perpetrator, internal punishment after a disclosure, and pressure that drives broken safety agreements [source: van der Hart et al. 2014; van der Hart et al. 1993].

4.22 Identifying and correcting substitute beliefs, substitute actions and defensive fantasies

Purpose / when: Before trauma work and throughout. Some beliefs and actions stand in for realisation, such as:
- wishing to be rescued, or for a magical cure;
- giving up responsibility;
- idealising the perpetrator;
- self-blame ('It was my fault');
- 'He'll know if I tell' [source: van der Hart et al. 2017; Steele et al. 2005; van der Hart et al. 1993].
Steps:
1. Notice the belief or action and what it avoids realising.
2. Explore with the client what it protects them from.
3. Test it against present reality, using cognitive work and gentle challenge from other parts.
4. Revise it repeatedly. Expect these beliefs to persist [source: van der Hart et al. 1993].
5. Steele also teaches working with 'defensive fantasies' and 'conflict statements' [source: Sheppard Pratt workshop page]. The procedure itself is not detailed here [uncertain].
Example language (illustrative): 'If you believe it was your fault, there's a kind of control in that, because you could have done something differently. What would it mean to know you couldn't?'
Watch for: Intellectual agreement without any change in feeling. It is working when the belief loosens and grief or anger can be felt.

4.23 Working with resistance as phobic avoidance

Purpose / when: When therapy stalls. Chronic resistance is understood as 'a co-creation of therapist and client' and as phobic avoidance of what feels intolerable [source: Sheppard Pratt workshop page; Steele et al. 2017 TOC ch. 11–12].
Steps:
1. Name the impasse without blame.
2. Ask what feels intolerable and which part fears it.
3. Look at your own contribution: pushing, avoiding or colluding.
4. Grade the next step down to something tolerable.
5. Address the specific phobia involved, whether of feelings, parts, memory, realisation or fusion [source: van der Hart et al. 2014].
Example language (illustrative): 'We seem to have been circling this for weeks. I wonder if I've been pushing a bit fast, and some part of you has been putting the brakes on for good reasons. What would happen if we went forward?'
Watch for: Interpreting resistance as unwillingness. It is working when you can name the avoided content and the client can approach it in small steps.

4.24 Managing dependency

Purpose / when: When the client hides and tries to please the therapist, or demands more and more support and rescue [source: ESTD 2026 flyer; Steele et al. 2017 TOC ch. 13].
Steps:
1. Separate adaptive from maladaptive dependency. Understand intense yearning as linked to the separation or attachment cry [source: ESTD 2026 flyer].
2. Keep a collaborative model of the relationship, with clear and predictable contact limits that are explained, not imposed [synthesis].
3. Help the ANP and inner carers meet the needs of needy parts.
4. Use inner resources, such as the inner source of wisdom (4.18), to reduce dependence on the therapist [source: van der Hart 2012].
5. Avoid the therapist reactions that lead to impasse: defensiveness, withdrawal and appeasement [source: ESTD 2026 flyer].
Example language (illustrative): 'I can hear how much that part needs me between sessions. I won't be available every evening, and I don't want her left alone either. Who inside can be with her, and what can we set up together?'
Watch for: Burnout and resentment in the therapist, and escalating crises around separations.

4.25 Recognising and resolving enactments

Purpose / when: When an unconscious replay of trauma shows up between client and therapist. Both contribute to it [source: ESTD 2026 flyer].
Steps:
1. Notice the relational signs: you are acting out of character, feeling a strong pull to rescue, punish or withdraw, or the same pattern keeps repeating.
2. Reflect on your own history and role in it.
3. Name the pattern collaboratively.
4. Help the client reflect on the current behaviour and link it to the past.
5. Do something different in the present.
Steele's specific interventions are listed only as objectives in the source [uncertain].
Example language (illustrative): 'I notice I've been more careful with you than usual since you got angry with me, almost walking on eggshells. I wonder if something old is happening between us.'
Watch for: Defensiveness on either side. It is working when the pattern can be talked about and loses its charge.

4.26 Working with shame

Purpose / when: Shame is everywhere in this population and often goes unreported. It can block every phase [source: van der Hart et al. 2014; Steele et al. 2017 TOC ch. 15].
Steps:
1. Ask about shame directly, especially before memory work [source: van der Hart et al. 2014].
2. Notice shame about inner experience and about parts (4.8) [source: van der Hart et al. 2013].
3. Slow down. Reduce exposure, for example by not requiring eye contact, and use relational warmth [synthesis].
4. Normalise shame as a survival response [synthesis].
Example language (illustrative): 'You've gone quiet and looked away. Sometimes that's shame. If any part is feeling it, it's welcome here, and you don't have to look at me.'
Watch for: Shame that presents as hostility or withdrawal.

C. Phase 2: Treatment of traumatic memories

Safety and consent for all Phase 2 work. Check the readiness criteria and contraindications in Section 2 first. Get informed consent, and make sure the client understands the risks:

effects on daily life;
acting out;
social consequences;
urges to re-enact the trauma.

Agree a coping plan for after the session [source: van der Hart et al. 2014, 2017]. Use hypnosis or EMDR only if trained, if the client is used to the method and has consented [source: van der Hart et al. 2017].

4.27 Preparation for synthesis

Purpose / when: Before each memory or cluster of memories. It may take several sessions [source: van der Hart et al. 2014].
Steps:
1. Build a lifeline and group memories by episode, perpetrator, belief or emotion. Follow the client's own grouping [source: van der Hart et al. 2014].
2. Choose a target. Options include:
  - a recent, mild, isolated incident for a first experimental session;
  - present triggers first;
  - a developmental sequence [source: van der Hart et al. 2014].
3. With the parts who can describe the memory from a distance, explore cognitively how it began, how it ended, and its 'pathogenic kernels' or 'hot spots'. Ask how it ended: the worst moment may not be the obvious one [source: van der Hart et al. 2014, 2017].
4. Decide which parts:
  - hold the memory;
  - will share it;
  - will help, offering courage, structure or comfort;
  - will observe;
  - will wait in safe places [source: van der Hart et al. 2017].
5. If no observing part exists, have the parts explore worst-case scenarios and plan how to cope [source: van der Hart et al. 2017].
6. Address substitute beliefs (4.22) and any wishes for rescue or a magical cure.
7. Agree which life areas, such as work or parenting, are to stay protected [source: van der Hart et al. 2017].
8. Arrange logistics:
  - a ride home;
  - time off;
  - rest scheduled afterwards;
  - a check-in call at a set time;
  - a follow-up session at short notice [source: van der Hart et al. 2017; van der Hart et al. 1993].
9. Explain the procedure several times: to the ANP, then to observing parts, then to the parts involved [source: van der Hart et al. 1993].
10. Gather the participating parts and build connection and empathy among them [source: van der Hart et al. 2017].
Example language (illustrative): 'Before we decide anything, I'd like the part who can watch from a distance to tell us how that night started and how it ended. Just the outline, no feelings needed yet.'
Watch for: Pressure from the client or therapist to 'get it over with', and parts that have not agreed. It is working when the client and all parts can describe the plan and agree to it.

4.28 Guided synthesis (rapid, counted)

Purpose / when: When the client is ready and the memory is suitable. The relevant parts share the pathogenic kernels of the memory in a short, intensive, controlled experience [source: van der Hart et al. 2017].
Steps:
1. Parts that are not taking part go to their safe places before any cognitive discussion.
2. Prepare an objective account with an observing part. Divide it into numbered segments, often 1–5 or 1–10, running from the onset to after the event is over [source: van der Hart et al. 2017; van der Hart et al. 1993].
3. Remind the parts that the memory does not need to be relived. They 'need only experience' what is necessary to know, understand and heal [source: van der Hart et al. 2017].
4. The therapist counts through the segments, announcing each one as it is shared. Keep arousal moderate; the 2005 paper suggests about 3 on a 1–5 scale. Prevent panic, switching and re-dissociation.
5. Keep the client grounded throughout. Reinforce the adult, present perspective and direct attention to the body and to the therapist's voice.
6. At the end of the count, support the parts and ask what percentage has now been shared. Negotiate another round only if needed. The 1993 paper limits this to at most three rounds per session, with rest in between.
7. Close the session (4.31).
Example language (illustrative): 'We'll go from one to five, and at each number the parts will share just that piece. You only need to feel what is needed. You are here with me, an adult, in 2026. One...'
Watch for: Flooding, switching, or 'abreaction' mistaken for progress. Watch also for leftover material: in one case, a final small remainder triggered serious suicidality [source: van der Hart et al. 1993]. It is working when the parts report that the material is shared and arousal settles by the end of the session.

4.29 Fractionated (titrated) guided synthesis

Purpose / when: When full synthesis would overwhelm the client, which is common when integrative capacity is low [source: Steele et al. 2005; van der Hart et al. 2017].
Steps: Divide the work across sessions using one or more of these options [source: van der Hart et al. 2014, 2017; van der Hart et al. 1993]:
- bottom-up: sensorimotor aspects first, then emotions, then cognitions;
- one sensory or emotional dimension at a time;
- one part's experience at a time, for example the fight part before the flight part;
- successive segments of the event, especially when different parts hold different segments;
- shorter counts, marked clearly with a beginning and a stop;
- very slow sharing of affect between sessions, a small percentage at a time (Kluft's 'slow leak');
- an intensity ceiling (Kluft): re-experience only up to a set level, and 'only that which is necessary';
- working with clusters of parts grouped by affect or theme (Fine);
- pairing with relaxation training.
Example language (illustrative): 'Today we'll share only what the body felt, nothing else. When I say "stop", everything else stays in the vault.'
Watch for: Loss of the overall thread, and parts that feel left out. It is working when distress (SUDS) falls for each fraction and no crisis follows between sessions.

4.30 Intensity control during synthesis (imagined rheostat, distancing, time distortion)

Purpose / when: To modulate arousal inside the synthesis.
Steps:
1. Install an imagined 'rheostat' with a built-in maximum, which the client can turn down [source: van der Hart et al. 2017].
2. Use distancing imagery: watching through a window, listening by intercom, or a movie screen or observer stance [source: van der Hart 2012; van der Hart et al. 1993].
3. Hypnotically trained clinicians may use time distortion, so that synthesis feels shorter and rest breaks feel longer [source: van der Hart et al. 2017].
4. Take rest breaks between segments.
Example language (illustrative): 'Notice the dial. It can't go above where we agreed, and you can turn it down anytime.'
Watch for: Distancing that becomes depersonalisation, so that nothing is actually shared.

4.31 Closure and aftercare after synthesis

Steps:
1. Affirm what the parts have accomplished together. Healing imagery can be used, for example a light embracing them [source: van der Hart et al. 1993].
2. Put any material that was not shared back into containment. Parts agree not to share it between sessions [source: van der Hart et al. 2017].
3. Return the client fully to the present with the ANP in control, as in the closing third of a rule-of-thirds session [source: van der Hart et al. 2014].
4. Confirm the plan for getting home, the check-in call and the follow-up session. Journaling or homework may be used [source: van der Hart et al. 2014].
Watch for: Delayed reactions in the next 24–72 hours [synthesis: the time frame is not given in the sources].

4.32 EMDR-adapted synthesis, including the 'tip of the finger' strategy (EMDR-trained clinicians only)

Purpose / when: To bridge from Phase 1 to Phase 2, and to titrate processing [source: van der Hart et al. 2014].
Steps:
1. Tip of the finger strategy: target a small peripheral sensation, emotion or belief connected to the memory, not the memory itself.
  - First confirm that the EP and the system agree.
  - Ask the EP to notice the sensation.
  - Apply one short set and check the response.
  - Repeat only if intensity falls or adaptive associations appear.
2. Use shorter, slower sets, for example 5–10 movements. Some clients need longer sets to get through peak arousal.
3. For hypoarousal, keep talking and give present cues. Use CIPOS (constant installation of present orientation and safety). If agreed, use touch or the finger-lift signal.
4. Use cognitive interweaves: time-orientation questions, self-care prompts, and statements such as 'The EP who kept all this is part of you'. Use sensorimotor 'acts of triumph' to complete defensive movements that were blocked.
5. When the client is ready, hold both perspectives on the perpetrator during slow, short sets.
Watch for: Looping or blocked processing. When this happens, check the meeting place for objecting or new parts.

4.33 Working through insecure attachment to the perpetrator

Purpose / when: This phobia is worked in Phase 2 [source: Steele et al. 2005].
Steps:
1. Do not set the client against the perpetrator.
2. Explore all the conflicting feelings and beliefs among the parts (loyalty, longing, fear, rage) without taking sides.
3. Give psychoeducation about healthy boundaries.
4. Address parts that idealise the perpetrator or keep in contact with them.
The goal is to free the parts from trauma time, not to get the client to condemn the perpetrator [source: van der Hart et al. 2014, 2013].
Example language (illustrative): 'It makes sense that one part still loves him and another part hates him. Both are part of what happened to you, and both get a voice here.'
Watch for: Ongoing contact that involves abuse. If so, return to safety work first.

4.34 Guided realisation (personification and presentification)

Purpose / when: After synthesis, and over a long period. The aim is for the client to own the memory ('it happened to me') and to know it is over, while living in the present [source: Steele et al. 2005; van der Hart et al. 2014, 2017].
Steps:
1. Assess realisation: can the client tell a coherent narrative without reliving it or depersonalising?
2. Have the client tell the story repeatedly while you bear witness. Telling it becomes a shared testimony [source: van der Hart et al. 1993; ESTD 2026 flyer].
3. Use interweaves for personification ('this happened to me') and for presentification (being here now while aware of past and future).
4. Hold cognitive processing sessions between synthesis sessions [source: Steele et al. 2005].
5. Revise self-blame and build new meaning. Work through existential themes: death, intolerable pain, meaninglessness, isolation, responsibility and identity [source: van der Hart et al. 1993].
6. Expect to reprocess the same memory across several parts [source: van der Hart et al. 2014].
Example language (illustrative): 'Tell me again what happened, as the woman you are now, sitting here. What is it like to know it was you, and that it's over?'
Watch for: The phobia of realisation: the client accepts the facts intellectually but keeps them at a distance. Grief may break through. It is working when the account is told in the first person and in the past tense, with feeling that can be tolerated.

D. Phase 3: Integration and rehabilitation

4.35 Grief work

Purpose / when: Grief begins during realisation and becomes central in Phase 3. The client mourns a lost childhood, lost years, and what can never be [source: Steele et al. 2005; van der Hart et al. 1993, 2017].
Steps:
1. Bear witness to specific losses.
2. Keep the client present while grieving (presentification), so grief does not slide back into reliving.
3. Let the affect come in tolerable waves, not as a 'storm' [source: van der Hart et al. 1993].
4. Prepare the client for grief to alternate with relief and joy.
5. EMDR option: target specific moments of loss [source: van der Hart et al. 2014].
Example language (illustrative): 'There's no way to get those years back. I'm here with you while you feel what that means.'
Watch for: Grief that turns into despair or suicidality. If so, reassess risk and return to stabilisation. The authors describe the ebb and flow of grief as a lifelong task [source: van der Hart et al. 2017].

4.36 Overcoming the phobia of normal life: activating neglected action systems

Purpose / when: When the client functions but life is narrow, with no play, exploration, rest or friendship [source: Steele et al. 2005].
Steps:
1. Appraise how 'normal' each area of life is: work, play, rest and relationships.
2. Use psychoeducation about the neglected action systems.
3. Set graded tasks, for example a hobby or a social contact, and include observing others.
4. Review what the client fears about normality, for example 'If I'm fine, what happened doesn't count'.
Example language (illustrative): 'When did you last do something just for fun? What happens inside when you imagine doing that this week?'
Watch for: Overload. Keep the steps small.

4.37 Overcoming the phobia of healthy risk-taking and change

Steps:
1. Identify substitute beliefs about change, for example that change is dangerous.
2. Correct them cognitively.
3. Set graduated exercises in taking healthy risks [source: Steele et al. 2005].
4. EMDR option: use flash-forward for catastrophic future images, plus future templates and resource development [source: van der Hart et al. 2014].
Example language (illustrative): 'What's the smallest risk you could take this week that would tell you something new about yourself?'
Watch for: Rebound avoidance after a step that went well.

4.38 Graduated work on intimacy

Steps:
1. Work in order: emotional intimacy first, then physical, then sexual.
2. Teach the client to set personal limits, to respect other people's boundaries, and to resolve conflict [source: Steele et al. 2005; van der Hart et al. 2014].
3. Involve partners only with consent [synthesis].
Example language (illustrative): 'Before anything physical, let's look at what it's like to tell your partner one true feeling and see what happens.'
Watch for: EPs reactivated by sexual or physical closeness. Return to Phase 1 skills as needed.

4.39 Fusion and integration of parts (overcoming the phobia of fusion)

Purpose / when: When parts have shared their memories and are ready to join. Fusion can happen in several ways [source: Steele et al. 2005; van der Hart et al. 2014; van der Hart et al. 2017]:
- through a formal fusion ritual, with or without hypnosis;
- spontaneously, after synthesis or outside therapy;
- gradually, through blending.
Steps:
1. Explore the phobia of fusion: fears of loss, death, or losing a valued capacity.
2. If the client agrees, have them imagine future integration cautiously. One part can experiment with imagining fusion first.
3. Agree on imagery that the client chooses. The published examples include light, such as a bright white light [source: van der Hart et al. 2017].
4. Follow up for signs of renewed dissociation. Do not assume the first fusion is the final one. Kluft's benchmark is 27 months without dissociative signs.
Example language (illustrative): 'Nobody has to disappear. Joining means you'll have her strengths and memories as your own. Is there one part who'd like to imagine just a little of what that might be like?'
Watch for: Fusion that is only apparent or pushed through by the therapist, and grief for 'lost' parts.

4.40 Relapse prevention, stress inoculation and termination

Steps:
1. Rehearse coping for future stressors and triggers [source: Steele et al. 2005].
2. Consolidate self-care.
3. Address the phobia of detachment from the therapist and what therapy has meant to the client.
4. Monitor your own feelings about ending [source: van der Hart et al. 2014].
5. Agree on how the client can return if needed [synthesis].
Example language (illustrative): 'Let's map what an early warning sign would look like, and what you'd do, before we plan our last sessions.'
Watch for: Crises that resurface as the ending approaches. Understand them as a separation phobia, not necessarily as a relapse.

5. Handling problems

Tags mark where each response comes from. [source] means from the cited papers. [synthesis] means clinical synthesis, consistent with the model but not found in the primary sources.

Client stuck, or therapy at an impasse:
- Treat the impasse as phobic avoidance that therapist and client have co-created. Identify which phobia is active: of feelings, parts, attachment, memory, realisation, fusion or normal life. Grade the next step down [source: Sheppard Pratt workshop page; van der Hart et al. 2014].
- Check whether the client is in the wrong phase, for example pushing into Phase 2 without the capacity for it. If so, return to Phase 1 [source: Steele et al. 2005].
- Look for a 'missed' part that holds an unshared kernel. In one case, a 0 SUDS rating masked a 7-year-old part that was still active [source: van der Hart et al. 2013].
Resistance from a part (refuses, sabotages, threatens):
- Negotiate, do not override. Acknowledge the part's protective function and ask what it fears.
- Remember that parts may punish the client for 'revealing secrets' [source: van der Hart et al. 1993].
- Use the meeting place to air the objection [source: van der Hart 2012].
Overwhelm and hyperarousal in session:
- Stop. Ground the client. Ask which part is activated.
- Orient that part to the present, and offer safe places to parts that are not involved.
- Use containment [source: van der Hart et al. 2014].
- Lower the dose next time.
Hypoarousal, collapse or shutdown in session:
- Keep talking, and cue the present through the senses and the therapist's voice.
- Use agreed signals.
- Train the client to notice early signs of disconnection and use them as a stop signal [source: van der Hart et al. 2014].
Uncontrolled switching:
- This is a contraindication to Phase 2 [source: van der Hart et al. 2017].
- In Phase 1, strengthen inner communication and agreements about who is in front. Use grounding [synthesis, building on 4.10 and 4.16].
Intrusion by unknown parts or new material during processing:
- Say repeatedly that only the named memory, or the named piece of it, is being worked on, and 'nothing else'.
- Use time orientation and containment [source: van der Hart et al. 2014].
- Afterwards, return to psychoeducation and presentification, and reassess the system [source: van der Hart et al. 2013].
Broken safety agreements:
- Do not just renew the contract. Explore which part was under pressure and where that pressure came from, often a perpetrator-imitating part.
- Reinforce the stop signal [source: van der Hart et al. 2014].
- Repeat the risk assessment [synthesis].
Between-session crises after memory work:
- Prevent them in advance: plan logistics, contain material, arrange a check-in call and a follow-up at short notice [source: van der Hart et al. 2017; van der Hart et al. 1993].
- Rest imagery for parts in acute pain (4.14).
- If risk is high, follow standard crisis care, including medication review by the prescriber or hospital admission [source: van der Hart et al. 1993].
Non-adherence to homework or skills practice:
- Ask which part objects to the skill. Relaxation or a safe place can feel dangerous to vigilant parts, and the word 'safe' can itself be a trigger [source: van der Hart et al. 2013].
- Get agreement from all parts before re-assigning the task. Shrink it to a one-minute version [synthesis].
Ruptures and enactments:
- Notice your own reactions: defensiveness, withdrawal, appeasement, rescuing.
- Name the pattern collaboratively, and link it to the past [source: ESTD 2026 flyer].
- Repair explicitly: acknowledge your part and restate the frame [synthesis].
Escalating dependency or demands for rescue:
- Use the collaborative model and explained limits.
- Help inner carers meet needy parts' needs.
- Use the inner source of wisdom (4.18) [source: ESTD 2026 flyer; van der Hart 2012].
- Watch for rescue fantasies that grow as the alliance strengthens [source: Steele et al. 2005].
Contradictory or implausible memory content:
- Expect different parts to hold different versions, some of which may include fantasy [source: van der Hart et al. 1993].
- Do not use suggestive or leading procedures to 'recover' memories. Focus on realisation of what is known, and do not validate details as fact [synthesis; consistent with the authors' 1999 Dutch papers contrasting phase-oriented treatment with 'recovered memory therapy', which are not drawn on here] [uncertain].
Ongoing contact with an abuser:
- Prioritise protection and safety planning. Do not start Phase 2 [source: van der Hart et al. 2014].
- Follow local safeguarding and reporting duties, for example if children are at risk [synthesis].
'Wanting it out now' (pressure for rapid memory work):
- Explore what the client hopes this will achieve, for example a magical cure.
- Review the contraindications. 'Less, rather than more' [source: van der Hart et al. 2014, 2017].
Therapist pitfalls:
- fascination with memories, or collusion with avoidance;
- equating abreaction with progress;
- neglecting Phase 3;
- using hypnosis or EMDR without specialist training.
Get consultation and supervision [source: Steele et al. 2005; van der Hart et al. 2017].
Client not suited to insight-oriented outpatient work:
- Some clients who are chronically disempowered need long-term supportive care, case management and crisis access rather than phase progression [source: Desclée preview of the 2017 book].

Sources

Sources:

Books cited (main text not drawn on; contents known from tables of contents, previews and the authors' papers):

van der Hart, O., Nijenhuis, E. R. S., & Steele, K. (2006). The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization. Norton.
Boon, S., Steele, K., & van der Hart, O. (2011). Coping with Trauma-Related Dissociation: Skills Training for Patients and Therapists. Norton. [uncertain: module content]
Steele, K., Boon, S., & van der Hart, O. (2017). Treating Trauma-Related Dissociation: A Practical, Integrative Approach. Norton.
Fraser, G. A. (2003). Fraser's 'Dissociative Table Technique' revisited. J Trauma & Dissociation (cited via van der Hart 2012).

← Previous · III-111Inner-child work Next · III-114 →Feminist therapy