Phase-oriented trauma treatment

1. Introduction

Version followed: the ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults (Cloitre et al., 2012; the 2015-updated text) is the main structure. Janet's three phases are given as reconstructed by van der Hart, Brown & van der Kolk (1989) and van der Hart, Steele, Boon & Brown (1993). Herman's three stages (1992) are drawn from secondary summaries and her programme's Guilford manuals, because the book itself is not drawn on. The applied sequenced model is Courtois & Ford's (2022). Where these versions differ, the text says so.

What it is. Phase-oriented (phase-based, sequenced) treatment is a framework for ordering therapy for complex trauma. It is not a single technique set. Clients with prolonged interpersonal trauma often have PTSD plus problems with emotion regulation, relationships, attention and consciousness (dissociation), beliefs, and somatic distress. The framework sets a hierarchy of treatment needs: (1) safety, stabilisation and skills; (2) processing of trauma memories; (3) consolidation and reconnection with ordinary life. The clinician fills each phase with specific evidence-based interventions. [source: ISTSS 2012/2015]

How change happens. In Janet's account, trauma is a disorder of memory that blocks effective action. Unintegrated (dissociated) memories persist as "fixed ideas", drain psychological energy and stop personality development. Recovery means first restoring energy and stability, then turning traumatic re-experiencing into an assimilated personal narrative, then rebuilding the personality and daily functioning. [source: van der Hart, Brown & van der Kolk 1989] Herman's version puts disempowerment and disconnection at the core of trauma. Recovery therefore depends on empowerment and on new relationships. Safety comes first, then telling and mourning the story, then reconnection. [source: Recovery Stories summary of Herman 1992; Yung 2020] ISTSS frames the goal of memory processing as integrating trauma into autobiographical memory, which yields a more compassionate, coherent and continuous sense of self. [source: ISTSS 2012/2015]

Status note. Later ISTSS work (the 2018/2019 guideline revision and its complex PTSD position paper) moved toward flexible, modular sequencing driven by symptoms and client preference rather than a fixed order. That position paper is not drawn on here and is known only through Karatzias & Cloitre. [uncertain] This guide follows the phased model and shows where the modular alternative differs. [source: Karatzias & Cloitre, c. 2019]

2. Framework

Phase names across versions [source: van der Hart et al. 1989, 1993; Recovery Stories; ISTSS 2012/2015; Courtois & Ford 2022]

• Janet (via van der Hart): (1) stabilisation and symptom reduction; (2) identification, exploration and modification of traumatic memories; (3) personality reintegration, relapse prevention and rehabilitation.
• Herman: (1) safety; (2) remembrance and mourning; (3) reconnection with ordinary life.
• ISTSS 2012: (1) safety, stabilisation and skills; (2) trauma memory processing; (3) consolidation and transition.
• Courtois & Ford: (1) safety, emotion regulation and stabilisation; (2) trauma memory processing; (3) reflective self-discovery, relational engagement and consolidation. They describe the sequence as recursive, not linear.

Phase 1: Safety, stabilisation, skills

• Goals:
  • patient safety, the first priority of any mental health treatment;
  • fewer symptoms and less unhealthy coping (substance misuse, self-injury, risk-taking, aggression);
  • better emotional awareness and expression;
  • a more positive self-concept, with work on guilt and shame;
  • interpersonal and social competence;
  • better executive functioning and life skills. [source: ISTSS 2012/2015]
• Herman: safety includes regulating bodily functions, managing self-destructive behaviour, and gaining control and predictability in the environment. Further work should wait until a reliable degree of safety is reached. [source: Yung 2020, summarising Herman]
• Janet: restore energy through rest, sleep, diet and simplifying life ("mental economy"), and build the relationship before memory work. [source: van der Hart et al. 1989]
• Format: individual therapy is preferred; a therapist-led group is an acceptable alternative. Add medication review for symptom acuity and a safety plan if the client is still in danger. [source: ISTSS 2012/2015]
• Duration: the expert majority suggested about 6 months. Severely impaired clients may need far longer. [source: ISTSS 2012/2015]

Phase 2: Trauma memory processing / remembrance and mourning

• Goals: recount the trauma in an organised way, mainly in words, sometimes supported by art or symbols. Then reappraise its meaning and integrate it into autobiographical memory while emotion and relationship skills keep developing. [source: ISTSS 2012/2015] Herman: tell the story "completely, in depth and in detail", and mourn what was lost. [source: Recovery Stories] van der Hart et al.: preparation, then synthesis, then realisation and integration, with grief as the bridge between them. [source: van der Hart et al. 1993]
• Setting: an environment that is actually safe and that the client experiences as safe. The therapist offers presence, encouragement, guidance and feedback so the client stays emotionally engaged without falling apart. [source: ISTSS 2012/2015]
• Format: individual therapy, alone or combined with a group. Herman's programme uses a time-limited, goal-focused Stage 2 group, the Trauma Recovery Group. [source: ISTSS 2012/2015; Guilford, Mendelsohn et al. 2011]
• Duration: about 3–6 months by expert majority. ISTSS gives no session counts or within-session dosing; dosing guidance in this guide comes from other sources. [source: ISTSS 2012/2015]

Phase 3: Consolidation, reintegration, reconnection

• Goals:
  • consolidate emotional, social and relational gains;
  • apply them in safe social networks and in intimate and family relationships;
  • plan education, work, recreation and social activities;
  • plan booster sessions, relapse prevention and alternative resources. [source: ISTSS 2012/2015]
• Janet: relapse prevention, treating residual deficits through skills training, graded practice of neglected activities, and gradual termination. [source: van der Hart et al. 1989]
• Format: weekly visits that taper as the client's state allows. [source: ISTSS 2012/2015]

Overall dose

• The expert majority estimated 9–12 months in total. Research trials lasted 4–5 months.
• Some clients need several years or intermittent care across life. [source: ISTSS 2012/2015]
• Courtois & Ford's case ran about 80 sessions over two years, with reassessment every four months. [source: Courtois & Ford 2022]

Criteria for moving between phases

• Phase 1 to 2: clinician and client agree the client has enough skills and life stability. Markers include reduced symptoms, reduced unhealthy coping, and improved executive functioning and life skills. [source: ISTSS 2012/2015] Further markers:
  • a working alliance;
  • the client can use grounding and self-regulation;
  • the client understands how processing could help;
  • willingness, which must be told apart from readiness. [source: Courtois & Ford 2022]
  • For dissociative clients, assess:
    • intrapsychic and interpersonal safety;
    • suicide and self-harm risk;
    • coping and functioning of dissociative parts;
    • supports;
    • motivation. [source: van der Hart et al. 1993]
• Phase 2 to 3: symptoms have been generally and consistently remitting over time, decided together. [source: ISTSS 2012/2015]
• Back to Phase 1: relapses during Phase 2 are expected and planned for. Return to Phase 1 to relearn or reconsolidate skills, and also when ongoing trauma or other stressors appear. [source: ISTSS 2012/2015] Memory work often alternates with the other phases in layers. [source: van der Hart et al. 1993]
• Modular alternative: in the most flexible version there is no fixed order at the outset. Modules are chosen by current symptoms and client preference and adjusted using routine measurement. [source: Karatzias & Cloitre]

3. Guiding principles

• Hierarchy of needs: assess before treating; safety and the most impairing problems come first. In practice: write a ranked problem list at intake and revisit it each phase. [source: ISTSS 2012/2015]
• Safety takes precedence: no memory work while there is acute risk, ongoing abuse or chaotic living. In practice: start every session with a safety check, and pause processing when safety drops. [source: Yung 2020 on Herman; ISTSS 2012/2015]
• Empowerment: in Herman's words, the survivor must be "the author and arbiter of her own recovery". In practice: offer choices about pace, topic and method, even in emergencies. [source: Recovery Stories]
• The client chooses whether to face the past: in practice, memory work starts only with the client's informed, revisable agreement. [source: Recovery Stories]
• Recovery happens in relationship: in practice, reliability matters (keep times, return when you said you would, repair lapses). [source: Recovery Stories; Yung 2020; Courtois & Ford 2022]
• Witness and ally: in practice, take a position of moral solidarity with the survivor rather than detached neutrality about the harm. [source: Recovery Stories] [uncertain: Herman's own discussion of therapist neutrality]
• Pacing between constriction and intrusion: avoiding memories stalls recovery, but approaching them too fast causes damaging reliving. In practice: keep arousal within a workable range and adjust session by session. [source: Recovery Stories]
• Recursive, not linear: in practice, a return to Phase 1 is part of the plan, not a failure. [source: ISTSS 2012/2015; Courtois & Ford 2022]
• Individualised and strength-based: in practice, choose interventions by the client's most prominent symptoms and build on existing strengths in every phase. [source: ISTSS 2012/2015]
• Collaborative transitions: in practice, decide phase changes together using concrete markers. [source: ISTSS 2012/2015]
• Measurement-guided: in practice, use brief validated measures (e.g. the ITQ for ICD-11 CPTSD) at intake and regularly after, and discuss results with the client. [source: Karatzias & Cloitre; Courtois & Ford 2022]
• Balanced control (Janet): the client must accept some guidance, but the therapist keeps control to a minimum and leaves the client in charge of their own life. Too much control breeds dependence. In practice: make few directive decisions, and hand back decisions as stability grows. [source: van der Hart et al. 1989]
• Mental economy (Janet): raise "income" (sleep, diet), cut "expenses" (crises, medical problems), and "liquidate debts" (resolve memories). In practice: treat sleep, chaos and health as targets in their own right, not as distractions. [source: van der Hart et al. 1989]
• Avoidance is self-protection: in practice, explore what the avoidance protects rather than confronting it as resistance. [source: Courtois & Ford 2022]
• Careful warmth: be genuine, but be wary of overt niceness and "we" language, which can feel empty or enmeshing. Treat empathy and alliance as things that grow over time. [source: Courtois & Ford 2022]
• Memories are the client's experience: in practice, never use suggestion, hypnosis or imagery to search for unremembered events. Work with what the client already remembers, and tolerate uncertainty about the facts. [synthesis, consistent with Putnam's caution quoted in van der Hart et al. 1993]

4. Intervention inventory

The framework mostly sequences interventions from other models (skills training, cognitive restructuring, narrative or exposure work). The ISTSS guidelines name the intervention classes but not session scripts. Steps below come from the cited sources where they give them. Otherwise they are marked [synthesis]. All example language is illustrative.

A. Phase 1: Safety, stabilisation and skills

A1. Hierarchy-of-needs assessment and treatment plan

• Purpose: decide what comes first and set the baseline for phase decisions. [source: ISTSS 2012/2015; Karatzias & Cloitre]
• Steps:
  1. Take a trauma and developmental history at the pace the client can tolerate. Do not take detailed accounts yet. [synthesis]
  2. Map current problems across the PTSD and complex PTSD domains: emotion regulation, relationships, dissociation, beliefs, somatic distress. [source: ISTSS 2012/2015]
  3. Screen risk: suicide, self-harm, substance use, current violence or exploitation, and medical issues. [source: ISTSS 2012/2015; van der Hart et al. 1993]
  4. Give brief standardised measures. Courtois & Ford suggest the ITQ, TSI-2 and DES alongside a clinical interview; describe instruments to the client, do not reproduce them. [source: Courtois & Ford 2022]
  5. Rank targets with the client, write a phased plan, and set a reassessment date. Courtois & Ford reassessed every four months. [source: Courtois & Ford 2022]
• Example language (illustrative): "Before we decide where to start, I'd like a picture of what's making life hardest right now. Then we can agree on an order that feels workable to you."
• Watch for:
  • flooding while giving the history: slow down and ground;
  • high dissociation scores, which call for specialist pacing;
  • ongoing danger, which turns the plan into safety planning first.

A2. Safety planning (including ongoing danger)

• Purpose: first-priority safety when the client is at risk from self or others, or still lives with danger. [source: ISTSS 2012/2015]
• Steps:
  1. Identify current threats: suicidal or self-harm urges, the perpetrator's access, housing, substances.
  2. List warning signs and internal coping steps.
  3. Name safe people, places and services. ISTSS mentions involving family or community resources such as safety patrols.
  4. Do lethal-means counselling: safe storage or removal, not method detail.
  5. Write the plan down, share copies as the client agrees, and review it each session in Phase 1. [source: ISTSS 2012/2015; steps 1–5 detailed as synthesis]
• Example language (illustrative): "Let's write down what you'd notice first if things started sliding, and what you'd do, step by step, before it got to crisis."
• Watch for: plans the client cannot actually carry out. Plans for domestic violence must be specific to that risk. [synthesis]

A3. Psychoeducation about trauma and dissociation

• Purpose: normalise symptoms as understandable effects of sustained or early trauma, reduce shame, and give a rationale for phasing. [source: ISTSS 2012/2015; Karatzias & Cloitre]
• Steps:
  1. Link the client's own symptoms to how chronic trauma affects emotion regulation, attachment and memory.
  2. Explain dissociation as a survival response. [source: Courtois & Ford 2022]
  3. Explain the three phases and why memory work waits for skills.
  4. Check understanding and invite questions.
  5. Repeat explanations over time. [synthesis]
• Example language (illustrative): "Spacing out when things get intense was your mind protecting you when there was no way out. We'll work on having more choice about it now."
• Watch for: the client hearing "damaged for life". Stress adaptation and change. [synthesis]

A4. Emotion regulation skills

• Purpose: core Phase 1 work: emotional awareness, regulation and expression. [source: ISTSS 2012/2015]
• Components named: focused breathing, emotional awareness (identifying and labelling feelings), self-soothing, and skills for expressing emotion. Karatzias & Cloitre cite STAIR-type modules as the example; STAIR itself is a separate manualised protocol and is not drawn on. [source: Karatzias & Cloitre]
• Steps: [synthesis]
  1. Track one emotional episode a week: trigger, body signs, label, urge, action, outcome.
  2. Teach and rehearse one breathing or soothing skill in session.
  3. Agree home practice when calm, then use it in rising distress.
  4. Review what worked and adjust.
• Example language (illustrative): "Where in your body did you feel it first? What name would you give it, even roughly?"
• Watch for: skills used only to suppress feeling. Success looks like shorter, less intense episodes and less self-harm or bingeing. [synthesis; outcome markers from ISTSS 2012/2015]

A5. Grounding and present-orientation

• Purpose: interrupt flashbacks and dissociation, and widen tolerance before memory work. [source: Courtois & Ford 2022; van der Hart et al. 1993]
• Steps:
  1. Teach orientation to the present: date, place, the therapist's presence, the safety of the room now.
  2. Add sensory and somatic anchors: feet on the floor, standing, movement, body awareness. Courtois & Ford's case used standing and movement to build energy and agency.
  3. Agree a cue the client can use alone. van der Hart et al. describe cue-conditioning for returning to the present.
  4. Practise when the client is mildly activated, not only in crisis. [source: Courtois & Ford 2022; van der Hart et al. 1993; step 4 synthesis]
• Example language (illustrative): "Look around and name three things you can see in this room. Press your feet down. It's Tuesday, you're here with me, and that was then."
• Watch for: glazed eyes, a delayed response, a changed voice. If grounding works, the client's eye contact and speech come back within minutes. [synthesis]

A6. Containment of reactivated memories

• Purpose: reduce intrusions between and within sessions. [source: van der Hart et al. 1993]
• Steps (as listed by van der Hart et al.):
  1. Identify the trigger and remove or neutralise it.
  2. Promote the safe present.
  3. Create mental distance from the material.
  4. Use a cue to return to the present.
  5. For clients with dissociative parts, shield parts from the outside world.
  6. Arrange a co-therapist or deputy therapist.
  7. In crisis, use medication review or a brief hospital stay.
  • Imagery such as an imagined vault for keeping incomplete material safe was described within clinical hypnosis. It should be used only by clinicians trained in hypnosis, with consent, and never to search for new memories.
• Example language (illustrative): "We don't need to go into that today. Can you picture putting it somewhere secure until our next session, when we'll decide together whether to look at it?"
• Watch for: containment slipping into avoidance of all trauma-related talk. Review it at the phase decision. [synthesis]

A7. Cognitive restructuring: self-concept, guilt and shame

• Purpose: build a more positive self-concept and address guilt and shame. [source: ISTSS 2012/2015; Karatzias & Cloitre]
• Steps:
  1. Identify a recurring self-belief (for example, "I am worthless" or "it was my fault").
  2. Examine evidence and its origin in the trauma context.
  3. Develop and rehearse a more balanced or self-compassionate view. Karatzias & Cloitre point to compassion-focused work here.
  4. Expect slow change and repeat over many sessions. van der Hart et al. note that cognitive change needs repeated reinforcement. [source: Karatzias & Cloitre; van der Hart et al. 1993; steps 1–3 synthesis]
• Example language (illustrative): "If a child you cared about told you this happened to them, what would you say about whose fault it was?"
• Watch for: intellectual agreement without felt change, which needs revisiting later.

A8. Interpersonal and social skills

• Purpose: increase relational competence and social engagement. [source: ISTSS 2012/2015; Karatzias & Cloitre]
• Steps:
  1. Identify a current relational pattern, such as expecting betrayal or giving in.
  2. Explore flexible alternative expectations.
  3. Practise communication, assertion and limit-setting through role-play.
  4. Agree a small real-life task and review it. [source: Karatzias & Cloitre for the content; steps synthesis]
• Example language (illustrative): "Let's try it: I'll be your manager, and you tell me you can't take on the extra shift."
• Watch for: the same pattern appearing in the therapy relationship. Name it gently and use it.

A9. Stress management, mental economy and daily structure

• Purpose: restore energy and stability.
• Janet's version: rest and simplified living. Teach basic functions such as eating and sleeping. Cut crises and expenses, and build energy through graded tasks. [source: van der Hart et al. 1989]
• ISTSS version: stress management and basic self-management skills, with mindfulness and meditation as strong secondary interventions, not sufficient alone. [source: ISTSS 2012/2015]
• Steps: [synthesis]
  1. Assess sleep, eating, activity and chaos in daily life.
  2. Choose one area at a time.
  3. Set small, graded routines.
  4. Review weekly.
• Behavioural activation: Courtois & Ford's case used it for depression and isolation. [source: Courtois & Ford 2022]
• Example language (illustrative): "Your energy is a budget. What's draining it most this week, and what one thing could top it up?"
• Watch for: perfectionist overloading of tasks.

A10. Medication review (referral)

• Purpose: reduce symptom acuity, for example sleep, hyperarousal and nightmares, as an adjunct. [source: ISTSS 2012/2015; Yung 2020]
• Steps: refer to a prescriber, coordinate care, and monitor effects on engagement. No dosing is given here.
• Watch for: sedation that blunts session work. Janet already saw sedatives as a "necessary evil". [source: van der Hart et al. 1989]

A11. Stage 1 group: Trauma Information Group

• Purpose: a supportive, psychoeducational group for survivors early in recovery, focused on safety, stability and self-care. [source: Guilford, Herman & Kallivayalil 2018]
• Format: session-by-session guidelines with reproducible handouts are in the manual, which is not drawn on. Number of sessions, size and leadership are not confirmed. [uncertain]
• Use: as an adjunct to individual Phase 1 work, or as the main Phase 1 format. A therapist-led group is acceptable per ISTSS.
• Watch for: members sharing graphic detail too early. Redirect to present-day coping. [synthesis]

A12. Building internal communication (dissociative clients; specialist)

• Purpose: for clients with dissociative identity disorder or similar disorders: identify dissociative parts and their conflicts, build communication and cooperation between them, contain intrusions, build ego strength and self-care. [source: van der Hart et al. 1993]
• Steps: these are specialist skills. Get training and supervision, and follow ISSTD guidelines, which are not drawn on here. [uncertain]
• Hypnosis: van der Hart et al. describe hypnosis supporting control over dissociation and containment, only in therapists with specialised training. It must not be used to defend against or uncover material.
• Watch for: rapid switching, which produces dysphoria and further dissociation. Slow down. [source: van der Hart et al. 1993]

A13. Clinical hypnosis for stabilisation (historical and specialist)

• Janet's use: hypnosis for relaxation, symptom relief and protection in life-threatening states. He also used it to uncover memories, together with automatic writing and dream suggestion. [source: van der Hart et al. 1989]
• Current use: uncovering methods are not part of current practice and must not be used: suggestion can shape memory. [synthesis]
• Steps (if trained):
  1. Obtain informed consent.
  2. Use a permissive induction.
  3. Give suggestions for calm, a safe inner place and containment.
  4. Re-alert fully and debrief.
  5. Teach self-hypnosis for self-soothing. [synthesis, within the clinical-hypnosis frame]
• Contraindications: screen out psychosis. Proceed with great caution in severe dissociation, and only with specialist training. [synthesis]

B. Phase 2: Trauma memory processing, remembrance and mourning

B1. Readiness review and informed decision to begin processing

• Purpose: move to memory work only when it is safe and agreed. [source: ISTSS 2012/2015; Courtois & Ford 2022]
• Steps:
  1. Review the ISTSS Phase 1 markers: fewer symptoms; less self-injury, substance misuse, risk-taking and aggression; better daily functioning and life skills.
  2. Check that the client can ground and self-regulate within a session, and that the alliance holds.
  3. Check the client understands how processing could help and what it will feel like.
  4. Tell willingness apart from readiness: a client eager to "get it out" may not yet be ready.
  5. For dissociative clients, check the van der Hart et al. safety list (Section 2) and the cooperation of parts.
  6. Agree the decision together and write it into the plan. [source: ISTSS 2012/2015; Courtois & Ford 2022; van der Hart et al. 1993]
• Example language (illustrative): "You've said you want to talk about what happened. Let's check together whether the tools are in place, so that doing it helps rather than knocks you over."
• Watch for: a move after only a few sessions. Courtois & Ford judged a move around session 14 premature: dissociation and three weeks of missed sessions followed. [source: Courtois & Ford 2022]

B2. Preparing each memory session

• Purpose: keep processing within tolerance. [source: Courtois & Ford 2022; van der Hart et al. 1993]
• Steps:
  1. Choose the target memory together. Consider starting with less intense or more distant events.
  2. Define the endpoint of the incident: the point at which it was over.
  3. Prepare the client for intense emotion.
  4. Agree a stop or help signal.
  5. Plan the remaining session time for closure.
  6. Plan aftercare: how the client gets home, who is available, and a scheduled check-in or short-notice follow-up. [source: Courtois & Ford 2022; van der Hart et al. 1993]
• Example language (illustrative): "If at any point it's too much, raise your hand and we'll pause and ground. You stay in charge of the pace."
• Watch for: the client having no support after the session. Reschedule rather than proceed. [synthesis]

B3. Organised trauma narrative with reappraisal (core Phase 2 method)

• Purpose: recount the trauma in an organised way, mainly through language (art or symbols can support it), and then reappraise its meaning. The aim is integration into autobiographical memory. Narrative Exposure Therapy is cited by ISTSS as an example; any established trauma-focused protocol (narrative, exposure, cognitive processing) can fill this slot and should then be delivered per its own manual. [source: ISTSS 2012/2015; Karatzias & Cloitre]
• Steps (titration as described by Courtois & Ford):
  1. Ground the client first.
  2. Have the client narrate from before the event, in sequence.
  3. Slow the narrative and add grounding comments when distress climbs.
  4. Pause at key transition points to attend to inner states.
  5. Highlight the client's own actions to balance powerlessness.
  6. Continue to the defined endpoint, then extend the narrative past it into safety.
  7. Follow the client's lead, and notice themes that recur across memories. [source: Courtois & Ford 2022]
  8. Discuss the meaning: what the client concluded about self, others and the world, and what they see now. [source: ISTSS 2012/2015; detail synthesis]
• Dosing: ISTSS gives no within-session dosing. Keep the narrative segment well within the session and leave time to close. For exposure-based protocols, use that protocol's published timing. [uncertain/synthesis]
• Example language (illustrative): "Take it slowly. Where are you now in the memory? What are you noticing in your body? Stay with that a moment, and feel the chair under you."
• Watch for:
  • signs it is working: emotional engagement with distress that rises and then settles; a more coherent and complete account over repetitions; a shift from present-tense reliving to past-tense telling; new, more compassionate meanings. [synthesis, consistent with van der Hart et al. 1993 on moving from re-experiencing to narration]
  • signs to stop: numbing, absence or switching. See Section 5.

B4. Graded / fractionated processing

• Purpose: process overwhelming memories in tolerable portions.
• Janet's "neutralisation": stepwise re-experiencing and verbalising from least to most threatening material. He noted it could increase resistance and intrusions. [source: van der Hart et al. 1989]
• Fractionated approaches reviewed by van der Hart et al. (1993):
  • Divide the event into numbered segments, so that counting gives structure and shows how much remains.
  • After each round, ask what proportion has been integrated.
  • Limit the number of rounds per session (three at most in their parallel-synthesis description), with rest between rounds.
  • Allow re-experiencing at reduced intensity (Kluft's method), on the principle that the client need only experience what is necessary to know, understand and heal.
  • Introduce dissociated components one at a time.
  • Leave small remainders for the next session unless the client can safely finish them alone. [source: van der Hart et al. 1993]
• Example language (illustrative): "Let's take just the first part, up to when you got to the door, and then stop and check how you are."
• Watch for: fractionation becoming permanent avoidance. Track how much of the memory remains unprocessed. [synthesis]

B5. Synthesis with dissociative parts (specialist, DID-spectrum only)

• Purpose: in van der Hart et al.'s model, dissociative parts share their parts of an already-identified trauma with each other and the therapist, to relieve dissociation. Two forms are described:
  • serial synthesis: chronological, guided, with present orientation kept throughout;
  • parallel synthesis: after a detailed inventory of which parts were involved and which should be protected. [source: van der Hart et al. 1993]
• Caution: the 1993 procedures are delivered within hypnosis by specially trained clinicians. The authors themselves note the risk of contradictory versions, and quote Putnam's doubt that truth can be sorted from fantasy. Use only with specialist training and supervision, only with material the client already reports, and never as a search for unremembered events. Current ISSTD guidance is not drawn on. [uncertain]
• Closure (1993):
  • While still in the altered state, affirm support and unity; healing imagery (e.g. light) may be used.
  • Return the client to full present orientation.
  • Arrange aftercare. [source: van der Hart et al. 1993]

B6. Cognitive work on trauma meanings

• Purpose: address distorted beliefs before and after processing. [source: van der Hart et al. 1993; ISTSS 2012/2015]
• Steps:
  1. List the beliefs the trauma installed: self-blame, being defective, the world as wholly unsafe.
  2. After processing, revisit each one in light of the full account.
  3. Reinforce new conclusions repeatedly across sessions. [synthesis on the source frame]
• Example language (illustrative): "Now that you've told the whole of it, what do you notice about what a 9-year-old could actually have done?"
• Watch for: the existential crisis themes van der Hart et al. list as following realisation: death or annihilation, isolation, meaninglessness, freedom and responsibility, identity, and unbearable pain. [source: van der Hart et al. 1993]

B7. Mourning and grief work

• Purpose: mourn what was lost, such as childhood, time, opportunities, relationships and the person one might have been. Grief is the transition between realisation and integration. [source: van der Hart et al. 1993; Herman via Recovery Stories]
• Steps: [synthesis]
  1. Name specific losses.
  2. Allow and witness sadness and anger without rushing to reframe.
  3. Use rituals or letters (unsent) if the client wishes.
  4. Expect grief waves to recur at lower intensity over time; van der Hart et al. describe this as a lifelong task.
• Example language (illustrative): "It makes sense to grieve the childhood you should have had. We don't need to tidy that feeling up."
• Watch for: fantasies of revenge, forced forgiveness or compensation. Herman's discussion of these is not drawn on. [uncertain] Explore them as part of mourning. [synthesis]

B8. Substitution and imagery-based change (historical; use with caution)

• Janet's practice: replace traumatic images with neutral or positive ones, or change the course or meaning of the event, for example through blossoming-flower imagery or reinterpretation. With guilt-ridden patients he worked on the verbal account through reassurance. [source: van der Hart et al. 1989]
• Later view: clinicians are often reluctant to use substitution with perpetrator-based trauma. A variant allows symbolic expression of anger after synthesis. Realisation requires the actual events and the wished-for outcomes to coexist, so substitution does not become denial. Be cautious with highly suggestible clients. [source: van der Hart et al. 1993]
• Use today: only within an established imagery-rescripting protocol, with the client fully aware the change is imaginal, and never to alter or create memories of what happened. [synthesis]

B9. Stage 2 group: Trauma Recovery Group

• Purpose: a time-limited group for clients who have basic safety and stability and are ready to process and integrate traumatic memories. [source: Guilford, Mendelsohn et al. 2011]
• Structure (from the table of contents):
  • screening and orientation;
  • introductory phase;
  • goal-work sessions on each member's individualised trauma-related goal;
  • concluding phase with a prepared concluding exercise;
  • co-leaders with supervision, and liaison with each member's individual therapist. [source: Guilford, Mendelsohn et al. 2011]
• Not confirmed: session counts and screening criteria come from the manual, which is not drawn on. [uncertain]

C. Phase 3: Consolidation, reintegration, reconnection

C1. Generalising skills into relationships and roles

• Purpose: consolidate gains and apply them in safe networks, intimate and family relationships, education, work and recreation. [source: ISTSS 2012/2015]
• Steps:
  1. Choose roles or relationships the client wants to develop.
  2. Set graded goals.
  3. Rehearse in session.
  4. Review real attempts. [synthesis]
• Janet's "education" and "excitation": model a task, have the client do it with support, then on their own. Practise neglected activities in grades. Address social fears and procrastination. Encourage pride in successes. [source: van der Hart et al. 1989]
• Example language (illustrative): "What would it look like to join that class? Let's break it into the first two steps."
• Watch for: withdrawal when relationships get closer. Treat this as an expected target, not a relapse.

C2. Reconnection and meaning

• Purpose: Herman's third stage centres on reconnection with ordinary life. [source: Recovery Stories]
• Sources' content: the tasks Herman lists (for example, reconciling with oneself, reconnecting with others, or a "survivor mission") are [uncertain].
• Steps: [synthesis]
  1. Explore values and identity beyond the survivor role.
  2. Explore chosen community.
  3. Explore any wish to turn experience into action, for example advocacy, without pressure.
• Watch for: the client taking on others' trauma before they are stable.

C3. Relapse prevention and booster planning

• Purpose: maintain gains and plan for setbacks. [source: ISTSS 2012/2015; van der Hart et al. 1989]
• Steps:
  1. List personal warning signs and likely triggers, such as anniversaries, contact with perpetrators and losses.
  2. List the skills that helped.
  3. Agree booster sessions and alternative resources. [source: ISTSS 2012/2015; detail synthesis]
• Example language (illustrative): "If old symptoms flare next spring, what will that tell you, and what's your first move?"

C4. Tapered termination

• Purpose: end in a way that consolidates autonomy.
• Steps:
  1. Taper from weekly sessions according to the client's status. [source: ISTSS 2012/2015]
  2. Lengthen the gaps between sessions and gradually reduce the therapist's influence. [source: Janet, via van der Hart et al. 1989]
  3. Allow time to review the work.
  4. Exchange letters as a symbol of continuing connection, if fitting. [source: Courtois & Ford 2022]
• Watch for: termination reviving abandonment themes. Name it and plan it well ahead. [synthesis]

5. Handling problems

Overwhelm or dissociation during memory work.

• Stop the processing. Ground and orient the client to the present: date, room, your voice, feet on the floor. Use present-focused orientation, mirroring and co-regulation. [source: Courtois & Ford 2022]
• Use the containment steps: identify the trigger, promote the safe present, create distance, use the return cue. [source: van der Hart et al. 1993]
• Do not finish the memory in the same session. Close, check that the client is fully present before they leave, and arrange a check-in. Next time, use a smaller segment or lower intensity (B4). [synthesis, consistent with van der Hart et al. 1993]

Repeated destabilisation or relapse in Phase 2.

• Treat it as expected. Return to Phase 1 to relearn or reconsolidate skills, then re-evaluate. [source: ISTSS 2012/2015]
• Courtois & Ford's case returned to Phase 1 for 23 sessions over about six months before successful processing resumed. [source: Courtois & Ford 2022]

Stuck in Phase 1 (endless stabilisation).

• Check the plan:
  • re-measure against the Phase 1 markers;
  • name the trade-off: the pull of avoidance (constriction) against the risk of being flooded (intrusion);
  • offer a small, low-intensity first processing trial with a clear exit.
• Consider the modular route: a modular approach that lets the client choose order may increase willingness to address trauma. [source: Recovery Stories on Herman; Karatzias & Cloitre]
• Watch your own part: check whether your own anxiety is driving delay. [synthesis]

Avoidance, missed sessions, non-adherence.

• Treat missed sessions after memory work as avoidance and self-protection, not defiance. [source: Courtois & Ford 2022]
• Respond:
  • reach out;
  • explore what felt unsafe;
  • revisit readiness;
  • make practice tasks smaller. [synthesis]

Ruptures and empathic failures.

• Repair openly. In Courtois & Ford's case, the therapist wrongly implied the client was misusing medication; acknowledging this through self-disclosure was judged helpful. [source: Courtois & Ford 2022]
• Repair steps:
  1. Name the moment.
  2. Take responsibility for your part.
  3. Ask about the client's experience.
  4. Link it to relational patterns, but only after the client feels heard. [synthesis]

Dependence, idealisation, boundary pressure.

• Janet's view: intense early dependence and idealisation are usually transient. Too much therapist control breeds dependence; too little lets passions run unchecked. [source: van der Hart et al. 1989]
• Keep a consistent frame:
  • agree between-session contact rules;
  • be cautious about touch, which is acceptable only if client-initiated and with no boundary-violation history;
  • monitor your own dissociation and countertransference. [source: Courtois & Ford 2022; van der Hart et al. 1993 on secure boundaries]

Suicidality and self-harm.

• Standard risk assessment every session in Phase 1 and around memory sessions. Keep the safety plan current. Pause processing while risk is elevated. Coordinate with crisis services or consider admission if needed. [source: ISTSS 2012/2015; van der Hart et al. 1993; specific steps synthesis]

Ongoing abuse or revictimisation.

• Return to safety planning and Phase 1. Engage outside resources. Do not process past trauma while the client is still being harmed. [source: ISTSS 2012/2015; synthesis on the last point]

Contradictory or uncertain memories.

• Do not adjudicate the facts. Work with the client's experience and meanings. Do not use hypnosis, suggestion or imagery to fill gaps. Keep careful notes, especially if legal proceedings are possible. [synthesis, informed by the Putnam caution in van der Hart et al. 1993]

Grief, despair or existential crisis after processing.

• Expect the existential crisis themes listed in B6. Increase support and session frequency temporarily, treat grief as part of integration, and reassess risk. [source: van der Hart et al. 1993; response synthesis]

Symptom substitution or recurrence in Phase 3.

• Janet observed that old or new symptoms can return when training fails. Revisit the formulation and relevant earlier-phase work. [source: van der Hart et al. 1989]

Group-specific problems.

• Graded disclosure in Stage 1 groups. Screening for Stage 2 groups. Liaison with individual therapists. [source: Guilford, Herman & Kallivayalil 2018; Mendelsohn et al. 2011; details uncertain]

Therapist strain and vicarious trauma.

• Use regular supervision. Co-leaders' supervision is built into the Trauma Recovery Group. [source: Guilford, Mendelsohn et al. 2011] Watch your caseload and self-care. [synthesis]

Sources

Sources

• ISTSS Expert Consensus Guidelines for Complex PTSD (updated 2015 PDF) — Cloitre, Courtois, Ford, Green et al., ISTSS, 2012
• Pierre Janet's treatment of post-traumatic stress — van der Hart, Brown & van der Kolk, Journal of Traumatic Stress, 1989
• The treatment of traumatic memories: synthesis, realization, and integration — van der Hart, Steele, Boon & Brown, Dissociation 6(2/3), 1993
• A sequenced, relationship-based approach to the treatment of complex PTSD (Chloe case commentary) — Courtois & Ford, Pragmatic Case Studies in Psychotherapy 18(2), 2022
• Treating adults with complex PTSD using a modular approach to treatment — Karatzias & Cloitre, c. 2019
• Approaching trauma in the inpatient psychiatric setting — Yung, AJP Residents' Journal, 2020
• Judith Herman: Trauma and Recovery (excerpts) — Recovery Stories, secondary
• Group Trauma Treatment in Early Recovery — Guilford publisher page
• The Trauma Recovery Group — Guilford publisher page

Books and papers cited as further reading (not drawn on) [uncertain where relied on]

• Herman, J. L. (1992). Trauma and Recovery. Basic Books.
• Herman, J. L., Kallivayalil, D., & Victims of Violence Program (2018). Group Trauma Treatment in Early Recovery. Guilford.
• Mendelsohn, M., Herman, J. L., Schatzow, E., Coco, M., Kallivayalil, D., & Levitan, J. (2011). The Trauma Recovery Group: A Guide for Practitioners. Guilford.
• ISTSS complex PTSD position paper (2018/2019 guideline revision).
• ISSTD (2011). Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation.