The Three Main Components Recovery

The Three Main Components of Recovery

For patients with trauma, I tend to keep the focus on what I have previously indicated as the “Big Three”. They are the three areas where trauma has the greatest adverse effects. Those are:

Dysregulation of the nervous system

A sense of deep shame

A distorted sense of self and identity

In my experience, it is helpful not only for my patients, but also for myself, to have this simple road map which keeps our focus on the most important areas to help positive change. It also is useful for patients in giving feedback at the end of each session if there is improvement or lack of improvement in any of these areas. The more the patient has a sense as an active collaborator with you the better the therapy tends to go.

I call working on these as the three components of therapy. For years we have looked at the three main phases of trauma recovery therapy. That is:

Stabilization and regulation

Reprocessing of trauma memories

Reintegration into a more cohesive self

We may call these three phases slightly different things but overall, I think most of us would agree that has been our general outline. I call them the three components of trauma recovery therapy as very few of our patients and very few of us have the luxury of time we used to. We have to find a way to address all of these classical phases at the same time, without causing more dysregulation or destabilization. So how do we do this? By slightly reconceptualizing what we are trying to do.

The most important component is the stabilization/regulation component. which we work on every session. I also like to remind myself and those therapists I teach or supervise, that this component is not preparatory to the trauma work – it is the most valuable aspect of all trauma work.

The second component, that of help in reducing shame, is my reconceptualization of phase two, of reprocessing trauma memories. For most of our patients I think that phase two has been our biggest error in how we have gone about therapy for complex developmental trauma. This is the phase that tends to destabilize our patients. We might not see that destabilization in the session but they experience the destabilizing effects at home, often for days. This is another reason I have a great deal of difficulty with what we often say to patients about this. We say things such as, “It has to get worse before it gets better”. I say “No, it does not”. If our patients are functioning worse in between sessions then we are doing something wrong. We want them to function better between sessions. That is why one of my repeated concepts for therapists and patients is, “It’s got to get better before it gets better”.

What component two is all about is allowing the patient. to tell their story, at their own time and at their own pace. What reduces shame is recognizing and verbalizing the truth of what happened to them. The details do not matter except to the degree the patient wants to disclose. What does not help is going over their story in more detail nor is it about having continued exposure to the thoughts and/or images of what they experienced. Yet, is useful to gently encourage the patient to talk about the shame they experienced from any of the events that happened to them, at the time when they feel ready to and they, not us feel it will be helpful to tell. Too many patients tell me that felt pushed by previous therapists to talk about things they did not feel ready to and felt worse afterwards.

You may ask, “But what about EMDR”? EMDR is a powerful modality. Some patients can benefit greatly. Some will greatly be harmed by it. Because it is a powerful modality, we need to respect that power and use it very thoughtfully and mindfully and be very clear what we are trying to accomplish. I believe there are a couple of guidelines to be aware of. First, for many their EMDR training is inadequate. One can get basic certification without the level of training or experience to know when not to do EMDR. Another guideline is the more the patient is dealing with recent event trauma or past single event trauma, the safer it is to use. The more the patient has developmental trauma and the more severe that trauma is, I feel very strongly that only the most experienced and highly trained EMDR therapists have any business using this modality. And the same thing applies for any patient who has dissociation, particularly complex dissociation.

So, component two is telling the trauma story while staying regulated. And, the best way for the patients to stay regulated during this component is telling the story at their own time, and their own pace.

When it comes to working on component three, addressing the sense of distorted negative self-image and identity, a good deal comes throughout the process as the patients stay more regulated in their daily lives as well as by the reduction in shame. In addition, I have found two very simple cognitive-behavioral exercises amazingly helpful.

The first is what I call the three things exercise. I ask them to get a small notebook or journal they will only use for this purpose. I then ask them at the end of the day before they go to bed, to write down three things they did well that day. These are not three good things that happened during the day, nor three things they are grateful for. Those can both be very helpful but that is not this exercise. I want them to bring this notebook to each and every session throughout the therapy. We usually review it together at the first of the session or sometimes in the earl part of the session. Like other things we ask them to do, if they haven’t done it, that’s ok. Remember, they cannot do the therapy wrong. If they have not done it at all we just do it verbally then and there for what they did the day before. If they can only think of one thing each day or if they have only written in the journal one or two days, that is also ok. We support what they have done and encourage them to continue to try.

I tell them not to expect to feel any better while doing this. I want them to continue as there will come a point, usually after a few weeks, where it starts to make a difference for them. They begin to notice things they do well in the day which they remember to put down that night. They begin to notice that even on really bad days, they are still doing something right. It also encourages the therapeutic principle to start the sessions with what is right with them rather than what is wrong with them. In addition, when they tell me what they have done the question becomes once more, “What was that like for you?” or “What do you notice as you tell me these things?” This often links the CBT exercise with the comatic component. It also once again encourages mindfulness. Most patients begin to like this night time habit. Many of them spontaneously start adding things they are grateful for or the good things that have happened to them. I like this exercise as it is simple, fairly easy for patients to be successful with it, and over time very powerful in helping the patient’s revise their view of themselves.

The second exercise I call “changing the mantra”. I do not add this exercise until they are regular and consistent with the three things exercise. I also wait to add it until the three things exercise has started to be helpful to them. It is also an exercise that is invitational. I always ask if they want to try to add another exercise. There is no pressure here. If they want to try a new thing to add that is great. If not, that is great too.

If they want to do it, the changing the mantra exercise goes like this. I ask them to tell me one negative thing they tend to say about or think about themselves. For example, they may say “I’m worthless”. I tell them the only problem with that self-statement is it is too global, too all or nothing. I then ask them to come up with a modifier – a modifier, not a positive statement. It needs to be something that they can see is objectively true. I think positive affirmations can be very helpful for many people but they are not helpful for patients with depression or developmental or chronic relational trauma because they don’t believe them. An example could be “I really think I am worthless but I have been a good brother”, or anything they may be able to objectively say they recognize. I ask them to write down the modified statement, take it with them, and put it someplace in their home they may see it from time to time. There are two things they can do with this modified “mantra”. They can try to say it to themselves anytime they catch themselves calling themselves worthless or just every time they see where they have placed the written statement or both. This exercise tends to have a broader effect over time as they start to modify other negative self-statements on their own.

I like these two simple CBT exercises because the patients do them and they can be used no matter what is the main therapy modality.