Therapists learn how to use therapy tools and Trauma Therapists learn how to use trauma therapy tools. Usually there is a structured approach to a problem and that makes it a whole lot easier to approach it at all. These tools and exercises just don’t hold up to real life. It is necessary to work with the patient who is in the room and not just a model patient from a case example in a therapy book. Real life usually doesn’t fit neatly into the toolbox and exercises need to be adapted to the needs of patients. The creation of evidence-based treatment manuals is a good starting point but if therapy ends there, it stops being helpful quickly. While treatment approaches can be normed and generalized, patients will always be free creatures full of individuality and surprises. We are not all the same and we cannot all be treated the same. A program that gives guidance on the rough direction therapy can take should never become a one-size-fits-all treatment modality without compromise because it in fact does not fit all. It barely fits anyone properly and the most average people can make it work for themselves somehow. But the best fit is one that is created for the individual. There is a need for precision that is met when classic tools get adapted to specific personal needs. I will share some examples from my own life to illustrate how that might look like.
Discrimination
Modern trauma programs use the Past vs Present exercise to discriminate experiences. When something triggering happens, we tell ourselves that in the past things were in a specific way but in the present they are different. This exercise makes a lot of sense to me when I work with old rules or beliefs. I struggle with it when it comes to triggers. Because the trigger is right here and it is triggering me. There is no obvious difference in the present as the measure I am testing against. This is why I teach trigger discrimination as ‘same but different‘ instead of past vs present. The trigger looks the same and the response is the same but when I observe carefully I can realize that it is different and the whole situation is different, so my response can be different too. It is not merely about time that passed. The elements of the situation are different. In my mind, ‘same but different’ makes a lot more sense and gives me the ability to grasp what is happening and to find my way out. There are other specific situations where I prefer PvP as an intervention but it is not for triggers. I know from community conversations that I am not the only one. The standard exercise is always just the starting point, not the end of all wisdom. A small adaptation and an intentional choice on which version fits best could improve the outcome.
Mindfulness
Mindfulness exercises are a standard in trauma therapy and they are most often taught to manage dysregulation. The way I was taught mindfulness was borrowed from DBT: Observe, don’t judge, label, let it pass. I believe that this has a place in therapy when it comes to waves of emotion coming up (although I prefer more active tracking). I also believe that this approach is inferior to good old Orientation and Grounding when it is used for dysregulation in PTSD. I get dysregulated because of triggers or the overall assessment that the situation is ‘not safe’. If I learn to orient towards safety I can correct my assessment and calm down. Just observing my stress response does not break the cycle. My body in distress keeps telling me that it truly must be unsafe. I can observe my stress response and label it but it won’t go down just because of that. If I am lucky, I will observe some safety in the room while I do that and mindfulness will have an effect. But not because of mindfulness itself. It happens because I get a bit of orientation and grounding on the side. Maybe it would be more efficient and more gentle to just do orientation and grounding in the first place and not hope for useful side effects of something else. Mindfulness is ultimately not the same as grounding and when I deal with trauma and distress I need orientation and grounding first. Replacing one standard exercise with another one that more precisely fits the trauma background can make a difference.
Roles
I believe that parts have been labeled with roles from the beginning of organized treatment. This one is a inner self-helper and this one is a persecutor. Labels changed over the years. We don’t say persecutor anymore, we say abuser-imitating part. I admit that I found this useful in the first years of getting to know each other. It created a sense of order and understanding. It gets trickier for me the more progress I see in my system. What if parts emancipate themselves and they want to do different things? One of my former ‘persecutors‘ is now co-hosting. Some of the trauma holders grew up to become helpers. They did not change in their inner core, they just do different things. I feel very much drawn to a distinction between parts based on the will that drives them to act, what Nijenhuis calles ‘modes of longing and striving‘. They are more stable than roles and don’t seem as limiting. Parts who were assigned a role might struggle to change it when the whole system sees them in that old role. Longing and striving can manifest in many different ways without changing in its core. My old ‘persecutor‘ still does things because she likes to decide what happens and how it happens. She just stepped up to do it herself instead of making others do it. I think that time will tell if this view on parts will turn out to be more helpful. I am not easily excited when it comes to new perspectives on DID but this enactivistic approach that looks for the will that drives parts to act makes a whole lot of sense to me and it stays consistent into phase 3 of treatment when roles don’t. I think it is less limiting/judgemental and less scary for parts because it does not demand that they change their very nature to fit in. They are invited to actually get their will. This might show how the needs concerning models shifts over time and what fits well at the beginning might need to get more precise or change later in the process.
Skills
The use of DBT Skills in trauma treatment is a pet peeve of mine and I know not everyone agrees, but hear me out. Skills are small objects or activities that can be used to interrupt intense emotions or stress states. I believe that the stimulation they offer serves best as a form of irritant to initiate re-orientation. Only some skills are actually also useful for nervous system regulation. There is a tendency to call everything a skill these days if it is helpful and that might be a diversion from precise interventions. If I need a distraction I can specifically look for distractions, I don’t have to call it a skill. The use of irritants has its place but putting them in the same category with a calming techniques gets confusing. And regulation oftentimes needs something different from mere distraction, especially in DID. A fronting part who distracts themselves from triggered parts using skills does not resolve any problem or co-regulate any part. The distress is back the moment the distraction stops and no regulation has taken place. I believe that we might do better when we use irritants when we want irritants, distractions when we want distraction and calming things when we want calming things. With trauma, chances are high that what we really need is orientation and grounding, discrimination or a reality check. These are sharper tools to manage our dysregulation than just sensory stimulation by itself. If I hear one more nurse who asks ‘have your tried skills yet‘ for every problem on earth, I might scream. There is no clarity in the broad overuse of skills. If skills are taught as a panacea for all mental health struggles, I as a patient might never learn to distinguish between different needs and what actually works more precisely for my situation. How am I to learn what exactly is happening to me and what is helpful in that case when that is never prioritized? Sensory stimulation does not replace trauma-specific interventions and it does not automatically initiate regulation. ‘Go use your skills’ is the most imprecise intervention I can think of. I hope you hear the extent of my disdain. We deserve the care that goes into choosing precise interventions. Instead of using general, broad and unspecific interventions we get better results when we are taught how to distinguish between problems and resolve them with exercises specifically meant for this problem.
It is my firm belief that interventions are more effective and efficient when they actually fit the need or problem. It often only takes a moment longer to figure out what would be the best fit for what is happening. I don’t think it is an impossible demand to ask for this moment of attention to detail from our therapists. The one size fits everything approach is easy on therapists but patients might never see proper results with that at all. I might be a bit extra/neurospicy because I actually need precision and can’t make random attempts fit my brain. But I do believe that everyone would profit from precise interventions.
[This is, obviously, an opinion piece by someone with lived experience and a commentary on treatment practices and no medical advice.]