Fragmented selves: a first person account on trauma and dissociation

This first person account on recovery from trauma and dissociation has been written by a social scientist who went through a long journey in mental health care before receiving adequate treatment. A steady therapeutic relationship paired with different resources of the Comprehensive Resource Model eventually provided enough stability to overcome dissociation and process trauma. Although traditional psychotherapy is based on a psychoanalytical framework, it was helpful to look for framings that affirm a social and hermeneutic dialogue. This paper provides reflections that have proven to be helpful for the author and that might be helpful for others with similar problems. first person account; recovery from psychiatric disability; trauma; dissociation


INTRODUCTION
There is growing evidence of a link between mental health distress and trauma, as well as evidence that the current mental health system can re-traumatize survivors [1]. A systematic review estimated that half of those in the mental health system had experienced physical abuse (25-72 %) and more than one-third had experienced sexual abuse (24-49%) in childhood or adulthood, significantly higher than in the general population [2]. Trauma informed care approaches aim to position care in a sociocultural perspective and start from the awareness that survivors of trauma and violence are highly represented amongst users that end up in Mental Health contexts.
The standard of care for clients suffering from severe trauma and dissociation includes individual psychodynamic psychotherapy incorporating several modalities eclectically and a phase oriented treatment approach [3]. The Comprehensive Resource Model (CRM) is one of the newest experimental psychotherapeutic modalities available for clients suffering from severe trauma and dissociation. It claims to be a neurobiologically based, affect-focused trauma treatment model which facilitates targeting of traumatic experiences by "bridging the most primitive aspects of the person and their brain, to their purest, healthiest parts of the self" [4]. Like most other psychotherapeutic modalities, CRM recognizes the importance of a safe, contained, boundaried and empathic therapeutic relationship. Furthermore, there is an additional emphasis on somatic entrances and resources using different methods stemming from shamanistic practices [4]. This provides the necessary resources to navigate survival terror and reprocess traumatic events, without uncontrolled abreac-tion, dissociative switching and emotional overwhelm. It involves aspects from parts work (ego state therapy), breathwork, imagery, hypnotherapy and spirituality all together.
This article is a first person account from the author and will provide reflections from a personal journey on dealing with trauma and dissociation.

HEARING VOICES
At the age of 9 I remember I started "messing around with food" which I assume was an attempt to control and express feelings in a way I couldn't do differently. I started hearing "voices" that told me to cut my diet. In the meantime I also emotionally distanced from my mother, while I was desperately seeking for other parental figures. I was always longing for substitute moms and dads and held warm transference feelings in secrecy for many of my teachers in primary and secondary school. There was a little girl inside me who kept striving for perfection and had a huge hunger for warmth and love while she wanted to fade away at the same time. Lack of roots and trust, negative self -esteem, emotional neglect and abuse formed the ideal substances of an almost poisoning cocktail resulting in an eating disorder and post-traumatic stress disorder. The struggle of my little girl was a lonely one and to whatever extent the outside world wished to support me, the relationship with my so-called inner parts was often hidden and yet very intense.
At the age of 17 a severe pneumonia caused me to drop back in weight and I was admitted in hospital for several days. After that period I was advised to consult mental health care and I got diagnosed with eating disorders, dissociative and compulsive symptoms, attachment disorder, identity problems and mild depression (dysthymia). It was hard to find proper help and I always felt fearful and avoidant when starting treatment. I repeatedly dropped out of care after a few days. From my 17th to my 23rd I attended 8 treatments (both in -and outpatient), at 5 different treatment centers in the Netherlands. I felt very lost when I -in 2004 -contacted a nearby hospital where I met my current psychiatrist. Until then I had not felt understood in this jour-ney through mental health. However, from the very first moment the psychiatrist who assessed me, acknowledged he couldn't help me properly. To my surprise I was referred to a therapist with whom I proceeded the following 6 years, not only resulting in a personal transformation, but also attaining a long desired role as a mother. Five years later (2015) I unfortunately relapsed and revisited the hospital.

TREATMENT PROCESS
The same psychiatrist as I visited before, suggested to start Eye Movement Desensitization and Reprocessing (EMDR) treatment but after quite some sessions, we both realized that this led to further dysregulation. During most of the EMDR sessions, I saw myself separating internally and I left the room feeling totally estranged from myself and experienced a lot of hyperarousal and distress in between sessions. We concluded we couldn't do proper traumawork, because I couldn't stay within a window of tolerance. I was bothered by internal conflicts of my fragmented selves. We mapped my system and then discovered that there are several dissociative parts living inside me. Some of them were stuck in trauma time, others continued daily normal life. This post traumatic phenomenon is also understood and referred to as "a structural dissociation of the personality" [5]. I suffered from some amnesia, but only for short period of times (minutes to couple of hours). Some parts were not even aware of other parts in my system and were not oriented to my body and/or the present time. After this realization it was helpful I started reading literature and talking with my practitioner about all parts as if they were different people. We started focusing on the three C's: co-consciousness, communication and corporation of all parts. This was the actual start of the dissociation treatment in 2017. With my consent my practitioner started using resources from the Comprehensive Resource Model as represented and referred to in the following table.
CRM resources [4] Attunement The three types of attunement utilized are between: therapist and the client, therapist and all parts of himself and between client and all parts of herself.

Breathing
There are breathing exercises to breathe through or into sensations, such as ocean breath, earth, heart and fire breathing.

Sacred place
A sacred or special place can be visualized as part of the groundwork for in-depth trauma processing. This is helpful to overcome the sense of fear and stay connected somatically.
Resource grids A resource grid links a number of places in the body and is a somatic anchor to feeling, sensing and knowing from within.
Power beings/animals A power animal or being is called in, as a secure attachment figure within the client to develop healthy attunement behaviors internally between wounded parts and the adult.
At first my practitioner and I worked on attunement and intention setting of all parts (A). We attuned to one another by voice while I listened to "shamanic healing" music during the sessions, providing both internal peace and bilateral stimulance. We also explored the breathing work (B), which was quite challenging for me, because it easily triggered some of the youngest parts in my system. In the beginning heart breaths and "breathing without breathing" were most helpful exercises to stay present.
A second major part of the work has been the further investment in resourcing and internal communication. We therefore used the remaining resources of the CRM model. We started inviting all parts in sacred places (waterfall, mountains and forest) (C). We spent many sessions organizing parts in comfortable places, well protected and at the right distance. Another reorganization was that I started pairing childparts with adultparts outside the sessions. During the sessions we constructed 3-point somatic grids (D), with one favorite reusable grid, connecting feet, hands and shoulders. We found sacred beings (E) for most of my parts, e.g a shiny sun for my six year old and a rainshower for an adult part. All of my formerly split protectorparts eventually merged with their counterparts with the help of sacred beings that provided strength to these childparts. This was actually one of the biggest challenges. It took me more than two years to consider some seemingly evil parts, as part of myself and succeeded to stop the self-harming behaviors of those parts entirely.
Simultaneously we managed to process some of my youth trauma facilitated by the Flash technique, which is an effective method that uses micro-exposure to reduce the intensity of se-vere trauma memories [6,7]. We embedded this technique in a CRM landscape and chose positive activities that were especially engaging for my childparts, such as playing with bricks and drawing.

LESSONS LEARNED
A first insight is that my practitioner invested in a therapeutic relationship: he dared to take risks and has not given up on me. This was really empowering and gave me confidence and strength to continue the traumawork, even when I felt lost at times. With my consent my practitioner worked with the Comprehensive Resource Model (CRM), a psychotherapeutic modality, mostly familiar in the USA and UK. Although this model has not (yet) gained evidence based credentials, working this way has been an appropriate because of the severe dissociation.
Secondly, it was very important to develop a shared language and notion about structural dissociation based on trauma and dissociation literature [5,8,9]. The professional discourse has however not been dominant, e.g. I never identified my parts as alters. Sometimes I call them "persons" or, if less fragmentized, "fragments". I believe in working with dynamic hypotheses and striving for consensus between therapist and client in this regard.
Thirdly, structural dissociation requires a lot of puzzling on how the internal system functions and how to organize parts best during the sessions. This took a lot of time and effort. Especially working with child and protector parts asked for slow and cunning movements. Also, my adult parts were in need of resources and support, just as much as my childparts. It was utterly helpful that my practitioner facilitated the communication between those parts. Thanks to the resources of the CRM model, we were able to work on co-consciousness and communication whereafter we succeeded to obtain cooperation between my parts in order to do actual trauma work.
Furthermore, talking about transference processes openly has helped me to decrease shame and not feel like a burden. Through an analytic lens, my transference feelings were sometimes framed as "classical reenactments" by (psychoanalytic oriented) colleagues of my practitioner, which was not helpful to me. Because of my professional background in social sciences and education in social constructionism, I preferred to look for meaningful framings that affirm a social and hermeneutic dialogue. For instance meeting my practitioner spontaneously outside the treatment setting helped me to decrease both positive and negative transference, because all parts realized that my practitioner was real and has a personal life with different roles as a husband and father outside the therapy room.
Lastly, the treatment in itself positively impacted my transference issues, since it targeted my internal attachment. During the therapy-process my practitioner learned me to strengthen my parts (with personal resources), instead of feeling dependent on others. Over the timespan of my therapy I gained in self-comfortableness and tolerance with most of my parts. Since my adult parts still need time to adapt to all changes, full integration is currently not within reach, but I aim for the harmonization of parts, also sometimes referred to as "multiplicity" in the literature.