THE TREATMENT OF
TRAUMATIC MEMORIES:
SYNTHESIS, REALIZATION,
AND INTEGRATION
Onno van der Hart, Ph.D.
Kathy Steele, R.N., M.N., C.S.
Suzette Boon, Ph.D.
Paul Brown, M.D.
Onno van der Hart, Ph.D., is a professor in the Department
of Clinical and Health Psychology, Utrecht University, The
Netherlands, and a psychologist at the Regional Institute for
Ambulatory Mental Health Care Amsterdam South/ New West,
Amsterdam, The Netherlands. Kathy Steele, R. N., M.N., C.S.,
is a psychotherapist with the Metropolitan Psychotherapy
Associates, Atlanta, Georgia, and is Clinical Administrator
of the Post traumatic Stress and Dissociative Disorders
Program at Parkwood Hospital, Atlanta, Georgia. Suzette
Boon, Ph.D., is a research fellow in the Department of
Psychiatry, Free University, Amsterdam, The Netherlands,
and a clinical psychologist at the Regional Institute for
Ambulatory Mental Health Care Amsterdam South/New West,
Amsterdam, The Netherlands. Paul Brown, M.D., is a psy-
chiatrist at the Northpark Hospital Centre, Bundoora,
Melbourne, Victoria, Australia.
For reprints write Onno van der Hart, Ph.D., Riagg Z/NW,
P.O. Box 75902, 1070 AX Amsterdam 5, Netherlands.
ABSTRACT
This paper is based on Pierre Janet's dissociation theoryand his con-
cept of the non-realization of a traumatic event. A model of treat-
ment that integrates Janet '
temporary trauma-based models of therapy is delineated. The nature
of traumatic memories is described, and a stage-oriented model for
their treatment in patients with multiple personality disorder (MPD)
is presented. Ideally a discrete phase in the overall treatment of MPD,
this phase can itself be subdivided into the following stages: (1)
preparation; (2) synthesis; and (3) realization/integration. Although
a numberof treatment recommendations are offered, the emphasis
here is more on clarifying concepts than on the description of tech-
niques.
Multiple Personality Disorder (MPD) usually results
from severe and repeated traumatization in childhood
(Putnam, Guroff, Silberman, Barban, & Post, 1986; Ross,
Norton, & Wozney, 1989; Schultz, Braun, & Kluft, 1989).
The core pathogenic problem, i.e., the presence and dis-
rupted impact of dissociated traumatic memories, is often
independent of the form or complications of the MPD.
Experienced therapists concur that this disorder cannot be
completely resolved until these traumatic memories have
been successfully processed. Modern clinicians working with
MPD have developed effective treatment strategies to achieve
this (e.g., Fine, 1991; Putnam, 1989, 1992; Ross, 1989; Steele
& Colrain, 1990), but in our opinion the conceptual lan-
guage in which these strategies are couched is inadequate.
In two related papers, some of the authors drew attention
to the uncritical use of the term "abreaction," and they argued
in favor of the concept of dissociation over repression in
describing and explaining the origins and maintenance of
traumatic memories (van der Hart, & Brown, 1992; van der
Hart, Steele, & Brown, manuscript in preparation) . Recently,
Peterson also underlined the need to substitute more appro-
priate concepts for the term "abreaction " (Peterson, 1993).
Subsequently, in their treatment manual on processing trau-
matic memory, Sachs and Peterson (1994) only retained the
term "spontaneous abreaction" as a synonym for flashback,
and otherwise used the term "memory processing" when
referring to treatment of traumatic memory.
The purpose of this paper is to develop a phase-orient-
ed treatment model based on Janet's concepts of dissocia-
tion and the "non-realization" of traumatic memories. Within
this model a number of existing treatment techniques are
comprehensively integrated. Since other publications-- in
particular Steele and Colrain (1990) - already provide excel-
lent practical guidelines, the present emphasis is on con-
ceptual aspects of the treatment model.
The authors first describe MPD, in Janet's terms, as a
"disorder of non-realization." They then explore the nature
of traumatic memories, describing their various forms, and
the dissociative reactions which they may evoke. Next, they
describe the treatment of traumatic memories as a distinct
core phase within the overall treatment of MPD. This phase
can be clinically and theoretically divided into the follow-
ing stages: (1) preparation stage; (2) synthesis stage; and (3)
realization/integration stage. Finally, they discuss "synthe-
sis" of traumatic memories versus expression of emotions;
the substitution of traumatic memories with positive men-
tal images; and finally "realization" as a social act, as a con-
tinuous mental operation, and as the beginning of integra-
tion.
MPD AS A DISORDER OF NON-REALIZATION
Janet (1904, 1919/25) observed that traumatized indi-
viduals appear to have had the evolution of their lives arrest-
ed.
They are "attached" to an obstacle which they can-
not go beyond. The happening we describe as trau-
matic has brought about a situation to which the
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VAN DER HART/STEELE/BOON/BROWN
individual ought to react. Adaptation is required,
and adaptation is achieved by modifying the outer
world and by modifying oneself. Now, what char-
acterizes these "attached" patients is that they have
not succeeded in liquidating the difficult situation
(Janet, 1919/25, p. 660).
Janet (1935, 1945) added that these traumatized individu-
als have not "realized" the traumatic event. Thus realization
requires putting the event into words, relating it as a narra-
tive, and reconciling the experience within the personality,
thereby restoring continuity to the individual's personal his-
tory. Non-realization of the trauma can exist to varying degrees.
Many traumatized people have a subliminal awareness of
their traumatization, but cannot bear to put it into words.
They tend to evade all references to the event. If they are
confronted with it, they become highly anxious, aphenomenon
which Janet (1904) called a phobia for the [traumatic] memory,
and which van der Kolk (1988) regarded as an inability to
tolerate the feelings associated with the trauma. Their anx-
iety is, in fact, an act of separating themselves from the trau-
matic memory, a flight from the act of realization (Janet,
1945). Complete non-realization is found in those patients
who
do not make any allusion anymore to the verbal
formula which expresses the suppressed event, nor
to the anxietywhich stops them: for them, the event
... seems never to have occurred.
(Janet, 1905, p. 184)
Janet called this the hysterical form ofnon-realization ,which
was most clearly demonstrated in MPD patients (Janet,
1910). In a comparable contemporary vein, Ross (1989, p.
59) characterized MPD as occurring when a little girl who is
abused imagines it happens to somebody else. As an adap-
tation to continuing abuse, she creates alter personalities
who alone suffer the abuse. Non-realization is complete in
this child in the sense that for her, the abuse seems not to
exist at all. For her traumatized alter personalities, the expe-
rience of the traumatic events continues to exist as dissoci-
ated "traumatic memories" and, as such, these too are also
not realized.
A central focus in the treatment of traumatized patients
is the processing of their traumatic memories. This enables
them to overcome their phobia for, and avoidance of these
traumatic memories, to reverse the dissociation of these mem-
ories, to realize the distressing experiences, and to integrate
them into the whole of their personality. The total process
of therapy, moving as it does inexorably towards integration
may, thus, also be described in terms of increasing realiza-
tion.
THE NATURE OF TRAUMATIC MEMORIES
One of the central features of traumatized patients, such
as those suffering from MPD, is that their traumatic memo-
ries continue to exist as highly distressing dissociated psy-
chophysiological states. These traumatic memories are states
in which the traumatic events are, partially or completely,
re-experienced. In the clinical literature on PTSD they are
regarded as forms of intrusive recall (e.g., Blank, 1985) , while
in the MPD literature, they are often referred to as " sponta-
neous abreactions." The latter expression was the subject of
the authors' recent critique (van der Hart & Brown, 1992),
as it is based on the Freudian hydraulic model of pent-up
emotions.
However denoted, traumatic memories are part of expe-
riential recall, and must be distinguished from ordinary or
narrative memory (van der Kolk & van der Hart, 1991).
Traumatic memory is characterized by a sense of timeless-
ness and immutability, has no social function, and is reacti-
vated by trigger stimuli. It also follows the principle of resti-
tutio ad integrant, the tendency of all elements of the trauma
to be reactivated, once one element is called into play (Janet,
1907, 1928).
The term "traumatic memories" should also be intro-
duced in the clinical literature on MPD to describe those
states which are partial or complete re-experiences of the
trauma. Because of its lack of specificity, Jung's (1921/2)
alternative expression "complex" is much less adequate.
When only in the dispositional or dormant state, trau-
matic memories are not usually a hindrance. When reacti-
vated, they then exert their harmful influence. Like "para-
sites in the mind," they overgrow consciousness (Charcot,
1887; Janet, 1894). Traumatic memories never exist as whol-
ly isolated states. They are always "part of some personality"
(McDougall, 1926, p. 543). In describing acutely trauma-
tized combat soldiers, Myers (1940) thus titled their trau-
matized state the "emotional personality." He observed that
this state went on to alternate with the "apparently normal
personality." He spoke about the "apparently normal,"
because the traumatic memory could still manifest itself
indirectly, for instance through intrusive somatic dissocia-
tive phenomena such as motor paralyses.
In MPD, this doubling of the personality is more com-
plex. During actual trauma itself, through the process of dis-
sociation, a number of alter personalities sequentially expe-
rience different aspects of the trauma. The authors prefer
to call this process linear dissociation (as proposed by B.
Friedman, personal communication, (November, 1993). Alter
personalities may also contain a range of different (non-suc-
cessive) dimensions of the traumatic event, in which case
the authors speak of simultaneous dissociation. Janet (1907)
distinguished the visual, auditory and kinesthetic dimensions,
among others. Braun (1988a&b) systematized these dimen-
sions in his BASK model. BASK is an acronym for behavior,
affect, sensation, and knowledge (in which we would also
include the cognitions of the individual at the time of the
trauma). For many MPD patients, traumatic memories can
be manifested both in a linear and a simultaneous manner.
It is now widely recognized among clinicians and
researchers in the field of post-traumatic stress, as it was by
Janet before them, that traumatic memory is reactivated under
particular conditions, specifically in situations which are rem-
iniscent of the original traumatic situation (Courtois, 1988;
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DISSOCIATION, Vol. Vi,
-'1 TMENT OF TRAUMATIC MEMORIES
Gelinas, 1983; Steele & Colrain, 1990; Solomon, Garb,
Bleich & Grupper, 1987; van der Hart & Friedman, 1992;
van der Kolk, 1994). These situations are called triggers or
reactivatingstimuli (van der Hart, Boon, Friedman & Mierop,
1992). For practical purposes, the following types of reacti-
vating stimuli may be distinguished: (1) sensory data; (2)
time-related stimuli; (3) daily life events; (4) events during
the therapeutic session; (5) emotional states; (6) physiological
states; (7) stimuli recalling intimidations by perpetrators;
and (8) current trauma (van der Hart & Friedman, 1992;
van der Hart et al., 1992).
Blank (1985) distinguished four types of reactivated trau-
matic memories in Vietnam combat veterans with PTSD: (1)
vivid dreams and nightmares of the traumatic event; (2) dreams
from which the dreamer awakens, and then has difficulty
shaking off the sense of the recollected traumata, possibly
even manifesting motor behavior related to the dream con-
tent; (3) conscious flashbacks, in which the subject vividly
experiences images of traumatic events; and (4) unconscious
flashbacks, wherein the survivor has a sudden, discrete expe-
rience that leads to actions, and where the manifest psychic
content is only indirectly related to the trauma. Furthermore,
in unconscious flashbacks the survivor does not have a con-
scious awareness of reliving traumatic events, either at the
time of the flashback or later. Amnesia can follow both con-
scious and unconscious reminiscences.
In MPD, the re-experiencing of a trauma by alter per-
sonalities may, in some cases, involve complete loss of con-
tactwith present reality as well as amnesia for both the occur-
rence and its contents. The authors therefore suggest the
following distinction between two forms of reactivated trau-
matic memories: (1) partial re-experiences, and (2) com-
plete re-experiences. The former concern the reactivation
and re-experience of the trauma, while the executive per-
sonality and its habitual consciousness also remains, to a cer-
tain degree, in touch with the current situation. By contrast,
during a complete re-experience, the trauma becomes the
total current reality for the dominant personality.
Partial re-experiences are reflexive, incomplete, and frag-
mentary, with much of the content occurring outside the
awareness of the executive personality (Steele & Colrain,
1990; Loewenstein, 1991) . Any dimension of the trauma can
be reactivated and " relived. " During a flashback, the trau-
ma survivor is usually still relatively aware of his or her cur-
rent surroundings and situation. There is a kind of doubling
of consciousness, i.e., of reliving the past (to which the per-
son also begins to respond) while at the same time partial-
ly staying in the present. The dissonance occurring between
these parallel experiences can induce survivors to feel
"crazy."
An important distinction is made in the literature
between conscious flashbacks and unconscious flashbacks
(Blank, 1985). During a conscious flashback, there is usu-
ally a strong visual component of the traumatic memory,
implying that there is a cognitive dimension to the re-expe-
rienced trauma. Trauma survivors are also partially aware of
their present circumstances, and usually remember the con-
tents of the flashback afterwards. This combined awareness
of both the trauma and the present situation can give rise
to a confused sense of time. Although both the trauma and
the present situation are experienced in the present, the
current circumstances may be experienced in a more deper-
sonalized manner.
It can also occur that the executive personality is more
aware of other sensory dimensions of the trauma than the
visual one. Janet (1898) described in detail examples per-
taining only to hearing certain sounds such as screaming,
to certain physical sensations such as pain, and to emotions
such as fear and anger. These elements were dissociated
from the rest of the traumatic memory, and may be re-expe-
rienced at a subconscious level by other alter personalities.
The executive personality may then be unable to compre-
hend what s/he is (re)experiencing.
As previously mentioned, Blank (1985) distinguished
the so-called unconscious flashback. In this the trauma sur-
vivor has a sudden, discrete experience leading to actions,
where the manifest psychic content is only indirectly relat-
ed to the original trauma. The survivor does not have con-
scious awareness of reliving the trauma, either at the time
of the flashback or later (Blank, 1985, p. 297). The authors
regard this phenomenon as being due to the dominance of
the behavioral dimension of the traumatic memory, with
other (e.g., cognitive) dimensions dissociated from the exec-
utive personality.
Complete or near complete re-experiences were described in
the classical literature as hysterical attacks, or as somnam-
bulistic crises (Briquet, 1859; Charcot, 1887; Janet, 1889,
1907). Recently, Loewenstein (1991, 1993) spoke of major
dissociative reenactments. During these, the executive per-
sonality is completely disoriented, and experiences him or
herself back in the original traumatic situation without any
grounding in present reality. When the behavioral dimen-
sion is also involved, one usually speaks of a behavioral re-
enactment (e.g., van der Kolk, 1987b) . Patients maybe com-
pletely oblivious to the current situation and circumstances,
such as the presence of persons in the same room. It is also
possible that these persons are perceived, but only in the
traumatic context. For example, when a rape is re-experi-
enced during a therapy session, the therapist may be per-
ceived as the rapist. In complete re-experiences, the patient
has amnesia afterwards, not only for the contents of the expe-
rience but often for the fact that anything unusual occurred
at all. Instead, the subject experiences a puzzling loss of time
or " amnesia for amnesia " (Kluft, 1987).
The partners of some MPD patients report observing
them having had severe nightmares, during which a trauma
was apparently re-experienced. In such cases, alters gain exec-
utive control and completely relive the traumatic experi-
ence, sometimes with an intense behavioral re-enactments.
DISSOCIATIVE REACTIONS TO REACTIVATED
TRAUMATIC MEMORIES
Re-experiencing a trauma can also be a traumatic expe-
rience in its own right. Just as in the original acute trauma,
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VAN DER HART/STEELE/BOON/BROWN
further dissociative responses may occur. Depersonalization,
for example, not only can take place during or directly after
traffic accidents (Noyes, Hoenek, Sc Kupperman,1977) , but
also during or after a reactivated traumatic memory. The
authors distinguish two broad categories of dissociative
responses to reactivated traumatic memories:
1. Brief Reactive Dissociative disorder.
Sometimes the dissociative reaction is so intense, that it
can be compared to acute stress disorder, the diagnostic cat-
egory proposed for inclusion in DSM-N (Spiegel & Cardena,
1991). It occurs during or directly after a distressing event,
and is characterized by one or more of the following intense
and often persisting symptoms: (1) stupor; (2) derealiza-
tion; (3) depersonalization; (4) perceptual distortions; (5)
subjective sense of numbing; (6) amnesia following the dis-
tressing event; (7) sudden experience of terror, or other
signs of physiological arousal.
2. Switching to Alters
For MPD patients, the distressing event has usually been
experienced by several alter personalities. During a reacti-
vated traumatic memory the personalities can alternate again.
In response to this reactivation, it is also possible for switch-
es to occur either to alters who know only of the trauma, or
to those who are completely ignorant of it.
This switching may occur very rapidly. Many agitated
alters, especially child alters, alternate rapidly with one anoth-
er without being able to reduce the attendant terror. Since
the primary psychological function of dissociation is to avoid
re-experiencing traumatic elements, it would appear that
rapid switching defeats the original defensive purpose. It
instead generates intense dysphoria and dysfunction, and
promotes further dissociation in reaction to the dysphoric
rapid switching process itself.
In summary, traumatic memories are sensorimotor
states that may be partially or completely re-experienced by
the individual. In addition they may be conscious or uncon-
scious. They may remain temporarily in a quiescent state,
butare often reactivated by stimuli that resemble some aspect
of the trauma, either literally or symbolically. The evocation
of one dimension of dissociated memory tends to reactivate
all dissociated components, and reactivated traumatic mem-
ories may themselves retraumatize the patient.
A PHASE MODEL FOR THE TREATMENT
OF TRAUMATIC MEMORIES
The introduction of phase-oriented treatment models
for traumatically-induced disorders, dissociative and non-
dissociative, is widespread, and the treatment of traumatic
memories per se is usually seen as a distinct phase. In Janet 's
original treatment approach to post traumatic stress, three
phases could be distinguished (van der Hart, Brown & van
der Kolk, 1989): (1) containment, stabilization, and symp-
tom reduction; (2) modification of traumatic memories; and
(3) personality integration and rehabilitation. Janet 's stage
model is very similar to modern models of treatment for
post-traumatic stress disorder (PTSD) and dissociative dis-
orders such as MPD (Boon & van der Hart, 1991; Braun,
1986; Brende, 1984; Brown & Fromm, 1986; Herman, 1992;
Horowitz, 1986; Parson, 1984; Kluft, 1987; Putnam, 1989;
Ross, 1989; Sachs, Frischholz & Wood, 1988; Sakheim, Hess
& Chivas, 1988). For example, Sachs et al. (1988) identified
five phases in the treatment of MPD: (1) making and shar-
ing the diagnosis; (2) identifying the various personality states,
and understanding their purpose and function; (3) sharing
with the therapist, and with each personality state, the spe-
cific traumata associated with those personality states; (4)
integrating the various personality states into a single func-
tional whole; and (5) learning new coping skills that enable
functioning of the unified personality, and prevent future
personality splitting.
In this article, the prime focus is on Janet's stage two,
the modification of traumatic memories, which corresponds
to phase three in the MPD treatment model of Sachs et al.
(1983). Their definition of this phase as the sharing of spe-
cific traumata with the therapist and other personality states
iswell chosen. Successful treatment of traumatic memories
involves relinquishing related dissociations. This means that
alters both involved in the traumatic experience and inde-
pendent of it must share with each other their respective
post-traumatic dissociations. The authors call this commu-
nication the synthesis of the traumatic memory. In the older
literature, the term "re-synthesis" was used (cf. Brown,
1920/1; Myers, 1920/1). However, this term incorrectly
implied that the traumatic memory had not been dissociat-
ed. This is in contrast to the authors' view that dissociation
is an immediate defensive reaction to trauma.
The purpose of synthesis is to alleviate the dissociation,
by helping alters to share their respective traumatic experi-
ences of the trauma both with each other, and with the ther-
apist. This orientation is, at the very least, semantically dif-
ferent from those approaches which encourage abreaction
and catharsis of emotions. The authors consider "abreac-
tion" to be an incorrect explanatory principle, and an inap-
propriate treatment technique (cf. van der Hart & Brown,
1992).
However, the present approach does not stand for blan-
ket discouragement of the expression of emotions. On the
contrary. When the patient needs to express the cry which
she suppressed during the actual abuse, she is told that she
can now cry safely, and she is encouraged to do so. This
expression of emotion leads to realization and completion.
Abreaction or uncontrolled catharsis of overwhelming trau-
matic affects leads to states of hyperarousal and, at times, to
complete psychological decompensation. The hydraulic
view of affect ("It is in there, and needs to get outl") con-
trasts with the Janetian notion that the affect, as well as the
other elements of the trauma, needs to be realized and inte-
grated or " metabolized. "
Therapeutic synthesis of traumatic memories is a pur-
poseful mental action, based on a conscious decision either
by the whole personality, or by the alters involved in the trau-
matic experience. For this endeavor to succeed the patient,
or the alters involved, needs the complete support of the
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TREATMENT OF TRAUMATIC MEMORIES
therapist, not only through his or her sharing in the trau-
matic experience (as emphasized by Sachs et al., 1988) , but
also through encouragement and guidance
When synthesis of a trauma occurs, the memory ceases
to be re-experienced in a traumatic way. The trauma becomes
a "neutral " historical fact. In order to achieve this, the patient,
or the group of alters concerned, undergoes a process of
"realization" of the personal disaster which has occurred.
The patient substitutes and integrates into his or her life his-
tory or autobiography, a narrative memory of the event in
place of the experiential traumatic reminiscences (Janet,
1919/25), i.e., into the whole of the personality. This inte-
grative mental work is both a time and an energy-consum-
ing reorganization of the personality.
The treatment phase of traumatic memories can be divid-
ed into the following stages, each of which will be described
below: (1) preparation stage, (2) synthesis stage, and (3)
realization/integration stage.
STAGE 1: PREPARATION
The treatment of traumatic memories can be a stormy
process and so must be planned carefully. The preliminary
groundwork follows the general guidelines for establishing
and maintaining a secure therapeutic setting, with particu-
lar attention paid to boundaries, consistency, and pre-
dictability (Kluft, 1991, 1993; Courtois,1991; Fine, 1991, 1993;
Putnam, 1992; Steele, 1989; Steele & Colrain, 1990) . In addi-
tion, in working with victims of childhood trauma and with
dissociative disorders, the following strategies should be
employed: (1) identification of alters and their respective
conflicts; (2) development of a reasonable degree of inter-
nal communication and cooperation among alters; (3) con-
tainment of traumatic intrusion phenomena; (4) develop-
ment of ego strength in the host personality, as well as in
the various alters; and (5) development of self-care capaci-
ties, i.e., capacities to tolerate affects, to self-soothe, to tol-
erate aloneness, and to regulate self-loathing (McCann &
Pearlman, 1990); and (6) the introduction and use of hyp-
nosis. The latter is for the purpose of enabling the patient
to develop control over dissociation, for containment and
affect modulation, for creation of a safe psychological space,
internal communication, symptom relief and/or substitu-
tion, and for management of other dissociative crises.
There are two important caveats regarding the appli-
cation of hypnosis: (1) It must be implemented within the
context of well-conducted psychotherapy and therefore
should he used only by therapists with specialized training;
and (2) particularly in the later phase of treatment, care
should be taken to prevent the defensive use of trance to
avoid painful issues. During the earlier synthesis phase, how-
ever, hypnosis is particularly useful.
Once treatment of traumatic memories has been initi-
ated, the stage is set to prepare for the synthesis and real-
ization/integration of traumatic memories. The prepara-
tion phase addresses: (1) safetyfactors; (2) issues of controlling
or containing reactivated traumatic memories; (3) explo-
ration of traumatic memories; (4) correcting cognitive
errors and distortions; and (5) careful explanation and plan-
ning of synthesis sessions (Steele & Colrain, 1990).
Issues of Safety
Steele and Colrain (1990) presented an excellent
overview of the preparations required to ensure safety both
during and between synthesis sessions. Preparation pertains
to: (I) intrapsychic safety; (2) interpersonal safety, both of
the patient and the therapist; and (3) a safe therapeutic envi-
ronment. The latter is best provided in a minority of cases
by a short term hospital stay. Additional safety issues which
should also receive careful consideration include: (1) the
degree of cooperation and communication among alters;
(2) the general level of hyperarousal and hypersensitivity to
affective stimulation, as well as the level of affective maturi-
ty; (3) the potential for suicide and self-harm; (4) the gen-
eral level of coping of the individual and the alters involved
in maintaining function in the world (i.e., will these alters
participate in the integrative memory work, and what effect
will that have on functioning?) ; (5) the range of support sys-
tems and resources available; and (6) the level of motiva-
tion to work through traumatic memories.
Controlling or containing reactivated traumatic memories
Traumatic memories do not usually emerge in a planned
or controlled manner. They are often triggered by a reacti-
vating stimulus. When the timing is not right for their syn-
thesis, either in the overall course of treatment, or because
the particular therapeutic session is too far advanced, these
re-experiencing phenomena should be controlled or con-
tained using any of the following techniques either alone
or, still better, in combination: (1) identifying the reacti-
vating stimulus and, when indicated, relating it to the orig-
inal trauma; (2) removing the reactivating stimulus; (3) neu-
tralizing the reactivating stimulus (involves teaching the patient
to regard the trigger as belonging to two different contexts,
the present neutral one and the past traumatic one, and
helping the patient realize that the object itself holds no
emotional charge) ; (4) promoting and emphasizing the safe
present; (5) suggesting temporary amnesia for, or creating
more mental distance from, the traumatic memory [for exam-
ple, hypnotic interventions such as the movie screen tech-
nique, the use of adult observers, and the use of affective
regulation techniques as described by Fine (1991) and Kluft
(1989)1; (6) cue-conditioning to help the patient return to
the safe present (the patient can be trained to respond to a
certain cue in returning to the present if he or she should
get lost whilst reliving a traumatic memory); (7) screening
traumatized alter personalities from the outside world; (8)
introducing a co- or deputy therapist; and (9) medication
and hospitalization as crisis intervention (van der Hart &
Friedman, 1992; van der Hart et al., 1992).
Exploration of the Traumatic Memory
Either parallel to, or following safety preparation, the
therapist begins to collect information about the content of
the traumatic memories.
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DISSOCIATION Vol.
VAN DER HART/STEELE/BOON/BROWN
l) Charting the Context of the Trauma
The authors first recommend defining the histori-
cal context, including the personal history (devel-
opment, school history, training and occupation,
supportive figures, pets, objects and other attach-
ment objects, etc.), and the family circumstances
(social, cultural and economic factors); domestic
factors (e.g., who lived in the home, who shared
bedrooms, family rules and discipline) (Steele &
Colrain, 1990).
2) Completing the Story of the Trauma
Although most alters involved cannot, by definition,
relate a narrative of the unassimilated trauma, there
are often some alters who have a cognitive aware-
ness without any associated affect, and who will be
able to relate what happened. Often this is an observ-
ing alter who watched happened " from a distance. "
In completing the story, it is important to collect
information from the whole sequence, including
directly before the trauma, during the trauma itself,
and directly thereafter. This not only provides a con-
text for the trauma, but also ensures temporal con-
tinuity.
When an observing alter is asked to relate what
happened, care is taken to inquire if the trauma-
tized alters can be protected from hearing the story.
In this way, untimely reactivation of the whole trau-
matic memory can be prevented.
3) Identifying the Alters and Their Role in the Trauma.
It is preferable to know prior to the actual synthe-
sis which alters are involved, and what are their func-
tions in the traumatic experience (Sachs, Braun, &
Shepp,1988). Ignorance ofwhich alters are involved,
and which should participate, may allow some alters
to withdraw and refrain from sharing their experi-
enceswith the others. Dissociated aspects of the trau-
matic memory will then continue to exist, and can
eventually be reactivated. Braun's (1988a&b) BASK
Model may serve as a checklist to determine whether
all relevant dimensions of the trauma are covered
by the alters known to the therapist.
The purpose of this inquiry is therefore not acquisition
of details for their own sake, but rather to become aware of
all of the dissociated elements, or "pathogenic kernels" (van
der Hart & Op den Velde, 1991), which must be synthesized
in order to neutralize the traumatic memory. Often the per-
sonal meaning in these "pathogenic kernels " ismore impor-
tant than the objective factual details. Personal or subjective
meaning of the trauma is most often experienced in the
form of existential crises. Pathogenic kernels frequently devel-
op in response to, and contain in an undiluted and unas-
similated form, intense existential crises that are related to
the trauma. Such crises are partially related to "stuck points"
created by discrepancies between prior belief schemes and
new schemata generated by the traumatic experience (Resick
& Schnicke, 1992). These existential issues will be discussed
further in a later section of this paper, as well as specific
approaches to the synthesis and integration of pathogenic
kernels.
Apart from knowing which alters were involved in the
trauma, and which should therefore participate in the syn-
thesis session, the therapist should discover which of the
other alters can remain in the session as well, and which of
them should be protected from it, e.g., by encouraging with-
drawal behind an inner, dissociative "wall." It is also impor-
tant to ascertain whether there are alters who still actively
object to the memory work. If so, these should be engaged
in negotiation to prevent internal punishment for prema-
ture revelation of trauma-related "secrets."
Correcting Cognitive
This phase of therapy also enables the patient to rec-
ognize and confront any cognitive distortions or errors that
create dysfunction and misperception of the self and oth-
ers (Fine, 1988, 1990, 1991, 1993; Fish-Murray, Kolb, & van
der Kolk, 1987; Janoff-Bulman, 1992; McCann & Pearlman,
1990; Orzek, 1985; Ross, 1989; Ross & Gahan, 1988).
Cognitive schemas that were developed in environments of
chronic abuse and neglect are inevitably negative, with lit-
tle associated flexibility or adaptive personality functioning.
They remain fixed along with the traumatic memories. The
latter are reinforced by intense post-traumatic affects. The
negative cognitions, in their turn, reinforce these negative
affects. During synthesis the cognitions also become avail-
able for therapeutic exploration and change.
The trauma is encoded within specific cognitive schema,
and continues to be interpreted within this context by the
patient until the therapist assists in the reconstruction of
new assumptions, beliefs, and expectations about the self
and others. Cognitive distortions frequently pose obstacles
to initial memory work, and contacting the alters involved
before the actual synthesis helps the therapist to motivate
them for this intense and painful work. Resistances often
emanate from deeply embedded beliefs about the trauma,
e.g., "It lasted forever"; about the perpetrator, e.g., "He'll
know if I ever tell"; and about the self, e.g., "It was my fault, "
or "It didn't happen to me."
Thus, in a case of sadistic sexual abuse by the father, a
female patient 's "father-alter" had first to acknowledge that
this was the part of her personality which, by identifying with
the abuser, had helped her to survive the trauma. At the
time, her defensive dissociation helped her to believe that
the intolerable abuse did not occur to her but to somebody
else. Another alter, in the same person, had to accept in
treatment that she was not really crazy. She believed that
expressing her anger directly against her father would have
made him abuse her even more.
Assisting the patient, and alters, to change inappropri-
ate and distorted cognitions is an approach which may be
required throughout the whole course of therapy (Fine, 1988,
1990, 1991; Ross & Gahan, 1988; McCann & Perlman, 1990).
Fine has extensively delineated the necessity of cognitive
work throughout the course of MPS treatment, and has uti-
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DISSOCIATION, Vol, VI. No, 2 3. Junei Sept 1993
TREATMENT OF TRAUMATIC MEMORIES
lized Beck's (1979) cognitive therapy approach (Fine, 1990,
1991, 1993). Many cognitive errors and distortions may be
accessed prior to synthesis, but a number emerge in the
course of eradicating the post-traumatic dissociation. These
distortions must he identified and processed following syn-
thesis. Others even emerge after the synthesis, when inte-
gration is taking place.
It must be realized that such cognitive distortions have
created a gestalt of schema that comprise the individual's
entire worldview, a view that has been held for a lifetime.
The survivor 's defenses are based on these cognitions, and
usually have been incorporated into the entire character
structure itself. Change on such a scale of magnitude pro-
gresses slowly, yet such change is necessary if the survivor is
to heal. New, adaptive cognitions must be reinforced over
and over in the course of therapy in order to completely
replace old, negative injunctions (Steele & Colrain, 1990).
Explaining and Planning the Synthesis Session
During the preparation phase, it is necessary to give a
clear explanation of the various steps and procedures to be
followed, and to provide a cognitive framework for the assim-
ilation of the traumatic memories.
A global explanation will have been given earlier in ther-
apy. Now it is augmented in a detailed manner. It must be
repeated a number of times, initially with the host person-
ality (or the alter who is most active in therapy), followed
the observing alters who are able to provide information
about the trauma, and then the other alters who are involved
in the traumatic memories. Sometimes the observing alter
will be the one to inform these latter alters.
Prior to synthesis, the possibility of using artwork or other
non-verbal therapeutic modalities is explored. For example,
severe abuse which is dominated by intense physical pain
destroys language and impedes verbal communication
(Starry, 1985). Thus, initial use of non-verbal modalities in
severely traumatized individuals may facilitate verbal com-
munication. Symbolic images may also provide a framework
and a "container," perhaps for the first time, for the trau-
matic experiences of all the alters.
The rationale provided for this treatment approach is
that reactivated traumatic memories continue to exert their
intrusive and disturbing effects because of their dissociative
nature. They have yet to become shared and integrated parts
of the alters involved, as well as of the whole of the person-
ality. To achieve this, the alters involved with the trauma
share their respective part-experiences with each other, uni-
fying them into one whole, and sharing this eventually with
the remaining alters. The therapist emphasizes that the suc-
cess of the procedure is dependent on the completeness of
the synthesis. This implies that all dissociated "pathogenic
kernels" must be synthesized. To share the trauma with each
other, the alters need to experience it intentionally, while
also staying in the safe present, and keeping contact with
the therapist.
In many instances, all of the alters involved may accom-
plish the relief of the dissociation, and the synthesis of the
traumatic memory, in one session. This is called parallel syn-
thesis.With greater severity and duration of the trauma, res-
olution may take a number sessions, which is called serial
synthesis. Whether synthesis is accomplished in one or in sev-
eral sessions, it is crucial for the patient to pursue his or her
own optimal pace. If two or more sessions are needed, great
care should be taken that the traumatic memories are well
contained between the sessions.
STAGE 2: SYNTHESIS
Synthesis of a traumatic memory involves its controlled
reactivation in a collaborative effort by the therapist and the
patient. The involved alters re-experience and share their
respective parts of the trauma with each other, and with
other alters. In this way the existing dissociations are relieved.
A century ago Delboeuf formulated this reactivation as
follows: Using hypnosis the therapist "puts the subject back
into the state in which his trouble manifested itself, and com-
bats the same trouble with spoken words, but in a state of
rebirth" (1889, p. 71; cf. Macmillan, 1991, p. 82). The "ther-
apist ' s words" help the patient to stay in touch with the pre-
sent, and with the therapist, while the patient is, and the
alters involved are, returning to the traumatic experience.
All dissociated aspects of this experience must be re-expe-
rienced. The memory must eventually be shared with every
part of the personality. That the presence of the therapist
is an essential factor in this process was aptly formulated by
Jung (1921/2):
The support and understanding of the therapist
raise the level of the patient's consciousness and
enable him to consciously bring the autonomous
traumatic memory once more under the control of
his will. (p. 15).
While (re)experiencing the trauma, the patient enters an
altered state of consciousness, and loses the sense of chrono-
logical time. There is no sense of past or present relative to
the trauma, and so the trauma seems timeless. Synthesis must
counteract this and add a sense of continuity and finitude
(Steele & Colrain, 1990) . Using details collected during the
preparation stage, the therapist helps the patient to evolve
from the period directly before the trauma, through the
trauma itself, to the period directly after it. The patient there-
by experiences a beginning and an end to the trauma (Putnam,
1989).
In addition to ensuring the chronological context, it is
critical to help the patient recover the subjective experience
of the trauma, which is often held in the various alters. This
subjective experience includes a number of dimensions: the
various meanings given to the trauma (e.g., "this can't hap-
pen, " "this has never happened to anyone else, " " this is too
terrible to ever tell," etc.) ; internalized injunctions that are
either implied or verbalized (e.g., "if you tell, I'll kill you,"
"you know you like this, " etc.); the various BASK dimensions
including cognitions, and existential crises (Steele & Colrain,
1990).
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DISSOCIATION', Vol. VI,No. 23. une.ept. 1993
VAN DER HART/STEELE/BOON/BROWN
Existential Crises
Yalom (1980) saw an existential crisis as "a conflict that
flows from the individual's confrontation with the givens of
existence" (p. 8). The crisis occurs at the moment when the
issues shift from the abstract to the experiential dimension,
most likely when some form of realization occurs. They become
so real and intolerable that disintegrative anxiety occurs (Steele
& Colrain, 1990). Lifton (1980) aptly referred to the moment
of existential crisis in the traumatic memory as the "ultimate
horror. " Dissociation of the personality often occurs at this
point, and particular alters may be the embodiment of dif-
ferent aspects of the crisis. There are six important aspects
relating to: (1) death or psychological annihilation, (2) iso-
lation, (3) meaninglessness, (4) freedom and responsibili-
ty, (5) identity, and (6) intolerable pain.
Janoff-Bulman (1985, 1992) extensively discussed the
destructive impact of trauma on basic ontological assump-
tions (i.e., belief in ameaningful and benevolent world, per-
sonal invulnerability, and positive self-worth) . These assump-
tions are shattered by trauma, and, in the case of early and
prolonged child abuse, never develop. In both cases, the
result is a propensity to existential crises. The moment of
the crisis is unbearable, and becomes fixed in the traumat-
ic memory without a temporal or meaningful context. It is
accompanied by disintegrative anxiety and terror that is dif-
fuse, intense, and non-verbal, i.e., the classic state of hyper-
arousal in response to overwhelming trauma (van der Kolk,
1987a, 1988, 1994; Krystal,1988).
For each trauma there may be one or a series of exis-
tential crises. Since these moments are so laden with affect,
it is crucial to recognize them in the synthesis session, so
they may be processed during realization.
Parallel and Serial Synthesis
Two fundamental approaches to the synthesis of trau-
matic memories in MPD patients can be distinguished: seri-
al and parallel synthesis. The first often involves a number
of sessions, each returning to the original sequence of events.
The second is concentrated in one session with the thera-
pist and patient striving towards maximum involvement of
all alters concerned.
Serial Synthesis
The rule in classic serial synthesis of traumatic memo-
ries is to follow the patient, and to stay where the patient is
at (Putnam, 1989, 1992). Clinicians pursuing this approach
risk not knowing which alters are involved, and which should
be excluded from participating at any given point in the
actual synthesis work.
The essence of serial synthesis is to bring the patient,
after the necessary preparations, back before the traumatic
event. Then, while constantly remaining oriented to the ther-
apist and to the present, the patient is chronologically guid-
ed through the experience (i.e., by asking, "And after that,
what happened next?") Using the BASK Model (Braun,
1988a&b), for example, the therapist attempts to elicit var-
ious dissociated traumatic responses, and to include miss-
ing aspects requiring synthesis.
Sometimes the whole process must be repeated a num-
ber of times, so that all alters involved in the original trau-
matic event can make their respective contribution. Should
synthesis not be completed, reactivation of the same trau-
matic memory can occur following the session. Putnam spoke
of this in regard to the resulting contradictions and the prob-
lems of credibility which ensue:
The patient may relate very different versions of
the same event and express widely divergent emo-
tions. In MPD patients, different alters will often
embody these contradictory perceptions. In some
cases, specific events or specific versions of an event
will have clear fantasy components; in many other
cases, the therapist and patient will never be sure
what actually occurred, and what was fantasy, in
these cases. I do not know of any way to sort out
truth from fantasy in these cases. (Putnam, 1989,
p. 245)
First, it is important to be aware that different alters may
indeed have experienced widely different aspects of the trau-
ma. An alter identifying with the abusive perpetrator might
relate a quite different version from an alter experiencing
the pain and fear during abuse; another alter who is com-
pletely dissociated from all pain and fear might even expe-
rience sexual arousal.
Secondly, it has frequently been observed that some alters
may have fantasy experiences during a traumatic event, which
should also be synthesized. Charcot (1887) described a clas-
sic case of adult traumatization in which a fantasy played a
major part in the post-traumatic symptomatology. His patient
Lelog was in a traffic accident with a horse-drawn wagon,
after which his legs were paralyzed. Although he fell against
the ground, and was unconscious, there were no neurolog-
ical signs indicating a somatic cause of the paralysis. Instead
itwas discovered that as he fell, just before losing consciousness,
he saw the wheels of the car approaching him, and strong-
ly believed that he would be overrun. This fantasy was dis-
sociated and gave rise to his paralysis.
Hypnotic Techniques
To ensure the safe and effective course of synthesis, the
therapist may draw upon specific hypnotic techniques. Some
of these, such as creating a safe imaginary place for alters
not yet ready to participate in the actual synthesis, usually
have been implemented during earlier therapy phases or
during the preparation stage. Other hypnotic techniques
may be used to ensure gradual synthesis over a number of
sessions. One such technique involves the use of an imagi-
nary video screen on which elements of the trauma can he
displayed. The patient may then relate associated thoughts,
emotions and sensations. Another approach involves plac-
ing the incomplete traumatic memory in " safe keeping" (e.g.,
in an imaginary vault or similar location). More extensive
descriptions of these and other relevant hypnotic techniques
can be found in Brown and Fromm (1986) , Hammond (1990) ,
Kluft (1988, 1989), Peterson (1991; 1993), Putnam (1989),
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BISSOCLAT1O1. Vol. CI. No. 2:3. June/Sept. 1993
TREATMENT OF TRAUMATIC MEMORIES
Ross (1989), Spiegel (1981), Sachs and Peterson (1994),
Steele and Colrain (1990) , and van der Hart, Boon, and van
Everdingen (1990) .
Parallel Synthesis
Parallel synthesis is a much more structured approach.
The development of the idea of parallel synthesis, as well as
the several techniques involved in its execution, like many
other ideas and techniques in the field of MPD, maybe attribut-
ed to several different sources. The authors have attempted
to attribute credit as accurately as possible, while acknowl-
edging that on occasion it is difficult, if not impossible, to
determine a primary source in a field with such a strong ori-
entation to workshops and oral tradition. Kluft, Comstock
and Sachs, for example, taught variations of parallel syn-
thesis in workshops and conference presentations during
the 1980 's, and Judith Peterson did the same during the
early 1990' s (Peterson, 1991) . The variation described below
was traced to Stephen Ray, as personally related to the authors
by Barbara Friedman ( personal communication, September
1990) and Pamela Reagor (personal communication,
November 1990). In the literature, Kluft (1988, 1989), Fine
(1991, 1993) , and Sachs and Peterson (1994) have made sig-
nificant contributions to this concept and associated tech-
niques.
Parallel synthesis is based on a detailed simultaneous
inventory of the traumatic event. Making this inventory involves
seeking answers to questions such as what actually happened,
which alters were involved in the trauma, and in which ways,
e.g., on the dimensions of the BASK Model. It also involves
determining with the patient, or, preferably, with an alter
who has an overview, which alters should attend the syn-
thesis, and which alters should temporarily be protected from
such knowledge and participation.
The actual synthesis starts by repeating the rationale and
the actual steps involved. The therapist emphasizes that the
success of the technique depends on the completeness with
which it is executed. At the beginning of the synthesis ses-
sion, the patient is guided into a state of intense concen-
tration (i.e., hypnosis) . Those alters who are required to syn-
thesize their respective parts of the traumatic memory are
brought forward, and others permitted to attend are also
invited. By contrast, those who should withdraw are instruct-
ed to go their safe places behind the pre-established pro-
tective barrier.
A written account of the traumatic event has been divid-
ed into 10 segments. The therapist counts from 1 to 10, for
example, beginning at "1" with the onset of the trauma, and
ending with "10" after the traumatic experience is over. Each
segment that the therapist subsequently mentions is pre-
ceded by its appropriate number. This counting gives a clear
structure to the session, reminding the patient of the stage
reached in the process, and how much more is still to come.
During the synthesis, all alters involved are encouraged to
share their respective experiences, so that they coalesce into
a single whole, and relieve existing dissociations.
After the last count, the therapist offers additional appro-
priate support to all alters involved, and asks what percent-
age of the total traumatic event has been brought together.
Often a significant percentage, particularly pertaining to
the worst pain and fear, is left behind, and must be more
explicitly included in the next round. Within a given ses-
sion, the whole procedure is executed no more than three
times. This is often more than adequate.
It is useful to intersperse this "titrated " (re)experienc-
ing with episodes of hypnotic "resting, " in which the patient
is induced into a very deeply relaxed state. This employs hyp-
notic time distortion, with the suggestion that the patient
may rest as long as is necessary before the next synthesis
module during the session. Suggestions include: "seconds
seem like minutes, and minutes like hours, " "in a short time
you may feel relaxed, refreshed and renewed as though you
had rested for a long time."
Where there is little outstanding dissociated material,
say up to five percent, this may in some cases be processed
safely by the patient on his or her own. However, reassur-
ances by patients that they can do this last bit alone, must
be tempered by the therapist's clinical judgement. In one
female patient the last five percent "at the end " was respon-
sible for the activation of serious suicidal tendencies. It per-
tained to an earlier suicide attempt made in response to a
rape by her father at the age of nine. She had subsequent-
ly believed she was pregnant, and failed in an attempt to
induce an abortion. Thus it is important to be sure that the
remaining dissociated elements do not contain material that
will be overwhelming, and that they do not link to further
traumas that are not yet ready to be synthesized.
Parallel synthesis may involve many variations. Fine empha-
sized the importance of first working with "like-clusters " of
personalities so that affect and knowledge is shared among
groups of alters grouped according to affective or cognitive
themes. In this way, the affect is processed and modulated
prior to being shared with other alters within other clusters
(Fine, I991, 1993). Fine advocated fractionated synthesis in
order to avoid retraumatization to the patient. Comstock
(1986) suggested various approaches to managing the treat-
ment of traumatic memories through modulating affect and
content. As presented already in his workshops during the
early 1980's, Kluft (1988, 1989) developed specific approach-
es to fractionate traumatic material, in which it is suggested
to the patient and alters that they need not re-experience
their part in the trauma to the full extent, but for instance
to a degree of 4 on a scale of 1 to 5. They are further instruct-
ed that they "need only experience that which is necessary
to know, to understand, and to heal. " Another variation is
the instruction that, if necessary, one specific alter or one
dimension of the traumatic experience, may be left out dur-
ing the first attempt and may be included later. This trans-
forms parallel synthesis into a highly structured serial syn-
thesis. It is also the case when subsequent sessions are
systematically focussed on the synthesis of successive episodes
of a complex traumatic event.
While the parallel approach initially involves active par-
ticipation by the therapist, utilization of detailed informa-
tion regarding the traumata, and sharing the experiences
of the respective alters involved, it also lends itself to rela-
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DISSOCIATION, vol. v1. No. 23, Jane Sept. 1993
VAN DER HART/STEELE/BOON/BROWN
tively autonomous work by the patient. Some patients
become so accustomed to its application, that they can do
the necessary work with certain traumatic memories with-
out the therapist being informed about all of the relevant
details. At first counting is often experienced as very help-
ful, but after a while some patients indicate that they do not
need it anymore. This implies that they are not utilizing dis-
sociation as much as before, and that they are now better
able to tolerate and modulate affects related to the trau-
matic memory.
An important issue is the degree of involvement of the
host personality (where one exists) in the synthesis of the
traumatic memory. When this has been present during the
trauma, the answer is of course in the affirmative. In other
cases it depends on the host's ego strength - or "psycho-
logical tension " in Janet 's terms (cf. van der Hart & Friedman,
1989) - and motivation, among other factors. In general,
it is important to tailor synthesis to the patient's needs.
Termination of the Synthesis Session
Towards the end of the synthesis session, while the patient
is still in an altered state of consciousness, the therapist ensures
that all alters involved are supported, and suggests a posi-
tive sense of accomplishment and unity. After having shared
their terrible ordeals, they can now share their warmth and
wellbeing, not only with each other, but also with all other
alters as well. The therapist may use additional healing imagery,
such as projecting the image of a white, healing light, which
embraces them, and brings them all the more closely togeth-
er (Kluft, personal communication, January 1987) . The authors
believe that such experiences provide a powerful model for
future integration and unification. Finally, the patient is
brought back to a state of full awareness and orientation to
the present time and place (Putnam, 1992).
Aftercare
Good preparation for a synthesis session requires know-
ing how (and, in some cases, with whom) the patient will
return home after the session, and what type of support will
be available, if needed (Putnam, 1992). It is sometimes use-
ful to have the patient contact the therapist at a pre-deter-
mined time at the end of the day, or at the beginning of the
next day, and to make available a follow-up session at short
notice.
STAGE 3: REALIZATION AND INTEGRATION
With successful synthesis the traumatic memory ceases
operating at a sensori-motor level. McDougall (1920/1) for-
mulated this as follows:
As soon as the dissociation is overcome, though the
same train of thoughts may recur, its power to pro-
duce distress is greatly weakened by the patient ' s
accompanying awareness of his present surround-
ings and his knowledge that the experience belongs
to the past. The process of readjustment of his emo-
tional attitude can then begin, or, in other words,
he makes progress in `autognosis' (1920/1, p. 27;
1926, p. 457).
What McDougall called the "process of readjustment"
requires both acceptance of the memory as real, and a con-
ciliation between this narrative memory and the patient's
personality. The traumatic memory has now been transformed
from an intrusive re-experiencing, to a trauma-related nar-
rative within the overall stream of consciousness. At this point,
therapy shifts to mitigating the impact of the trauma on the
self and on relationships with others. Herman stated that
the core experiences of this stage are "empowerment and
reconnection " (1992, p. 197).
Janet (1935, 1945) called this conciliation " realization "
of the event and its consequences. Realization is the for-
mulation of a belief about what happened (the trauma),
when it happened (in the past), and to whom it happened
(to self). The trauma becomes personalized, relegated to
the past, and takes on symbolic rather than sensorimotor
properties. In order to resolve existential crises, realization
requires the development of new cognitive schema, such as
accepting the event and resigning oneself to its occurrence,
reframing one's attitudes to the event, the perpetrator, and
oneself, and reorganizing one's overall behavior (Janet, 1945) .
Yet, it is more than cognitive process; realization is an expe-
rience of one's history as one's own. It provides a transition
from the non-verbal dissociated realm of traumatic intru-
sion into secondary mental process in which words can con-
struct meaning and form, thereby facilitating the transfor-
mation of traumatic memory into narrative memory.
Integration or assimilation involves multi-dimensional change
in the life of the survivor. Realization then becomes lived
experience. As one survivor said, "I don't have to live my old
story anymore now that I know it; I'm creating a new one
every day. I'm no longer stuck with one script!"
Realization evolves over time as more of the events and
their meanings are digested and resonate throughout the
mind and as the various dissociated layers are uncovered
and integrated. The trauma thus becomes gradually assim-
ilated or integrated into the patient's personality; it is incor-
porated into the patient's narrative memory or autobiogra-
phy (Janet, 1919/25). The patient should not only be able
to narrate the story of the abuse without re-experiencing it,
but:
must know how to associate the happening with the
other events of his life, how to give it its place in
that life-history which each one of us is perpetual-
ly building up and which for each of us is an essen-
tial element of our personality. A situation has not
been satisfactorily liquidated, has not been fully
assimilated, until we have achieved, not merely an
outward reaction through our movements, but also
an inward reaction through the words we address
to ourselves, through the organization of the recital
of the event to others and to ourselves, and through
the putting of this recital in its place as one of the
chapters in our personal history. (Janet, 1919/25,
p. 662)
Clinical experience teaches us that this realization can be a
very difficult - if not initially impossible -challenge for
171
DISSOCIATION, Vol. VI. No. 2. 3, ime/Sept. 1993
r Me' E
some patients. This is sometimes due to the fact that sur-
viving dissociated elements of the traumatic memory have
been reactivated. But even when synthesis of the traumatic
memory has been completely successful, patients may ini-
tially feel unable to reconcile the narrative memory with
their self-representation. The realization for example that
their mother always hated them, that their father sadistically
abused them, that they themselves came to perform horri-
ble acts, is overwhelming and defies categorization or attri-
bution of meaning.
Integration and realization involve confronting enor-
mous loss. Grief and mourning are a crucial transition between
realization and integration. The patient must learn to grieve
deeply the lost childhood that can never be recovered; the
loneliness and the pain that have been and must continue
to be endured; the lost time, money, education, jobs, rela-
tionships, and energy spent avoiding or struggling with the
aftermath of the trauma; and finally, the awful truth that
must be carried throughout the rest of his or her life. Yet
grief, with all its pain and anguish, is ultimately healing. It
enables the survivor to relinquish unrealistic expectations,
to acknowledge what "is," and therefore, to move fully into
the present with new clarity and purpose - with sadness,
but also with newfound wisdom_
The first task of this stage is for the therapist to listen
empathically to the narration of the story, repeatedly, if need
be. Telling the story is an important component of realiza-
tion and integration; the narrative makes the story more real
and personal, as well as shifting the trauma from an autistic
re-experiencing, to a relational sharing and linking in with
the therapeutic alliance. The survivor is no longer alone in
the trauma. Words begin to allow the patient to form new
semantic structures that will assist him or her to assimilate
the trauma over time. Ager and Jensen (1990) stated that
the telling becomes a "testimony," a ritual that is healing
and restorative, and gives the story not only a personal, but
an interpersonal and social dimension, so that it can be put
in its broader context.
Cognitive work should also continue during this stage
(Ross, 1989). The patient develops more insight into the
origins of cognitive distortions, while the affective and
behavioral realms follow suit. The capacity for self-care becomes
established, and with it, a new-found confidence and self-
esteem. Personal psychological needs are acknowledged, and
the survivor begins to take an active role in creating an envi-
ronment in which trust, healthy dependence, autonomy,
power, esteem, and intimacy can flourish (McCann &
Pearlman, 1990). In short, the patient learns (or relearns)
to love, to work, and to play.
Substitution
Sometimes realization of a traumatic event requires mak-
ing the original trauma more acceptable (Janet, 1935). This
can be done in two principal ways: either by changing the
content of the traumatic memory itself, or by altering aspects
of the already transformed narrative recall.
The first approach is called the substitution technique,
and was originally developed by Janet (1889, 1898; cf. van
der Hart, Brown, &van der Kolk, 1989; van der Hart, Brown,
& Turco, 1990). In it he suggested a completely different
course to the original traumatic event. Thus, with his patient
Marie, for whom the unanticipated first menstruation had
been traumatic, he used hypnosis to regress her before it
and gave her appropriate preparatory instruction. He then
suggested that she would now "remember" her first men-
struation as having occurred in a normal and painless way.
A number of therapist have recently reintroduced this
technique (Lamb, 1985; Miller, 1986). With regard to trau-
matic events involving perpetrators (e.g., childhood sexual
assault), clinicians are mostly reluctant to employ substitu-
tion, since it might be perceived by the patient as an invali-
dation of the crime, something which has been done so often
by the perpetrators and by others who knew about the abuse.
However, minor variations can be employed with survivors
of child abuse. After synthesis, for example, the patient is
encouraged to express anger, and to do symbolically what
he or she had wanted to do against the perpetrator(s) dur-
ing or after the original traumatic event. Watkins (1949),
who applied this technique in the treatment of traumatized
combat veterans, stated that it may help the patient to bring
the original frustrating situation to a more satisfactory con-
clusion.
However, for true realization to occur, substitution must
occur in parallel with retention of the actual traumatic mem-
ory. What actually happened and what one wished to hap-
pen must exist simultaneously, so that substitution does not
lead to denial.
The second approach consists of changing narrative and
semantics aspects of the traumatic event. These often involve
reframing the patient ' s own interpretations (e.g., when the
patient blames herself for the abuse she suffered as a child
from her father), exploring different meanings, and cor-
recting cognitive distortions, all of which have been discussed
above.
Whichever the approach, the goal is always to "liquidate
the happening" (Janet, 1919/25, p. 681), i.e., to effect clo-
sure. In an era when the veracity of memories of abuse is
being questioned, and the possibility has been raised of "mem-
ories" being suggested by the therapist, it is prudent to con-
sider carefully in advance the implications of memory sub-
stitution. This technique offers the potential for resolution
and relief. In the highly hypnotizable and suggestible patient,
it can also lead to confusion, and should thus be used with
caution.
Resolution of Existential Crises
Resolution of existential crises identified in the synthe-
sis stage, particularly those associated with a sense of mean-
inglessness, is of prime importance in the process of real-
ization and integration. Chronically reenacted existential
crises often dominate the present reality of the survivor. These
crises are resolved once they, and the associated memories
are integrated into the personality structure. The patient
then accepts that the moment of crisis has past, and chron-
ic responses can be transformed into more adaptive cogni-
tions, affects, and behaviors.
172
DISSOCIATION. Vol. VI. No. 2 3, June Sept. 1993
VAN DER HART/STEELE/BOON/BROWN
First, the patient must accept that she or he has, indeed,
survived. The crisis of death has been continually re-expe-
rienced in the present as suicidality, self-destructive tendencies,
internal alters who kill or threaten to kill other alters, dead
or dying alters, and a sense of foreshortened future. One
patient described the synthesis and realization of the exis-
tential crisis of death as follows:
I couldn't remember for avery long time; I couldn't
bear to remember that I was so close to death so
many times. When I finally got to the point of being
able to remember, something became crystal clear:
I wasn't dead and I wasn't dying anymore. I real-
ized the reason why I was always so suicidal was
because somehow I had to be close to death all the
time. Somehow I got stuck in the very moment I
thought I was going to die. Terror is a very sticky
thing, you know, it sticks you like glue right to the
thing that happens, right to the part you are most
afraid of. Once I got unstuck, I didn't have to be
dying anymore. Now I can focus on living, and I
have a lot of catching up to do.
Psychological annihilation is experienced and associated with
the onslaught of overwhelming and primitive states of hyper-
arousal which have been termed "affective storms." In those
who do not have the capacity to soothe themselves or to
modulate or tolerate affect, the latter can occur with fright-
ening regularity. Severe trauma is often accompanied by a
terrifying loss of all self boundaries: "My body seemed like
it was flying apart, and then my insides shattered into a thou-
sand million pieces, and there was no more `me' anymore."
Although dissociation during trauma is usually considered
a natural defense, the process itself is quite often experi-
enced as intensely dysphoric and terrifying: "I melted into
the wall, and although it hurt and I knew this was the end,
I spread myself so thin I was invisible." "I shrank myself until
it was like a black hole in space, and it sucked me in there
and I was the black hole." "I became no-one and went to
nowhere into a black nothing. "
Once the process of dissociation is more under the sur-
vivor's central control, these dysphoric and annihilatory expe-
riences gradually cease. The work on the central self, begun
early in treatment, and continued throughout, should by
now have contributed significantly to the patient's capacity
to tolerate affectswithoutbeing overwhelmed by them. There
is a growing realization that feelings need not be life-threat-
ening events. Through synthesis, dissociative re-enactment
of annihilation in the trauma ceases. The survivor comes to
understand that there are experiences that none of us can
tolerate. Having tolerated these in the past by dissociating,
nonetheless, she or he gradually learns how to achieve dis-
tance from them in the present without splitting or disin-
tegration of the personality.
The experience of intolerable physical and emotional
pain is the basis of further existential crises which impede
healing. Repetitive intrusion of overwhelming affect and sen-
sation related to the abuse convinces the patient that she or
he cannot tolerate living. The fear is not one of dying, but
rather of living with such intolerable pain. This process under-
lies much of the suicidal ideation of survivors, since death
can be seen as leading to relief from pain.
Severe pain is thus a devastating and fragmenting expe-
rience (Starry, 1985). It destroys the self, eradicates the inter-
nal locus of control, and dismantles one's world view.
Emotional self-care functions do not develop adequately in
many childhood abuse victims. As they are unable to toler-
ate or regulate affect or the hyperaroused state generated
by pain, they therefore continue to be overwhelmed by it.
Tolerance for pain varies, and survivors with low threshholds
readily enter states of overwhelming hyper-arousal. Once
dissociated affects and sensations are integrated, significant
relief is obtained, and alters who contained the pain begin
to heal.
Grief is an important part of the emotional pain which
must be worked through. With the passage of time, episodes
of grief gradually decrease in intensity and duration. Survivors
come to understand and accept that loss is an inevitable part
of trauma, and that it is ultimately a lifelong task to assimi-
late the ebb and flow of re-experienced griefwith equanimity.
AssigningMeaning and Processing Information
Once the survivor has accepted that she or he will nei-
ther die nor be annihilated, and has successfully resolved
the pain, the difficult task of reconstructing meaning con-
tinues. A sense of meaninglessness accompanies the obses-
sive "approach-avoidance" process involved in attempting
to realize what has happened: `This is real" versus "I made
it up"; "This is real" versus "It didn't happen to me."As real-
ization proceeds, the survivor is helped to make sense out
of what has been senseless. Herman (1992) wrote eloquently
about the struggle to assign meaning to the trauma:
[The survivor] stands mute before the emptiness
of evil, feeling the insufficiency of any known sys-
tems of explanation. Survivors of atrocity of every
age and every culture come to a point in their tes-
timony where all questions are reduced to one, spo-
ken more in bewilderment than in outrage: Why?
The answer is beyond human understanding.
(p.178)
Assigning meaning is a basic need underpinning the expres-
sion of all cognitions and affects. Intrapsychic meaning pro-
vides the frame for organizing self concepts, and ultimate-
ly all cognitive schema (Frankl, 1963; Janoff-Bulman, 1992;
Ulman & Brothers, 1988; Yalom, 1980). Trauma not only
shatters existing meaning, but also impedes provision of new
meaning to the trauma itself. The extent to which cognitive
transformation is required depends upon the severity and
chronicity of the trauma. Single trauma mainly requires a
focus on integration of the traumatic memories, while pro-
longed and repeated trauma may require transformation of
the entire existing framework of thought. Thus, for those
individuals who experience chronic trauma in childhood,
early meaning structures and cognitive schema are faulty,
173
DISSOCIATION. Vol. CI, No. 2 lime Sql. 19 1
 P I IJ FrrtIL Ttl
and completely new ones must be constructed. This is an
arduous and time-consuming process, but the trauma can-
not be integrated without such reconstruction.
The processing of traumatic memories has been described
in terms of relief of dissociation, realization, synthesis and
integration. In Janet's words, it is a process aimed at "a con-
ciliation between two terms, between on the one hand the
narrative of the trauma, and on the other the personality of
the subject " (Janet, 1935, p. 357). Integration of traumatic
memories into existing frameworks of thought, as for exam-
ple in single trauma, was called "transformation of the first
term" by Janet, and "assimilation " by Piaget and his follow-
ers (Janoff-Bulman, 1992; Kleber & Brom, 1992. The much
more radical reconstruction of existing frameworks of
thought required in conditions characterized by chronic trau-
ma, such as in MPD, was described as "transformation of the
second term" by Janet, and "accommodation " by Piaget.
Such frameworks of thought were first called "cognitive
schema" by Sir Henry Head in 1920. The concept was elab-
orated by Bartlett (1932), and taken up by those research-
ing traumatic neuroses in the 1970's (e.g., Horowitz,
1976/1986) . Mandler (1979) stated that "a schema is formed
on the basis of past experience with objects, scenes, or events
and consists of a set of (usually unconscious) expectations
about what things look like and/or the order in which they
occur" (p. 263). Consistent with Janet's two forms of con-
ciliation, Hollon and Garber (1988) stated that schema-dis-
crepant information such as trauma maybe assimilated into
existing schema ("That never happened," "I caused it to hap-
pen") or schema may be altered to accommodate the new
information ("There is no safe place in the world." "This
happened because people chose to hurt me; it wasn't my
fault.").
Schema formed following trauma tend to be narrow and
fixed, and tend to "determine to what extent new informa-
tion is absorbed and processed" (van der Kolk & van der
Hart, 1991, p. 440). Frequently the survivor misinterprets
the meaning of current experiences as being dangerous and
hostile (the meaning given to the interaction in the trau-
ma). Survivors often speak of the helplessness and hope-
lessness they feel as they perceive a "random and chaotic"
world, where nothing is predictable or safe. In addition, many
struggle with issues of spirituality, rejecting their faith, and
questioning "Why would God allow this to happen?" The
concept of God inevitably acquires a negative connotation
as well as a negative transference: that of the sadistic abus-
er, or of the passive non-offending parent who knew but did
not protect.
Thus, without ontological, psychological, or spiritual mean-
ing structures that offer safety, hope, control, trust, and esteem,
the survivor lives in a seemingly random, chaotic, and cruel
inner and outer world. This continuing traumatic experi-
ence sets up vicious cycles that perpetuate the dissociative
and related defenses, and which ultimately prevent the indi-
vidual from resolving the trauma and from moving toward
health. During the realization/integration stage of treatment,
new meaning structures are therefore developed, and an
internal locus of control is gradually restored. The world
then gradually becomes a less hostile and formidable place.
Once new meaning, cognitions and expectations have
been established, the possibility of improving relationships
with others becomes more plausible; in the words of Lifton
(1988), "The survivor seeks vitality both in immediate rela-
tionships and ultimate meaning, the one impossible with-
out the other " (p. 26).
Survivors with severe PTSD and dissociative disorders
depend on dissociation and denial to maintain the pre-trau-
matic identity and intact related basic assumptions: "That
never happened" (temporal dissociation, or amnesia), or
"It happened to that other little girl" (parallel dissociation,
and the development of alters). The victim identity, denied
as it is of selfhood, is intolerable, and the survivor goes to
great lengths to develop any other identity: "Nothing real-
ly happened; I just made it up because I am crazy... because
I am bad... because I am evil." By way of contrast, some sur-
vivors tenaciously cling to the victim identity, since the trau-
ma overshadows or even destroys any other: they simply become
what happened to them.
Survivors are also unable to develop a post-trauma iden-
tity because of fragmentation and lack of realization. They
have a peculiar and frightening sense that they are not "whole "
or " real " (cf. Putnam, 1990). Those with MPD have many
identities conflicting with one another. The vicissitudes of
multiple identities in one body have been amply documented
in both the professional and the popular literature. Survivors
express the terror of experiencing a complete lack of iden-
tity or sense of self: "I don't know who I am until somebody
asks me to do something " ; "Maybe, after all these parts inte-
grate I won't be anybody; maybe there isn't a `real me' in
here; maybe I'm just empty and nothing." For the dissocia-
tive patient, realization of the self must coincide with real-
ization of the trauma.
As the intrapsychic structure of survivors is stabilized
and reinforced throughout treatment, they will begin to feel
more confident of selfhood. Many express feelings that they
deserve to exist or even to live for the first time. A core sense
of shame dissolves, as the therapist provides a positive iden-
tification for the patient in the context of the therapeutic
alliance. Survivors are urged to conclude that they have a
right to a selfhood, and can begin building on that foun-
dation.
Realization as a Social ActThe existential crisis of isolation is experienced at the
moment when the patient realizes that she or he was com-
pletely alone in experiencing the trauma, and that there
were often no consistent supportive figures in their child-
hood. This isolation is re-enacted in the immense struggles
to find and maintain connection with the self and with oth-
ers_ It is frequently associated with failures and narcissistic
wounding; the constant sense of abandonment and terrify-
ing aloneness; the utter certainty and shame associated with
the feeling that one is ultimately unworthy to be loved (e.g.,
"If you really knew me, you would be disgusted") , and final-
ly,with the keeping of the secrets, not only from others, but
from oneself (Schultz, 1990) . Chronic dissociation and deper-
174
DISSOCIATION, Vol. 17, No. 23. tine 'Sqit. 1993
VAN DER HART/STEELE/BOON/BROWN
sonalization leave the individual unable to feel sufficiently
connected in the present. Disrupted internal object rela-
tions preclude mutually satisfying and interdependent exter-
nal relationships.
Realization is not only an intrapsychic process, it is also
a social act. Janet (1935) described realization as a way of
unifying the total life experience, of linking the past with
the present and future. With regard to traumatic memories,
this requires an ability to tell the story, not only to one's self,
but also to others. Furthermore, testimony must not only be
given, it must also be heard.
This leads to consideration of social processes that actu-
ally promote non-realization and continued isolation of the
traumatized individual: collective denial. Realization is usu-
ally associated with social expectations. Thus, in the case of
loss of a family member, those around us, as well as society
at large, expect us to realize this loss and to take it into accoun t
in our social actions and in our personal belief systems (Janet,
1937). We are even provided with personal, social, and reli-
gious rituals to assist in realization and integration. However,
in the case of childhood abuse, society, including the men-
tal health field, has been extremely reluctant to acknowl-
edge (realize) either the occurrence or the impact of abuse
(Goodwin, 1985).
There is no social expectation or demand for adults to
realize their highly traumatized childhoods. In fact, there is
often enormous pressure from perpetrators and families to
continue the pattern of dissociation and denial that char-
acterizes collective non-realization (cf. Herman, 1992). The
mental health community merely expects survivors to become
asymptomatic, and if any acknowledgement is given at all,
it is in the form of: "That's all in the past; forget about it and
get over it." Goodwin (1985) formulated this social demand
for non-realization of abuse as follows:
We observe, in interactions with patients with MPD
and abused children and their families, a shared
negative hallucination. (...) The MPD patient and
the physician cling to the series of false symptoms
and false diagnoses in proportion to their mutual
need to blot out the reality of multiplicity, and to
blot out the unbearable experiences of real pain
that triggered it (p. 14).
Realization as a social act may thus be hindered, less by the
individual's reluctance to acknowledge what happened, than
by society ' s inability to accept the truth about abuse. The
survivor remains isolated in a dissociative "no man's land "
between truth and denial. Hopefully, as society becomes
increasingly aware of abuse and its dramatic negative per-
sonal and social consequences, this will change. Until that
time, the therapeutic relationship will be the primary medi-
um through which the survivor can explore the terrifying
abyss of isolation and engage in the social act of realization.
Perhaps for the first time, the survivor can re-experience the
trauma in the presence of an empathic listener, break the
isolation and emerge from the crisis, no longer alone or for-
gotten.
The secure boundaries of the therapeutic relationship,
and the honesty, clarity and consistency of the therapist allow
the patient accept the impossibility of the hoped for "per-
fect" relationship, while sensing that the therapist under-
stands the anguish of this perceived loss. The survivor learns
to negotiate a balance between closeness and distance, to
constructively utilize time spent alone, to remain in touch
with others even when alone, and to understand the impact
of the boundary violations experienced in the trauma. The
therapist aims to enhance the survivor 's ability to discern
and maintain awareness of interpersonal and intrapsychic
boundaries, and the capacity to view self and others as inte-
grated, the "good" with the "bad."
While the therapeutic relationship is a primary healing
force, the therapist must also assist the patient to develop
additional support systems. Partners and other supportive
family members may be engaged in family therapy with the
survivor (Sachs, Frischholz, &Wood, 1988) . This area is often
much neglected in the treatment of survivors. Intensive indi-
vidual therapy can often disrupt the delicate balance of domes-
tic relationships, and this must be attended to, if the sur-
vivor is not to sustain further loss. In many cases, this can be
prevented by early intervention. Partner support groups are
a growing phenomenon as therapists become more aware
of the survivor's current family needs.
The survivor must also find ways of rejoining the com-
munity at large. These may include a survivors support or
therapy group. Survivors often begin by expressing their hopes
and dreams for the future. These may include studies, a job
change, or volunteer work. The therapist should encourage
even the smallest desire of the survivor to be a part of the
"world."
Adult survivors frequently perceive themselves as hav-
ing no choice, no control over, or capacity to direct the course
of their lives. They passively await the next disaster, because
they are convinced they can do nothing about it. For some
survivors the very process of making a choice can lead to
hyperarousal, and they become anxious and unable to decide
(van der Kolk & Greenberg, 1987).
The roots of this loss of control are in childhood
(Summit, 1983) . Children are, by definition, powerless, depen-
dent, and vulnerable. By virtue of developmental limitations,
they are unable to take adequate responsibility for them-
selves or others. Yet, the abused child is often "parentified,"
becoming the caretaker and/or the surrogate "spouse " of a
parent. The child develops an egocentric set of beliefs that
she or he is responsible for the abuse. At the same time, the
abused child exists in an environment of inconsistency, arbi-
trary rules, and unpredictable violence. The child lives in
the throes of continual double binds inwhich responses may
be punished at one time, and rewarded at another (Bateson,
1972; Spiegel, 1986; Fine, 1990, 1991, 1993). She or he is
unable to control or stop the abuse, and usually, other adults
also make no attempt to stop it. The child learns that any
action results in the same outcome as no action: nothing is
effective. This is the genesis of learned helplessness (Seligman,
1975; Garber & Seligman, 1980).
In one case, a woman had not only sustained childhood
175
DISSOCIATION. Vol. VI. No. 2 3. umept. 1993
Y 1 I '1 1 TF - MEMORIES
abuse and severe neglect, but had then married a vicious
sadist. Double binds of forced choice were so great that she
became catatonic at the thought of having to make even the
smallest decisions. In tracing the roots of this extreme response,
it was discovered that her husband had repeatedly forced
her to choose which of their children he would torture, or
which method of torture she would "prefer." He persistently
told her that he would kill her if she tried to leave, as well
as telling her it was her fault that he "had" to hurt her and
the children. This patient was so fragmented and her abili-
ty to make choices so severely incapacitated that she could
not make the simplest decisions, and found elaborate ways
to have others make choices for her. This made her extreme-
ly vulnerable to exploitation, and to further revictimization.
In the course of long and arduous treatment, the patient
one day triumphantly reported that she had been able to
shop for groceries without assistance, the first " choice " she
had been able to make in well over a decade. Although this
is an extreme example, it highlights the survivor's difficul-
ties in learning to be responsible and to successfully make
choices.
In addition to an impaired capacity to choose and act,
the survivor feels a core sense of guilt, shame, and respon-
sibility for the abuse. In the case above, the patient emphat-
ically believed that she had been responsible for both what
had happened to her as a child, and for hurting her chil-
dren. All three children had MPD, and both she and the chil-
dren had well documented medical evidence of the torture.
This led to the belief that she must be punished for her
"sins," and that she had no right to recover or to have a good
life so long as her children continue to suffer. It was only
after a number of years of therapy that she could even begin
to acknowledge and realize her previous helplessness and
lack of choice, and could move gradually toward empower-
ment in the present.
CONCLUSIONS
This paper, and related literature on trauma, presents
the treatment of traumatic memories as a separate step in
the phase-oriented therapy of MPD. In actual practice, it is
important to realize that this specific phase often alternates
several times with other treatment phases. Traumatic mem-
ories frequently present in a layered fashion. A number of
fusions of alter personalities - usually seen at a later phase
in therapy - may have occurred before all traumatic mem-
ories have been processed adequately.
In this regard, the realization and integration of past
traumata should also be seen as an ongoing mental process.
Traumatic events, together with other significant aspects of
the patient's past, are shared with an increasing number of
alter personalities, whose fusions demand further reorga-
nization of the patient's "autobiography" and personality.
Only some time after the last fusion may this reorganization
be considered completed, albeit for the time being. The
more patients succeed in linking their past to the present
and future, the more they are able to live fully independent
lives. Yet, for all of us, integration continues as a lifelong
process.
The psychology of realization and integration of chron-
176
is trauma still remains in its infancy. Much more compre-
hensive work has been done regarding the processing of sin-
gle traumatic events or series of events that occurred in adult-
hood. Much of this work is not directly applicable to MPD
patients, since their defenses have had years to solidify and
become thoroughly incorporated into the personality struc-
ture. This is particularly true of the dissociative defense, which
often becomes the preferred method of coping with even
the smallest of inconveniences. Many MPD patients were never
able to develop what are considered to be basic adaptive
assumptions about themselves and others. Their cognitive
schema and meaning structures are distorted and entrenched,
and there are often no pre-traumatic structures on which to
begin to build a new foundation.
This lends a complexity to the therapeutic work that is
inadequately addressed in the literature on adult trauma.
The realization and integration of a lifetime, or at the very
least, of an entire childhood of trauma is a monumental
task, requiring all the skills of the therapist, the energy and
motivation of the patient, and the strongest therapeutic rap-
port. The work is slow, grueling, and, at times, tediously rep-
etitious, again and again contrasting the old worldview with
the new.
There is still much to learn about this process, and much
in this paper will need investigation and elaboration. This
has been a pioneering effort to clarify current conceptions
about traumatic memories, and to integrate the work of Pierre
Janet with contemporary trauma-based models of therapy.
It provides a sound conceptual framework for the resolu-
tion of traumatic memories in adult survivors of chronic
childhood abuse.
Acknowledgement
The authors thank Barbara Friedman, M.A., M.F.C.C., for
her helpful comments on an earlier draft of this article. 
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