Coping With

Trauma-Related
Dissociation
Skills Training for Patients
and Their Therapists

SUZETTE BOON
KATHY STEELE
ONNO VAN DER HART

W. W. NORTON & COMPANY

New York • London
A NORTON PROFESSIONAL BOOK

This e-book contains some places that ask the reader to fill in questions or
comments. Please keep pen and paper handy as you read this e-book so that you
can complete the exercises within.
To our patients, who have taught us much,
and are the true inspiration for this manual
 CONTENTS

Preface
A Personal Word to Patients
Introduction for Patients

PART ONE
Understanding Dissociation and Trauma-Related
Disorders
1. Understanding Dissociation
2. Symptoms of Dissociation
3. Understanding Dissociative Parts of the Personality
4. Symptoms of Posttraumatic Stress Disorder (PTSD) in
Complex Dissociative Disorders
Part One Skills Review

PART TWO
Initial Skills for Coping With Dissociation
5. Overcoming the Phobia of Inner Experience
6. Learning to Reflect
7. Beginning Work With Dissociative Parts
8. Developing an Inner Sense of Safety
Part Two Skills Review

PART THREE
Improving Daily Life
9. Improving Sleep
10. Establishing a Healthy Daily Structure
11. Free Time and Relaxation
12. Physical Self-Care
13. Developing Healthy Eating Habits
Part Three Skills Review

PART FOUR
Coping With Trauma-Related Triggers and Memories
14. Understanding Traumatic Memories and Triggers
15. Coping With Triggers
16. Planning for Difficult Times
Part Four Skills Review

PART FIVE
Understanding Emotions and Cognitions
17. Understanding Emotions
18. The Window of Tolerance: Learning to Regulate Yourself
19. Understanding Core Beliefs
20. Identifying Cognitive Errors
21. Challenging Dysfunctional Thoughts and Core Beliefs
Part Five Skills Review

PART SIX
Advanced Coping Skills
22. Coping With Anger
23. Coping With Fear
24. Coping With Shame and Guilt
25. Coping With the Needs of Inner Child Parts
26. Coping With Self-Harm
27. Improving Decision Making Through Inner Cooperation
Part Six Skills Review
 PART SEVEN
Improving Relationships With Others
28. The Phobias of Attachment and Attachment Loss
29. Resolving Relational Conflict
30. Coping With Isolation and Loneliness
31. Learning to Be Assertive
32. Setting Healthy Personal Boundaries
Part Seven Skills Review

PART EIGHT
Guide for Group Trainers
33. Guide for Group Trainers
34. Introductory Session
35. Leave-Taking Sessions

Appendices
A. DSM-IV Diagnostic Criteria
B. Ground Rules for a Skills-Training Group
C. Participant Contract for a Skills-Training Group
D. Skills-Training Group Final Evaluation

References
Acknowledgments
Index
 PREFACE

Coping With Trauma-Related Dissociation is the first manual

developed for patients with complex developmental trauma
disorders such as Dissociative Identity Disorder (DID) and
Dissociative Disorder Not Otherwise Specified (DDNOS). The
treatment of complex dissociative disorders has gained increasing
acceptance because these diagnoses have been validated across
numerous populations, and treatment approaches based on expert
clinical consensus have shown consistent and significant promise
(for treatment guidelines, see International Society for the Study of
Trauma and Dissociation [ISSTD], in press). Studies to date,
although methodologically flawed, indicate patients with a
dissociative disorder benefit from treatment that “specifically
focuses on dissociative pathology,” with two thirds showing
improvements in a range of symptoms that include dissociation,
anxiety, depression, general distress, and posttraumatic stress
disorder (PTSD) (Brand, Classen, McNary, & Zaveri, 2009, p.
652). Preliminary efforts to empirically validate these treatments
have shown positive results (Brand, Classen, Lanius, et al., 2009),
and further research is underway.
In the 1990s, skills-training books for traumatized and other
psychotherapy patients began to emerge, but none were specific for
individuals with a complex dissociative disorder. Many focused on
a particular theoretical approach or techniques for problems related
to but not specific for trauma, and thus have become useful
additions to the treatment of traumatized individuals in general.
Some were intended as an adjunct to individual therapy or for
personal use, whereas others were designed for structured group
settings.
These valuable manuals cover a wide range of topics, including
safety, emotional regulation and affect phobia, social anxiety,
addictions, self-harm, depression, anxiety, and relationship issues.
Some of the prominent ones that have been particularly useful for
many trauma survivors include dialectical behavior therapy for
borderline personality (Linehan, 1993); systems training for
emotional predictability and problem solving (STEPPS; Blum et
al., 2008; Bos, Van Wel, Appelo, & Verbraak, 2010 also for
borderline personality; short-term psychodynamic treatment of
affect phobia (McCullough et al., 2003); and mindfulness and
mentalization-based treatments such as acceptance and
commitment therapy (ACT; Follette & Pistorello, 2007).
In the past decade, manuals that specifically address the
treatment of trauma have emerged, a number of them empirically
validated. Several are specific to PSTD, mostly based on cognitive-
behavioral therapy (CBT) and prolonged exposure (for example,
Rothbaum, Foa, & Hembree, 2007; Williams & Poijula, 2002).
Other PTSD manuals have integrated CBT with additional
modalities, including emotion regulation (for example, Ford &
Russo, 2006: trauma adaptive recovery group education and
therapy [TARGET]; Wolfsdorf & Zlotnick, 2001; Zlotnick et al.,
1997); interpersonal and case management for trauma and
addictions (Seeking Safety, Najavits, 2002); and an eclectic
approach Beyond Survival, Vermilyea, 2007). Cloitre, Cohen, and
Koenen (2006) were the first to develop a psychotherapy manual
specifically for complex PTSD in adult survivors of childhood
abuse, based on CBT and attachment-interpersonal-object relations.
In the Netherlands, a stabilization course for complex PTSD,
“Vroeger & Verder” (Dorrepaal, Thomaes, & Draijer, 2008), was
published, adapted from an original manual by C. Zlotnick et al.,
with some additional materials.
Some of these trauma-focused manuals are meant to
specifically address the treatment of traumatic memories, but expert
consensus indicates that patients with a complex dissociative
disorder are at significant risk of being destabilized and may even
decompensate when they are exposed prematurely to traumatic
memories. The vast majority of these patients require a significant
period of stabilization and skills building before they can
successfully tolerate and integrate traumatic memories. In fact, the
general clinical consensus for the treatment of chronically
traumatized individuals, including patients with DID or DDNOS, is
phase-oriented individual outpatient therapy, consisting of the
following: (1) stabilization, symptom reduction, and skills training;
(2) treatment of traumatic memories; and (3) personality integration
and rehabilitation (Boon & Van der Hart, 1991; Brown, Scheflin, &
Hammond, 1998; Chu, 1998; Courtois, 1999; Herman, 1992;
ISSTD, in press; Kluft, 1999; Steele & Van der Hart, 2009; Steele,
Van der Hart, & Nijenhuis, 2001, 2005; Van der Hart, Van der
Kolk, & Boon, 1998; Van der Hart, Nijenhuis, & Steele, 2006).
The treatment guidelines for DID and DDNOS (ISSTD, 2011)
and other publications by experts in the field provide an excellent
overview of treatment approaches (for example, Kluft & Fine,
1993; Kluft, 1999, 2006; Putnam, 1989; 1997; Ross, 1989, 1997;
Steele & Van der Hart, 2009; Van der Hart, Nijenhuis, & Steele,
2006). These publications also provide specific interventions.
Nevertheless, therapists are still left to cull a hodgepodge of
specific Phase I skills-based techniques from the literature and rich
oral traditions of the field of dissociative disorders, leaving any
given treatment at the mercy of the therapist’s creativity and
familiarity with the literature. In this manual, we have attempted to
gather fundamental Phase I stabilization techniques for patients and
their therapists, specifically tailored to address the dissociation that
underlies and maintains many of their symptoms. Some of these
skills include mentalization; mindfulness; emotion and impulse
regulation; inner empathy, communication, and cooperation;
development of inner safety; and cognitive, affective, and relational
skills.
At the heart of the manual is approximately 30 years of clinical
experience that each of the authors has had with patients who have
DID or DDNOS, coupled with the magnificent and foundational
work of many other colleagues who are pioneers in the field. It is
well known that clinical innovations come from clinicians, not
researchers (Westen, Novotny, & Thompson-Brenner, 2004), and
until sufficient randomized controlled studies have been conducted
on treatment of complex dissociative disorders, we are reliant upon
this hard-won clinical wisdom. For the first time, this manual
provides an operationalized treatment protocol that is subject to
empirical validation for this most-in-need population which has
been excluded from other studies on trauma treatments.

Development of the Skills-Training Manual

This manual is partly based on ongoing learning experiences with
outpatient day treatment programs for patients with DID in the past
decade in The Netherlands. These day programs usually ran daily
during the week for a half to a full day, and they included
adjunctive therapies, such as art and movement therapy. This
distinguished them from the more cognitively oriented courses for
borderline personality disorder. The nonverbal, experiential
components of these treatment programs proved to be particularly
destabilizing for many patients with complex dissociative disorders
in the early stages of treatment. These modalities can reactivate
traumatic memories and dissociative parts, which results in
disorganization of the person as a whole, especially when the
phobia of inner experience remains intense. These difficulties led
one of us (S. B.) to develop a manualized course of limited
duration, comparable to skills training such as dialectical behavior
therapy (Linehan, 1993) and STEPPS (Blum et al., 2008; Bos et al.,
2010), but specifically designed for patients with complex
dissociative disorders.
An empirically validated Dutch stabilization course for patients
with complex PTSD, developed by Ethy Dorrepaal, Kathleen
Thomaes, and Nel Draijer (Dorrepaal, Thomaes, & Draijer, 2006,
2008), was the most important published source of inspiration for
Coping With Trauma-Related Dissociation. As part of a research
study, one of the authors (S. B.) conducted in 2005 a group for
complex PTSD patients with an earlier unpublished version of this
Dutch manual, Vroeger en Verder (Dorrepaal, Thomaes, & Draijer,
2006, 2008), and was greatly impressed with the results. However,
patients with a complex dissociative disorder (DID and DDNOS
subtype 1) were excluded, which further galvanized efforts to
produce a manual specific for dissociative disorders. A positive
experience with the Complex PTSD group was the impetus for the
first author (S. B.) to develop a manual for patients with a complex
dissociative disorder.
This manual has a comparable format to, and overlap in some
themes in, Vroeger & Verder (Dorrepaal, Thomaes, & Draijer,
2008) and the STEPPS manual for emotion regulation in borderline
personality disorder (Blum, Pfohl, St. John, & Black, 1992); it also
has some similarities with other trauma-related skills manuals
(Cloitre, Koenen, & Cohen, 2006; Harris, 1998; Najavits, 2001).
What is unique about this manual is that it highlights ways for both
the dissociative patient and the therapist to effectively work with an
underlying dissociative organization of the personality as an
essential part of coping with many of the well-known symptoms of
chronic traumatization.
Over the past 6 years, several expert clinicians, including one of
the authors (S. B.), have used an earlier version of the manual to
conduct skills-training groups in The Netherlands, and more
recently in Norway and Finland, resulting in further suggestions to
improve the manual. Finally, over the past 3 years, the authors have
collaborated intensively to refine and expand the manual. We have
consulted with numerous other colleagues and some patients in an
effort to receive a wide range of feedback and suggestions.
Although the manual was originally developed as a structured
skills-based group treatment, we quickly came to realize that it can
also be an invaluable adjunct to patients in individual therapy and
can serve as a handbook for therapists. Thus, the manual can be
used either for group or for individual purposes. And although this
manual was developed specifically for patients with complex
dissociative disorders, much of the content is also highly relevant
for people with complex PTSD and trauma-related personality
disorders.
Therapists who use the manual as part of individual therapy
with patients should note that chapter 34, Introductory Session, and
chapter 35, Leave-Taking Sessions, are for group use only.
All clinicians and patients should be cautioned that this manual
is in no way a substitute for comprehensive treatment of
dissociative disorders, nor for adequate training and supervision in
the treatment of complex dissociative disorders. We strongly
recommend that anyone using this manual become familiar with the
updated International Society for the Study of Trauma and
Dissociation Treatment Guidelines for DID and DDNOS (ISSTD
Treatment Guidelines, 2011).
For more information on treatment of dissociative disorders,
visit the Web site of the International Society for the Study of
Trauma and Dissociation at http://www.isst-d.org or the Web site
of the European Society for Trauma and Dissociation at
http://www.estd.org.
For more information about Coping with Trauma-Related
Dissociation, the authors, and specialized training for therapists,
visit our Web site at http://www.copingwithdissociation.com.
 A PERSONAL WORD TO PATIENTS

Let’s keep this just between us, but if someone had offered this
book to me a few years ago, I would have run away screaming—if
not on the outside, then certainly inside of me. I admit that this
would not have been the best response given the situation, but hey,
it was not unusual for me at that time to react differently from how
I should have done. Back then, I felt like I was constantly pushing a
wheelbarrow full of frogs down a bumpy, winding road. The frogs
would not stay put; they croaked at the slightest movement and
made the wheelbarrow lean over dangerously whenever I
encountered a bump or a pothole on my way. It often took more
strength than I thought I had to keep this wheelbarrow upright and
to continue down the road.
The worst part, however, was that I didn’t see anyone else
struggling with such a peculiar load. I was ashamed of my
wheelbarrow and did my best to make sure that nobody would
notice it. After all, what could I answer if someone were to ask me
how I came by so many frogs? To be honest, I hardly knew most of
my frogs. I thought of them as green monsters and regarded them
as no more than a burden that I had to bear. I did not even know
how or when some of them had climbed into my wheelbarrow—or
why.
Then one day, when I arrived at the biggest, deepest pothole in
the road, I realized that I could no longer do this alone and that I
needed help from someone else to keep the wheelbarrow upright on
this stretch of the road. It took a lot of courage and a great deal of
trust to dare ask for that help—trust in that other person, but even
more, genuine trust in myself. I needed to believe that I could ask
for such help, that I would not helplessly collapse if someone cast
an eye on my many frogs, and that together we would find a way
past, through, or over the biggest obstacles.
Trust is an important theme in this book. Again and again, you
will read that you and all of your parts must learn to rely on each
other, that it is important to connect with people you can count on,
and that you can be sure of the support of your therapist. Of course,
it is not at all easy to have or to feel such trust. However, that may
be the most important (and most beautiful) lesson you can learn
from this book: that there are people you can trust and that you are
worthy of letting yourself be seen by them.
The authors of this book are such people. When you read what
they have written, you will find that they have your very best
interests at heart. They possess the knowledge, the experience, and
the empathic skills to help you. I know, because I have worked
through each and every topic in this book as part of my own
process. Suzette Boon, Kathy Steele, and Onno van der Hart know
what they are talking about. When I look back on the years I
struggled with the topics they discuss in this book, I can only say
that what they write is true. And, much more important, it helps.
I know my frogs now. If anything, they have turned from green
monsters into dear green friends. They sit still when I want them to
—and if the path becomes somewhat treacherous again at times,
they are very willing to lend a hand and help push my
wheelbarrow. They have considerably diminished in number, by
the way, but that doesn’t even seem important anymore. Together,
the load was a lot easier to carry anyway.
In order to come to this point, I have had to learn many new
skills. All of those skills are included in this book. I did not write
the book, of course. Still, it feels like it’s about me. That is
probably exactly why I would have run away if someone had given
it to me at the beginning of my therapy: It named that which I did
not want to have named and it showed what I preferred never to
look at. As I said above, it was not unusual for me at that time to
react differently from how I should have done. With the wisdom
that comes from hindsight, I would now accept it with both hands.
If this were indeed my book, I would dedicate it to my therapist
—for the way she taught me how to trust her and for the trust she
had in me. However, it is not my book. It belongs to you. And to
your therapist. Now all you need to do is to take a deep breath, turn
over the pages, and get to work. Believe in yourself, believe in all
your parts, and believe in your therapist.
I know you can. I trust in you.
—Jolanda Treffers
 INTRODUCTION FOR PATIENTS

This manual was developed for those of you who are struggling
with complex trauma-related dissociative disorders, that is,
dissociative identity disorder (DID) and dissociative disorder not
otherwise specified (DDNOS, subtype 1). These disorders are often
misunderstood by the public, and publications about treatment have
been written primarily for mental health professionals. There is
little reliable and practical help to be found, other than that which
your therapists have been able to offer. Many of you have spent
years in the mental health system before your core dissociative
problems were recognized and treated. This manual offers you
practical solutions to dissociative problems during the first phase of
your treatment. We explain dissociation and other trauma-related
symptoms in basic language, and we help you understand and work
with dissociative parts of yourself in a rational manner. You will be
introduced to essential ideas and themes useful to your healing
from dissociation and trauma, and you will also learn practical
skills to help you manage in daily life.
We strongly recommend that you use this manual only in the
course of individual therapy or in a structured skills-training group
run by trained clinicians, so that you will make the most of your
experience and will receive adequate support. This manual is not
intended to be used by yourself when you are not in therapy,
although some content may be helpful. The manual may also be
helpful to your loved ones who wish to understand and support you
more effectively.
Each chapter includes an educational topic relevant to trauma
and dissociation, as well as strategies to help you cope more
effectively with your dissociation and other trauma-related
problems. Homework assignments are included for every topic to
help you practice your new skills. If you are using this manual in
your individual therapy rather than participating in a group, you
may ignore the agenda at the beginning of each chapter, as well as
the entire Part 8, chapters 33–35, which are focused on group
participation.
Some topics may not be relevant to you. Nevertheless, you may
find some helpful tips in those chapters, so we encourage you to at
least read about the topics before you decide to skip those chapters.
Some topics may be too overwhelming or premature for you at this
time. That is fine. Just skip those chapters and continue with those
chapters that are right for you.
It is essential that you practice the homework exercises and
modify them to your own needs as necessary. Reading the manual
may be helpful, but it is no substitute for the consistent practice that
earns you new skills. Make sure you collaborate with your therapist
in your work in the manual.
It is essential for you to pace yourself in your work on this
material. At any time you begin to feel overwhelmed, simply stop
and practice grounding exercises and focus on the present moment,
and consult your therapist, if needed. Healing takes time, and
pushing yourself too hard can actually slow your progress. On the
other hand, not pushing yourself at all to overcome avoidance of
painful issues or to practice new skills also slows your healing.
Find your pace, and if needed, ask your therapist to help you know
when to push and when to slow down.
Participation in any of the exercises in this manual is voluntary.
We have attempted to make the exercises appropriate for a wide
range of individuals, but of course, not all exercises may be helpful
or even right for you as an individual. Even though people with a
dissociative disorder have much in common, they also have many
differences. You will receive maximum benefit from the course if
you can practice the exercises as much as possible, but you should
also be aware of what is and is not helpful to you. Feel free to
modify exercises for your benefit, to come up with some of your
own, or to enlist the help of your therapist in additional ways to
practice the various skills in this manual.
Throughout the manual you will often be asked whether you
encountered any difficulties in completing your homework.
Awareness of these obstacles is the first step in overcoming them. It
is essential for you to take any difficulties to your individual
therapist to receive further help and support.
 Coping With
Trauma-Related Dissociation
 PART ONE

Understanding Dissociation and

Trauma-Related Disorders
 CHAPTER ONE

Understanding Dissociation

AGENDA
• Welcome and reflections on the introductory session
• Exercise: Learning to Be Present
• Topic: Understanding Dissociation

Introduction
Learning to Be Present
Understanding Dissociation
The Origins of Chronic Dissociation
Dissociative Disorders

• Homework

Reread the chapter.

Practice the Learning to Be Present exercise twice a
day, morning and evening, or an equivalent exercise
that you and your therapist have agreed is best for you.
Complete Homework Sheet 1.1, Reflections on What
You Have Learned.

Introduction
This manual focuses on helping you understand and cope with
dissociation and the major dissociative disorders, as well as related
experiences and problems. It is important from the beginning that
you pace your work in this manual and also in your therapy
according to what is tolerable for you at a given time. You may find
that focusing on your dissociative symptoms may increase your
anxiety temporarily; however, gaining an understanding of what is
happening within you and learning more effective ways to cope
will soon help you feel more relaxed and comfortable with your
inner experiences. If you become too anxious at any time while
working in this manual, stop for awhile and practice the Learning to
Be Present exercise found later in this chapter or other exercises in
this book that will help you become calmer and more grounded.
You can always return at a later time to finish a chapter. You will
begin by learning more about how to stay present. Once you have
practiced the exercise suggested for being present, you can read
about dissociation in the chapter.

Learning to Be Present
Being in the present, being aware of your surroundings and of
yourself, is essential to learning, growing, and healing from a
dissociative disorder. In the moment you are present, the past is
behind you. Thus, before introducing any other topics, we begin
with an exercise to help you focus on being present, because it is
the foundation for all the work you will do in this manual and in
your therapy, and because we know that when you have a
dissociative disorder it can be a struggle to be present.
People with dissociative disorders encounter a number of
problems that interfere with being present. When you are under
stress or faced with a painful conflict or intense emotion, you may
have a variety of ways to retreat from the present in order to avoid
it. Although retreat may feel better in the moment, in the long run
you will become increasingly avoidant of the present, which can
make your problems worse.
There may be times when you feel spacey, foggy, or fuzzy. You
may lose a firm connection with the present without even being
aware of it, and only realize afterwards that you were not very
present. Perhaps you become engulfed by negative images, feelings
or thoughts from the past, or worries about the future such that you
are so preoccupied in your own mind that you are not aware of the
present. You may have times when you are aware of your actions,
as though you are watching yourself, but do not feel you have
control over them. It may seem as though you are present and not
present at the same time! In addition, some people with complex
dissociative disorders lose time, that is, they cannot account for
what happened during significant periods of time in the present.
And some people may “blank out” for periods and not be aware of
anything. Other people retreat to fantasy or daydreams when life
feels too stressful.
 The following concentration exercise can help you focus your
attention on the here and now. You can begin to learn to stop
yourself from spacing out and eventually to overcome much of
your dissociation by learning to stay present. Remember to gauge
whether the following exercise is helpful to you, and if not, stop or
modify it.

EXERCISE
LEARNING TO BE PRESENT

• Notice three objects that you see in the room and pay close
attention to their details (shape, color, texture, size, etc.).
Make sure you do not hurry through this part of the exercise.
Let your eyes linger over each object. Name three
characteristics of the object out loud to yourself, for example,
“It is blue. It is big. It is round.”
• Notice three sounds that you hear in the present (inside or
outside of the room). Listen to their quality. Are they loud or
soft, constant or intermittent, pleasant or unpleasant? Again,
name three characteristics of the sound out loud to yourself,
for example, “It is loud, grating, and definitely unpleasant.”
• Now touch three objects close to you and describe out loud to
yourself how they feel, for example, rough, smooth, cold,
warm, hard or soft, and so forth.
• Return to the three objects that you have chosen to observe
with your eyes. As you notice them, concentrate on the fact
that you are here and now with these objects in the present, in
this room. Next, notice the sounds and concentrate on the fact
that you are here in this room with those sounds. Finally, do
the same with the objects you have touched. You can expand
this exercise by repeating it several times, three items for
each sense, then two for each, then one, and then build it up
again to three. You can also add new items to keep your
practice fresh.

Examples
• Sight: Look around the room for something (or even
someone) that can help remind you that you are in the
present, for example, a piece of clothing you are wearing that
 you like, a particular color or shape or texture, a picture on
the wall, a small object, a book. Name the object to yourself
out loud.
• Sound: Use the sounds around you to help you really focus
on the here and now. For example, listen to the normal
everyday noises around you: the heat or air conditioning or
refrigerator running, people talking, doors opening or
closing, traffic sounds, birds singing, a fan blowing. You can
remind yourself: “These are the sounds of normal life all
around me. I am safe. I am here.”
• Taste: Carry a small item of food with you that has a pleasant
but intense taste, for example, lozenges, mints, hard candy or
gum, a piece of fruit such as an orange or banana. If you feel
ungrounded, pop it into your mouth and focus on the flavor
and the feel of it in your mouth to help you be more here and
now.
• Smell: Carry something small with you that has a pleasant
smell, for example, a favorite hand lotion, perfume,
aftershave, or an aromatic fruit such as an orange. When you
start to feel spacey or otherwise not very present, a pleasant
smell is a powerful reminder of the present.
• Touch: Try one or more of the following touch exercises that
feels good to you. Touch the chair or sofa on which you are
sitting, or your clothes. Feel them with your fingers and be
very aware of the textures and weight of the fabric. Try
pushing on the floor with your feet, so that you can really feel
the floor supporting you. Squeeze your hands together and let
the pressure and warmth remind you that you are here and
now. Press your tongue hard to the roof of your mouth. Cross
your arms over your chest with your fingertips on your collar
bones and pat your chest, alternating left and right, reminding
yourself that you are in the present and safe (the butterfly
hug, Artigas & Jarero, 2005).
• Breathing: The way in which we breathe is crucial in helping
us to be present. When people dissociate or space out, they
are usually breathing very shallowly and rapidly or hold their
breath too long. Take time to slow and regulate your
breathing. Breathe in through your nose to a slow count of
three, hold to the count of three, and then breathe out through
your mouth to a slow count of three. Do this several times
 while being mindful of how you breathe.

Notice whether there are already ways in which you ground

yourself in the present.

Understanding Dissociation
In the following sections, you will learn about dissociation that
developed from past trauma. This concept is based on years of
careful observations and study (Boon, 1997; Boon & Draijer, 1993;
Van der Hart & Boon, 1997; Van der Hart, Nijenhuis, & Steele,
2006), including historical research into the original 19th-century
literature on the subject and the lessons of the late 20th-century
pioneers in the dissociative disorder literature (for instance, Braun,
1986; Chu, 1998; Horevitz & Loewenstein, 1994; Kluft, 1985;
Kluft & Fine, 1993; Loewenstein, 1991; Michelson & Ray, 1996;
Putnam, 1989, 1997; Ross, 1989, 1997). Dissociation is a word that
is used for many different symptoms, and at times, it is understood
differently by various professionals. We will begin by explaining
integration, which is what you strive for as a major part of your
healing.

Integration
To understand dissociation, it is helpful first to understand a bit
about its opposite, that is, integration. In the context of dissociative
disorders, integration can be understood as the organization of all
the different aspects of personality (including our sense of self) into
a unified whole that functions in a cohesive manner.
Each of us is born with a natural tendency to integrate our
experiences into a coherent, whole life history and a stable sense of
who we are. Our integrative capacity helps us to distinguish the
past from the present and to keep ourselves in the present, even
when we are remembering our past or contemplating our future. It
also helps us develop our sense of self. The more secure and safe
our emotional and physical environment as we grow up, the more
we are able to further develop and strengthen this integrative
capacity.
Each of us develops typical and lasting ways of thinking,
feeling, acting, and perceiving that are collectively called our
personality. Of course, personality is not a “thing” that can be seen,
or that lives and breathes, but rather is a shorthand term that
describes our unique characteristic responses as complex, living
systems. Usually, people function in a coordinated way so that they
make smooth transitions between their response patterns to adjust
and adapt to different situations, like shifting gears in a car. They
can go from home to work and smoothly shift their thinking,
feeling, decision making, and acting, yet still experience
themselves as the same person. In this sense, our personality is
stable and predictable. Yet, to be most effective in our lives, we are
always subtly changing, adjusting, adapting, and reorganizing our
personality as we learn and experience more. In this sense, our
personality is flexible.

Sense of Self
Over the course of our development, we gradually learn to connect
our life experiences across time and situations with our sense of
self. We can then have a fairly clear perception of who we are, and
we can place these experiences in our “life history” as an integral
part of our autobiography. Each of us has a sense of self that is part
of our personality and that should be consistent across our
development and across different circumstances: “I am me, I am
myself as a child, as an adolescent, as an adult, as a parent, as a
worker. I am me, myself in good, in difficult, and in overwhelming
circumstances. These circumstances and experiences all belong to
me. My thoughts, behaviors, emotions, sensations, and memories—
no matter how pleasant or unpleasant—all belong to me.”

Dissociation
Dissociation is a major failure of integration that interferes with and
changes our sense of self and our personality. Our integrative
capacity can be chronically impaired if we are traumatized. It can
also be disrupted or limited when we are extremely tired, stressed,
or seriously ill, but in these cases, the disruption is temporary.
Childhood traumatization can profoundly hamper our ability to
integrate our experiences into a coherent and whole life narrative
because the integrative capacity of children is much more limited
than adults and is still developing.
Of course, not all failures in integration result in dissociation.
Integrative failures are on a continuum. Dissociation involves a
kind of parallel owning and disowning of experience: While one
part of you owns an experience, another part of you does not. Thus,
people with dissociative disorders do not feel integrated and instead
feel fragmented because they have memories, thoughts, feelings,
behaviors, and so forth that they experience as uncharacteristic and
foreign, as though these do not belong to themselves. Their
personality is not able to “shift gears” smoothly from one response
pattern to another; rather, their sense of self and enduring patterns
of response change from situation to situation, and they are not very
effective at adopting new ways of coping. They experience more
than one sense of self, and they do not experience these selves as
(completely) belonging to one person.

Dissociative Parts of the Personality

These divided senses of self and response patterns are called
dissociative parts of the personality. It is as though there are not
enough links or mental connections between one sense of self and
another, between one set of responses and another. For example, a
person with a dissociative disorder has the experience that some
painful memories of her childhood are not hers: “I did not have
those bad experiences; I am not that little girl. She is scared, but
that is not my fear. She is helpless, but that is not my helplessness.”
This lack of realization, this experience of “not me” is the essence
of dissociative disorders.
The functions of each dissociative part of personality or self
may range from extremely limited to more elaborate. The latter is
especially true in cases of dissociative identity disorder (DID),
which will be explained in more detail in chapter 3. Dissociation
takes many forms, which we will discuss in the next chapter on
symptoms. Many dissociative symptoms are common in people
with dissociative disorders, but each individual may also have his
or her own unique subjective experience of dissociation.

The Origins of Chronic Dissociation

Dissociation generally develops when an experience is too
threatening or overwhelming at the time for a person to be able to
integrate it fully, especially in the absence of adequate emotional
support. Chronic dissociation among parts of the personality or self
may become a “survival strategy” in those who have experienced
early childhood trauma. To some degree, dissociation allows a
person to try to go on with normal life by continuing to avoid being
overwhelmed by extremely stressful experiences in both the present
and the past. Unfortunately, it also leaves one or more parts of the
person “stuck” in unresolved experiences and another part forever
trying to avoid these unintegrated experiences.
It is important for you to know that in your journey toward
understanding and coping with your dissociation, you do not need
to focus immediately on the painful past. Rather, the first goal is to
make sense of the dissociative aspects of yourself and to learn to
deal more effectively with them so you can feel better in your daily
life. Resolving the past comes after you learn to cope in the present
both with your external and with your inner world.
There are biological, social, and environmental factors that
make people more vulnerable to dissociation. Some people may
have a biological tendency to dissociate or perhaps have organic
problems with their brain that make it more difficult for them to
integrate experience in general. Young children have less ability to
integrate traumatic experiences than adults because their brains are
not yet mature enough to do so. Their sense of self and personality
are not yet very cohesive, and thus they are more prone to
dissociation. And it has long been recognized that those without
sufficient social and emotional support are more vulnerable to
developing chronic trauma-related disorders, especially those who
experience chronic childhood abuse and neglect. Finally, many
families simply lack the skills to deal well with difficult feelings
and topics; thus, they cannot help children who have been
overwhelmed to learn effective emotional coping skills. Such skills
are needed to overcome dissociation and resolve traumatic
experiences. It is these skills, among others, that you will learn in
this manual.

Dissociative Disorders
When people dissociate chronically in ways that disrupt their lives,
they may be diagnosed with a dissociative disorder. There are
several dissociative disorders, and it is important to know that these
classifications cannot completely describe any individual; in fact,
we are still learning about dissociation. There is general agreement,
however, that the major complex dissociative disorders typically
develop in childhood, and that they are the result of disruptions in
the integration of the child’s personality and sense of self, the
effects of which continue on into adulthood.
At present, there are two classifications of diagnoses, and they
differ to some degree from each other. One is the Diagnostic and
Statistical Manual of Mental Disorders (DSM), which is currently
in its fourth edition (American Psychiatric Association [APA],
1994), with the fifth in progress at the time of publication of this
manual. Each new edition includes changes to the criteria for
mental diagnoses based on further research and other developments
in the mental health field. The DSM is the major classification
system that is used in the United States and many other countries.
The other classification system is published by the World Health
Organization (WHO) and is known as the International
Classification of Diseases (ICD). Some European and other
countries primarily use the current 10th edition of the ICD (WHO,
1992). If we consider a continuum of trauma-related disorders, with
post​traumatic stress disorder (PTSD) being the most basic, and
developing in the aftermath of a traumatizing incident at any age,
then complex dissociative disorders are a more pervasive
developmental accommodation to trauma that originates in
childhood, and they are further along the continuum.
This manual focuses on two particular dissociative disorders:
Disso​ciative Identity Disorder (DID) and another dissociative
disorder that is a kind of catchall category for people who have
milder but similar symptoms of DID, called Dissociative Disorder
Not Otherwise Specified, Type 1b (DDNOS) (see Appendix A).
This latter disorder actually includes the majority of people who
seek treatment for a dissociative disorder. The central difficulty in
both disorders is a dissociation of the personality and self in which
dissociative parts may take control of behavior or experience, or
influence the person’s behavior or experience from within. Of
course, all dissociative parts compose the single personality of the
person as a whole (International Society for the Study of Trauma
and Dissociation [ISSTD], in press; Kluft, 2006; Putnam, 1989;
Ross, 1997; Van der Hart et al., 2006).
You should discuss your diagnosis with your therapist if you
have questions or concerns. Remember, diagnoses are not labels
that make a statement about who you are. Rather, they are just ways
to categorize broad experiences so that your therapist can help you.
Most people with complex dissociative disorders first enter therapy
with other complaints, such as anxiety, panic, depression, eating
and sleeping difficulties, substance abuse, self-harm, suicidal
tendencies, somatic problems, pseudoseizures, and relational
difficulties. If the therapist does not adequately screen for an
underlying dissociative disorder, such a person can spend much
time in treatment without necessarily getting the relief that he or
she needs. Usually these problems or symptoms will resolve when
it becomes clear how they are related to an underlying dissociation
of the personality, because dissociation can maintain these
symptoms until it is addressed.
In this manual we have tried to offer practical help for you to
cope with symptoms of dissociation that trouble you, rather than to
focus on diagnosis. Of course, diagnosis is important, because it
provides a map for you and your therapist to follow so that you get
proper help. But because the diagnostic criteria change from time to
time, and there are even legitimate disagreements about these
criteria, it is probably most helpful for you to focus on what will aid
you in resolving the dissociation that hampers your life, rather than
to worry too much about your diagnosis.
Practice the exercise at the beginning of the chapter: Learning
to be Present. Practice at least twice a day for a few minutes each
time. You might try doing the exercise as soon as you get up and
just before going to bed. You can also do this kind of exercise for a
few moments wherever you are during the day.


Homework Sheet 1.1

Reflections on What You Have Learned
Reflect on what you have read in this chapter about dissociation.

• Notice and write down what may and may not fit your
experience.

• Notice and write down any thoughts, emotions, concerns, fears,

questions, or other experiences that come to your mind.

• Notice if you tend to want to avoid the topic, and if so, how you
avoid.
 CHAPTER TWO

Symptoms of Dissociation

AGENDA
• Welcome and reflections on the previous session
• Exercise: Learning to Be Present
• Topic: Symptoms of Dissociation

Introduction
Problems With Identity or Sense of Self
Experiencing Too Little: Dissociative Symptoms
Involving Apparent Loss of Function
Experiencing Too Much: Dissociative Symptoms
Involving Intrusions
Other Changes in Awareness
Expansion of the Learning to Be Present Exercise:
Finding Your Own Anchors to the Present
• Homework

Reread the chapter.

Complete Homework Sheet 2.1, Recognizing
Dissociative Symptoms.
Continue to practice the Learning to Be Present
exercise twice a day, morning and evening (see
chapter 1).
Complete Homework Sheet 2.2, List of Safe Anchors
to the Present.

Introduction
Dissociation involves a wide array of symptoms, from mild to
severe, from temporary to chronic. For those with dissociative
disorders, symptoms are generally chronic and interfere with daily
life, at least to a degree. Some dissociative symptoms are not only
found in dissociative disorders but also in other psychiatric
disorders. Among professionals there is an ongoing discussion
about which symptoms should be considered dissociative, and
which may be other, more common, symptoms related to changes
in awareness and consciousness that everyone experiences to some
degree. In this and the following chapter, we will describe the most
important symptoms of dissociation.

Problems With Identity or Sense of Self

The majority of people with a dissociative disorder do not come to
therapy with complaints about their identity or sense of self.
Instead, they seek help for other problems, such as depression,
anxiety, sleep problems, or relationship problems. But they also
experience what seem to be strange and frightening symptoms that
do not make sense, and which often lead them to fear they are
“crazy.” They often have few words to describe these inner
experiences and may not share them unless asked because they are
ashamed. In fact, these symptoms are usually related to the
disowned actions of other parts of the personality or self. Once
people understand their dissociative symptoms, they usually begin
to feel more comfortable.
One of the major symptoms of dissociation is a sense of
involuntariness, that is, a person is aware of thoughts, feelings,
behaviors, memories, and events, and so forth, but these
experiences do not seem to belong to him or her. These experiences
have a quality of “not me.” Some people have a sense of being
“more than one person” or of having different “voices” or
identities, some of which may have their own name, age, and other
characteristics that are different from the person’s experience of his
or her own identity.
Each dissociative part of the personality has the potential to
develop a relatively individual view of self, others, and the world,
often with diverse thoughts, predictions, feelings and behavior from
other parts, even if very limited. As a result, individuals with a
dissociative disorder can be very confused about who they really
are, what they think, feel, do, wish, or experience in their body.
Dissociative parts of the personality are not actually separate
identities or personalities in one body, but rather parts of a single
individual that are not yet functioning together in a smooth,
coordinated, and flexible way. In the next chapter we will describe
dissociative parts of the personality in more detail.
The inner division of the personality can manifest in a range of
symptoms that can be described in terms of experiencing “too
little” or “too much.”

Experiencing Too Little: Dissociative Symptoms

Involving Apparent Loss of Functions
Some dissociative symptoms involve apparent loss of certain
functions or experiences that, in principle, you should be able to
own. Thus, you experience “too little.” For example, you may have
amnesia, the loss of (“too little”) memory for important events or
segments of your life. Or perhaps you may suddenly seem to lose a
skill or knowledge that otherwise is a natural part of your life, such
as being able to drive or manage money. Commonly, people who
dissociate report that they suddenly are unable to feel an emotion or
sensation in their body: They become emotionally or physically
numb. These losses are not permanent or due to medical conditions,
such as dementia or neurological problems. They are due to the
activity of other parts of the personality that are rather separate
from you.
These losses are only “apparent” because the function or
experience that tends not to be available to you may actually be
available to another part of yourself. For example, although you
may not remember being afraid as a child, another part feels fear or
terror whenever certain reminders of childhood events are evoked.
You can see from this example that while you may experience too
little (emotional numbness), another part of you may be
experiencing too much, for example, overwhelming feelings. We
will discuss symptoms of experiencing “too much” later in the
chapter.

Dissociative Amnesia (Loss of Memory)

Everyone has natural amnesia for most of life prior to the age of 3
years because of immaturity of the brain, and people may not recall
too much about the years before school. Of course, no one
remembers everything that has happened to him or her, and
everyone has a degree of normal forgetfulness and memory
distortion. But generally people should have a fairly consistent
recollection of their lives and the major events in their lives by the
time they start elementary school, enough to be able to tell a
flowing narrative about themselves.
Amnesia goes far beyond normal forgetfulness. It involves
serious memory problems that are not caused by illness or extreme
fatigue, by alcohol or other mind-altering substances, or normal
forgetting. Amnesia falls on a continuum. People with a
dissociative disorder may recall some aspects of an event but not
other essential parts of it. In some cases all memory for certain
events is unavailable for conscious recall. Some people with a
dissociative disorder describe their memory as being like “Swiss
cheese holes,” “foggy,” or “full of black holes.” They may suspect
that something happened, or may have even been told by others that
something happened to them, but have no personal recollection of
events and often feel afraid to think about them. People may have
amnesia for longer periods of time during which normal life events
took place, for example, a person may report being unable to
remember anything from the fifth grade, or from ages 9–12.
People may not only have amnesia for the past but also for the
present. This is called “time loss” and is a hallmark symptom of
DIDs. People may find themselves in a place and have no idea how
they got there, or they may report that there are hours or even days
when they do not know what they have been doing. Or they
discover that they have evidently done something (such as
shopping or going to the library) but have no memory of doing so.
They may meet others who recognize them, but have no
recollection of ever meeting the other person. Some people find
that others talk to them about a topic as though there had been some
previous conversations about it, but they do not recall any
conversations, and the topic does not seem familiar.
These symptoms, when they are not due to stressful inattention,
are often related to the fact that one part is engaging in a behavior
of which another part has limited or no awareness. Thus, there are
parts that go shopping or to the library, while other parts are
unaware of these actions, or in more extreme cases, parts that may
have their own friends while other parts have never met these
people. Frequent or prolonged time loss is much more common in
DID than in DDNOS.

Time Distortions
People with a dissociative disorder often have related problems of
time distortion (Van der Hart & Steele, 1997). They experience
time passing by much too slow or fast; perhaps more time has
passed than they thought, or an hour seems like an entire day. Some
parts of the personality are often quite confused about where they
are in space and time, believing they are still in the past.

Alienation or Estrangement From Yourself or Your Body

(Depersonalization)
Many people normally experience temporary forms of
depersonalization when tired or stressed, and it is a common
symptom in many mental disorders. There is some discussion
among professionals about whether some depersonalization
symptoms are dissociative or whether they might be better
categorized as other kinds of changes in awareness (Boon &
Draijer, 1993, 1995; Steele, Dorahy, Van der Hart, & Nijenhuis,
2009; Van der Hart et al., 2006). We describe these other changes
of awareness in the last paragraph of this chapter.
Feeling estranged from yourself often involves dissociative
parts of the personality, for example, one part of you may feel
numb, blank, or foggy, but there may be another part that likely is
overwhelmed. Or you may have the experience of watching
yourself from outside your body, and see another part of yourself
doing things as if you are watching someone else.
Some people with a dissociative disorder are able to know and
recall what has happened in a situation, that is, they do not have
amnesia, but they feel as if it did not really happen to them
personally, as if it was a movie or a dream they were watching. Or
they may know it happened, but they do not realize it happened to
them, as though they were watching it happen to another person. In
this way, they are able to continue to distance themselves from
overwhelming experiences. Disconnection from emotions can make
people feel as if they exist solely “in their head,” as if they are dead
inside, or like they are “wrapped in cotton,” or feel like
“cardboard” or “one dimensional.” It seems as though they are not
really in the present; they feel unreal, like they do not really exist or
have any control over their actions. Some people also report a sense
of being on automatic pilot or like a robot.
When people with a dissociative disorder are alienated from
their body, they may be insensitive to physical pain or lack
sensation in parts of their body. Some people report that they do not
always properly register heat and cold, cannot feel whether they are
hungry or tired, or feel numb in their body. Again, it is typically the
case that other parts of the self do feel the physical pain, the
hunger, or other bodily sensations.
There are many different symptoms of depersonalization, but in
every case it seems to be a way of avoiding or attempting to
regulate overwhelming feelings or experiences. Depersonalization
symptoms may be temporary or chronic.

Alienation or Estrangement From Your Surroundings

(Derealization)
In addition to alienation from yourself, you may also have the
unsettling experience that your surroundings or people around you
seem unreal. For example, your own house may appear to be
unfamiliar, strange, or unreal, as though you are visiting someone
else’s house. Or a person you know well may seem strange and
unfamiliar. The world may feel unreal as though you are in a dream
or a play. Sometimes your surroundings may appear hazy, foggy, or
distant. People’s voices may sound very far away, as if down a long
tunnel, even though they are close, or they seem far away visually
even though they are right next to you. In people with a dissociative
disorder, these symptoms of unfamiliarity or unreality may, at least
some of the time, be related to parts of the personality that are
living in trauma time, that is, they confuse the present with the past
and thus do not experience the present as real or familiar. These
parts may influence your perception of the reality to such an extent
that you can become confused.

Experiencing Too Much: Dissociative Symptoms

Involving Intrusions
Dissociative intrusions are those symptoms that occur when one
dissociative part intrudes into the experience of another. Intrusions
may happen in any arena of experience: memories, thoughts,
feelings, perceptions, ideas, wishes, needs, movements, or
behaviors. That is why so many different symptoms have a
dissociative underpinning.
Possible dissociative intrusions include flashbacks of past
traumatic events; sudden feelings, thoughts, impulses, or behaviors
that come “out of the blue;” unexplained pain or other sensations
that have no known medical cause; a sense of being physically
controlled by someone else or other forces beyond your control;
hearing voices commenting, arguing, criticizing, crying, or
speaking in the background; or other jarring inner experiences that
do not feel like your own. These experiences occur when a
dissociative part of yourself enters your conscious awareness and
you are privy to at least some aspects of what that part of you is
experiencing. Such symptoms may wax and wane, depending on
the circumstances and how much stress you are under.
At least in the beginning of therapy, it is often hard to know
whether a symptom is dissociative, that is, related to a dissociative
part of the personality. It is important for you to take your time in
understanding the origin and meaning of your symptoms. One
difficulty in recognizing dissociation is that people sometimes do
not have words to describe their symptoms. It is important for you
to practice being aware of and describing inner experiences,
whether dissociative or not. This awareness will allow you to make
more sense out of all of your experiences, and it will gradually help
you cope more effectively with your inner experiences. The
homework exercises at the end of the chapter are designed to help
you become more aware of and more able to describe your
dissociative experiences.

Other Changes in Awareness

Dissociation is strongly associated with other changes in awareness
that are common in everyone and are also found in other mental
disorders; thus, they are not unique to dissociative disorders. These
symptoms may be easily produced by fatigue, illness and stress,
and drugs or alcohol, and they are often only temporary. They
include not feeling present; spacing out; being very forgetful and
losing track of time; inability to concentrate or pay attention; being
so absorbed in an activity (for instance, reading a book or watching
a movie) that you do not notice what is going on around you;
daydreaming; imaginative involvement; trance-like behavior,
including “highway hypnosis”–driving so automatically that you do
not recall much of your trip and sometimes miss your exit; time
distortions; and low mental energy.
These symptoms may range from mild to severe, may be merely
an aggravation, or may seriously impair a person’s function, and
they may be more temporary or more chronic (Steele et al., 2009;
Van der Hart et al., 2006). People who have a dissociative disorder
often suffer from many of these changes in awareness to a serious
degree, in addition to symptoms related to dissociative parts of the
personality or self. In fact, each dissociative part may experience
variations of these problems with awareness, and the intrusion or
interference of dissociative parts may also result in some changes in
awareness.

EXPANSION OF THE LEARNING TO BE PRESENT

EXERCISE:
FINDING YOUR OWN ANCHORS TO THE PRESENT
You can expand the exercise from chapter 1, to be present in the here and
now, and tailor it to your specific needs. Practice this exercise in your own
home, finding anchors to the present in each room. Always begin this
exercise when you are rested, preferably during the day, as light helps you
stay more present. In fact, all new exercises should be practiced at times when
you are at your best, because this is when you are most able to learn from
them. Once you become more practiced, it will be easier to employ them
when you are stressed.

Walk around your home and in each room concentrate on

the various things you can see, the sounds you hear, the smells
you can smell, the things you might taste in the kitchen, the
things you can touch or hold. What is important is that you find
things that are neutral or pleasing to experience, that is, to see,
hear, touch, and that connect you to the present. For example,
look at a picture or poster on the wall, listen to music that you
like, taste something pleasant from the kitchen, and so on. For
each room, choose three things you can see, hear, feel, or
touch. Consider whether you might want to make a written list
of these anchors to have available when you need them,
because people often forget to use their anchors when they are
under stress. You may even ask someone to record a list of
these things for you on audiotape, so you can listen to them
when you feel stressed. The point is for you to concentrate on
objects that help you to realize that you are in the present, and
for you to have these available when you need to ground and
orient yourself in the present in your home. Thus, every room of
your home should now have anchors, familiar places or objects
that ground you and remind you to be present. When you are
 having a hard time, use these anchors repeatedly to help keep
you, and all parts of you, in the safe present.
You might even want to buy a little something for yourself
that reminds you of being in the present and give it a special
place in your home, for example, a photo, a stone, a statue,
anything that may help you or parts inside to connect to the
present. Every time you look at it or pick it up, you remind
yourself that this object is from the present and you are here
and now with it. Some parts of your personality may find
different items more important or helpful for grounding than you
do. And some may not like something you choose. For
example, some parts who experience themselves as younger
may want to have something that adult parts may believe is
childish. Yet it is often these young parts that have the most
trouble staying present and need help in doing so. Try to be
inclusive and respectful, so that all parts of yourself get what
you need to feel safe and comfortable.

Note: As you search for anchors to the present in your home, you
may come across items that remind you of painful experiences in
the past. For the time being, put these away if you are able. You
can find specific suggestions about how to avoid or reduce these
traumatic reminders in chapter 15. Some objects may trigger
painful experiences for one part of you, but not for another; thus, it
is important to take into account the needs and feelings of all parts
as best you can when deciding whether to remove or avoid certain
items.


Homework Sheet 2.1

Recognizing Dissociative Symptoms

1. What was it like for you to read about dissociative symptoms?

a. Describe your thoughts, emotions, and/or physical sensations

as you read about the symptoms. For example, did you feel
relief, confusion, fear, shame?

b. Describe whether and how some of these symptoms may fit

your experience.

2. Circle any two dissociative symptoms that you may have noticed
in the past week:

Sense of fragmentation or division of self or personality

(may include some awareness of dissociative parts)
Amnesia in the present
Alienation from yourself or your body
Alienation from your surroundings
Experiencing too little: loss of functions
Experiencing too much: intrusions
Other changes in awareness

3. Describe your experience of each of these two symptoms and

how they affected your functioning at the time.

4. What have you done in the past that has helped you deal with
these dissociative experiences?

5. What dissociative symptoms would you most like help with?



Homework Sheet 2.2

List of Safe Anchors to the Present
Reread the instructions for finding anchors in your home.

1. Make a list below of anchors in each room of your home (for

example, bedroom, bathroom, living room, and kitchen). Notice
your experience when you think of these anchors.

2. Make a list of anchors in other places where it is important for

you to stay present, for example, in the car, in your therapist’s
office, or at work or school.
 CHAPTER THREE

Understanding Dissociative Parts of

the Personality

AGENDA
• Welcome and reflections on previous session
• Discussion of homework
• Topic: Understanding Dissociative Parts of the Personality

Introduction
The Inner World of the Dissociative Individual
The Meaning and Functions of Specific Types of Parts
of the Personality
• Review of exercise on Developing Personal Anchors
• Homework

Reread the chapter.

Continue to practice the Learning to Be Present
exercise.
Complete your list of anchors.
Complete Homework Sheet 3.1, Identifying
Dissociative Symptoms.
Complete Homework Sheet 3.2, Recognizing
Dissociative Parts of Yourself.

Note: This chapter contains a significant amount of material.

If you are using this manual in a group setting, it may be
helpful to take more than one session to cover the content.

Introduction
People with a complex dissociative disorder have a dissociative
organization of their personality that is comprised of two or more
dissociative parts, each having (at least somewhat) different
responses, feelings, thoughts, perceptions, physical sensations, and
behaviors. The inner world of these individuals involves
interactions among various parts of the personality, whether or not
within conscious awareness. Everyone’s personality, as we noted
before, is a complex dynamic system that, like all systems, involves
continuous actions and reactions, with parts of the system
interfacing for better or worse. Dissociative parts may take control
or influence the person as a whole to a greater or lesser extent. As
we have noted, these parts, no matter how separate they are
experienced, are not other “people” or full “personalities,” but
rather are manifestations of the way in which your single
personality is organized. You are still one person, although we
understand that you may not always feel that way.

The Inner World of the Dissociative Individual

Images of the “Inner World” of Dissociative Parts

Many people with a dissociative disorder (though not all) visualize
an inner space or world in which their parts reside, and they may
also visualize an image of a particular part. They may describe
inner scenes such as hallways with doors, houses with rooms, or
particular scenes in which parts “live,” such as a child huddled in
the corner, or a teenager with stringy hair who looks very angry.
These images are helpful because they can be changed
therapeutically to increase inner safety and communication. For
instance, rooms may have intercoms installed for better
communication, or the image of a warm blanket or stuffed toy
might be added to the picture of a child huddled in the corner to
increase a sense of safety and comfort.

The Basic Functions of Parts of the Personality

Although each person may have some unique features of his or her
dis​sociative parts, there are some typical underlying similarities in
the basic functions of parts. When people have been traumatized,
their personality is generally organized into at least two types of
parts based on functions. The first type of part is focused on dealing
with daily life and avoiding traumatic memories, while the second
type is stuck in past traumatic experiences and focused on defense
against threat (Van der Hart et al., 2006).
 The part(s) of the personality that function in daily life often
comprise the major portion of the personality. Most people with
DDNOS have only a single part that functions in daily life, while
those with DID have more than one. This type of part usually
avoids dealing with or even acknowledging other parts, though it
may be influenced by them in various ways, which we will discuss
below. This part may avoid situations or experiences that might
evoke traumatic memories. Such avoidance originally helps people
cope with daily life while keeping painful (past) experiences at bay.
However, over time, it results in a life that becomes increasingly
limited.
While the part of the personality that copes with daily life is
avoidant, at least one other and usually more than one other part
remain “stuck” in traumatic memories and think, feel, perceive, and
behave as though these events are still happening (at least to a
degree) or are about to happen again. These parts are typically
stuck in repeating behaviors that are protective during threat, even
when they are not appropriate. For example, some parts fight to
protect even when you do not need such protection in the present,
others want to avoid or run away even though you are safe, some
freeze in fear, and others completely collapse. These parts are often
highly emotional, not very rational, limited in their thinking and
perceptions, not oriented to the present time, and are overwhelmed.
They primarily live in trauma-time, that is, they continue to
experience the traumatic past as the present, and hold emotions,
beliefs, sensations, and so forth that are related to traumatic
experiences.

Awareness of Parts for Each Other

Dissociative parts may have varying degrees of awareness for each
other. Some are not aware at all of other parts or are only aware of
a few other parts. One part may be aware of another, but not vice
versa. Some may be aware that other parts exist but do not
understand the meaning of those parts. Even when parts are aware
of each other’s existence, they often are not in agreement about
issues that are important to the person as a whole. One of your
goals in using this manual is to learn to develop skills for reaching
agreements among parts–which is different from forcing other parts
to comply with you or ignoring their needs.
The Influence of Parts on Each Other
Regardless of the degree to which parts are or are not aware of each
other, they do influence each other. Any part may intrude on and
influence the experience of the part that is functioning in daily life
without taking full control of functioning, an experience referred to
as passive influence (Kluft, 1987) or partial intrusion (Dell, 2002).
In the previous chapter we discussed briefly some of these intrusion
symptoms. You can be influenced by other parts in your thoughts,
feelings, body sensations, perceptions, urges, or behaviors. For
example, while in a store, people with a dissociative disorder may
hear an inner voice that says, “Get out, get out, it’s not safe in here!
You have to go home!” even though they know that nothing is
wrong. This is more than a wish, but rather a desperate inner voice
that comes from another part of the personality that may be
visualized as a terrified young child. Perhaps such individuals
might also hear or sense other inner voices that tell the child part to
shut up or that complain about how stupid they are to go shopping
because they do not need anything.
Such people may then feel confused, ashamed, and afraid of
what is happening inside themselves and might feel a sense of
impending doom, as though something terrible is about to happen.
And all the while, they remain aware that they are simply in a store
where everyone else is going about their business quite normally.
In addition, they may hear or sense interactions among several
inner parts so they feel like a bystander to a conversation or
argument in which they are not included.
These intrusions have a different quality than the normal
distress some people without a dissociative disorder may
experience in a crowded store (“This store is crowded and I am
eager to finish and leave”). Instead, it is as though a person with a
dissociative disorder has (at least) two completely different minds
that do not understand each other or are conversing about
completely different topics. These intrusions may seem so bizarre
or alien that you might have worried that you are insane, but this is
not the case. Even though you may not fully understand yet, other
parts of you have their own agendas, their own perceptions,
thoughts, feelings, wishes, needs, and so forth for good reasons.
Your challenge is to learn about and accept them without judgment,
even if you do not agree with them. Only from that point of
understanding can you make changes that support all parts in
working together more smoothly.

Executive Control
In some cases, especially in DID, one dissociative part may take
full control of your behavior in the world. The process of one part
taking over from another, often an involuntary event, is called
switching. If you experience switching, you may lose time when
another part of you is in control. Or perhaps you are aware of what
is happening, but it is as though you are watching and have no
control over your behavior. For example, one person lost time
whenever she was in a crowded store. She “came to” in her car with
all her groceries but could not remember buying them. Another
person experienced watching herself in the store as though she were
walking behind herself or seeing herself from above, outside her
body, wondering why she was being so slow in shopping. She
reported being back in her body once she returned to her car.
Most dissociative parts influence your experience from the
inside rather than exert complete control, that is, through passive
influence. In fact, many parts never take complete control of a
person, but are only experienced internally. Frequent switching
may be a sign of severe stress and inner conflict in most
individuals. However, for some patients with DID, switching in
daily life is common.

Elaboration and Autonomy of Parts

Parts of the personality may have a very wide range of elaboration
of their characteristics, and autonomy, that is, a sense of being
separate from other parts (Kluft, 1999, 2006; Putnam, 1997; Ross,
1997; Van der Hart et al., 2006). Some may have their own names,
ages, sex, and preferences, but not all of them. But each part does,
at the least, have a set of relatively limited memories, perceptions,
thoughts, emotions, and behaviors. A few parts may become quite
elaborated, with a much wider range of actions, skills, and more
complex sense of self, particularly in individuals with DID. For
example, a part may be active at work and also in social situations,
requiring very complex emotions, thoughts, behaviors, and sense of
self, while another part may only cry without words and feel afraid.
This latter part has a very limited repertoire of experiences,
behaviors, emotion, thoughts, and perceptions. Of course, most
people with dissociative disorders have a single main part of the
personality that is quite separate and complex, and which functions
in the world. As a general rule, the more parts, that is, the more
fragmented the personality, the more rigid and limited is the
experience of many (not all) such parts. The more active a part, the
more interactions with other people and with other parts, the more
this part may extend its own life history and activities. Parts also
vary in their degree of autonomy, that is, the degree to which they
are able to act on their own outside the control of other parts,
including gaining full or executive control (Chu, 1998; Kluft, 1999,
2006; Putnam, 1997; Ross, 1997; Van der Hart et al., 2006).

Number of Parts
People sometimes wonder how many parts they may have. The
actual number is not important in itself. It is significant only in that
the greater the fragmentation of the personality, the lower the
person’s integrative capacity tends to be. This usually means that
people who have “more” parts may need to work more in therapy
on increasing their capacity to integrate their experiences.

The Meaning and Functions of Specific Types of

Parts of the Personality
Parts of the personality have their own unique characteristics based
on their functions within the person as a whole. Their
characteristics, such as age, gender, emotional range, beliefs, and
behaviors indicate what still needs to be integrated for the whole
person. For example, a very young child part who calls for her
mother likely holds longings for love and care that the person as a
whole has found overwhelming, shameful, or otherwise
unacceptable. Because parts of the personality are representations,
they may take an infinite variety of forms, limited only by a
person’s experience and creativity. For example, a strong male part
in a female individual protected her when she was vulnerable in a
frightening situation, thus avoiding the realization that she was
actually helpless. Another person described a part as a bird. That
part could eventually be understood as a part that, in her
imagination, tried to fly away and escape when experiences were
overwhelming. Thus, the characteristics of a part are informative
but are not the important focus of therapy, and they should not be
taken literally. It is the meaning and function of what they represent
that is essential for you (and your therapist) to understand.

Parts of the Personality With Functions in Daily Life

As noted earlier, people with DDNOS have one major part of their
personality that functions in daily life, while those with DID have
more than one part active in the world, for example, parts that go to
work or take care of children. In extreme cases of DID, parts that
function in daily life are not aware of each other. More commonly,
there is some awareness, at least for many individuals, but also a
degree of avoidance. And most parts that function in daily life are
phobic of parts stuck in trauma-time.

Parts of the Personality That Hold Traumatizing Experiences

There are several typical types of parts of the personality that are
stuck in trauma-time. These parts are representations of common
conflicts and experiences that tend to be difficult to integrate.
Please note that the following descriptions are general and that the
examples that are given may not fit for you. It is important that you
accept your own inner experience as it is and not try to make it fit
any descriptions in this manual.
Young parts. Most people with a dissociative disorder who
experienced childhood trauma will have parts of the personality
that experience themselves as younger than the person’s actual age:
adolescents, child parts of primary school age, and even toddler or
infant parts. It is as though these parts are stuck in various
developmental time periods of the past. They often hold traumatic
memories, distressing, painful emotions or sensations, but
sometimes also have positive memories. They typically hold
unresolved feelings of longing, loneliness, dependency, and need
for comfort, help, and safety, and also of distrust and fear of
rejection or abandonment. These parts will be discussed more
thoroughly in chapter 25.
Of course, it is completely natural and understandable that
people who have been neglected or abused have these experiences
of need. At the same time it is common for other parts of
themselves to find these normal needs repulsive or dangerous,
because they have had negative past experiences with expressing
what they want or need. Thus, some parts of the personality reject
“needy” parts and have the belief that it is better to have no needs
and to be completely self-reliant. This sets up a typical inner
conflict between parts that need and parts that are fearful or
repulsed by those needs.
Helper parts. Some people with a dissociative disorder, but
certainly not all, have “helper” parts in their inner world that take
care of the well-being of other parts, an inner form of regulation
that can be a resource and basis for learning further self-soothing
skills. Sometimes helping parts are modeled on a kind person from
the past or on an appealing character from a book or movie or
television. These parts are the traumatized child’s attempt to soothe
and comfort himself or herself. For some people, the major part of
the personality who functions in daily life can learn to be quite
empathic and helpful for inner parts as well.
Parts that imitate people who hurt you. Usually there are parts
of the personality that hold anger and rage that are unacceptable or
very frightening to other parts. Some may resemble people from the
past who were abusive. These parts shame, threaten, or punish
other parts inside, or they may direct their anger to other people in
the outside world. Although the behavior of these parts can be quite
frightening or shameful, as well as unacceptable, it is important for
you to understand that these parts have good reason to exist and are
representations, and thus not the same as the people who hurt you.
They originally developed to protect you by containing many
distressful experiences of anger, helplessness, and sometimes guilt
or shame. Furthermore, their function often is to prevent other parts
behaving in a way that, in the past, evoked fear or shame. Over
time it is important to appreciate why they exist, even though their
“methods,” that is, their behavior and attitudes, may not be
acceptable. Your fear and shame about these parts must be
overcome in order for you to heal. These parts, like all parts of
yourself, need to become part of an internal “team” that collaborate
and represent you as the whole person and your own history. And
once they do so, you will be surprised at what tremendous help they
will be to you. These parts are further discussed in chapter 22.
Fight parts. Some angry parts are stuck in a fight defense
against threat. They have the explicit function of protecting the
individual by means of fight responses, either toward other people
or toward parts inside that in some way evoke a sense of threat.
Fight parts often believe that they are strong, have not been hurt,
and are capable of carrying out strong aggressive reactions to
perceived threat or disrespectful behavior. Often they view
themselves as a “tough” child or teenager or a large, strong man.
Ashamed parts. Shame is a major emotion that maintains
dissociation (see chapter 24 on shame). Some parts of the
personality are especially avoided and reviled because they hold
experiences, feelings, or behaviors that you, or some parts of you,
have labeled as shameful or disgusting. You will need to be
especially empathic and accepting toward these parts of yourself.
A central problem for people who have a dissociative disorder
is that parts of the personality avoid each other and their painful
memories and experiences, or they tend to have strong conflicts
with each other. In the literature this has been described as phobia
of dissociative parts (Van der Hart et al., 2006). Parts typically feel
fearful, ashamed, or repulsed by other parts. In particular,
dissociative parts that function in daily life want as little as possible
to do with dissociative parts that are fixed in traumatic experiences.
Parts stuck in trauma-time often feel abandoned and neglected by
the parts that try to move on without them in daily life.
These ongoing inner conflicts can be painful and frightening,
and they cost a person with a dissociative disorder a tremendous
amount of energy. As we said before, all parts need to learn to
accept and cooperate with each other. After all, in order to adapt
and be at our best, we must learn to accept ourselves and all our
aspects. Only in acknowledging and accepting are we able to make
positive changes in ourselves.
However, we are aware that getting to know yourself and
working more cooperatively internally can be a long and difficult
process. You cannot expect yourself to immediately function
differently when parts have spent a lifetime avoiding each other or
being in conflict. Please remember that you will need much
patience and self-acceptance in this work and go at your own pace.
Remember to be empathic and accepting of yourself as a whole
person.
The following exercises that help you to stay in the present can
be useful to the parts stuck in the past, especially finding “anchors”
in the present.


Homework Sheet 3.1

Identifying Dissociative Symptoms

1. Circle two dissociative symptoms that you may have had in the
past week:

Sense of fragmentation or division of self or personality

(may include some awareness of dissociative parts)
Alienation from yourself/not feeling real
Alienation from your surroundings
Experiencing too little/loss of function, for example,
amnesia
Experiencing too much/intrusions

2. Describe your experiences of these symptoms and how they

affected your functioning at the time.

3. What have you done in the past that has helped you deal with
these dissociative experiences?


Homework Sheet 3.2

Recognizing Dissociative Parts of Yourself
There are various ways in which you can notice parts of yourself.
For example, consider the following:

• You have lost time and you discover that something has been
done that only you could have done, yet you have no memory
of it.
• You hear yourself talking, but it seems as though the thoughts
or words you hear are not your “own” and you have no
control over what you say.
• You experience yourself as outside your body, as though you
are looking at someone else.
• You have body sensations that do not feel they belong to you
or that seem to come “out of the blue” and do not fit with
your present situation. Sometimes these sensations are
accompanied by feelings of fear or panic.
• You have thoughts or emotions that you experience as
sudden, not appropriate to the situation, or as not belonging
to you.
• You hear voices in your head that talk to you or to each other.
• You find yourself in a place and have no idea how you got
there.
• You feel your body, your movements, or behaviors are not
within your control.

1. Describe one example of noticing the (inner or external) actions

of another part of yourself. How did you become aware of this
part?

2. Describe what you understand about your own internal

organization of parts. For example, how do parts of yourself seem
to interact, if at all? Which parts do you avoid or are avoided by
other parts of you? What emotions are held in parts of yourself?
Are there parts you feel more comfortable with? Less comfortable?
Do some of your parts communicate with each other?
 CHAPTER FOUR

Symptoms of Posttraumatic Stress

Disorder (PTSD) in Complex
Dissociative Disorders

AGENDA
• Welcome and reflections on previous session
• Homework discussion
• Break
• Topic: Symptoms of PTSD in Complex Dissociative
Disorders

Introduction
What Is PTSD?
What Are the Symptoms of PTSD?
DID and DDNOS as Complex Posttraumatic Stress
Disorders
Optional Reading: Complex PTSD and Dissociation
• Homework

Reread the chapter.

Complete Homework Sheet 4.1, Identifying PTSD
Symptoms.
Complete Homework Sheet 4.2, My Coping Skills for
PTSD Symptoms.
Complete Homework Sheet 4.3, Repeat Practice:
Learning to Identify and Cope With Dissociative Parts
of Yourself.
Practice the Stress Reduction and Healing exercise
from this chapter at least once a day.

Introduction
Trauma-related disorders have extensive overlap in symptoms, so it
is possible for a person to fit several diagnostic categories. This
does not mean more is wrong with you; rather, it speaks to the fact
that descriptions of trauma-related disorders are not very precise
and have a lot of overlap. In this chapter we will discuss some of
the most basic and common symptoms of trauma-related disorders,
those of posttraumatic stress disorder (PTSD). Dissociative
disorders are considered to be more complex forms of PTSD that
arise when traumatizing events affect a child’s normal personality
development, and in fact, many PTSD symptoms involve
dissociation. Thus, it is likely that you have had or currently
experience some symptoms of PTSD. Once you understand these
symptoms, you can work to overcome them with some practical
skills.

What Is PTSD?
PTSD involves a set of symptoms that arise after a traumatizing
event (or many events). These symptom groups include avoidance,
intrusion of traumatic memories, and physiological dysregulation.
These symptoms will be discussed further later on in this chapter.
Posttraumatic stress symptoms develop some time after a
traumatizing event. For example, PTSD is commonly seen in many
victims of war, rape, and natural disasters. People with PTSD often
also experience depression, substance abuse, and physical
complaints. Some professionals have proposed a diagnosis called
Complex PTSD, which is a category that fits somewhere between
PTSD and dissociative disorders (Herman, 1992; Pelcovitz, Van
der Kolk, Roth, Mandel, Kaplan, & Resick, 1997; Van der Hart,
Nijenhuis, & Steele, 2005). If you like, you may read more about
that proposed diagnosis in the optional reading material at the end
of the chapter.

What Are the Symptoms of PTSD?

Basic symptoms of PTSD include three core groupings:

• Intrusions of traumatic experiences (for instance, flashbacks,

nightmares)
• Avoidance, numbing, and detachment
 • Hyperarousal (startle reflex, anxiety, fear, agitation)

Intrusion Symptoms

• Flashbacks, that is, reliving some or all of a traumatizing

event as though it is happening in the present. Flashbacks can
involve images, smells, sounds, taste, emotions, thoughts,
and physical sensations.
• Nightmares of traumatizing events or of similar content
• Hallucinations, delusions, or illusions that are related to
traumatizing events
• Severe, recurring anxiety reactions or panic, with heart
palpitations, rapid breathing, sweating and trembling, and
sense of impending doom
• Feeling paralyzed with fear or wanting to run away

These reactions mainly occur in situations that remind (trigger)

you of a past traumatizing event, or rather some part of yourself
that is “stuck” in that original situation, that is, living in trauma-
time (Van der Hart, Nijenhuis, & Solomon, 2010). Thus, that part
responds to these reminders with the same sense of overwhelming
threat as was the case in the past.

Avoidance Symptoms

• Strong efforts to avoid any thoughts, feelings, or situations

that might evoke traumatic memories, for example, by
focusing too much on work, excessive cleaning, staying too
busy, using drugs or alcohol, or spacing out
• Amnesia, that is, inability to recall some or all of significant
aspects of traumatizing events
• Emotional numbness
• Inability to enjoy life or feel love
• Feeling as though you are on automatic pilot
• Isolation and avoidance of other people
• Reluctance to talk about traumatic experiences

Hyperarousal Symptoms

• Persistent physical symptoms of tension: tenseness, agitation,

 restlessness, impatience, and feeling constantly on the alert
• Jumpiness, easily startled, and hypersensitivity to what is
going on around you
• Irritability, outbursts of anger or rage
• Emotional outbursts
• Serious difficulty falling asleep or frequent waking
• Concentration and attention problems

Our bodies and minds are innately prepared to deal with

emergency threat situations by automatically shutting down certain
activities and enhancing others. For example, digestion is slowed
down, heart rate and breathing increase, blood rushes to the brain
and limbs, and our muscles tense to prepare for running away or
fighting. We shift from a “normal, everyday” state in which we
love, learn, work, and play, to one of high alertness that involves
hypervigilance, fight, flight, and/or freeze. Activity shifts from the
parts of our brain that help us think through complex problems to
the parts of the brain that help us react in life-threatening situations
during which there is probably not enough time to think about
options. These automatic actions can help us survive threat in the
same way that animals of prey use them to survive a predator.
Unfortunately, when dissociation occurs, parts of the personality
can become stuck or fixed in being hyperaroused. When these parts
are activated, you will experience symptoms of hyperarousal.

Hypoarousal Symptoms
Although hypoarousal symptoms are not currently included in the
symptoms of PTSD, there has been increasing awareness and
acceptance of the fact that some people experience a kind of
dissociative shutdown in response to trauma, rather than
hyperarousal (Lanius et al., 2010). In fact, most people with PTSD
alternate between these two physiological conditions, both of which
many experts consider to be dissociative. We humans are very
much like mammals in our reactions to danger. In addition to
hyperarousal, we–like our animal cousins–have a line of defense
that involves hypoarousal. It is an automatic, unconscious
physiological strategy to help ensure survival when there are no
other options available. Heart rate and breathing slow drastically,
muscle tone becomes limp, and our mind and bodies go into a kind
of deep hibernation. We conserve energy by going into this
automatic state of “collapse,” sometimes called “death feigning” in
animals. Opossums do this when they “play dead.”
Symptoms of posttraumatic hypoarousal include the following:

• Emotional numbness
• Physical numbness, inability to feel pain
• Blank mind, unable to think or speak
• Profound detachment
• Inability to move or respond
• Extreme drowsiness and even temporary loss of
consciousness

Just as with hyperarousal, hypoarousal reactions may be due to the

intrusion of a part of the self that is chronically in this physical
condition. Usually these parts are triggered when hyperaroused
parts can no longer be effective or become exhausted.

DID and DDNOS as Complex Posttraumatic Stress

Disorders
DID and DDNOS are considered to be complex trauma-related
disorders on a continuum with PTSD. Thus, most people with a
complex dissociative disorder have a degree of chronic
posttraumatic stress symptoms. Each part of the personality may be
stuck in a particular group of PTSD symptoms. For example, some
parts that are fixated in traumatic memories are chronically
hyperaroused, while others are extremely shut down (hypoaroused).
Some parts, usually those functioning in daily life, are avoidant and
emotionally constricted, or sometimes are irritable and impatient,
depressed, and have nightmares and other intrusive symptoms. The
work you accomplish with this manual will help you develop a
strong foundation for resolving these posttraumatic stress
symptoms.

STRESS REDUCTION AND HEALING EXERCISE

When you have posttraumatic stress symptoms, it is important to learn how to
reduce your stress and feel calmer and more present. The exercise that
follows, or a variation that you create yourself, may be helpful to you.
You will need a stress ball, also sometimes called a squeeze ball—a small
soft ball that fits in the palm of your hand and which you can squeeze. These
are very inexpensive and are readily available in a wide variety of stores or
online. You will also need a small object to hold in your hand that represents
healing and calm for yourself. Perhaps this may be one of your anchoring
items, which you developed earlier, or a rock, a stuffed animal, a book—
whatever you can hold in your hand and that feels right to you.

Find a position that feels comfortable, preferably sitting or

standing, both feet on the floor. If you are standing, place your
feet slightly apart, in line with your shoulders and keep your
knees slightly bent, that is, do not lock your knees. Begin the
exercise by holding a stress ball in your nondominant hand (for
the right-handed person, this is the left hand and vice versa).
Concentrate your attention on your nondominant hand.
Squeeze the ball as hard as possible while you imagine that
you are letting all the tension and unpleasant feelings converge
from all over your body and begin to flow toward your arm,
down your arm, down into you hand, and then flow through your
hand into the ball. You can visualize the ball as working like a
magnet, drawing all the tension towards it, through your
shoulder and your arm, your hand and fingers. Watching the
ball and noticing your squeezing motions may help you stay
focused and present. When the ball is saturated like a sponge
with your tension and unpleasant feelings, you can open your
hand and let go of the ball, allowing all your tension to be held
in the ball, away from you. As soon as you let go of the ball, the
tension leaves it and dissipates into the air, disappearing from
the room. You can practice this exercise several times until you
feel that all negative tension has been released out of your
body. You might remind all parts of yourself that they are also
welcome to use the ball to release their tension, too.
When you feel calmer and less stressed, let go of the ball
one last time and turn your attention to your dominant hand
(that is, the hand that you use most often; for most people, this
will be the right hand), and follow the suggestions below.
Choose an object that you can easily hold in your hand, and
which symbolizes a sense of well-being or healing for you,
perhaps one of your anchors to the present. Hold this object in
your dominant hand. Imagine that this object holds all the well-
being and healing that you need: a sense of safety and
contentment, of peace and calm, of mental and emotional
clarity, free of tension and conflict. Now allow these feelings of
well-being and healing to radiate warmly and gently from the
object through your hand, your arm, your shoulder, all through
your body. Allow it to gently flow through your body, your mind,
and your heart. All parts of you can take in this well-being and
healing in their own way, in a way that works for them. With
each breath in, allow more well-being and healing to flow
through you. With each out breath, let any remaining tension
go.
Whenever you wish to remind yourself of this sense of well-
being, your dominant hand can automatically recall the feeling
of the object, its shape and texture, its temperature and color,
and you can fully experience those positive feelings and
sensations of well-being and healing once again. As you
practice more, your dominant hand can almost automatically
close as though holding the object of your healing, and at any
time you wish or need, you can once again experience that
sense of well-being and healing.


Homework Sheet 4.1

Identifying PTSD Symptoms
Check or underline any PTSD symptoms that you might have
recently experienced. If you are not currently experiencing any
symptoms, circle those you have had in the past.

Intrusion Symptoms

• Flashbacks, that is, reliving some or all of a traumatizing

event as though it is happening now. Flashbacks can involve
images, smells, sounds, taste, emotions, thoughts, and
physical sensations.
• Nightmares
• Hallucinations, delusions, or illusions that derive from
traumatizing events
• Severe, recurring anxiety reactions or panic
• Feeling paralyzed with fear or wanting to run away

Avoidance Symptoms

• Strong efforts to avoid any thoughts, feelings, or situations

that might evoke traumatic memories, for example, by
focusing too much on work, excessive cleaning, staying very
busy, using drugs or alcohol
• Amnesia, that is, inability to recall some or all of significant
aspects of traumatizing events
• Emotional numbness
• Inability to enjoy life or to feel love
• Feeling as though you are on automatic pilot
• Isolation
• Unwillingness to talk about your experience, shutting
yourself off from others

Hyperarousal Symptoms

• Persistent physical symptoms of tension: tenseness, agitation,

restlessness, lack of patience, and feeling constantly on the
 alert
• Jumpiness, easily startled, and hypersensitivity to what is
going on around you
• Irritability, episodes of rage or crying
• Difficulty falling asleep or frequent waking
• Concentration and attention problems

Hypoarousal Symptoms

• Physical numbness, inability to feel pain

• Blank mind, unable to think or speak
• Profound detachment
• Inability to move or respond
• Extreme drowsiness and even temporary loss of
consciousness


Homework Sheet 4.2

My Coping Skills for PTSD Symptoms
You have probably been living with trauma-related symptoms for a
large part of your life, and you have likely already discovered
certain things that can be of help. For example, perhaps you call a
friend, write or use art, take a walk, go shopping, meditate, or
exercise. Make a list some of the helpful ways you have learned to
cope with these symptoms. You can add more strategies as you
learn them over time.

1.

2.

3.

4.

5.


Homework Sheet 4.3

Repeat Practice: Learning to Identify and Cope With
Dissociative Parts of Yourself
This homework sheet is meant to help you practice more of what
you learned in chapters 2 and 3.

1. Describe an experience of noticing a part of your personality

(this may be some inner experience, such as hearing a voice, or a
situation in which another part was active in the world).

2. What was your reaction to this part of you? (For example, what
did you think, feel, sense, or do?)

3. What might help you become more accepting of this part? (For
example, you might try understanding why this part of you feels a
certain way, or know that you can get help in working with this part
from your therapist.)

Optional Reading: Complex PTSD and Dissociation

Some clinicians who work extensively with PTSD have found that
many trauma survivors who experienced chronic interpersonal
traumatization tend to have more problems and symptoms than
those who only have PTSD and who have experienced a single
trauma. They thus proposed a new diagnostic category, sometimes
referred to Complex PTSD or disorders of extreme stress, not
otherwise specified (DESNOS; Herman, 1992; Pelcovitz et al.,
1997). This diagnosis is not yet included in the DSM or ICD.
People with complex dissociative disorders typically suffer from at
least some of the symptoms of Complex PTSD described in the
next section. As noted earlier, this proposed diagnosis falls
somewhere in the middle of a continuum of trauma-related
disorders, between PTSD and the currently recognized dissociative
disorders in DSM-IV. For those with a dissociative disorder, various
parts of the personality may have these symptoms, and they may be
experienced by you, the person as a whole.

Symptoms of Complex PTSD

Complex PTSD consists of six symptom clusters, which also have
been described in terms of dissociation of the personality (Van der
Hart et al., 2005). Of course, people who receive this diagnosis
often also suffer from other problems as well and diagnostic
categories may overlap significantly (Dorrepaal et al., 2008). The
symptom clusters are described next.

Alterations in Regulation of Affect (Emotion) and Impulses

Almost all people who are seriously traumatized have problems in
tolerating and regulating their emotions and urges or impulses.
However, those with Complex PTSD and dissociative disorders
tend to have more difficulties than those with PTSD because
disruptions in their early development have inhibited their ability to
regulate themselves. The fact that you have a dissociative
organization of your personality makes you highly vulnerable to
rapid and unexpected changes in emotions and sudden impulses.
Various parts of the personality intrude on each other either through
passive influence or switching (see chapter 3) when you are under
stress, resulting in dysregulation. Merely having an emotion, such
as anger, may evoke other parts of you to feel fear or shame, and to
engage in impulsive behaviors to stop or avoid the feelings.

Changes in Attention and Consciousness

People with Complex PTSD suffer from more severe and frequent
dissociative symptoms, as well as memory and attention problems
than those with simple PTSD. In addition to amnesia due to the
activity of various parts of the self, people may experience
difficulties with concentration, attention, other memory problems,
and general spaciness. These symptoms often accompany
dissociation of the personality, but they are also common in people
who do not have dissociative disorders. For example, almost
everyone can be spacey, absorbed in an activity, or miss an exit on
the highway. When various parts of the personality are active, by
definition, a person experiences some kind of abrupt change in
attention and consciousness.

Changes in the Perception of Self

People who have been traumatized in childhood are often troubled
by guilt, shame, and negative feelings about themselves, such as the
belief that they are unlikable, unlovable, stupid, inept, dirty,
worthless, lazy, and so forth. In complex dissociative disorders
there are typically particular parts that contain these negative
feelings about the self while other parts may evaluate themselves
quite differently. Alternations among parts thus may result in rather
rapid and distinct changes in self-perception (Van der Hart et al.,
2005).

Changes in Relationships With Others

It is especially hard to trust other people if you have been
repeatedly abused, abandoned, or betrayed as a child. Mistrust
makes it very difficult to make friends, and to be able to distinguish
between the good and bad intentions in other people. Some parts do
not seem to trust anyone, while other parts may be so vulnerable
and needy that they do not pay attention to clues that perhaps a
person is not trustworthy. Some parts like to be close to others or
feel a desperate need to be close and taken care of, while other parts
fear being close or actively dislike people. Some parts are afraid of
being in relationships, while others are afraid of being rejected or
criticized. This naturally sets up major internal as well as relational
conflicts.

Somatic (Physical) Symptoms

People with Complex PTSD often have medically unexplained
physical symptoms such as abdominal pains, headaches, joint and
muscle pain, stomach problems, and elimination problems. These
people are sometimes most unfortunately mislabeled as
hypochondriacs or as exaggerating their physical problems. But
these problems are real, even though they may not be related to a
specific physical diagnosis. Some dissociative parts that are stuck
in past experiences that involved pain may intrude such that a
person experiences “unexplained” pain or other physical symptoms.
And more generally, chronic stress affects the body in all kind of
ways, just as it does the mind. In fact, the mind and body cannot be
separated. Unfortunately, the connection between current physical
symptoms and past traumatizing events is not always so clear to
either the individual or the physician, at least for a while. At the
same time, we know that people who have suffered chronic trauma
are much more likely than the average person to suffer from serious
medical problems. It is therefore very important that you have
physical symptoms checked out, to make sure you do not have a
problem for which you need medical help.

Changes in Meaning
Finally, chronically traumatized people lose faith that good things
can happen and people can be kind and trustworthy. They feel
hopeless, often believing that the future will be as bad as the past,
or that they will not live long enough to experience a good future.
People who have a dissociative disorder may have different sets of
meaning in various dissociative parts. Some parts may be relatively
balanced in their worldview, others may be despairing, believing
the world to be a completely negative, dangerous place, while other
parts might maintain an unrealistic optimistic outlook on life.
 PART ONE
SKILLS REVIEW
You have learned a number of skills in this section of the manual.
Below you will find a review of those skills and an opportunity to
develop them further. As you review, we encourage you to return to
the chapters to read them again and repractice the homework a little
at a time. Remember that regular, daily practice is essential to learn
new skills.
For each skill set below, answer the following questions:

1. In what situation(s) did you practice this skill?

2. How did this skill help you?
3. What, if any, difficulties have you had in practicing this
skill?
4. What additional help or resources might you need to feel
more successful in mastering this skill?

Chapter 1, Learning to Be Present Exercise

1.

2.

3.

4.

Chapter 2, Developing and Using Anchors in the Present

1.

2.
3.

4.

Chapter 4, Stress Reduction and Relaxation Exercise (With Stress

Ball)

1.

2.

3.

4.
 PART TWO

Initial Skills for Coping With

Dissociation
 CHAPTER FIVE

Overcoming the Phobia of Inner

Experience

AGENDA
• Welcome and reflections on previous session
• Homework discussion
• Break
• Topic: Overcoming the Phobia of Inner Experience

Introduction
Understanding the Phobia of Inner Experience
Why People Develop a Phobia of Inner Experience
The Need to Overcome the Phobia of Inner Experience

• Homework

Reread the chapter.

Complete Homework Sheet 5.1, Becoming Aware of
Avoiding Inner Experience

Introduction
Our inner experience is that which we think, feel, remember,
perceive, sense, decide, plan, and predict. These experiences are
actually mental actions, or mental activity (Van der Hart et al.,
2006). Mental activity, in which we engage all the time, may or
may not be accompanied by behavioral actions. It is essential that
you become aware of, learn to tolerate and regulate, and even
change major mental actions that affect your current life, such as
negative beliefs, and feelings or reactions to the past that interfere
with the present. However, it is impossible to change inner
experiences if you are avoiding them because you are afraid,
ashamed, or disgusted by them. Serious avoidance of your inner
experiences is called experiential avoidance (Hayes, Wilson,
Gifford, & Follette, 1996), or the phobia of inner experience
(Steele, Van der Hart, & Nijenhuis, 2005; Van der Hart et al.,
2006). In this chapter you will learn about the phobia of inner
experience and build a foundation of skills to overcome it.

Understanding the Phobia of Inner Experience

Most people think of phobias as a fear and avoidance of something
external such as spiders, heights, or flying. But some people can be
equally terrified of a feeling like rage or sadness, of a thought or
wish, or a prediction that if they try something new it will fail, or
even of physical sensations such as the rapid heart beat and
difficulty breathing that accompany panic. Such a phobia of inner
experience may involve shame or disgust in addition to fear
(Hayes, Follette, & Linehan, 2004; Van der Hart et al., 2006). The
phobia of inner experience is a serious problem, contributing to
ongoing psychological stress and inhibition of pleasant or
spontaneous activities (Kashdana, Barrios, Forsyth, & Steger,
2006).
For example, people may be intensely ashamed of feeling rage,
because they believe that emotion could only belong to a “bad”
person, or because they fear the consequences of expressing it.
They feel enraged, and instead of being able to deal with the anger,
they increase their misery by giving themselves negative labels:
Their misery has thus become compounded. Subsequently, they
avoid anger and situations that might evoke anger, and any time
they begin to feel angry, they recoil in shame and disgust. Other
people may have intense fantasies of being cared for, yet feel very
afraid, ashamed, and disgusted by these wishes, because they have
negative beliefs that being “needy” or “dependent” is weak and not
normal, again creating more inner distress and preventing them
from accepting important needs.
Many individuals with a dissociative disorder are afraid of inner
voices that come from other parts of themselves. They label
themselves as “crazy” and feel ashamed and afraid of these voices.
Such feelings are sometimes intensified if they have been labeled
psychotic or “crazy” by mental health professionals or others who
did not understand the dissociative nature of the voices.
Some inner experiences may feel so threatening that almost any
means of avoidance or escape may be used, no matter how
destructive. Perhaps you avoid your inner experience by working
too much, so you do not have to pay attention to yourself, as
Marilyn Van Derbur, a survivor of child abuse, noted: “That was
my survival mechanism, staying so busy there was not time to have
unthinkable memories surface” (2004, p. 45). Other avoidance
behaviors might include using drugs or alcohol or other addictive
behavior, increasing self-criticism, withdrawing from others, or
blaming others for your inner problems. Of course, each
dissociative part of yourself is a part of your inner experience that
you likely avoid, even to the point of not feeling or knowing it is
“your” experience.
Avoidance can be conscious or unconscious. We will begin by
helping you be more aware of the ways in which you avoid inner
experience in conscious ways. Once you become more comfortable
in noticing how you consciously avoid your inner experience, you
gradually can begin to feel more secure to focus on some inner
experiences of which you may not yet be aware. For example, you
may become more aware that you cringe and feel fear when you
hear an inner voice, but you may not yet know much about why
that voice exists or what that part of you experiences.

Why People Develop a Phobia of Inner Experience

Generally the phobia of inner experience develops for three
different reasons. First, many people who were traumatized early in
life did not get much help in learning how to understand and cope
with typical intense inner experiences such as overwhelming
emotions. They received too little help and reassurance from
caretakers. Thus, they feel easily overwhelmed, simply because
they do not understand these experiences and feel they are not
controllable.
Second, people tend to evaluate their inner experience as
“good” or “bad.” They go on to label themselves in the same way:
“Anger is bad and dangerous, so if I feel anger, I must be bad and
dangerous;” “Only people who are unlovable and worthless feel
shame; so if I feel shame it means I am a failure and unlovable.” Of
course, we all want what is good and pleasant, and we want to
avoid what is painful, just as we want to be good people, not bad
ones. But our inner experiences are not what make us good or bad;
they are just a natural part of everyone’s internal world.
Finally, certain inner experiences serve as reminders of past
traumatic experiences or as signals that something terrible is about
to happen. For example, when people, or some dissociative parts of
themselves, feel anxious, the emotion and physical sensations may
immediately remind them, even if only on an unconscious level, of
the fear they felt when they were being hurt in the past. They thus
try to avoid feeling anxious so as not to be reminded of unresolved
traumatic memories. Others might perceive an inner experience as a
signal that something is about to go wrong. For instance, a person
who feels sadness may believe or merely sense that this emotion
precedes an overwhelming experience of despair, lack of comfort,
and aloneness. Thus, sadness is avoided to prevent the other
expected and really difficult experience from occurring. The
painful paradox is that what is fearfully anticipated and avoided
would not likely take place if the present feeling of sadness is
accepted and calmly experienced.

The Need to Overcome the Phobia of Inner

Experience
It is completely understandable that you might want to avoid
certain inner experiences that are related to past traumatizing
events. Yet healing requires you to work with these inner
experiences in order to understand and change them. And you
cannot change that which you avoid or do not know. Although it
may be difficult, it is essential for you to learn how to accept,
understand, regulate, and cope with all of your inner experiences.
Inner experiences have good reason to exist and should not be
judged as “good” or “bad.” Everyone has internal experiences;
some are more congruent with who you want to be, others less so.
Some are more comfortable, others are not. Some are more under
your control, others occur spontaneously. All humans have this
wide range of inner experiences. Everyone gets angry, feels afraid,
ashamed, or incompetent at times. If you are able to tolerate those
feelings and their accompanying thoughts and sensations, you can
begin to learn to sit back and understand a bit more about them, and
thus what to do about them. Otherwise you remain a captive of
your inner experience, with it in control of you.
Your work in your therapy and with this manual can help you
learn to accept your inner experiences without judgment, including
dissociative parts of yourself. In fact, this entire manual is geared
toward helping you begin to overcome your phobia of various
aspects of your inner experience and to feel less vulnerable and
more comfortable as a whole person. You will learn much more
about how to approach your inner experiences in the next chapter.


Homework Sheet 5.1

Becoming Aware of Avoiding Inner Experience
Each day this week try to notice a time when you consciously avoid
some type of inner experience. You do not have to make yourself
stop avoiding it, but just notice what you are avoiding and under
what circumstances you avoid it. For example, perhaps you want to
avoid a feeling of anger, a thought that things are hopeless, or the
sound of a dissociative part crying or criticizing you.
Name one inner experience (emotion, thought, sensation,
memory, fantasy, etc.) of which you are a little afraid or ashamed.
Imagine that you put your fear or shame on a scale of 1 to 10, with
1 being very little and 10 being very much. Choose an experience
that is closer to 1 or 2, so that you will not get overwhelmed.
Complete the following questions for each day of the week:

1. What inner experience did you avoid or want to avoid?

2. What were your beliefs or concerns about what might happen if

you allowed yourself to accept that inner experience?

3. What did you do to avoid the experience?

4. What help or resources do you imagine you might need in order

to be less avoidant of this inner experience?

Example
1. I avoided feelings of sadness, I don’t like to cry and I can’t think when
I am crying. There is a part of me inside that cries all the time. I hate
hearing it. I just want to get away from that sound and feeling.
2. If I give in to being sad, I am afraid I will get so depressed that I
cannot work. I’d like to get rid of that crying part of me. Nobody likes
a crybaby.
3. I just worked and worked and kept busy all week so I didn’t have time
to think about it or feel anything.
4. I need help to feel safer with being sad. I am so afraid that I will never
 stop crying.

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday
 CHAPTER SIX

Learning to Reflect

AGENDA
• Welcome and reflections on previous session
• Homework discussion
• Break
• Topic: Learning to Reflect

Introduction
Reflection: Empathic Understanding of Yourself and
Others
Example of Reflective Functioning
Problems With Reflection for People With a Complex
Dissociative Disorder
Retrospective Reflection
Tips for Developing Reflective Skills

• Homework

Reread the chapter.

Complete Homework Sheet 6.1, Learning to Reflect.
Complete Homework Sheet 6.2, Reflecting on Your
Inner Experience in the Present.
Continue practicing the Learning to Be Present and
Developing Your Anchors exercises from chapters 1
and 2.

Introduction
The empathic understanding of yourself and others involves the
ability to reflect, also known as reflective functioning. This skill is
defined more generally as the ability to consider our inner
experience and make sense of it. A specific type of reflective
functioning, called mentalizing, is the ability to accurately infer our
own motivations and intentions, as well as those of others (Fonagy
& Target, 1997). Reflection is an essential skill in learning to
overcome the phobia of inner experience. In this chapter you will
learn how to reflect on your own experience as well as how to
reflect accurately on other people’s intentions toward you.

Reflection: Empathic Understanding of Yourself and

Others
Reflection helps us understand our own reactions rather than just
being in the middle of them, and reflection supports us in changing
automatic reactions to chosen responses. It also helps us more
accurately predict what another person might be feeling, thinking,
and what he or she is likely to do next in a relationship. When we
can understand and predict ourselves and others, we naturally feel
more secure and more “in sync” with those for whom we care. In
other words, reflective skills involve the capacity to make sense of
our own minds and the minds of others (Allen, Fonagy, &
Bateman, 2008; Fonagy, Gergely, Jurist, & Target, 2002).
Most animals simply react to emotions and impulses. Their
emotions direct their behaviors: Anger evokes fight or attack,
hunger evokes a search for food, fear evokes freezing or running
away, and so forth. With a very few exceptions—such as some
primates, elephants, and dolphins—animals do not seem to have
self-awareness. But as humans with self-aware minds, we have the
opportunity to add richness to our experience by understanding the
meaning of our mental activities, challenging narrow beliefs, and
changing how we respond to what we hold in mind, and to what we
believe others are thinking, feeling, or perceiving. We take in what
we perceive and make sense of it based on our accumulated
experiences, knowledge, and beliefs, and on our needs and goals.
Reflection helps us understand the nature of feelings, our
patterns of thoughts, our emotional reactions, and our habitual
movements, so that we can change them and act in ways that are
more effective. Reflection also helps us realize that other people
also have their own minds and their own needs and goals, which
may involve quite different perceptions, thoughts, feelings,
motivations, and intentions than we have. Of course, we cannot
“read” people’s minds by assuming we know what is there, but we
can make some fairly accurate predictions based on our experience
of that individual person. We can weigh different alternatives and
points of view.

Example of Reflective Functioning

Imagine that you are startled by someone walking into the room
unexpectedly, and you react with terror and panic, convinced you
are going to be hurt. This reaction is not reflective, but rather
automatic, that is, prereflective (Van der Hart et al., 2006). If you
can reflect, you are not just stuck in this terror, in the grip of your
feeling, and behaving fearfully. Rather you are able to step back
from the situation a bit and observe that your fear is not
proportional or even appropriate to what is happening. Instead of
just feeling or thinking without awareness, you notice what you feel
and think, how you experience those feelings and thoughts in your
body, and perhaps why you feel and think a certain way. This is
reflective functioning. You can learn to acknowledge and accept
the feeling, having some empathy for yourself: “I am feeling very
afraid right now. Let me take some breaths and slow myself down.
It’s OK that I have this feeling even though I know I am safe.” You
can learn to observe that the person who entered the room has no
expression of malice, and in fact, is not even focused on you. You
remind yourself that this person is known to you and would not hurt
you. You can consciously relax your body. You can give yourself
time to sort out why you might be feeling so very scared. Is it
something from the past? Is there a dissociative part of yourself that
is reacting without much awareness of the present? You can work
on calming yourself down and using the fearful experience to learn
more about your patterns of emotion, thought, and behavior.

Problems With Reflection for People With a

Complex Dissociative Disorder

Reflective functioning is a learned skill. Children learn it over time

when their caregivers are sufficiently attuned to their feelings and
needs, and it can help them be curious about their mind and how it
works. Unfortunately, these reflective skills are often absent to a
large degree in dysfunctional and abusive families, where
caregivers typically do not have these skills to pass on to their
children. So you may not have had much experience with self
reflection or reflecting on others. But like any skill, reflection can
be learned. However, it is not always easy: Reflection takes more
energy and mental work than automatic reactions, especially as you
are just beginning to learn. But be patient and persistent, and it will
become a natural part of your coping.

Reflective Functioning Can Be Impeded by Dissociation

As we explained in previous chapters (chapters 2 and 3), people
with a complex dissociative disorder experience a division in their
self or personality and, as a result, have conflicting and alternating
experiences and perceptions of themselves and others. They may be
influenced by wishes, needs, emotions, thoughts, and so forth, that
emerge from other parts of self, and they may be relatively unaware
of these parts. Thus, their inner experience seems arbitrary,
inconsistent, and confusing, making reflection more difficult than
usual. As we explained earlier, people may be very phobic of their
inner experiences, including dissociative parts of self. This phobic
reaction can seriously hamper their ability to reflect.
Revisit the earlier example about being startled by someone
coming into the room unexpectedly. Imagine that you were so
frightened that you dissociated and lost time as soon as someone
walked in the room, and you became aware again only after the
person left. You might then have no idea what happened and be
afraid that perhaps something bad had occurred. The very fact that
you do not remember frightens you, increasing your fear reaction.
Perhaps you found yourself huddled in a corner and cannot recall
how you got there, or you have a strong urge to run away and hide
that does not make sense to you as an adult. Various parts of
yourself may be activated; you may hear crying in your head, or
yelling about what a coward you are, or a voice that urges you just
to get back to work and not think about it. You may begin to have
flashbacks of past traumatic experiences. Perhaps you experience
contradictory feelings, impulses, thoughts, and so much inner chaos
in your head that you find it hard to think at all, much less reflect
on what is happening and how best to respond. These are some of
the added burdens of dissociation when learning how to reflect.
The materials in this manual begin to help you overcome your
dissociation through regular reflection. In this chapter you will
begin to learn how to reflect on your own inner experiences,
including the ways in which you interact (or avoid interacting) with
dissociative parts of yourself. You will also learn more about how
to reflect about other people so that you are able to “read” their
intentions more accurately. In fact, you will be using reflective
skills in every chapter of this book, and in therapy, so you will have
a lot of practice! At first, you will learn to reflect in retrospect, that
is, you may only be able to reflect on a situation after the fact.
Gradually it will become a more natural skill that you employ in the
moment.
Just like everyone else, you will be able to reflect most easily
when you feel relatively safe, relaxed, calm, and free from
distractions. You also need to learn to become more curious about
yourself, for example, why you always respond to criticism by
freezing, and explore the possibility of physically responding
differently. You can never know everything about yourself; no one
can. The first step is just accepting your experience as it is, without
judgment or urgent need to change or avoid it. You do not need to
know everything about yourself all at once, and in fact, uncertainty
is a very normal part of everyone’s experience.

Retrospective Reflection

As noted earlier, you first learn reflection by looking back at an

experience. In the following section, you will find some examples
of retrospective reflection that will help you understand more about
how to use it for yourself, including all parts of you, and for other
people.

Example 1: Using Reflection With a Chronic Reaction to an

Emotion
We all develop automatic (conditioned) reactions based on past experience.
For example you, or parts of yourself, may have learned to automatically
isolate from others when you feel sad, because you believe you will be
ridiculed or hurt when you are vulnerable (this likely involves core beliefs;
see chapter 21). You may or may not realize that you are sad; you just
withdraw. And perhaps you may not even be especially aware of becoming
more isolated. You just stop spending time with others. Perhaps you do not
even notice that you feel sad, but you hear a persistent crying or keening in
your head that greatly disturbs you, or just have an uneasy sense that
something is not right.
Reflection helps you notice that you feel sad, to recognize the physical
sensations of sadness, and notice the thoughts that accompany the feeling.
You may or may not know why you (or parts of you) are sad, but you can
accept that it is what you are feeling in the present. If you hear a sad or crying
voice, you do not avoid it, but try to understand and help that part of you, or
perhaps ask other parts to help. The sad part of you may then feel comforted
and understood, the voice quiets, and you feel calmer. You notice that you are
isolating yourself, and that this may not be the best solution. You learn early
signs of your tendency to withdraw so you can do something different. You
call a friend to have dinner, even though it takes energy. You remind yourself
that connection with others helps sadness. You can work with isolated parts
of yourself to help them learn to feel safer with people. You are now learning
to be more in charge of your experiences by understanding all parts of
yourself better and by taking all their needs and points of view into
consideration. You are learning to reflect on your own inner experience, make
sense of it, and use it to help you feel better.

Example 2: Using Reflection with a Dissociative Part of Yourself

You often hear the voice of an inner part of yourself that makes negative
comments about what you are doing, or says that you are stupid. You react by
being afraid of that part, and even of hearing the voice, and ashamed because
you believe what it says is true (at least on some level). Sometimes your
reaction to the voice is so painful that you engage in some destructive
behavior to make it stop, such as using alcohol or drugs, physically hurting
yourself, or overeating. This cycle may go on and on. You may label yourself
as crazy because you hear this voice and you feel very ashamed (see chapter
24).
Reflective skills can help you observe the process of what happens when
you hear this voice, and to change your reaction to it, and eventually to
change the entire interchange between you and that critical part of you. You
can begin to notice what you feel as you hear that voice: perhaps crazy, or
afraid, or ashamed, or frustrated. You notice when you hear that voice, you
stop talking in therapy and perhaps have a panic attack. Every time you hear
that inner criticism, you notice that you cringe, your body gets tight, your
head hangs down, and you do not want to move. When you can notice your
tendency to react without doing so immediately, you can then begin to
respond differently. You can be curious about why that voice is there (you
may have always assumed it is there just to speak the “truth” about yourself,
but there are likely other reasons). You could begin to dialogue with the part
whose voice you are hearing. You could ask that part of you to help, and
begin to work to develop inner empathy and cooperation, as you will be
learning through this manual. You can empathize with yourself about how
painful it is to always feel criticized, scared, less than others, hopeless. You
can empathize with how hard that part of you works, yet never seems to get
satisfactory results. You could take some deep breaths, hold your head up,
and put your shoulders back. You have options to respond to the voice that
you did not have before.
In the same way that we use our ability to reflect to better understand
ourselves, we also use reflection to understand the minds of other people, that
is, to make sense of their motivations and intentions.

Example 3: Using Reflection to Understand Other People

You call a friend to invite her out to dinner. She does not return your call.
You assume she has not responded because she does not want to be your
friend anymore or that you are not important to her. You decide you do not
want to have anything to do with her.
These prereflective beliefs about why your friend did not call back are
typically based on your past experiences and on your ongoing fears of being
rejected, long before you could even think of the many possibilities of why
she might not have returned your call. They are a kind of implicit and
inaccurate reflection, a reaction based on a reaction, your own reactions (from
the past) rather than on really understanding your friend. And you may have
contradictory thoughts and feelings about your friend coming from parts
inside—some wanting to continue the relationship, some feeling she is not
worth having as a friend, some believing she is dangerous—confusing you
even more. However, it turns out that your friend’s phone was out of order,
and she did not receive the message.
You have a tendency to react the same way each time you feel rejected:
You withdraw, feel hurt, and assume that people do not like or want to be
around you. But reflective skills allow you to explore many possibilities of
your friend’s intentions toward you. We will start with the one that you
probably assumed, and then move to other possibilities that allow for
reconnection and relational repair.

• Your friend does not like you or care enough about you and
she intentionally chose not to call you back (intentionally
hurtful; the reason you assumed).
• She was sick, or out of town (unable to respond to you, and
not intentional).
• She did not expect a call from you and did not check her
messages (not intentional).
• She intended to call you back, but forgot to respond because
there was a crisis at work or in her family (unintentional, and
not because you are unimportant or she does not care, but
still hurtful).
• She forgot to call you back because she tends to be scattered,
 forgetful, and not very reliable (in this case, her own issues
have created a problem, but still it was not intentional,
although hurtful).
• She did call you back, but when you did not answer the
phone, she did not leave a message (not intentional, but
irritating!).
Reflective skills can also help you sort out your own experience and those
of other parts of yourself. You might say something like, “Of course, I am
disappointed that she didn’t respond to me. It is only natural that I would first
assume that she didn’t like me or was mad at me. But I can understand that
perhaps there might be other reasons she did not call back which have
nothing to do with me. I feel sad that it is so hard for me to trust others, and
that I always tend to assume people don’t like me. It feels very lonely and
shameful to feel I am not likable. Perhaps next time, if someone doesn’t
respond to my first call, I will take the risk to call again.” You might have an
inner dialogue with parts of yourself that may have had different
interpretations of and feelings about the situation, empathizing with each one,
but also reminding all parts of you that there are many possible motives and
intentions behind the behavior of others. It is always helpful to get more
information before jumping to conclusions.

Tips for Developing Reflective Skills

To be reflective, you will be learning how to gradually have more
awareness of the present moment, of all parts of yourself, and of
other people.

Be in the Present
It is impossible to reflect on your inner experience if you avoid or
are not aware of it. Likewise, it is hard to reflect on your current
situation if you do not feel present. Reflection begins with being as
present in the moment as much as you are able, which takes
consistent and concentrated practice. Use your anchors for the
present (practice the exercises on anchors in chapters 1 and 2).

Notice Your Inner Experience Without Judgment

Take time to turn your attention inwardly to your thoughts,
feelings, sensations, and other parts of yourself. If you do not
understand what you notice, do not judge yourself; just do the best
you can and move on. If you do not notice anything, do not judge
yourself; simply note that you do not notice anything and move on.
It helps for you to be curious about yourself, about what is going on
inside, and why you think or feel or behave in particular ways.
Even though you may try to understand your mind and that of
others, some of your perceptions, assumptions, or beliefs may be
inaccurate (you will learn more about inaccurate thoughts and
beliefs in chapters 21, 22, and 23). Your reflection may be limited
by past experiences that are no longer relevant to the current
situation (for example, having a prereflective belief that your
therapist is going to yell at you in anger, because your parents did
so, even though your therapist has never yelled) or by inaccurate
beliefs and predictions (for example, believing you are crazy and
will “be put away” because you hear inner voices). In fact, each
part of you likely has a particular set of reactions to other people,
many of them inaccurate. Notice these beliefs and thoughts, as well
as the feelings and behavioral tendencies that accompany them.
Write them down so you can reflect on them more easily.

Notice Similarities and Differences

It helps for you, and all parts of you, to notice similarities and
differences—in your inner experience, in others, in situations. That
is, you can begin to separate the past from the present, your inner
fears or beliefs from external realities. You can notice that you
react similarly each time you feel lonely, rejected, sad, or angry.
You can notice that you have patterns of reactions that go back to
your past history, that have become automatic. You can begin to
notice what is different about the current circumstances that might
call for a different response from you (for example, your friend will
never hit you, so you need not expect it).

Be Empathic
You must be empathic with yourself, including all parts of yourself,
each toward the others, and also empathic with other people’s
foibles and struggles. You can develop the capacity to “walk in the
shoes” of another and of different parts of yourself (for instance,
noticing yourself with empathy when you feel angry, incompetent,
or ashamed). Over time, you will be able to recognize all parts of
yourself as you. And you will learn much more about successfully
developing and maintaining secure and safe relationships with
others.


Homework Sheet 6.1

Learning to Reflect
Reflect in retrospect on a minor situation in which reflective skills
might have been helpful. Use the aforementioned examples as a
guide.

• Briefly describe the situation as you perceived it at the time.

• What were your thoughts, feelings, sensations, predictions?

• What did you do in this situation?

• If you are aware that any other parts of yourself were involved in
the situation, whether directly, or by having an inner, private
reaction, please describe those reactions.

• Describe ways, if any, in which dissociative parts of yourself

affected your behaviors and decisions in that situation.

• Was your reaction (for example, your feelings, thoughts,

sensations, or behavior), or that of other parts of yourself, a familiar
pattern? If so, please describe the pattern.

• Notice in retrospect ways in which you or other parts of yourself

might have reacted not only to the situation but to your own
feelings, thoughts, or behaviors. For example, feeling ashamed of
feeling jealous, and criticizing yourself for being jealous.


Homework Sheet 6.2

Reflecting on Your Inner Experience in the Present

1. Notice your current inner experience, including any thoughts,

feelings, sensations, or other parts of yourself. Try to acknowledge
and accept those experiences with interest and without judgment.
Notice any possible negative reactions that may occur during this
exercise, for example, thinking that this is a stupid exercise or
being convinced that you cannot succeed in learning the skills in
this manual. You may write down what you notice.

2. Reflecting about another person’s intentions and motivations.

Choose a person with whom you are acquainted but not very close,
and whose behavior has bothered you at some point in time.
Describe the behavior and in what ways it bothered you or other
parts of yourself.

a. Describe what you thought and felt about yourself and the
other person.

b. Describe what you imagine the other person thought and felt.

c. Imagine and list possibilities, even if you do not agree with

them, about why that person might have acted in that
particular way.

d. Can you feel empathy for that person and for yourself? If so,
please describe your experience of feeling empathy (for
example, your thought and feelings). If not, describe what
you did think and feel (without judgment).
 CHAPTER SEVEN

Beginning Work With Dissociative

Parts

AGENDA
• Welcome and reflections on previous session
• Homework discussion
• Topic: Beginning Work With Dissociative Parts

Introduction
Initial Dilemmas in Working With Dissociative Parts
of the Self
First Steps in Working With Dissociative Parts of the
Self
Forms of Inner Awareness and Communication
Techniques for Inner Communication

• Break
• Homework

Reread the chapter.

Complete Homework Sheet 7.1, Stages of Awareness
and Acceptance of Dissociation.
Complete Homework Sheet 7.2., Recognizing
Dissociative Parts of Yourself.
Complete Homework Sheet 7.3, Practicing Inner
Communication.
Consult with your therapist as needed for help with
working with parts of yourself.
Continue to practice the Learning to Be Present
exercise and practice your reflecting skills.

Introduction
Connecting with yourself and reflecting on your experiences are
essential tasks in which you must engage every day in order to
function at your best. The more you know and understand about
yourself—all of you—the better decisions you can make to
improve your life. Every day you need to make many choices and
compromises. All people sometimes have conflicting thoughts,
wishes, needs, and feelings. This is no different for individuals with
dissociative disorders, except that their inner experience happens to
be organized as relatively compartmentalized or divided parts of
the personality that have their own “minds,” so it is harder for you
to be aware of inner conflicts or to resolve them. You must learn to
take into account the various needs and feelings of dissociative
parts that seem as though they do not belong to yourself. In this
chapter you will learn some basic approaches to understanding
more about parts of yourself and how to work with them.

Initial Dilemmas in Working With Dissociative Parts

of the Self
Cooperating with various parts of yourself is sometimes more
easily said than done because there is so much avoidance and
conflict that keeps dissociative parts separated. We previously
mentioned that many people initially find it difficult to accept their
diagnosis, in part because they have a strong avoidance, that is, a
phobia for dissociative parts of the personality (Van der Hart et al.,
2006). Others find it a great relief to finally be understood. People
with dissociative disorders often make comments such as: “That
(part) isn’t me!” or “That voice doesn’t belong to me!” or “I don’t
want anything to do with those voices or those other parts!” These
attitudes are quite understandable and are the result of confusion
about, or fear or shame of the experiences contained by other parts.
People also fear losing control to other parts because some parts
may have such different or unacceptable emotions and behaviors.
For instance, some parts want to come to therapy, while others
would rather avoid it or believe that there is no need for it. Some
parts want to focus on work, while others find work boring and
would rather have fun or stay in bed. Some parts want to have a
close relationship, while others are terrified of being close. Some
parts are focused on daily life, while others are stuck in the past.
The more you tend to avoid these conflicts and dissociative parts of
yourself, the more difficulties you are likely to have in daily life.
The less collaboration among parts, the more inner conflict you
have.

First Steps in Working With Dissociative Parts of the

Self
When you have a dissociative disorder, there are several stages of
realization about how your personality and self are organized and
function. In your homework in this chapter you will find a
description of these stages, which range from complete
unawareness or avoidance to complete acceptance. First, you must
learn to acknowledge dissociative parts, and accept the sense of
being and feeling fragmented. It is typical for you to need support
to overcome your fear or shame of other parts of yourself. Then
you can decide how you might be able to make conscious efforts to
communicate internally with parts.
The first dialogues among parts should be focused on building
internal communication and cooperation solely toward improving
the quality of everyday life. These inner dialogues include the
following:

• Learning to deal with triggers, that is, stimuli that evoke

(aspects) of traumatic memories (see chapters 15 and 16)
• Increasing internal and external safety
• Working together in therapy
• Cooperating to complete daily life tasks

Traumatic memories, emotions, or sensations generally should not

be shared among parts at this point. That work is for later, when
you feel more calm and steady, and parts have more empathy
toward each other, are working together well, and are better able to
cope with emotions.
Finally, it is important to realize that various parts actually have
often been cooperating for years for mutual aid or protection
without your conscious awareness. Sometimes this happens almost
automatically (for instance, one part automatically takes over from
another part in a particular situation, or some parts that are very
troubled are inactive while you are at work). Other times it is a
deliberate, conscious choice.
 When parts of yourself are not cooperating with each other,
when they do not function in a coordinated and effective way, and
when they each emphasize different priorities, then inner conflict,
chaos, and confusion can ensue. The first step toward resolution is
to help all parts of yourself to focus on what you are doing in the
present, especially in relation to therapy and daily life tasks.

Forms of Inner Awareness and Communication

Cooperation among parts of yourself requires you to learn to accept
and then communicate with all of you. We will now focus on basic
inner communication.

Gradually Acknowledge and Accept Parts of Yourself

When you have not been very reflective in your life, you are not
accustomed to paying attention internally. Becoming aware of parts
of yourself is one of the early tasks toward the end of
acknowledging and accepting yourself as a whole person, with all
your thoughts, emotions, your body, and your behaviors. We have
already discussed some ways in which you can begin to notice parts
of yourself in Homework Sheet 2.3. Acknowledging and accepting
yourself is not always easy, even for people who do not have a
dissociative disorder. It can be complex and sometimes daunting at
first. But each time you are aware of a part of yourself, you can also
begin to be aware of how you think and feel about that part of you.
Those thoughts and feelings are extremely important to your
therapy work.
Once you notice parts of yourself, you can begin to accept them
without judgment. When you are less judgmental, you feel less
afraid or ashamed, less threatened. And when you feel less anxious,
you may become more curious about parts of yourself, how they
function, and how you can work together more effectively.

Listen to and Communicate With Parts of Yourself

Once you are able to acknowledge and accept parts of yourself, you
can then learn to communicate, which involves listening and
sharing. Many people with a dissociative disorder hear inner voices
that represent various dissociative parts. They are able to carry on
internal conversations. Others may experience this a little more
indirectly, by “sensing” or having a kind of strange “knowing”
about what parts are trying to communicate. In learning to
communicate with another part, others find it helpful to imagine
talking to a real person, though, of course, parts of yourself are not
other people. The imaginal exercise is just a way to develop a better
sense of other parts of you. Some people find it effective to write
from the perspective of each part. It is important for you to find
your own way of communicating that is comfortable for you.
Listening to and talking with the voices in your head instead of
trying to make them go away will ultimately be the fastest and most
effective way of healing.
But initially you may find inner communication difficult. Do
not hesitate to ask your therapist to help you during these initial
attempts. Everyone finds it helpful to set aside a specific, quiet,
calm time each day for inner communication. At first, you are
likely quite naturally afraid or ashamed of parts of yourself, and
you may want to avoid communication. And some parts may also
want to avoid you. Sometimes it may seem as though all parts of
you are talking at once. People describe this as a chaotic noise or
incessant murmur in their head which is overwhelming and
confusing, making it hard to think. Generally this experience occurs
when you (or other parts of you) are feeling especially anxious,
threatened, or ashamed.
A common difficulty in the beginning is inner threats when you
try to communicate with parts of yourself. Usually this comes from
a dominant, highly critical part of you. Such parts, as noted in early
chapters, are only trying to protect you by reacting with the limited
and rigid patterns of response that are familiar to them. These parts
need help to learn more effective and empathic ways of protecting
you and dealing with fear, anger, and shame. It is easiest, if
possible, to start inner dialogue with a part of yourself with which
you feel most comfortable.
One way to start communication is to find common ground
upon which all parts can agree. For example, it is highly likely that
all parts of you want to feel better, no matter how they seem to feel
or act. Usually every part can agree with this goal, even though
they are not likely to agree on how to achieve it in the beginning.
But it is a place to start.
When daily life is going more smoothly, we all tend to feel
better. One of your first objectives is to focus on learning to help all
parts of you become more cooperative and communicative about
daily life. You might have inner discussions, for example, about
how to work together to get to appointments on time or to complete
chores more efficiently, or how to best use your leisure time. You
may not be able to communicate with every part of yourself
immediately. This is normal and expected. It may take some time
for all parts of you to feel comfortable and safe enough to allow
more communication.

Techniques for Inner Communication

Following are some alternatives to “inner dialogue” that might be
helpful to try.

Written Forms of Communication

Try writing to parts of yourself, introducing your therapy as an
avenue of healing, and sharing your good intentions. Emphasize
that even though you are scared or ashamed, you still want to make
the effort to get to know all parts of yourself in a paced way. You
are willing to try. Also emphasize that traumatic memories should
be contained for the time being, until parts begin to feel more safe
and comfortable with each other and are able to work together more
effectively in daily life. Many people like to write on the computer.
It is faster and the file may be deleted quickly if you are worried
that someone might read what you have written. What is most
important is that you begin to learn to tolerate knowing a little more
about parts of yourself in the present.

Talk Inwardly
Another way of communicating or making contact is “talking
inwardly,” in other words, having a one-sided conversation with
parts of the personality, even if you are not yet ready for them to
communicate back to you. You can use this technique if you seem
agitated, anxious, confused, or afraid inside. You do not always
need to know immediately the reason for your inner turmoil or
which part(s) is having trouble to be able to help. Just quietly talk
inwardly to all parts of yourself, calming and reassuring these parts
of you that you are safe, that you are willing to learn to care for
yourself more effectively, that you are getting help. Remind all
parts of the present by looking around and noticing your
surroundings. Use your anchors in the safe present from the first
two chapters. The goal is to connect to parts of yourself and let
them know you are willing to pay attention and help.

Inner Meetings
Some people may be ready to conduct “inner meetings,” in which
parts come together internally to discuss issues. Some may find this
too overwhelming or not fitting. We describe the details of this
technique in chapter 27, if you feel ready to practice it at this point
in time. It is essential to take your time and go at your own pace.


Homework Sheet 7.1

Stages of Awareness and Acceptance of Dissociation
Below you will find a list of steps toward acknowledging,
accepting, communicating, and cooperating with parts of yourself.
You should work at your own pace and not expect to be able to
accomplish all these steps at once. Circle all statements that apply
to you now. Later in the course of therapy, you can revisit these
steps to check your progress.

• I do not want to accept that I have dissociative parts.

• I am aware that some parts exist with which I am not in
communication.
• I am aware, but avoidant of (some of) my parts.
• I accept the existence of (some of) my parts.
• I am beginning to communicate with (some of) my parts.
• I can negotiate and collaborate about some issues in daily life
with (some of) my parts.
• I take into account the needs of (some) parts of myself.
• I understand and accept the functions of (some of) my parts.
• I feel empathy for (some of) my parts.
• I am able to help (some of) my parts feel more safe and
comfortable.
• I have regular communication with (some of) my parts to
discuss issues of daily life.


Homework Sheet 7.2

Recognizing Dissociative Parts of Yourself
There are various ways in which you can notice the presence of
another part of yourself. Read the following examples and see if
they fit your experience. Below the examples, describe one
experience of becoming aware of a part of yourself.

• You have lost time and discover that you have done
something of which you have no memory, yet you know you
must have done it.

• You hear yourself talking, but it seems as though the words

you hear are not your “own.”

• You experience yourself outside your body, as though you

are looking at someone else from a distance and you cannot
control your actions.

• You have thoughts, emotions, sensations, memories that you

experience as not belonging to you.

• You hear voices in your head that talk to you or to each

other.

• You find yourself in a place and have no idea how you got
there.

• You feel your body, your movements, or actions are not

within your control.


Homework Sheet 7.3

Practicing Inner Communication
Record your attempts at inner communication each day this week.
Answer these questions for each day of the week.

1. Describe what you said or did to establish empathic

communication with a part of yourself.

2. Describe the response of that part of yourself.

3. What, if anything, made it difficult to communicate?

4. What if, anything, helped you communicate?

Sunday
1.

2.

3.

4.

Monday
1.

2.

3.

4.
Tuesday
1.

2.

3.

4.

Wednesday
1.

2.

3.

4.

Thursday
1.

2.

3.

4.

Friday
1.

2.

3.
4.

Saturday
1.

2.

3.

4.
 CHAPTER EIGHT

Developing an Inner Sense of Safety

AGENDA
• Welcome and reflections on previous session
• Homework discussion
• Topic: Developing an Inner Sense of Safety

Introduction
Developing an Inner Sense of Safety

• Break
• Exercise: Experiencing an Inner Sense of Safety
• Homework

Reread the chapter.

Practice the exercise Experiencing an Inner Sense of
Safety each day.
Complete Homework Sheet 8.1, Developing an Inner
Sense of Safety and Safe Places.

Introduction
Being safe in the external environment is a major initial goal in
therapy for traumatized people who are still threatened in their
present-day life. In chapters 28–31 we will address the subject of
choosing safe people in your life and of setting limits when you do
not feel at ease with someone. If you are not safe in your current
external environment, it is imperative to discuss this serious
problem with your therapist, so you can get help. However, even
though many traumatized people are (relatively) safe in their
environment, they still do not feel safe. Thus, a major goal in
therapy is to establish a sense of inner safety, of being safe with
yourself, all parts of yourself, with your inner experiences. An
inner sense of safety, also referred to as a safe state (O’Shea, 2009),
is the awareness of feeling relaxed and calm in the present moment,
when there is no actual threat or danger.

Developing an Inner Sense of Safety

Inner safety is strongly related to being able to be present in the
here and now, and in feeling secure in at least one or two trusting
relationships with other people. When young children grow up in
the context of safe and trusting relationships, where they are
provided a safe environment, they naturally develop an inner sense
of safety. Many people with a history of early traumatization have
not had many opportunities to experience a safe environment or
safe relationships, and therefore they have been unable to develop a
sense of inner safety and security. Thus, it may be hard for them to
even imagine what it feels like to be safe. They may know
cognitively that their current environment is safe, and yet they do
not feel safe or comfortable at all, as though something terrible is
going to happen any minute. And even when their present situation
is safe, some parts of them remain stuck in trauma-time, unable to
experience the safe present. In addition, traumatized individuals
often do not feel safe with their own inner experiences, that is, with
some of their own emotions, thoughts, sensations, and other actions
of dissociative parts. Subsequent avoidance of inner experience
makes it hard to stay present, and it sets in motion an inner cycle of
fear, criticism, and shame, adding yet more to a lack of inner safety.
Even if you cannot imagine feeling totally safe, probably there
have been times when you have felt less unsafe than others, and
you can begin learning about safety from that point. If the concept
of “safety” seems too foreign to you, you may think instead of a
pleasant and calm place, a place where you feel understood and
accepted, or perhaps a place where you are alone and know you
will not be disturbed.
Next we describe ways to create a sense of inner safety,
including imagery of safe places in which you and other parts of
you can find safe and calm refuge from the stresses of daily life and
from your painful past, until you are able to heal more fully.

Being in the Present

First, we will focus on developing an inner sense of safety in the
present. It is essential to help all parts of yourself feel calm and
relaxed once you are able to determine that the present moment is
actually safe externally. You can train yourself to consciously let
go of inner tension, to allow all parts of you to notice this moment
of safety and well-being, of relaxation and inner quiet, even though
at first these moments may be few and far between. Some parts of
you may find it easier to experience an inner sense of safety than
others. For some parts of you, finding that state is easier with
someone whom you trust; for others it may be when you are alone,
when you are with a beloved pet, listening to your favorite music,
or outdoors in a special, quiet place in nature.
Most certainly, an inner sense of safety can only be experienced
when your environment is actually safe. And even if there are
situations that feel threatening in the present, there are still
moments when you are actually safe. It is in these moments that
you can begin to focus on developing an inner sense of safety.
A sense of safety can occur when all parts of you can agree to at
least temporarily let go of inner conflicts and criticism and to focus
on the present moment. This may be difficult to achieve and may
not last long in the beginning, but you will find that all parts of you
appreciate this state, and the more you practice, the easier it will
become.

Developing Imaginary Inner Safe Places

Inner safe spaces are images of places where you can be safe,
relaxed, and cared for. These images have been shown to be helpful
to many people, not just those with dissociative disorders. This type
of imaginal activity is well known to produce a feeling of
relaxation and well-being in those who use it regularly. If your
inner experience feels so jarring, unsafe, and frightening, as it often
does in individuals with dissociative disorders, the ability to
imagine these spaces becomes especially important and helpful.
When you have a dissociative disorder, some parts of you
remain stuck in trauma-time and thus do not experience a sense of
safety. They may be on high alert for potential danger and thus
unable to relax enough to feel safe. And individuals with a
dissociative disorder typically experience a vicious cycle of rage,
shame, fear, and hopelessness inside that contributes to a lack of
inner safety. Some parts are angry and critical, while others are
hurting, afraid, or ashamed. There are often strong conflicts among
these different parts. The more parts express their pain, the angrier
and more hurtful other parts become, because they cannot tolerate
what they consider to be “weakness.” The more angry and critical
parts are toward other parts, the more these parts suffer. This
creates an endless loop of inner misery and lack of safety.
When you are able to create one or more imaginary safe places
for parts of you that are in pain or afraid, this opens the door to the
possibility of alleviating this negative loop. Angry parts feel some
relief once they learn that terrified or hurting parts are quieter when
they feel safer. Thus, you are able to reduce conflict by helping
both types of parts simultaneously. Once you are able to develop an
inner imaginary safe space, all parts of you can experience it and
have it available anytime you need or want. For example, when
some parts of the personality are overwhelmed, and you need to
accomplish an important task, these parts may go to the safe place
to rest while you complete your task. Such parts may feel calmer in
an imaginary safe place until such time that they can focus on their
healing during therapy. Or they can remain undisturbed in some
situations that might trigger painful past experiences, such as going
to a doctor or being in a meeting at work in which there is conflict.
Some people find that one imaginary place is sufficient for all
parts of themselves, while others feel the need for different places
that match the differing needs of parts. And of course, inner safe
places should always be paired with efforts to ensure your safety
with other people and in the world. You cannot have an inner sense
of safety without actually being safe!

Examples of Imaginary Inner Safe Places

• Pleasant outdoor places such as lakes, meadows, streams,

pools, islands, forests, mountains, oceans
• Structures: Tree houses, huts, porches, mountain and beach
cottages, safe homes
• Rooms especially adapted to the needs of each part
• Safe cave or cavern
• Spacecraft
• Your own special planet
• Submarine or underwater home
• Hot air balloon
• Although technically not spaces, some people like the image
 of protective covering: space suit, suit of armor, invisible
force field, invisible cloak (for more of this type of imagery,
see “The Store” exercise in chapter 14).

You may want a safe (or quiet) place for all parts of yourself
together, or some parts may want their own place. Pay close
attention to what various parts of you want or need. Remember that
imagination is limitless and can be continually adapted as your
needs change.
If you cannot imagine a place, do not hesitate to ask your
therapist to help you. Sometimes it helps to draw one or to find a
picture of a place that you like. And as we noted earlier, start with a
feeling of being less unsafe than at other times. You can make a list
of all the comfort measures you would like to have in your safe
place. Also remember that a prime rule is not to criticize or judge
parts for what they imagine, and for what they want or need, even if
you do not agree. Perhaps not all parts of you can yet participate;
that is fine. Just start where you are able.
A safe place should be a private place that only you know
about, and that no one else can find or intrude upon without your
permission. If you feel especially unsafe, you can imagine that your
place is surrounded by a fence, a wall, a special invisible field, or
an alarm system. You are in charge of whether you allow other
people there. You can also negotiate with all parts to respect each
other’s places and not intrude or “visit” without permission.
Your safe place can protect you or particular parts of yourself
from any overwhelming stimuli in the present, and it should be
comfortable and pleasant. It is a place in which you feel your needs
for safety, comfort, rest, and so forth are fulfilled. Feel free to add
anything you want in this place to improve your sense of comfort,
well-being, and safety. You can imagine comfortable beds; your
favorite foods, games, and movies; and animals that you like. Your
place can be populated with animals or other people, or no one but
yourself. You can have people nearby, but not too close. This place
is yours to construct, and yours alone.
Any part of you may go to a safe place at any time. Some parts
may voluntarily go to a safe place when there has been some inner
collaboration and agreement that this might provide temporary
relief or containment. However, never try to shut away or hide parts
to get rid of them! Prisons are not safe places, and trying to avoid
parts in this manner will only heighten your inner sense of being
unsafe. It is important for all parts of you to see the value of a sense
of safety and the use of safe places, and to do their best to
cooperate together to create this healing image.
A literal safe place at home is also important for many people.
You can create a special room or corner of a room that represents
your safe place. You may add items to this place that represent
safety and calm to you. Choose colors and textures that are pleasant
or quieting, objects that have a positive meaning to you,
photographs of people who care about you, or of places that you
find pleasant.

EXERCISE: EXPERIENCING AN INNER SENSE OF

SAFETY
Using the section above and Homework Sheet 8.1 as guides, you can practice
developing an inner sense of safety and a safe space now. In group, you can
help each other as desired, and you may use your group trainers as resources
as well.


Homework Sheet 8.1

Developing an Inner Sense of Safety and Safe Places

1. Practice feeling an inner sense of safety or calm.

a. First, describe a situation in which you can experience a

moment of inner safety and/or calmness. Would it be at home
alone, with another person, outside in nature, listening to
music?

b. Next, allow yourself and all parts of you to experience that

inner sense of safety. Describe your experience of it, that is,
your thoughts, emotions, sensations.

c. Notice what, if anything, disrupts your inner sense of safety

and describe it below. Is it a thought, a feeling, a sensation, a
shift away from being present? Is it another part of you that is
not yet able to share in this sense of safety in the current
moment?

d. Imagine that experience of inner safety now and notice again

what it feels like.

e. Try to create moments of inner safety every day. Regular

practice improves your ability to create your inner sense of
safety.

2. Describe, if you feel comfortable, your safe place. If you do not

want to share it, try to describe what you feel like when you are in
that place. Describe what is helpful about your safe place to you, or
other parts of yourself.
3. If other parts of you need their own unique safe place, work on
creating those images. Pay close attention to what those parts want
or need in terms of safety and comfort. If you feel comfortable
doing so, describe those places here.

4. If you have difficulties in developing an inner sense of safety or

safe places, please describe what has interfered below. You are
encouraged to get help from your therapist with these temporary
difficulties.
 PART TWO
SKILLS REVIEW

You have learned a number of skills in this section of the manual.

In this section you will find a review of those skills and an
opportunity to develop them further. As you review, we encourage
you to return to the chapters to read them again and repractice the
homework a little at a time. Remember that regular, daily practice
is essential to learn new skills.
For each skill set below, answer the following questions:

1. In what situation(s) did you practice this skill?

2. How did this skill help you?
3. What, if any, difficulties have you had in practicing this
skill?
4. What additional help or resources might you need to feel
more successful in mastering this skill?

Chapter 5, Overcoming a Phobia of an Inner Experience

(Thought, Sensation, Emotion, etc.)

1.

2.

3.

4.

Chapter 6, Reflecting on an Inner Experience

1.

2.
3.

4.

Chapter 7, Inner Communication With Parts of Yourself About

Current Issues in Daily Life (Not Your Past History)

1.

2.

3.

4.

Chapter 7, Developing Empathy Toward a Part of Yourself

1.

2.

3.

4.

Chapter 7, Cooperation Among Parts of Yourself to Accomplish a

Common Task or Goal in Your Daily Life

1.

2.
3.

4.

Chapter 8, Developing a Sense of Inner Safety and Safe Places

1.

2.

3.

4.
 PART THREE

Improving Daily Life

 CHAPTER NINE

Improving Sleep

AGENDA
• Welcome and reflections on previous session
• Homework discussion
• Exercise
• Break
• Topic: Improving Sleep

Introduction
Types of Sleep Problems
Factors That Contribute to Sleep Problems
Improving the Quality of Sleep
Tips for Dealing With Specific Sleep Problems
• Homework

Reread the chapter.

Complete Homework Sheet 9.1, Sleep Record.
Complete Homework Sheet 9.2, Making Your
Bedroom a Pleasant Place for Sleep.
Complete Homework Sheet 9.3, Developing a Sleep
Kit.
Complete Homework Sheet 9.4, Developing a Bedtime
Routine.

Introduction
People with complex dissociative disorders almost always suffer
from periods of disturbed sleep for a variety of reasons. Some of
these may be physiological; others are related to the activity of
various dissociative parts. They may even have an underlying sleep
disorder. Thus, it is important to discuss your sleep problems with
your primary care doctor. The less you sleep, the more tired you
are. This increases your chance of struggling in daily life because
you have less energy and are more prone to become emotionally
vulnerable and to have difficulties with thinking. In this chapter we
will discuss types of sleep problems and how to improve your
sleep, including how to cope with nighttime flashbacks and
nightmares, and with parts of yourself that may be disruptive
during the night.

Types of Sleep Problems

It is important for you, your therapist, and your doctor to know
what types of sleep problems you experience in the present, and
what you have struggled with in the past. Of course, sleep problems
may vary over time and even have different causes over time.
Following is a list of common sleep problems in people with
dissociative disorders. Check the ones that are currently a problem
for you.

• Difficulty falling asleep

• Difficulty staying asleep
• Frequent waking
• Very early morning waking
• Excessive sleepiness (for instance, falling asleep during the
day)
• Disturbed sleep–wake patterns (for instance, sleeping in the
day and being awake at night)
• Nightmares
• Night terrors
• Sleepwalking
• Teeth grinding
• Bedwetting
• Restless legs
• Panic during the night
• Sleep apnea (short episodes of not breathing during sleep;
often associated with obesity)
• Feeling that you have not slept deeply or well, and
subsequently feeling tired
• Activity of dissociative parts during the night
• Postponing bedtime due to being afraid of going to sleep or
getting in bed
 • Flashbacks as you fall asleep or awaken
• Illusions and hallucinations as you fall asleep or awaken
• Severe difficulty waking up or being roused by someone else
• Narcolepsy (sudden, uncontrollable episodes of deep sleep
during waking hours). Narcolepsy should be distinguished
from episodes of collapse, as described previously in the
manual, and must be diagnosed with a sleep study.

Factors That Contribute to Sleep Problems

There are numerous causes of or contributing factors to sleep
problems in those with dissociative disorders. Often more than one
factor is involved, making it important to receive a comprehensive
assessment for serious sleep difficulties.

Traumatization
It is harder to sleep well when you are traumatized. When it gets
dark and quiet, your mind sometimes starts to work overtime. If
you tend to avoid traumatic memories, you are more vulnerable to
having them emerge once you are no longer preoccupied with work
or other activities. Because some traumatizing events may have
occurred at night, in the dark, or in bed, many people are afraid of
the dark or dread going to bed. These fears may be prominent in
parts that live in trauma-time. You, or certain parts of you, may
also feel more alone, vulnerable, or unprotected in the dark or when
you are sleeping. You, or parts of you, can become more jumpy,
fearful, and hyperalert; therefore, you may sleep more lightly and
awaken often during the night.
People with a dissociative disorder often suffer from trauma-
related nightmares, night terrors, flashbacks, or nighttime panic
attacks. Thus, they tend to avoid going to bed or only sleep once it
is light outside. Sleepwalking, crying, moaning, shouting, or
fighting while asleep are not uncommon. A few may have
bedwetting on occasion. Although this may be embarrassing, it is
important to understand that some dissociative parts of the self may
experience themselves as very young and terrified. Such parts may
be too afraid to get out of bed to go to the bathroom, or they may be
so terrified that you urinate involuntarily. If this happens, do not be
hard on yourself. Just change your bed linens and continue to work
on grounding, inner empathy, and reassurance about present-day
safety for those parts of yourself. The more you can reassure and
comfort all parts of yourself, the fewer problems you will have at
night.

Struggle for Time Among Dissociative Parts

People with a complex dissociative disorder, especially DID, may
have an internal struggle for control among parts of themselves.
Parts may want or demand specific time for themselves, feeling that
they do not have enough time for their own activities. This may
become a major problem, interrupting not only daytime activities
but also sleep. Sometimes dissociative parts may be more active at
night, when the main part of the personality is more fatigued and
less “on guard.” Some dissociative parts may only be active during
the night. The following morning you may feel exhausted and not
understand why. You may find evidence of activities that you have
done, such as using the computer, eating, cleaning, or drawing.
Sometimes parts stay busy because they dread going to sleep or are
afraid to close their eyes. They may fear losing control or having
nightmares.

Other Emotional Problems

Sleep disturbances are common in those who experience moderate
to severe anxiety or depression. Many traumatized individuals
experience both. This additional biological contribution to sleep
problems can best be addressed with a combination of medication,
therapy, and healthy lifestyle changes.

Excessive Stimulation
Drinking too much caffeine or alcohol, or using drugs or tobacco
can have an adverse effect on your sleep. Heavy exercise or eating,
reading stimulating books, or watching exciting or disturbing
movies before bed can also affect your sleep. Some people may not
be aware that other parts are engaging in these behaviors. If you
lose time in the present and suspect this possibility, please discuss it
with your therapist.

Lack of Stimulation
On the other hand, sleeping or resting too much during the day,
being too sedentary, and inadequate exercise can also lead to poor
sleep.
Improving the Quality of Sleep
With a few adjustments in lifestyle and some inner empathy,
communication, and cooperation, you can improve your sleep.

Making Your Bedroom a Pleasant Place for Sleep

Make your bedroom, or the place where you sleep, a safe and
comfortable place for all parts of yourself. Set an agreeable
temperature in your bedroom: A bit cooler is usually preferable.
Make sure you have sufficient light to be able to get your bearings
if you wake up during the night, for instance, a night light or dim
lamp. It is helpful for your bedroom to be relatively uncluttered and
for your bed linens to be fresh. If you wish, spray a nice fragrance
in your room before sleep. Use the anchors you developed in the
exercise from chapters 1 and 2 and have them in full view in your
bedroom, to remind you of being in the present. Ensure that all
parts of yourself have anchors that are helpful to them. Also create
a “sleep kit” for yourself (see Homework Sheet 9.3). Remove items
from your bedroom that may be triggering. These could be objects
or colors that remind you of the past, but they could also be certain
sounds or smells. Some people find it helpful to take out everything
from their room that would be a distraction from sleep, including
televisions, radios, and video games. Others find it helpful to have
background noise, such as soft music or the TV, in order to sleep.
However, if you need noise, a steady, droning “white” noise is
preferable for sleeping, such as a fan.
If you, or parts of you, feel afraid during the night, make sure
your home is as secure as possible, for instance, lock the doors and
install a security system if you feel the need. Some people feel safer
with a pet in the house. Have your local emergency phone number
preprogrammed into your phone, and keep your phone by your bed.
These are common-sense precautions, but they may also provide an
extra feeling of security for parts of you.

Preparing All Parts of Yourself for Sleep

Take the time to communicate with all parts of yourself so that you
have maximum awareness of your concerns and needs about
sleeping. It is essential that internal agreement is made about a
regular time for you (all parts of you) to sleep each night. Some
parts may be active during the night because they perceive it as
“their time,” when you are not burdened by the responsibilities of
daily life. This activity is a sign that you are not giving yourself
sufficient personal time during the day. If you can communicate
and negotiate with these parts and allow for some regular personal
time during the day, you may see a drastic decrease in activity
during the night.
Some parts may have preferences about sleeping that other parts
do not share. Please be respectful of all parts of yourself, and pay
attention to everything that comes to your mind about improving
your sleep. For example, you may have a strong desire to keep a
stuffed animal on the bed, but as an adult, this makes you
uncomfortable. If there are parts of you who experience themselves
as younger, you may need to address their needs compassionately
and find compromises that are acceptable for all parts. Remember
that parts can be stuck in the past and experience themselves as
young, and your job as an adult is to help those parts of you feel
secure and safe in the present.

Establishing Sleep Routines

Everyone finds it helpful to have a regular time to go bed and to get
up. Set a time that is reasonable for going to sleep and aim to go to
bed around that time every night. It can be helpful to engage in
restful and relaxing activities before bed, activities that are not too
stimulating. For example, read a nice book, watch a funny TV
program, listen to your favorite music, take a relaxing bath or
shower, or a have a caffeine-free drink and small healthy snack.
Make a regular routine of activities that slowly wind you down
toward sleep.
Some people like to imagine younger parts of themselves
gathering around for a story, or imagine tucking them in to bed.
One person liked to hug a pillow as though she were hugging a
child, as she talked to her young self inside: “Don’t forget that I am
taking care of you and that you are safe.” Make sure that you, in
your own way, communicate with all parts of yourself to remind
yourself that you are safe and it is OK to go to sleep.
Most people prefer to wear something when they are sleeping—
pajamas might provide a feeling of safety and protection. Avoid
sleeping in your daytime clothing, because it may not be
comfortable, and changing into pajamas is a nice ritual that reminds
you it is now bedtime.
 If you have a TV in your bedroom and you need the sound to
help you sleep, make sure you do not watch programs that might be
upsetting to you or to parts of yourself. The point is to determine
what helps you get to sleep and stay asleep on a regular basis. Some
people prefer music, as long as it is relaxing and soothing. Others
enjoy recorded nature sounds, such as the ocean or the wind in the
trees. If you like to read and it helps you go to sleep, do so quietly
in bed for a while, but make sure what you are reading is pleasant
and not overly stimulating. If you read to avoid going to sleep, then
try not to take a book to bed with you. Try a short relaxation or
meditation exercise before going to sleep. One nice meditation is to
reflect on three or four things for which you are especially grateful
in your life.

Tips for Dealing With Specific Sleep Problems

If You Cannot Slow Down Your Thoughts

• Check with all parts inside. Ask whether some part of you
needs to communicate inside. If so, ask that part whether it
can wait until the next day. It is important to be able to
temporarily delay worry and thoughts that interfere with
much needed sleep. Find out whether parts of you need
something to be different in order to get to sleep. Be attentive
to and respectful of all parts of yourself.
• Distract yourself.

Count sheep (or your favorite animal), or count backward

slowly from 100 and stay focused on that mental activity,
as silly as it may sound. It keeps your mind from straying
into problem areas that would keep you awake. Each time
you lose track of the count, bring yourself back and start
at the beginning.
Imagine a big STOP sign each time you start thinking
about something. After you see the stop sign, refocus your
attention on breathing slowly in and out. Breathe in to the
count of three, hold for a count of three, and breathe out
to a count of three. Repeat several times, just focusing on
your breathing.
When you cannot get your mind off your problems when
 you lie down, imagine your thoughts flowing past you in
a stream, and one by one, they flow past you, and down
the stream. You know they are there, but you have no
need to do anything other than observe them flow through
your mind.
Some people find it helpful to get up and write down what
is bothering them, with an internal promise that they will
deal with it the next day.
Imagine putting your problems in a safe container
(computer file, bank vault, box, etc.) for the night. You
can return to them at the right time the following day.
Imagine one of the following:

A warm, white light that envelops you such that you

feel utterly relaxed and safe
A beautiful balloon that you inflate. As you blow air
into the balloon, imagine blowing all your tension and
problems into the balloon. When you feel more relaxed,
tie the balloon and allow it to float up into the sky. If
you wish, you may keep it on a string.
Leaning back against a very safe and caring person
Use one of the additional relaxing imagery exercises in
chapter 11.

If You Cannot Sleep After a Reasonable Amount of Time

• Turn the clock away so you cannot keep checking the time.
You will only become obsessed with the time if you cannot
get to sleep, which will make the problem worse.
• Remind yourself that there will be times when you cannot
sleep. You have always been able to function the next day. If
you cannot sleep tonight, then you may take something to
help you sleep the following night. Your body will eventually
sleep.
• Stop trying to make yourself go to sleep. Get up and go to
another room (or another part of the bedroom), do something
quiet to distract yourself (for instance, read a book or watch a
TV program that is not too exciting, listen to peaceful music,
do some stretching exercises), and go back to bed when you
feel sleepy. Do this as often as necessary during the night.
If You Wake Up After a Nightmare

• If you wake up at night after a disturbing dream or nightmare,

or feel anxious and panicky, it is important to be able to calm
down and comfort yourself and other parts that are anxious.
Work with yourself and your therapist to develop various
ways to help yourself.
• The first step is always to get your bearings in the present.
Use all the anchors to the present you have put in your
bedroom. Talk to yourself quietly and tell yourself out loud
where you are.
• Turn on the light and get out of bed. Perhaps have something
to drink and find something to distract you.
• Splash cool or cold water on your face, hands, and the back
of your neck. This will help you get more present and awake.
• Consciously slow your breathing. Try some breathing
exercises.
• Do some gentle stretching exercises to help your body
reorient to the present.
• If you have a pet, spend a little time petting or cuddling with
him or her.
• If you have physical symptoms, such as a bad taste in your
mouth, or pain or discomfort, be mindful in talking to
yourself inwardly as you do things to soothe yourself (for
instance, brush your teeth, have a noncaffeinated drink, suck
on a mint or hard candy, massage painful muscles): “I am in
the present now. Whatever happened to me is over. I am safe.
My mouth, my legs, my body, etc., are in the present. I am
doing all I can to help all parts of myself.” Try to be aware of
any internal sense of what might help.
• Some people find that it helps if they write down a distressing
dream or image and then put it away, tear it up, or bring it to
therapy. The idea is not to go further into the experience, but
to contain it by putting it on paper and leaving it until a more
appropriate time.
• You might try “changing” your nightmare. Add a supportive
or strong person to the dream, invent a way out of the
situation, or give yourself special powers to overcome any
sense of powerlessness or fear in the dream. Your therapist
may be able to help you with this kind of technique.
 • Some people wake up from a nightmare and find they are
unable to move. Although this is extremely uncomfortable
and even frightening, it will not last for very long. It is
simply the state of being paralyzed by fear. If this happens to
you, make sure you have some anchors to the present visible
from every angle from the bed: on your left, your right, even
on the ceiling. Even though you cannot yet move, you can
begin to see the anchor and gradually perceive you are in the
present. This perception will help your body shift out of that
paralysis mode. Try starting with a tiny movement, for
instance, blinking your eyes, and just barely twitching your
toe or little finger. When you can do this, then move the
opposite toe or finger. Then make a slight movement with
your hand or foot, then your arms or legs. Continue slowly
and patiently until your entire body has become more able to
move.

Using Sleep Medication Appropriately

If you have persistent sleep difficulties in spite of trying these
solutions, make sure you are checked by your physician. There may
be medical reasons for your sleep issues. Sleep disorders often
accompany trauma-related disorders. Ask your doctor about
whether you may need a sleep medication. Check with your doctor
before you take any nonprescription medications or herbs, because
they may interfere with your prescribed medications. Many sleep
medications are addictive; thus, they should be taken only as
prescribed. They cannot be mixed with other types of sedatives or
with alcohol or drugs. Often, it is sufficient to use medication for a
couple of nights to get yourself in a routine and then stop taking
them until the next time you have trouble.


Homework Sheet 9.1

Sleep Record
Use the record below to record your sleep difficulties during the
following week.


Homework Sheet 9.2

Making Your Bedroom a Pleasant Place for Sleep

1. Check to make sure your bedroom feels comfortable for all parts
of you. Describe your thoughts, emotions, and sensations when you
look around the room.

2. List anything you can and want to change in your bedroom to

make it more comfortable. What would you or parts of you like to
change?

3. Describe any inner conflict about your bedroom.

4. Notice any items that might trigger you. Remove or change them
if you are able. If it is not possible to remove or change them, post
a little note that says something like, “All is well here and now,” to
remind you of the present. Also, intentionally notice the difference
in the context for the item in the present. For example, “This bed
reminds me of my bed as a child, but it is in my room, with my
linens, on my floor. It is just a bed, and beds cannot hurt or scare. It
is just a thing.”


Homework Sheet 9.3

Developing a Sleep Kit
Develop a “sleep kit,” a real or imagined box full of items that can
help to reassure and calm you and all parts of you and bring you
back to the here and now. You can use your sleep kit before you go
to bed or if you awaken during the night feeling anxious or
triggered. Your kit might include relaxing and soothing music or
sounds, anchoring items, a special pillow or blanket, a night light, a
favorite piece of clothing, a doll or stuffed animal, a wonderful
book, photographs of people who care for you, or of safe and
relaxing places, a list of people you can call if needed during an
emergency, a list of pleasant experiences, or even a pet that helps
you feel safe. Remember that it is important to take into account the
needs and preferences of all parts in developing your sleep kit. List
your sleep kit items below.


Homework Sheet 9.4

Developing a Bedtime Routine

1. Describe what helps you and all parts of yourself to unwind and
prepare for bed.

2. List activities you know you should avoid before bedtime.

3. Describe a routine that you have or would like to establish once

you get in bed (for instance, a short meditation, breathing exercises,
imagery, reading a nice story).

4. Describe the best way for you to check in with all parts of
yourself at bedtime, and remind yourself that you are safe and it is
now time to sleep safely and comfortably (for example, talking
inwardly, asking inside, imagining all parts in a circle or curled up
in nice beds).

5. Are you willing and able to go to bed and get up at

approximately the same time every day? List your approximate
bedtime and wake time. If you are not willing or able, please
describe the reasons below. Obstacles to a regular sleep routine are
important to address.
 CHAPTER TEN

Establishing a Healthy Daily

Structure

AGENDA
• Welcome and reflections on previous session
• Homework discussion
• Exercises
• Break
• Topic: Establishing a Healthy Daily Structure

Introduction
Problems With Daily Structure for People With a
Complex Dissociative Disorder
Reflections on Developing a Healthy Daily Structure
Keeping Track of Time
Tips for Keeping Track of Time
Developing Healthy Work Habits
Reflections on Developing a New Healthy Daily
Structure
• Homework

Reread the chapter.

Continue working on your sleep kit and bedtime
routine if needed.
Complete Homework Sheet 10.1, Your Current Daily
Structure.
Complete Homework Sheet 10.2, Developing a
Realistic and Healthy Daily Structure and Routine.

Introduction
A daily and weekly structure, with a balanced distribution of work,
activity, and leisure, is of great importance for everyone. A
satisfying life includes knowing how to enjoy working but also how
to enjoy and use to best advantage your leisure or free time.
Everyone does best with a daily structure that is consistent, but not
too rigid. Structure helps people keep track of time and of what
they are doing, so they can be more attentive and able to
concentrate, and less worried or confused about what comes next.
Structure may help reduce the risk of intrusion of, or switching
among, parts of the personality; it may also help reduce the risk of
prolonged flashbacks or sinking into depression. Everyone has the
need to start and complete certain tasks in a timely manner, to
manage a household, and to make relatively balanced choices about
how he or she spends free time.
Daily and weekly structures should include a regular time to get
up and go to bed, regular and healthy meals, necessary chores (for
instance, shopping, cooking, paying bills, cleaning), time for
relationships and social contacts, personal (“me”) time, inner
check-ins, physical exercise, fun, and other safely stimulating
activities, and so forth. In this chapter we will focus on tools for
establishing a daily structure, including keeping track of time,
healthy work habits, and using your leisure time to best advantage.

Problems With Daily Structure for People With a

Complex Dissociative Disorder
The establishment of a daily structure is often difficult for
individuals with a dissociative disorder for a number of the
following reasons:

• Disrupted time sense and an often chaotic and conflicted

inner world.
• Dissociative parts may fight for time and have many
conflicting wishes, needs, and preferences about how to
spend time.
• As a consequence, different parts may begin certain activities
but cannot finish because other parts interfere or shift to
another task.
• Difficulty concentrating and completing tasks.
• Problems with impulse control and difficulty finishing a task
that does not easily hold your attention, for instance,
 cleaning, paying bills, studying.
• Structure and routine were often not something that was
modeled for you as a child, so you never learned how to
develop and keep a healthy structure and have not
experienced its benefits.
• You may have created an excessive and rigid structure,
incessantly going from one activity to the next, never taking a
rest, exhausting yourself (see also discussion that follows).

Finding a balance in your daily structure may present a big

challenge. Too much structure and busyness may be a way for you
to avoid feeling or knowing more about yourself or your inner
world. And perhaps it may be an attempt to feel competent by
doing “everything” or to prevent other parts from taking over from
you. But excessive busyness can deplete you more than you might
be aware.
On the other hand, if you have too little structure, problematic
symptoms can increase dramatically. Perhaps it is difficult for you
to decide exactly what you would like to do, or you have no idea
what you want or need to do, and thus plan nothing for the day.
You may notice that you have a more difficult time on totally
unstructured days, especially on the weekends. You may start and
stop a number of different tasks without finishing anything. This
“start-stop” behavior, often due to the interference of parts, leaves
all parts of you burdened by yet more unfinished business,
depleting your energy further. Or perhaps you feel unmotivated to
do anything, and just sit, watch TV, play computer games, or sleep.
For people with DID, some parts may be active at the expense
of others, so that they lose time and do things that they were not
intending to do, for instance, painting or watching TV instead of
completing tasks that need to be done, such as cleaning the house.
And without inner communication and cooperation, the activities
and plans of some parts may overlap and interfere with those of
other parts of yourself. Then you may find yourself overcommitted,
adding to a sense of being overwhelmed and conflicted.

Reflections on Developing a Healthy Daily Structure

Make a list of your basic daily tasks, for example, work or
volunteer time, taking care of children, cleaning, shopping and
other errands, cooking, laundry, paying bills, taking care of pets,
gardening or yard work, and so on. If more than one part of you is
engaged in these tasks, set aside some quiet time to communicate
and coordinate a reasonable schedule. The following questions may
be important as part of your inner reflection:

• Are there specific tasks that cause inner problems among

parts? For example, is a part triggered by caring for children,
or overwhelmed by the many choices presented to you in the
grocery store, or too impulsive to deal with spending money?
• If there are inner problems evoked by a certain task, which
seem the easiest to solve? Begin with that problem and as
you gain more confidence and practice with inner
communication and cooperation, you may move to the next
problem. Remember to be patient: You cannot change
everything at once, and no one expects you to do so.
• Do you or parts of you have a tendency to have too much
structure and exhaust yourself? If so, see if you can notice
why, for example, avoiding feelings or memories, feeling
pressured to achieve, afraid to stop, and so forth.
• What might be the benefits to you and other parts of you if
you were more flexible with your daily structure? For
example, better capacity to tolerate emotions, permission not
to work so hard, and the like.
• What activities are important for you as a whole person?
Negotiate with parts inside to plan a set number of activities
each week that is comfortable and reasonable to you and all
parts of you, not too many and not too few. If you are overly
active and busy, make sure you plan for down time between
engagements. And be sure to plan for the time it takes to get
from one place to another without having to rush.
• Do you or parts of you have too little structure? If so, see if
you can determine why. For example, some people are too
depressed or tired to provide themselves with structure to do
anything; others may not know where to start or how to use
structure, and so on.
• What might parts of you need in order to develop more
structure? For example, more support from other people or
from parts inside, some suggestions for structure, and so
forth.
 • Would you be willing to push just a little to do one or two
activities each day?
• If you decide to develop a new structure or routine, do not
criticize yourself or other parts if you are not able to keep it
all the time. Just try again! You do not have to be perfect to
be successful. For most people, it takes several months (and
sometimes even more) to make a new routine become a more
automatic habit.

Additional Tips

• Everyone needs time for relaxation and pleasure. Make time

for yourself and for parts of yourself every day, preferably
during the day or in the early evening, not at bedtime (see
chapter 11).
• Everyone needs time for personal reflection and inner
deliberation. Some people with a dissociative disorder find it
helpful to have an inner meeting with parts of themselves to
discuss daily routines, plans, and so forth (see chapter 27).
• Engage in some type of physical exercise every day (cycling,
walking, or some other form of activity). Try to go outside
every day and get 15 to 20 minutes of sun.
• Try to have contact with other people at least several times a
week, especially if you live alone. Isolating yourself is often
a habit that is not helpful. Be aware of when you want to
isolate and intentionally make plans with friends or
acquaintances instead, or just walk around where people are
nearby, for example, in a park or a mall.
• If you tend to lose yourself in an activity, try setting an alarm
to stay aware of time. Virtually every personal electronic
device now has reminder alerts that can be set.
• If you are living with someone else, you will both benefit by
having clear and fixed arrangements about who does which
chores. Fuzzy arrangements and lack of clarity can cause
irritation and resentment. You may need to be assertive to
make sure you have personal time for yourself and your
parts, and to make sure the tasks are distributed fairly.
• Many books and Web sites are dedicated to offering practical
tips for organization, routines, and structure. Make use of
these as needed. Personal organizers, trained individuals who
 help with your daily organization, are also available in most
areas.

Keeping Track of Time

A sense of time is essential to maintain structure and routines, but
when you have a dissociative disorder, an accurate time sense and
adequate time management are often problems. It is as though some
parts of you do not live in time and even have trouble
understanding the concept of time (Van der Hart & Steele, 1997).
Time can seem too fast or too slow, gaps of lost time make it hard
to keep track of the day, time may not be experienced at all, and
time sense may differ among various dissociative parts. All these
problems with a sense of time lead to confusion. In addition, many
people with a dissociative disorder have trouble with time
management due to problems with executive functioning, that is,
with planning, organizing, sequencing, and prioritizing abilities.

Tips for Keeping Track of Time

• Use a diary, a calendar, or a planning board, or all three (even

if you feel there is inner conflict about planning). Keep your
calendar in a place where you will see it every day. Mark off
days as they pass so you can easily find the day and date.
• If you have DID and lose time, written communication may
help all parts of you begin to coordinate a single schedule.
Invite parts to use the same planning tool. And the more you
have inner agreement about a schedule, the better you will be
able to keep it. Try to plan one week at a time.
• Put important reminders on your calendar, for instance, due
dates for bills and taxes, appointments, and errands to run
during the week.
• Wear a watch, so you can keep track of hours. Preferably use
a watch that has an alarm, so you can set it as a reminder for
appointments or tasks. Some people prefer to use their cell
phone to track time instead of a watch; that is fine, too, but a
watch on your wrist is a visual reminder to check the time,
perhaps more so than your phone.
• When you have an appointment, set a reminder alarm for 15
minutes before you should leave to make it on time. For
 example, if it will take you 30 minutes to drive to your
therapist, set your alarm to remind you that your appointment
is in 45 minutes. Do not allow yourself to get involved in
another task before you leave.
• Keep a list of things to do and appointments posted on your
refrigerator or calendar, which you will see every day.
• Put a colored hair band around your wrist to remind you that
you need to do something.
• If you tend to lose lists, keep them in a single notebook used
only for that purpose and keep the notebook in the same
place at all times. Make an agreement among parts not to
hide or destroy the notebook.
• Before going to the store, make a list of what you need that is
agreeable to all parts of you, so you need not spend hours
shopping or overspend. Only buy what is on your list; then
leave.
• If you have trouble remembering when and if you have taken
your medication (if you take any), buy a weekly pill
organizer box, available at any pharmacy. Each week, put
your medications in the appropriate box, and you can check
the box to see whether you have taken them. Set an alarm to
take your medication, if necessary.
• If you have DID, you may find some part of you is able to
keep good time and can remind you.

Developing Healthy Work Habits

Whether people go to a job each day, or whether they work at
home, raise children, or volunteer, they all need healthy work
habits. This includes the ability to concentrate and focus, organize
one’s work, start and stop activities on time, and balance work with
other important life priorities. People who work too much set up a
lifestyle of chronic exhaustion, rigidity, and imbalance, which
makes them more vulnerable to switching, flashbacks, and periods
of poor functioning. People who are unable to work generally do
not feel very worthwhile and may be unable to take care of
themselves financially. The resulting stress can lead to increased
symptoms and difficulties.
People often have particular dissociative parts that deal with
work, while other parts may be unaware of work. Some parts may
sabotage or interfere with work or projects, or prefer to play instead
of work. And parts living in trauma-time may become triggered by
various situations at work, such as an angry or irritated boss.
Dissociative parts that are focused solely on work typically are
not sufficiently aware of your body to know when you are tired or
stressed; thus, they tend to overdo. On the whole, such parts may
not be particularly interested in “cooperation” and slowing down
but are often only focused on a work goal that needs to be
accomplished. This is hardly surprising, because such parts likely
use work as a protection against the intrusion of painful memories
or the realization of a painful past, or against dealing with other
dissociative parts that might not be appropriate at work.
All people need to feel successful at their work, whatever it is,
because success helps us feel competent and good about ourselves.
It is thus understandable that people with dissociative disorders do
not want to take the risk of losing that area of competence and thus
are reluctant to decrease the barriers that protect parts that are able
to work. But as noted earlier, overworking prevents you from
having to cope with and confront your inner world. Thus, “staying
busy” and forcing yourself to do more and more is a very common
form of unhealthy coping. To heal, you must develop inner
collaboration to balance yourself in life and cope more effectively.

Reflections on Developing a New Healthy Daily

Structure

• Reflect on how you would like to ideally and realistically

spend your time. Please note if there are conflicts among
parts of you about how to spend time.
• What are your priorities about which activities you would
like to spend your time (for instance, work, being with
friends, play, reading)?
• When do you need more or less structure? Weekends?
Evenings? Daytime? Holidays?
• Are there particular times of day that are especially hard for
you? If so, imagine what changes you could make in your
routines and structure to help you (see chapter 16 on planning
to cope with difficult times).
• Consider how much time you can or should spend on work or
 tasks in a given day.
• Notice how your time is distributed among work/chores, and
leisure/social time, play and rest, and personal (“me”) time.
• Reflect on how to give yourself meaningful private time for
tending to your inner needs (including those of other parts of
you). This should include time for inner reflection and
contact with parts of yourself. How might you structure that
time to be fair and agreeable to all parts of yourself?
• Consider which activities give you energy or drain you of
energy. Try to cooperate with all parts of yourself to set a
realistic daily pace, given your energy level and the amount
of energy your activities give or demand of you.
• Take into account other ways to balance your life, for
example, exercise, socializing, getting out of the house,
enjoying a hobby.


Homework Sheet 10.1

Your Current Daily Structure
Describe your current daily structure and routines so you assess
what is working well for you and what might need to be different.
Include the approximate amount of time you spend in each of the
four categories listed below. You do not have to go into detail.

1. Work / tasks / chores / appointments / meals

2. Leisure and social time, for instance, hobbies, being with friends
or family
3. Personal time for yourself, including inner reflection and
communication with parts
4. Do nothing; that is, watch mindless TV, surf the Internet, play
video games, stare at the wall, sleep, and so on

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday


Homework Sheet 10.2

Developing a Realistic and Healthy Daily Structure and
Routine
Now describe a realistic and healthy structure and routine that you
would like to develop in the next few months. Before you begin,
you may want to refer back to the earlier section on reflections for
helping you develop your new structure and routine. Remember to
change only one thing at a time so you will not become
overwhelmed or discouraged.

1. Work / tasks / chores / appointments / meals

2. Leisure and social time, for instance, hobbies, being with friends
or acquaintances
3. Personal time for yourself, including inner reflection and
communication with parts
4. Do nothing; that is, watch mindless TV, surf the Internet, play
video games, stare at the wall, sleep, and so on

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday
 CHAPTER ELEVEN

Free Time and Relaxation

AGENDA
• Welcome and reflections on previous session
• Homework discussion
• Topic: Free Time and Relaxation

Introduction
Problems With Free Time and Relaxation for People
With a Complex Dissociative Disorder
Tips for Resolving Inner Conflicts About Relaxation
and Free Time
Tips for Managing Free Time
Learning to Safely Relax
Relaxation Exercises

• Homework

Reread the chapter.

Practice the relaxation exercises.
Complete Homework Sheet 11.1, Developing a
Relaxation Kit.
Complete Homework Sheet 11.2, Exploring Inner
Obstacles to Leisure Time and Relaxation.

Introduction
We all need time to safely relax and do what we like. An essential
part of your healing is learning to make use of free time for
relaxation, rejuvenation, fun, and new interests. Learning, laughing,
having fun, and being curious all help maintain balance and
perspective in daily life. In the same way as with balancing work,
people with dissociative disorders need to find the right distribution
of their free time, including personal time to communicate and
work with inner parts. However, for traumatized individuals, a
number of factors may impede the use of what should be healing
relaxation and leisure time.

Problems With Free Time and Relaxation for People

With a Complex Dissociative Disorder
You may find that you avoid free time, relaxation, or leisure
activities, even though other people generally find them to be
rejuvenating and essential. Such unstructured times may present an
opportunity for the inner turmoil and distress that you avoid to rise
up into your awareness. And perhaps you have developed negative
beliefs and fears about free time or relaxation. Thus, you may
encounter some of the following difficulties:

• If you try to relax, you may be afraid of losing control,

becoming overwhelmed, or of having other parts of you take
control.
• Various parts may have different needs and wishes about
leisure time, resulting in conflicts about how you should
spend your free time. And at times, some part might believe
that a particular activity, such as relaxing, is dangerous and
thus inhibits other parts from engaging in it. Ongoing
conflicts may sometimes result in a “stalemate” in which you
do not do anything at all.
• Free time (for instance, weekends, holidays) may trigger
memories of painful past experiences, making it more
difficult to enjoy your time in the present (see chapter 16).
• You may have inner feelings or voices that prohibit pleasure,
enjoyment, or play. Perhaps these messages are shame based,
coming from a belief that you do not deserve to feel good or
that you are lazy. Or they may be based on a fear that you
will “get in trouble” or that “bad things always happen when
you are feeling good.”
• You, or some parts of you, may be afraid to “let down your
guard.” That is, you feel a strong need to be on high alert all
the time and thus find it impossible to relax. In fact, attempts
to relax may actually increase a feeling of being vulnerable
or unsafe.
 The most effective way to deal with inner conflicts about how
to spend your free time is to reflect on the inner concerns, beliefs,
and needs of all parts of yourself. And then, as with all other inner
conflicts, steadily learn to empathize, negotiate, and cooperate
about your leisure time. Of course, it is important to be realistic and
reasonable about what you are able to do: Work, play,
relationships, and relaxation must be balanced and within your
capacity as a whole person. For example, you cannot stay up
having fun all night and expect to go to work and be at your best
the next day. Nor can you work excessively long hours each day
and expect yourself to have quality time for inner reflection and
care for inner parts of yourself. Always consider your
commitments, budget, and energy level in planning your free time.

Tips for Resolving Inner Conflicts About Relaxation

and Free Time
If you experience some of the conflicts described earlier or in
Homework Sheet 11.2 (at the end of this chapter) about free time
and relaxation, try some of the following suggestions to help you
resolve them:

• Take time to reflect on why you might be having difficulties

with free time or relaxation and make a list of these
obstacles.
• Do not judge yourself about these conflicts; just notice them.
• Prioritize as best you can from the least to the most difficult
conflicts on your list. Begin with the least difficult and
gradually work your way through to the most difficult. As
you gain mastery with resolving the less intense conflicts,
you and all parts of yourself become more confident and
trusting with each other, and they will be more willing to take
the next steps.
• Using an inner safe space, meeting room, or by talking
inwardly, determine whether all parts of you might agree that
relaxation might be a good thing if it were completely safe
and allowed. If so, good: You can take the next step. If not,
stop and reflect on why parts of you believe relaxing would
not be helpful even if it were safe and allowed.
• Let yourself imagine, all parts of you, a foreign land in which
 relaxation and free time are encouraged as a natural part of
every day. In this land, everyone works hard, but they also
play hard. No one is in a hurry. No one is critical of others.
No one is punished. Imagine yourself watching people in this
foreign land as they relax, rest, laugh, play, and enjoy
themselves after work. Notice how this image affects all parts
of you.
• You might talk inwardly to remind all parts of you that when
you (all of you) feel safe and relaxed in a safe environment,
there is less chaos and noise inside. All parts might benefit.
Critical or angry parts might find they have to spend less
energy managing young parts of yourself if those parts feel
safe and more relaxed, and even have fun.
• Remind all parts that enjoying relaxation and free time does
not mean you are lazy or not completing your work. It is well
known that people who take time off to relax and rest are
more productive and effective when they do work.
• Remind all parts that it is possible to be alert and relaxed at
the same time.
• If parts continue to feel unsafe in relaxing, ask whether
perhaps one part of you might remain “on guard” while other
parts of you rest. Various parts of you could take turns with
“guard duty” so that each part of you has rest times.
• Make sure you take time to orient all parts to the present and
reassure them that relaxation and free time are allowed and
healthy, and you will not get in trouble for taking some time
for yourself.
• If traumatic memories or intense emotions are triggered when
you have free time, help vulnerable parts to stay in a safe
place during that time, assuring them that they will be
attended to in the near future. And continue to orient them to
the present. Be sure to keep such promises as all parts must
learn to trust each other.
• Engage in inner discussions and negotiation about what to do
in your free time. If there are conflicts, try taking turns, doing
one activity one time, and another activity the next time. Or
try finding activities that are enjoyable to all parts of you (or
at least acceptable). Negotiate healthy “deals” internally. For
example, if a critical part allows you an hour of free time
without complaint, agree that you will work on a specific task
 in return after your free time. Be sure to follow through.
• Take small steps. For example, practice relaxation for 1
minute, if 10 minutes is too much. Or 30 seconds if a minute
is too much. Go only as fast as the slowest part of you, while
always helping such parts by giving them the resources they
need to take a step. Above all, do not be critical of yourself or
other parts of you.

Next you will find some tips on relaxing safely and using your free
time effectively.

Tips for Managing Free Time

• Schedule some free time for yourself every day. Begin by

structuring small amounts of free time, for example, 30
minutes or an hour (less if this amount is not tolerable).
• Become more aware of what activities you, and other parts of
you, might like to do or what you would like to learn to do
for enjoyment. Do not eliminate ideas with arguments about
why you cannot do them. Try to be open to new possibilities
and help other parts be open to trying something new as well.
• Make a list of what you might like to do. Setting aside
differences, are there any activities that all parts of you might
enjoy? Start with one of these activities first.
• If you avoid free time or relaxation, reflect and ask yourself
(or other parts that might be involved) of what you are afraid
or ashamed.
• If you have too much unstructured free time, be willing to
add more activities and use your time toward healing, for
instance, by attending to parts of yourself that need your care.
• If you have no idea what you want to do, notice what other
people do and see whether something appeals to you. Try
taking an art class, volunteering, hiking, or joining a choir.
Do not wait until you are sure about an activity. Try it, and if
you do not like it, you can always stop. Remember that trying
new things is a great way to learn whether you like them and
to have fun in the process.
• Try not to worry about failing. The task is to enjoy learning,
even if you do not do something well.
 • Be persistent and patient with yourself.

Learning to Safely Relax

People who have been traumatized often find it difficult to relax,
because they, or at least some parts of themselves, are almost
always on high alert. They may feel it is not safe to relax because
they would not be able to notice danger. But in reality, relaxation
occurs at many levels of awareness and alertness. A person can be
extremely relaxed, present, and alert or relaxed in a drowsy kind of
way. Being simultaneously alert and relaxed is actually the most
adaptive and flexible way to be most of the time. Parts of you can
help each other to realize this state of mind. In chapter 8, you
learned how to begin to develop an inner sense of safety. That
sense of safety is a foundation that will allow you to learn to relax
more effectively and easily.
To practice relaxation, try one of the following exercises at a
time when you are not pressured to do something or go somewhere,
and when your mind is relatively quiet.
Once you become accustomed to practicing an exercise and are
able to relax, begin using it when you are tired, stressed, or feeling
low. The earlier you intervene with yourself by helping yourself
feel calmer, the more effective the exercise. The following imagery
exercises are meant to help you and all parts of yourself feel better,
stronger, and to regain more emotional balance.
Try making an audio file of one of these exercises so you can
listen to it when you choose. You can do it yourself, or perhaps ask
your therapist or a friend or partner to make it for you. Play around
with the wording first, so that it fits just exactly right for you and
all parts of yourself.
Try one or more of the following exercises. Read through them
first to see whether one is especially appealing to you. If you wish,
you can change the setting (that is, imagine a mountain instead of a
safe tree; a forest instead of a healing pool).

RELAXATION EXERCISES

The Tree
 Sit or lie down somewhere quiet and pleasant and breathe
quietly, closing your eyes safely. Remind all parts of you that
you are safe and that you are working to help each part of you
feel better. Invite all parts to participate. If some parts do not
wish to do so, they may watch from a distance or go to their
own safe place. Gradually direct all parts of you that want to
participate to an imagined scene. This place is a quiet and safe
spot in the open air with beautiful scenery, just the right
temperature, in your favorite season of the year. And around
you, you see magnificent trees, resplendent in their green
finery. Look around slowly for a tree that appeals to you, one
that almost seems to invite you to become acquainted. Perhaps
it is a tree standing alone, tall and proud, or perhaps a tree in a
forest, one of many in a wise and strong community of trees.
Your tree may be short or tall, fat or thin, young or old, firm or
willowy. Take your time to choose your tree and remember that
you can always change to another tree if and when you wish.
Some parts of you may want to choose different trees, each
having their own, and of course, this is just fine. Once you, all
parts of you, have a clear image of your special tree, take your
time to examine it carefully. Notice its shape and texture, its
warm wood scent and palette of colors. Become aware of the
branches spreading out to shelter you, the leafy, soothing green
that extends an invitation for you to relax and rest. Take your
tree in until it becomes a natural memory, indelible in your
mind.
Walk up to your tree and get acquainted. Begin by exploring
the trunk and all its nooks and crannies. Run your hand over
the bark. Notice any knotholes or hollows. Put your arms
around your tree; notice if you can get your arms right round it,
or whether it is so thick you cannot encircle it. Lean up against
your tree. Feel its strength, solid and unyielding, protective and
grounding. If you wish, you can sit under your tree, with your
back comfortably against it, with confidence that it will support
you no matter how hard you lean. Now notice that your tree is
not standing on its own. It has powerful roots that go deep and
deeper, and deeper still into the earth, anchoring it to the
ground, and drawing sustenance up and up, all through the
tree, to the tiptop. Your tree is always grounded and dwells in
the present, its rich history inscribed in its rings, and its
branches ready for the winds that blow. It fears neither fair
weather nor foul, bending with the storm, swaying with the
breeze, resting under the heavens when all is quiet and still. In
rain and wind, sun and snow, storm and showers: always
steady and grounded. Feel this stalwart and faithful presence in
 your mind, in your body, and in your heart. Let you and all parts
of you feel rooted to the earth with your tree. Let you and all
parts of you feel the power and strength, the grounding and
readiness to meet what is, and what shall come, unwavering
and constant. Let yourself feel the power of your tree with its
enormous root system, connected to the earth.
Now draw your attention upwards, to the branches and
boughs, to the limbs and leaves. Each branch is unique, each
weaving with the other to design beautiful foliage that is never
exactly the same from day to day and year to year. The leaves
take in light and create energy. They provide you with shelter
and shade, safety and soothing, their gentle rustle a pleasant
sound in your ears. The play of shadow and light as the
branches move is pleasant to your eyes, giving you a sense
that all is right with the world. You may even want to climb your
tree and sit on one of those branches, gleefully swinging your
legs or thoughtfully surveying your world from up there.
Perhaps you take a nap in the shady haven of your tree. It is a
good, grounding, safe feeling, being with your tree.
Your tree is a refuge where birds may safely nest, small
animals may shelter from the elements, where a tree house
might be built, or a swing hung from its boughs. It is a hideout
that no one can see, that is just for you, where you can retreat
whenever you wish. The strength and beauty and peacefulness
of your magnificent tree give you a feeling of protection and
sturdiness. You, and any parts of you, can go there whenever
you like; you can picture it in your mind and look at it, lean
against it, or hide in it, as you wish or need.

The Healing Pool

Imagine a beautiful pool of water with just the right
surroundings. Perhaps you discover it in a quiet forest, or
nestled in the mountains, or in the midst of a meadow. The air
around it is fresh, clean, and just the right temperature for you.
The season of the year is your favorite. Perhaps it is spring,
with all living things blooming and growing. Perhaps it is
summer, lazy and languid. Or perhaps it is autumn, cool and
crisp. Or perhaps it is winter, a soft blanket of white on the
ground. The water is beautiful, inviting. Perhaps it is still, gently
fed by deep springs, reflecting back to you the sky or trees
above. Perhaps it is flowing and bubbling, at the bottom of a
waterfall or fed by rivers or streams. It may be shallow or deep,
or both at once. It is pleasant to watch, its freshness smells
 joyful and clean. So pleasant that you feel almost drawn to its
safety and soothing. The sounds around you are delightful:
rustling trees or meadow grass, the bubble and babble of water,
happy little animal sounds, and birds calling out joyfully. Notice
what is right for you. Take your time to notice your pool, its
shape, its surroundings, its depth, whether there are little fishes
or just clean, fresh water. Perhaps it is a shimmering blue or
sparkling green, or clear as a crystal. The light dances and
skips across the water and back again to you, inviting you to
take it all deeply in. This water calls you to relax, to feel utter
and complete contentment and safety. It is healing water, the
kind that soothes the sorest body and satiates the thirstiest
soul. It refreshes the worn-out mind, a balm for wounds of the
heart. When you are ready, allow all parts of yourself to explore
your pool and take in its healing energy. Perhaps some parts of
you would like to sit thoughtfully next to the water, while some
might dangle their feet, their toes dabbling in the water. Some
might get in and sit or even float. In fact, you become aware
that the water in this pool is the most special you have ever
encountered. It buoys you up so you cannot sink. It supports
you as you sit, as though you were leaning back into loving
arms. It nurtures and soothes, calms and restores, filling you
with a peace and a lightness so sweet and splendid that you
take it deeply within yourself, to each part of you, to every nook
and cranny of pain and stress and sorrow. Let your tension and
fear, your burdensome shame and worries be drawn from you
to the water and carried away. Let the water surround you, flow
around you, refreshing, relaxing, restoring every part of you. Let
the water surround you, flow around you. Feel it soothing your
body, your mind, your heart. You may remain as long as you
like, until every part of you can feel its gentle healing power.
This is your pool, where all parts of you can come as they
please. It is your special place of healing and hope, soothing
and safety, relief and release. It is yours and yours alone to
have within you, a wellspring of well-being.

If it is hard for you to use imagery for relaxation, try this exercise:

Physical Relaxation
Sit or lie comfortably. Take a deep breath in through your
nose to a slow count of three, hold for three counts, and
breathe out slowly through pursed lips for three counts. Repeat
three times. Now take in a deep breath and tighten every
 muscle in your body as tight as you can from head to toe, hold
to the count of five, and let go, breathing out as deeply as you
can and intentionally relaxing your muscles as much as you
can. Repeat the three deep breaths from the beginning of the
exercise. Then again take in a deep breath and tighten all your
muscles for the count of five, let go and relax, repeat the three
deep breaths. Continue until you feel physically relaxed.

Progressive Muscle Relaxation Technique

The following exercise is a well-known technique that might help
you gradually relax your entire body (Jacobson, 1974). When you
are anxious or fearful, your body becomes tense and you may
experience symptoms such as pain in your neck, shoulders, or back,
tension headaches, tight jaws, tensed muscles in legs or arms, and
sometimes your whole body may seize up. To train yourself to
progressively relax, you will begin by tensing specific groups of
muscles and then releasing the tension; focus on the differences
between the feelings of tension and relaxation of each group of
muscles. You will practice with one area of your body at a time:
head and face, neck, shoulders, back, pelvis, arms and hands, legs
and feet. If you have any injuries, skip that area of your body if
needed. Parts of you may or may not want to participate. As
always, pace yourself and do not force any part of you. Spend some
time collaborating internally to reach an agreement that is
acceptable for all parts of you.
Sit or lie comfortably in a quiet and safe place where you
will not be interrupted. You will tense and relax each muscle
group twice, taking a short break of about 30 seconds between
each cycle, and then move to the next area. When tensing a
muscle group, hold for about 5 seconds, then release and rest
for about 10 seconds. If you wish, you can combine this
exercise with one of the ones described earlier or with your
inner safe space.

• Begin by focusing on your hands. Clench your fists,

feel the tension of your muscles for 5 seconds, and
then release 10 seconds. Concentrate on the
differences between tension and release. Repeat
once more.
• Now focus on your arms, draw your forearms toward
your shoulder, feel the tension in your biceps (5
 seconds), and then let go and relax (10 seconds).
Concentrate on the differences between tension and
release. Repeat once more.
• Tighten your triceps—muscles on the underside of
your upper arms—by stretching your arms out
straight and locking your elbows. Feel the tension in
your triceps and then let go, relaxing your arms.
Concentrate on the differences between tension and
release. Repeat this once more. As your arms relax,
just let them lie by your side or rest on the chair.
• Next, concentrate on your face. Tense the muscles
in your forehead by raising your eyebrows as far as
you can, feel the tension in your face and eyebrows,
hold and then relax. And again, concentrate on the
differences between tension and release. Repeat a
second time.
• Tense the muscles around your eyes by squeezing
them tightly shut and then relax. Observe the
different sensations when you tense and when you
relax your eyes. Repeat.
• Tighten your jaws by opening your mouth as wide as
possible, hold and then relax. Repeat.
• Focus on the muscles in your neck, bow your head,
your chin on your chest, then turn your head slowly
to the left, return to the center line and lean your
head back as far as it will go, then again return your
head to its normal position. Turn your head to the
right and then again to the normal position. Repeat
this slowly and carefully, since there is often a lot of
tension in your neck. And again, concentrate on the
differences between tension and release.
• Focus on your shoulders. Raise them as though you
were going to touch your ears, hold and feel the
tension, and then relax. Focus on the different
sensations between tension and relaxation of your
shoulders. Repeat.
• Then focus on your shoulder blades; pull your
shoulder blades back as though you want them to
touch them together. Tense and release. Notice the
difference between the tension and release. Repeat.
• Stretch your back by sitting up very straight, tighten
and let go, then relax. Repeat and focus on the
different sensations between tension and relaxation.
• Tighten your buttocks by squeezing them together,
hold, and then relax. Repeat.
• Hold your breath, pull your belly in, tighten it, and
relax. Repeat and feel the difference in your
stomach and belly.
• Now focus on your legs. Stretch your legs out and
feel the tension in the muscles of your thighs, hold
on, and then relax your legs. Notice the difference
between tension and release. Repeat.
• Now extend your legs and point your toes back
towards you. Feel the tension in your calves and
feel the relaxation after you let go. Repeat.
• Finally focus on your feet. Point your toes down as
far as possible and feel the tension in the muscles of
your feet; tighten them and then relax. Observe the
different sensations when you tense and when you
relax the muscles in your feet.
• Now scan your whole body mentally and look for
any residual tension. If a particular muscle group is
still tense, return to this area once more.
• Now imagine that relaxation is spreading through
your whole body; your body may feel warm, a bit
heavy, and very safe and relaxed.


Homework Sheet 11.1

Developing a Relaxation Kit
In the same way that you developed a sleep kit in chapter 9, you
may design your own “relaxation kit.”

1. Begin by making a list below of activities and exercises, music,

or other items or experiences that are enjoyable or fun. List things
you imagine would be enjoyable and relaxing, even if you have not
tried them yet. Make sure to take into account the different needs
and desires of all parts of yourself. Highlight any activities that
might be agreeable to all parts of yourself, that is, that you can
enjoy as a whole person.

1.

2.

3.

4.

5.

6.

7.

8.

9.
10.

2. Just as you did with your sleep kit, you may make a special box
or basket with various items for your relaxation and comfort, for
example, music CDs, relaxing videos, special bath salts, pleasant
lotions, a comfortable shawl or sweater, a pair of old slippers, warm
socks, candles, special teas or coffees, healthy snacks, a good book,
favorite photos, or mementos.

3. List one or two new activities you would be willing to try for
relaxation or fun.

4. Describe any inner obstacles to trying these activities.



Homework Sheet 11.2

Exploring Inner Obstacles to Leisure Time and
Relaxation
You may find it difficult to enjoy your free time or to relax. Below
you will find common reasons why this might be so. Check or
circle any that apply and then complete the questions at the end.
You (or a part of you):

• Do not feel comfortable with or know how to “play.”

• Do not like to move your body, so you avoid leisure activities
that require any physical exertion.
• Are afraid or ashamed of the feeling of excitement.
• Are afraid or ashamed of the feeling of enjoyment.
• Believe enjoyment is dangerous or bad.
• Believe you do not deserve to relax or feel good.
• Feel out of control when you are excited or enjoying yourself.
• Are afraid you will fail at any leisure activities.
• Are afraid people will ridicule you.
• Are afraid someone will criticize what you are doing.
• Feel that people will not take you seriously.
• Have a belief that having free time means you are lazy or not
working hard enough.
• Fear that you will be punished if you have a good time.
• Fear that something bad will happen if you enjoy yourself.
• Fear that if you relax, you will not be able to notice danger.
• Find that certain words, such as “relax,” “enjoy,” “pleasure,”
or “play,” are a trigger.
• Experience flashbacks as soon as you start to relax.
• Have panic or serious anxiety as soon as you start to relax.
• Become immediately depressed when you try to relax.
• Feel too much pressure to work and feel guilty or
preoccupied if you try to relax.
• Have inner conflict among parts about relaxation and leisure
time.
• Have trouble being alone, and thus relaxation is more
difficult.
• Other? If so, please describe.
1. Using the list above, and reflecting on other possible reasons,
describe two or three fears, concerns, or beliefs that you, or parts of
you, have that impede your ability to relax and enjoy free time. You
may also refer back to #4 of the previous homework assignment,
where you listed obstacles to trying a new leisure activity.

2. Using the section in this chapter, Tips for Resolving Inner

Conflicts about Relaxation and Free Time, spend time identifying
inner common ground for relaxation and free time. (For example,
all parts might agree to practice relaxation exercises for 15 minutes
each day this week and see if it is helpful. If so, you can negotiate a
next step. If not, parts can discuss what is not agreeable and why,
and renegotiate.) Describe your inner communication and
negotiation below, as well as what worked and did not work for
you.
 CHAPTER TWELVE

Physical Self-Care

AGENDA
• Welcome and reflections on previous session
• Homework discussion
• Topic: Physical Self-Care

Introduction
Factors Affecting Your Body Awareness and Physical
Self-Care
Managing Alcohol, Illicit Drugs, and Prescribed
Medications
Regulating Your Physical Energy
Tips for Resolving Inner Conflicts About Physical
Self-Care
Tips for Improving Your Physical Self-Care

• Homework

Reread the chapter.

Complete Homework Sheet 12.1, Physical Self-Care
Questionnaire.
Complete Homework Sheet 12.2, Making a Healthy
Change in Physical Self-Care.

Introduction
Taking care of your body and maintaining your physical health are
important aspects of healing and living well. Your body is not
separate from you, even though it may feel like a “thing” with
which you do not want to bother sometimes. But your body is you,
and you are your body. Your emotions involve physiological
changes in your body that produce physical sensations and
movements; your beliefs and perceptions are mirrored in your
posture, movements, and level of physical arousal. Your physical
health affects your mental health, and vice versa. Many people who
have experienced childhood abuse and neglect avoid dealing with
their bodies or even find them disgusting or terrifying. Healing
comes through more compassionate acceptance of mind and body
as one together. This acceptance is not always easy or quick to
accomplish, but it is an important goal for you and parts of
yourself. In this chapter we will discuss some basic ways to care for
yourself physically and overcome some of your reluctance about
dealing with your body.

Factors Affecting Your Body Awareness and

Physical Self-Care
People with a dissociative disorder may have many reasons for
avoiding their bodies and neglecting physical self-care. In the
following sections we discuss some of the major factors, which you
may recognize for yourself.

Basic Physical Self-Care Was Never Learned

Some families neither practice nor teach their children basic
physical self-care. Such children may not have ever been taught to
care for their bodies, to prevent disease, to eat healthily and
exercise, to get routine medical and dental checkups, or to
recognize symptoms that require a visit to the doctor. These skills
can be acquired with practice, attention, and persistence, and you
can find a multitude of readily available resources on physical self-
care.

The Body Is Perceived as an Object of Fear, Hatred, Disgust,

or Shame
Many people with a dissociative disorder, or at least some parts of
them, find their bodies repulsive. There is no enjoyment of their
physical being, and their bodies feel alien to them, a burden, and a
reason for others to find them undesirable. They tend to avoid
certain physical sensations, movements, or postures. They often
perceive their bodies as objects, not as an integral part of existence.
In addition, control issues can be evoked if people do not feel well
and cannot function in the way that they want or find they are
physically weaker or less attractive than they wish. The body can
seem like an enemy when it is expected to be perfect and function
like a machine.
When people are abused by others, they often experience
physical pain in their bodies, as well as emotional pain. And of
course, emotional pain can be experienced intensely at the physical
level of the body. Thus, survivors sometimes condition themselves
to avoid their bodies in order to avoid pain and suffering.
Others tend to blame their bodies as the reason they were
abused and thus feel terrible shame. For example, people may
believe that if only their bodies had been stronger, they could have
stopped the abuse. They blame their bodies for what happened,
instead of accepting that they were too young to stop what
happened. And sometimes, certain parts of the personality may
hold this belief, while others may not.
Some people who were sexually abused may have been told
that their bodies were beautiful and thus blame themselves for what
happened: “If only I had not been so pretty!” They may develop
shame and hatred for their bodies. For example, some women (or
parts of themselves) come to hate anything feminine about their
bodies. They have associated being female with being abused:
“Girls get abused; therefore, I hate being a girl. My body is bad
because it is female.”

Dissociation Involves Altered Physical Sensations

Dissociation not only involves mental symptoms but also physical
ones, some of which are intense and uncomfortable. On the other
hand, dissociation may involve physical numbness or diminished
pain sensitivity. You may want to review some of these symptoms
in chapter 2. Dissociative parts of the personality that are stuck in
the past may reexperience in the present some physical sensations
related to past trauma, such as pain or cold. Such seemingly
“unexplained” intrusive sensations can be frightening and
confusing, and thus people may become increasingly avoidant and
unaware of their bodies. Some people have difficulty distinguishing
between physical pain that is the result of an injury or illness in the
present and pain that is a reexperience of the past. If you are not
sure whether a certain symptom stems from a traumatic experience
or is associated with a current physical problem, do not hesitate to
discuss it with your therapist and your primary care physician.
Many people with a dissociative disorder report some degree of
physical numbness and thus may not experience normal levels of
sensation and pain. They have difficulty, for example, in
determining whether bath water is too hot or cold, or they do not
notice when they have hurt themselves. They also may tend to
ignore fatigue, hunger, thirst, and other bodily needs to the
detriment of physical well-being. Thus, their bodies suffer from
neglect.
While some parts are too numb, others may be exquisitely
sensitive to the slightest of physical changes and find discomfort or
pain intolerable. It is as though they experience their bodies as
constant irritants, at best. They may become increasingly reactive
to and phobic of body sensations.
And of course, every emotion you experience is accompanied
by its own set of physical sensations, muscle tension, posture, and
tendencies to move. If you are afraid or ashamed of an emotion (or
a particular thought), you likely have also learned to avoid the
physical experiences of it as well.
In sum, you, or parts of you, may have learned over time that
physical pain could be intolerable (during abuse); you may have
associated your body with that abuse; subsequent intrusive
dissociative experiences in your body were painful or frightening;
and the physical experience of emotions (or thoughts) may have felt
overwhelming to you. For all these reasons, you have perhaps
learned to despise, fear, or be ashamed of your body, making it
difficult to take care of yourself.

Failure of Parts to Accept the Body as Their Own

In DID, some dissociative parts that experience themselves as
relatively separate from the individual may not experience the body
as belonging to them. Such parts may believe they have a different
body and may not experience bodily sensations that other parts do,
and they may even want to “get rid of” or hurt the body, as though
it is a foreign object or belongs to another person. If the individual
has a physical problem, such parts may deny that it exists because
they do not feel the body. They may even “see” their body as being
entirely different than in reality. Occasionally these parts may hurt
the body with impunity because they insist it is not theirs, or they
may engage in risky behaviors because they do not believe the
individual is affected.
Physical Self-Care May Trigger a Phobia of Inner
Experiences
Physical self-care involves at least some degree of body awareness.
People with a dissociative disorder have often learned to avoid their
bodies in order to avoid particular inner experiences such as
traumatic memories, disturbing thoughts, or painful emotions. The
image of their bodies, or awareness of sensations or movement, can
suddenly evoke traumatic memories. For example, some people
find that paying attention to their body as they try to practice
breathing exercises, or in the normal course of washing, can evoke
difficult memories, feelings, and sensations. For some, looking in
the mirror may evoke an instant feeling of shame or self-hatred.

Fear of Doctors or Physical Examination

Many people with a dissociative disorder find going to the doctor
and getting a physical exam very anxiety producing; thus, they do
not seek medical care when they need it. Some parts may be afraid
to be touched or find that being “looked at” is a trigger. They may
not trust doctors or nurses for various reasons, or they may fear
being out of control or trapped. They sometimes are afraid they are
exaggerating and will be ridiculed, or will not be taken seriously, or
will be told something is wrong and do not feel they can handle
“bad news.”
Because people with a dissociative disorder often have a lot of
physical symptoms that have no obvious cause, they may have been
told that their symptoms are “in their head,” resulting in feeling
ashamed and belittled. Actually, their physical symptoms are in
their mind and also in their body, as are all symptoms for everyone.
The mind and body are inseparable. Such individuals are not
imagining their symptoms; rather, these symptoms may be a
combination of physical intrusions from dissociative parts, and the
chronic stress response of the body, the latter of which often leads
to more serious physical problems over time.
Note: Make sure you find a competent and understanding
primary care physician. Make a list of qualities you would like to
have in a doctor and interview several to find a best fit for you. Ask
friends for recommendations. If you feel it would be helpful, you
may ask your therapist and physician to be in contact with each
other to ensure that you have an integrated health team.
Managing Alcohol, Illicit Drugs, and Prescribed
Medications
Many traumatized people tend to self-medicate with substances
because they have chronic inner chaos, depression, anxiety,
flashbacks, loneliness, or other emotional pain. They may misuse
drugs or alcohol or prescription drugs to relax, numb out, or feel
better in the short run. In some cases, particular dissociative parts
of a person will misuse substances and there may be inner conflict
about using. In a few cases, a person with DID may have little to no
awareness (amnesia) that a part is using drugs or alcohol. Self-
medication can easily lead to addiction over time.
Although this manual does not address addiction treatment, if
you are dependent on substances or are abusing them, it is of the
utmost importance to share this problem with your therapist and
make it a major focus of your current treatment. Any addiction
seriously complicates the effects of being traumatized and
interferes with treatment. If you are not sure whether you are self-
medicating or addicted, please discuss it with your therapist. Keep a
record of what you use, how much, how often, and what prompted
you to use. You can draw on the skills in this manual to help
yourself learn to handle your problems more effectively than by
using substances.
Many psychiatric medications are meant to be taken on a
regular basis, every day, unless otherwise prescribed. You should
understand what you are taking, why you are taking it, and have a
basic understanding of how it works. Perhaps you have inner
conflicts among parts about taking medication. Some parts may
believe taking medication is a sign of “weakness” or a “crutch.”
Nothing could be further from the truth. Psychiatric medications
often help your brain function more effectively, just as a heart
medication might make your heart work better if you have a cardiac
problem, or as insulin augments what your pancreas is not able to
produce if you have diabetes. Make sure you take your medication
as prescribed. Some medications (for example, antidepressants)
take days or even weeks to become effective: They cannot be taken
only during times when you feel bad. Others that act quickly and
have short-term effects should not be taken too often: These are
generally prescribed to take “as needed.” For instance, you may
have been given something for anxiety that you take only when you
feel especially anxious. Either before or when you take this type of
medication, also use your skills to calm yourself and all parts of
you. For example, talk inwardly to orient and calm parts of
yourself, listen to what parts may need, step back and reflect on
your inner experience, practice relaxation or safe space exercises,
go for a walk, or call a friend. Finally, feel free to discuss your
medications with your doctor and share inner conflicts about them
with your therapist (and your doctor, if applicable).

Regulating Your Physical Energy

Physical self-care involves regulating your energy level. Almost all
people with a dissociative disorder have some difficulty regulating
their energy. Some push themselves beyond what is reasonable, for
instance, by working too much or spending too much time doing
for others, and thus are constantly exhausted and depleted. Others
are far too inactive, which further contributes to lethargy,
depression, and disinterest in life. It is essential for you to learn to
pay attention to your body’s signals of hunger, thirst, fatigue, and
illness. Your body needs replenishment and rest on the one hand,
and activity on the other. It is essential to reach a degree of
cooperation among parts of yourself to ensure you have the proper
amount of rest and activity for your healing (see also chapters 10
and 11).

Tips for Resolving Inner Conflicts About Physical

Self-Care

• Take time to reflect on why you might be having difficulties

with physical self-care and/or body awareness and make a list
of them.
• Do not judge yourself about these conflicts; just notice them.
• Prioritize as best you can from the least to the most difficult
conflicts on your list. Begin with the least difficult and
gradually work your way through to the most difficult. As
you gain mastery with resolving the less intense conflicts,
you and all parts of yourself become more confident and
trusting with each other, and you will be more willing to take
the next steps.
 • Using an inner safe space, meeting room, or by talking
inwardly, determine whether all parts of you might agree that
physical self-care might be a good thing if it was completely
safe and allowed. If so, good: You can take the next step. If
not, stop and reflect on why parts of you believe taking care
of yourself would not be helpful even if it was safe and
allowed.
• You might talk inwardly to remind all parts of you that when
you (all of you) take care of yourself, you feel better
physically, which helps you feel better emotionally. All parts
might benefit.
• Remind all parts of you that your body is safe in the present
and that body sensations are normal messages to help you
care for yourself.
• If parts of you believe you do not deserve to take care of
yourself, remind them that self-care has nothing to do with
being deserving. Those parts might prefer, for the time being,
to think of self-care as similar to maintenance of your car.
Your car needs gas to take you where you need to go; it
needs repairs to run. You cannot just neglect it. You need rest
and replenishment to do what you need to do and health
maintenance so you can continue doing what you do.
• Make sure you take time to orient all parts to the present and
reassure them that you will not get in trouble for taking care
of yourself.
• If traumatic memories or intense emotions are triggered when
you become aware of your body, help vulnerable parts to stay
in a safe place during that time (for example, when you
shower or bathe), assuring them that they will be attended to
in the near future. And continue to orient them to the present.
Be sure to keep such promises.
• Engage in inner discussions and negotiation about the ways
in which you can engage in physical self-care. If there are
conflicts, be open to hearing respectfully another point of
view and try to find common ground, that is, those self-care
activities on which all parts of you can agree.

Tips for Improving Your Physical Self-Care

• Learn to understand the messages your body gives you. Are
you able to recognize when you are tired, hungry, thirsty,
cold, hot, in pain, or ill?
• Are you able to distinguish—at least some of the time—
between a sensation or symptom that is part of a flashback
and those that are indications of present-day illness or injury?
If you have pain or other physical discomfort, you might
check inwardly to see whether any part of you might be able
to help you understand better.
• When you get up each morning, check in with yourself not
only emotionally but also physically. How do you feel in
your body? Tired? Ill? Energetic? Sore muscles? Achy
joints? Stomachache or headache? Relaxed? These physical
sensations are messages about your physical and emotional
needs.
• Practice physical relaxation every day, as noted in earlier
chapters. Develop internal agreement about these activities
and times you should practice them. Chronic physical tension
adds to mental and emotional stress, and it takes a toll on
your body.
• Exercise regularly, even if only a little.
• Make sure you are getting enough rest. Most people need 7 to
8 hours of sleep each night; some need a little more or less.
People with a dissociative disorder usually sleep much less,
but if sleeping is a problem make sure you are at least taking
short rests during the day. All parts of you need to agree that
a specific time is set aside for sleep (see chapter 9).
• If doctor or dentist appointments are difficult, try taking a
supportive person with you, talk with your doctor or dentist
about your anxiety, practice relaxation techniques, and
imagine parts of you being in a safe place during the
appointment, or perhaps sleeping through it (see chapter 8 on
inner safe places). If needed, take a prescribed antianxiety
medication before you go, if you have one. It also helps to
write down your fears, including those of other parts, and
challenge them or think about how you could help yourself
make the appointments less scary or shameful.
• Imagine caring for young parts of yourself internally, if that
is helpful to you. For example, imagine giving them a warm
bath, pampering them physically, giving them a sense of
being cared about and cared for. Or imagine that all parts of
you are experiencing the self-care you are giving yourself.
All parts need to be reminded that self-care is a part of daily
life and necessary for healing.


Homework Sheet 12.1

Physical Self-Care Questionnaire
The following questions are designed to help you learn more about
your areas of strengths and need for growth in physical self-care.
This is not a test: There is no pass or fail. Various parts of you may
have different answers to the same question. If so, note it so you
can understand and help those parts of yourself. Completing this
questionnaire will help you chose one or two target areas on which
you would like to work as a beginning to better self-care (see
Homework Sheet 12.3).

For each question, circle the number that best applies to you at the
present time:

0 Does not apply to me

1 Rarely applies to me
2 Sometimes applies to me
3 Often applies to me
4 Almost always applies

1. I pay very little attention to my physical health. 0 1 2 3 4

2. My physical health is poor. 0 1 2 3 4
3. I am afraid to see a doctor. 0 1 2 3 4
4. I do not have a primary care doctor. 0 1 2 3 4
5. I never see a doctor even if I have serious symptoms. 0 1 2 3 4
6. I have trouble feeling pain or cold/heat in my body. 0 1 2 3 4
7. I am afraid to go to the dentist. 0 1 2 3 4
8. I never see a dentist. 0 1 2 3 4
9. I do not eat healthy meals. 0 1 2 3 4
10. I often forget to eat. 0 1 2 3 4

11. I eat at irregular times. 0 1 2 3 4

12. I am underweight. 0 1 2 3 4
13. My weight often fluctuates. 0 1 2 3 4
14. I regularly have bouts of binge eating. 0 1 2 3 4
15. I frequently vomit after eating. 0 1 2 3 4
16. I take laxatives regularly. 0 1 2 3 4
17. I am inclined to overeat. 0 1 2 3 4
18. I am overweight. 0 1 2 3 4
19. I exercise more than 2 hours a day. 0 1 2 3 4
20. I exercise regularly. 0 1 2 3 4
21. I do not get enough exercise. 0 1 2 3 4
22. I have physical problems that I am ashamed
to discuss. 0 1 2 3 4
23. I do not follow through with medical 0 1 2 3 4
recommendations
24. I am afraid to take prescribed medication. 0 1 2 3 4
25. I take medications for all my aches and pains. 0 1 2 3 4
26. I have daily aches and pains that really bother me. 0 1 2 3 4
27. People tell me I drink too much sometimes. 0 1 2 3 4
28. I drink alcohol when I feel upset. 0 1 2 3 4
29. I sometimes drink until I pass out. 0 1 2 3 4
30. I use illicit drugs socially. 0 1 2 3 4
31. I use illicit drugs when I am upset. 0 1 2 3 4
32. I do not recognize hunger or thirst. 0 1 2 3 4
33. I do not recognize when I am tired. 0 1 2 3 4
34. I have physical problems, but a doctor has told me 0 1 2 3 4
there is nothing wrong, or that it is “in my head.”
35. I do not get enough rest. 0 1 2 3 4
36. I stay busy all the time. 0 1 2 3 4
37. I do not have any energy. 0 1 2 3 4
38. I sleep too much. 0 1 2 3 4
39. I have trouble sleeping. 0 1 2 3 4
40. I cannot tell if I am really physically sick or not. 0 1 2 3 4


Homework Sheet 12.2

Making a Healthy Change in Physical Self-Care
Look over the previous questionnaire. Choose one or two target
areas on which you would like to work. Complete the section
below. Remember to take small steps toward changing your
behaviors and habits. It takes a few months for a change to become
a habit. Enlist the support of your therapist and others who can help
you.

Example
Item number (from the questionnaire): #22 I have physical problems I am
ashamed to discuss.

Describe your problems in this area: I feel ashamed to talk about my body. I
feel like I have done something wrong, if something is wrong with my body. I
hear an angry voice telling me not to say anything. Sometimes I can’t tell if I
am exaggerating a symptom or if it is real.

My objectives (what I want to do differently about the problem): To tell my

therapist about at least one physical problem so I can work with all parts of
myself to resolve fear and shame about that problem.

Inner conflicts or concerns about changing my behavior: A part of me

thinks I am weak and whining if I mention something physical. If I start
telling my doctor all the physical symptoms I have, I am afraid she will think
I am a hypochondriac.

Steps to achieve my objectives:

1. I will choose one small physical problem: pain in my back from lifting
something heavy that is keeping me awake at night.
2. I will ask internally whether all parts are aware of the pain and how
much it interrupts my sleep.
3. I will ask whether any part of myself has some suggestions to help me
take care of my back by helping me be more aware of how I am
moving and lifting things.
 4. I will rest my back for 2 more days. If it is not improved, I will see the
doctor.
5. In the meantime, I will discuss with my therapist the shame and fear I
feel when something is wrong physically, as well as my reaction of
shutting down and suffering in silence.

Following the example above, complete your targeted change in

self-care.

Item number (from the questionnaire):

Describe your problem:

Your objectives (what you want to do differently about the

problem):

Inner conflicts among parts or concerns about changing your

behavior:

Steps to achieve your objectives:

 CHAPTER THIRTEEN

Developing Healthy Eating Habits

AGENDA
• Welcome and reflections on previous session
• Homework discussion
• Topic: Developing Healthy Eating Habits

Introduction
The Many Meanings of Food and Eating
Eating Problems in People With a Complex
Dissociative Disorder
Tips for Resolving Inner Conflicts About Healthy
Eating

• Homework

Reread the chapter.

Complete Homework Sheet 13.1, Record of Your
Eating Patterns.
Complete Homework Sheet 13.2, A Plan for Improving
an Eating Problem.

Introduction
The focus of this chapter is to help you resolve problems with
eating related to traumatization and dissociation. Eating is an
integral part of healthy living and an often overlooked partner in
healing from trauma. Sensible and healthy eating nourishes and
helps heal your body, which is under chronic stress when you have
a dissociative disorder. When your body feels better, you feel better
in general. But if you grew up in a home in which eating was
associated with tension and stress at mealtimes, or food was not
healthy or readily available, or was used as excessive reward or
punishment, various aspects of eating may be difficult for you. We
begin with an understanding of the many meanings of food and
eating, and then discuss ways in which you might deal with any
eating problems that may be related to your dissociative disorder.

The Many Meanings of Food and Eating

Food and eating are often associated with positive thoughts and
feelings for most people. Being fed as an infant is one of the very
first ways we experience a relationship. Eating is a way we care for
ourselves and receive care from others. Thus, it is connected with
giving and receiving, with nurturing and care, that is, with people
and relationships. At social gatherings, food is often central. We
experience food in many ways: through sight, smell, taste, touch,
and even sound (the sizzle and pop of some dishes), so that
awareness of foods can affect all of our senses. Certain foods also
evoke emotions because they have become associated with
particular memories.
Eating is also a necessity, providing us with the energy and
nutrients we need for living. Poor eating habits can cause both
physical and psychological symptoms. Eating too little can lead to
becoming seriously underweight, vitamin and mineral deficiencies,
brittle bones, dental problems, anemia, poor memory, and
difficulties in thinking clearly and rationally. Overeating can result
in obesity, an increased risk of heart disease, diabetes, asthma, joint
and bone problems, and even of certain types of cancer. In addition
to physical symptoms, eating problems can give rise to numerous
psychological symptoms, such as shame and self-loathing,
depression and anxiety, a disturbed body image, and a tendency to
isolate from others.
Attention to and knowledge about healthy eating habits differ
from person to person, family to family, and culture to culture. If
you need basic nutritional guidance, cooking skills, help with
efficient food shopping, or tips for healthy meal planning, there are
many Web sites and books readily available on those subjects. If
you need more personalized guidance, we suggest that you consult
a nutritionist, whom your therapist or primary care physician can
help you locate.

Eating Problems in People With a Complex

Dissociative Disorder
A majority of people with dissociative disorders have at least some
difficulties with eating (for example, Boon & Draijer, 1993;
Goodwin & Attias, 1993; Vanderlinden & Vandereycken, 1997).
Different parts of yourself may have different eating preferences or
problems, resulting in unstable or chaotic eating patterns. Some
parts of you may have reasons to avoid food as much as possible,
while others may have a tendency to overeat or binge.
If you are not yet very aware of dissociative parts of yourself, it
may be difficult for you to understand certain eating problems that
occur due to the activity of these parts. For example, perhaps you
find evidence that you have been eating during the night without
awareness, or find food in the kitchen that you do not like but must
have bought, or feel intense urges to binge or purge, or limit your
food unreasonably. You may have food preferences or craving that
suddenly begin and end without warning. It may be uncomfortable
or perhaps even frightening to realize that other parts of you have
actually bought, prepared, or eaten food outside of your awareness.
But as you become more comfortable with parts of yourself, you
will feel less afraid and more able to negotiate and coordinate the
essential activity of eating.
Following is a list of eating problems that are often experienced
by people who have a dissociative disorder. Check or circle the
ones that may apply to you or to other parts of yourself.

• Bingeing (eating excessive amounts of food in one sitting,

beyond what is healthy, to the point of feeling bloated and
sick)
• Purging (forced vomiting, use of diuretics or laxatives to get
rid of food and decrease weight)
• Food restriction (eating too little or a very limited variety of
food compared to what the average person consumes)
• Being triggered by particular foods or by eating in general,
and associating food with negative feelings and beliefs, or
memories
• Lack of knowledge about basic nutrition
• Difficulties shopping for food
• Difficulties making food choices
• Difficulties with food preparation (for example, it feels too
 complicated or overwhelming to make a meal)
• Sudden loss of knowledge about how to prepare food or
sudden lack of familiarity about how to use kitchen
appliances
• Problems establishing healthy and regular eating routines
• Forgetting to eat due to problems with time management
and/or inattention
• Inability to feel hunger or thirst due to physical numbness
and avoidance of physical sensations
• Desire to maintain a body shape that is not within a healthy
range because it feels protective (for example, being
overweight helps you feel insulated; being underweight helps
you feel less like an object of desire, or it gives you the
certainty that you cannot get pregnant)
• Conflicts among parts of yourself about whether, what, and
when to eat
• Food and eating are associated with shame and self-loathing
• Difficulty being around others when eating
• “Emotional” eating, that is, using food to cope with emotions
• Food restriction or withholding as punishment

Tips for Resolving Inner Conflicts About Healthy

Eating

• Learn to recognize and understand your difficulties with food

and eating. Reflect on any inner conflicts about aspects of
eating (for example, regarding shopping, staying within
budget, preparation, types of food). Make a short list of any
problems and check the ones with which you want to begin.
Remember to begin with easier problems before you work on
more complex ones.
• Recognize that some parts of yourself may be stuck in
trauma-time and may have found solutions in the past to
regulate intense emotions through their eating habits (under-
or overeating), and other parts may be triggered by certain
foods or mealtimes. Begin by acknowledging the purpose and
intention of these eating problems, rather than blaming parts
of yourself.
• Eating problems, like many other problems, can take time to
 resolve. Be patient and empathic with all parts of yourself.
Allow yourself to be content with taking small steps at a
time.
• Begin by choosing one small problem area about food and
eating, for instance, shopping, or cooking, or irregular meal
times. These are tasks that are usually accomplished by you
or other parts that have a function in daily life. Make a list of
small and very specific steps you need to put into action.
Spend time communicating internally to get a sense of how
various parts of yourself should be involved with a plan.
• If some part of you is triggered by food to the degree that it
makes you unable to eat, help this part of yourself be in an
inner safe place during food preparation and mealtimes as a
temporary containment. Later, when you are ready, you can
help this part overcome what is triggering.
• You might spend a little time considering what foods you
appreciate and enjoy, and whether there are different
preferences among parts of yourself. If helpful, use a diary or
your computer to create a file where all parts may list their
food preferences. You can learn to take into account wishes
of other parts in a reasonable way, instead of ignoring or
criticizing them.
• Notice what happens when you think about your eating
problem, for example, shopping or eating irregularly. Of
what beliefs are you aware? What emotions and sensations?
Are you aware of any parts of yourself that might have a
different experience with eating than you do? Be
compassionate with yourself as you become more aware.
• Make every effort to eat at least three times a day in order to
get into a healthy routine. Reach an inner agreement with
other parts to do so. Make a plan to remind yourself to eat by
using a timer or alarm, if you need it. Set some dates to go
out with friends to eat. Put a list of meals on the refrigerator
and cross them off when you have eaten.
• If you have a daily inner struggle about cooking, or if you
have little time for cooking due to work or other obligations,
make large portions of food at a time, divide them into
individual servings, and freeze them or store them in the
refrigerator, so that you will have something healthy to pull
out and eat quickly when you do not feel like cooking or do
 not have time.
• If particular parts of you have strong food preferences or
aversions, try to allow some flexibility in responding to them.
Perhaps you can temporarily avoid a food if it is triggering to
a part of you. Or you might provide a food preference in
moderation for a part of you.
• It is important to set healthy limits on the food that various
parts want to eat. It will not help you to give in to a part that
only wants to eat ice cream or cookies, for example. After all,
your job is to begin to provide yourself (including all parts)
with a healthy lifestyle.
• Eating patterns often have an underlying emotional goal: You
may eat when you are tired, bored, angry, depressed, and so
forth. When you feel hungry, yet do not need to eat, notice
what emotions or thoughts you are having. Are there any
feelings or situations that you might want to avoid by eating?
Also pay attention to whether a part of you needs something,
such as comfort or attention from you.
• When you have eaten well, and some part of you still feels
the need to eat, determine whether this part is oriented to the
present. If not, try to orient this part to the present so that you
can share your physical sensations of being satiated. You
may also imagine an inner safe space where food is plentiful
for parts of you that may feel chronically deprived.
• Binge eating is usually a way of regulating unbearable
feelings. If you suffer from (nocturnal) attacks of binge
eating (with amnesia), inner communication and cooperation
with parts can help stop this behavior. For example, perhaps
parts will agree that nighttime is only for sleeping (see
chapter 9 on sleep), and not for eating. A safe inner place
with plentiful food may be sufficient to stop parts of you
from actually eating during the night. With the help of your
therapist you can begin to understand more about the parts of
yourself that engage in such behaviors and then try to help
them make positive changes, which may include finding
suitable alternatives that meet their needs adequately.
• Try to make more social contacts that involve eating. If you
have problems with regular meals, make an agreement with
friends or colleagues that each person will cook a large meal
to share with everyone each week (for instance, a big pot of
 soup, stew, pasta, chili, etc.), so you do not have to cook as
often. This activity and sharing also helps you become more
accustomed to socializing while eating.
• If you or parts of you find it hard to eat, pair your eating with
something enjoyable about which all parts can agree, for
instance, taking a picnic to eat on a pleasant hike; sitting
outdoors and enjoying the breeze while you eat; arranging
your food nicely on the plate and adding a special garnish;
setting the table nicely and adding flowers, candles, and
music; and so forth.
• If there is a day that you really cannot eat, use liquid
nutritional supplements.
• If you have serious eating problems, be honest with your
doctor, dietician, and therapist and let them help you make a
stepwise plan that works for you.


Homework Sheet 13.1

Record of Your Eating Patterns

1. List healthy eating habits you and parts of yourself already

employ and wish to continue.

2. In the chart below, list your successes and challenges in eating.

Successes might include eating at a regular time, eating healthy
food, preparing a meal. Challenges might include forgetting to eat,
refusing to eat, bingeing, eating junk food, or difficulty in shopping
or preparing a meal. Use this chart to keep track of your eating.


Homework Sheet 13.2

A Plan for Improving an Eating Problem
Based on the example below, list one eating problem, your
objectives for what you want to change, any inner conflicts among
parts of yourself, and specific steps to help yourself. Objectives
should always be measurable, defined, specific, and include simple
steps.

Example
Eating Problem Describe Your Problem
Eating unhealthy food Eat a lot of junk and fast food; not enough
vegetables; too many sodas; hate to cook
Eating at irregular Forget to eat; eat on the run; snack all day; find
times evidence that I am eating during the night

My objectives (what I want to do differently):

Eat a healthy meal (including fresh fruits and vegetables or salad) at least
once a day at a regular time: lunch (between noon–1 p.m.) or dinner (between
6:30 p.m.–7:30 p.m.)

Inner conflicts or concerns about changing my behavior:

1. Parts of me like junk food, and it’s a comfort for them and
me.
Possible solution: Buy one type of junk food and have it, but in
limited quantities; that is, eat one serving portion. Chew your food
slowly and mindfully, and savor it; this will make you feel more
full and satisfied. Be mindful that you have given yourself a treat.
2. I don’t like change and I am afraid of additional inner
struggles.
Possible solution: I will try to communicate (maybe with help of
my therapist) with parts of myself so I can understand more about
the fear of change. I will find and discuss with all parts of myself.
I will start small, changing one thing at a time. I will introduce
one healthy food at a time, and I will begin with one regular meal
that includes some healthy food.

Steps to achieve my objectives:

 1. Take time for inner communication, cooperation, negotiation, and
joint decision making about each step of my plan.
2. Gain a better understanding of what foods are and are not healthy.
3. Set specific times to eat each day and set an alarm as a reminder.
4. Choose a couple of healthy and easy recipes or find places where I can
buy prepared healthy food that is within my budget.
5. Make a list before going to the grocery store; take into account
different preferences of all parts of myself.
6. Ask a friend to shop with me, so I will stick to my list.
7. Go to grocery store only once a week.

Eating problem (describe your problem in detail):

My objectives (what I want to do differently; be specific):

Inner conflicts or concerns about changing my behavior:

Steps to achieve my objectives (begin with small, manageable

changes; be specific).
 PART THREE
SKILLS REVIEW
You have learned a number of skills in this section of the manual.
Below you will find a review of those skills and an opportunity to
develop them further. As you review, we encourage you to return to
the chapters to read them again and repractice the homework a little
at a time. Remember that regular, daily practice is essential to learn
new skills.
For each skill set below, answer the following questions:

1. In what situation(s) did you practice this skill?

2. How did this skill help you?
3. What, if any, difficulties have you had in practicing this
skill?
4. What additional help or resources might you need to feel
more successful in mastering this skill?

Chapter 9, Developing a Bedtime Routine; Developing and Using

a “Sleep Kit”

1.

2.

3.

4.

Chapter 10, Developing a Realistic and Healthy Daily Structure

and Routine

1.
2.

3.

4.

Chapter 11, Relaxation Exercises (The Tree, The Healing Pool,

and Muscle Relaxation)

1.

2.

3.

4.

Chapter 11, Developing a Relaxation Kit

1.

2.

3.

4.

Chapter 12, Making a Healthy Change in Physical Self-Care

1.

2.
3.

4.

Chapter 13, A Plan for Improving an Eating Problem

1.

2.

3.

4.
 PART FOUR

Coping With Trauma-Related

Triggers and Memories
 CHAPTER FOURTEEN

Understanding Traumatic Memories

and Triggers

AGENDA
• Welcome and reflections on previous session
• Homework discussion
• Break
• Topic: Understanding Traumatic Memories and Triggers

Introduction
Autobiographical Memory and Traumatic Memory
Understanding Triggers
Recognizing Triggers
Types of Triggers
Triggers for Positive Experiences

• The Store: An Exercise for Support, Strength, and

Protection
• Homework

Reread the chapter.

Practice The Store exercise.
Use the Learning to be Present exercise from chapter 1
as needed.
Complete Homework Sheet 14.1, Identifying Triggers.
Complete Homework Sheet 14.2, Reflecting on
Reactions to Triggers.
Complete Homework Sheet 14.3, Identifying Positive
Triggers.

Introduction
The instability experienced by people with a complex dissociative
disorder is often related to the reliving of past traumatizing events,
also known as flashbacks or reactivated traumatic memories (Boon,
2003; Van der Hart et al., 1992). In this chapter you will learn
more about traumatic memories and how they are different from
everyday, normal memories; why they are so overwhelming; and
how they are related to dissociative parts of yourself. Traumatic
memories are often evoked or triggered by a stimulus (trigger) in
the present that is a reminder of some aspect of the original
traumatizing event. You will learn more about triggers and how to
recognize them. In the next chapter, you will then learn how to
reduce and cope with triggers.

Autobiographical Memory and Traumatic Memory

Generally people are able to recall important events they have
experienced in the past. They realize the event has happened to
them and that it is not happening now. The memory is, so to speak,
a part of their “autobiography.” But as you may painfully
experience at times, this is not the case with traumatic memories.
When you, or a dissociative part of you, reexperiences a traumatic
memory, you feel as though it (or at least some aspect of it) is
happening in the present.
Traumatic memories may include intense or overwhelming
feelings, such as panic, rage, shame, loss, guilt, despair; conflicting
beliefs and thoughts; physical sensations such as pain; visual
images, sounds, and smells; and also behaviors, such as running
away, fighting, freezing, or shutting down. Each of these aspects of
a traumatic memory can occur simultaneously, in succession, or
separately at different times. Typically, these reactions are not
appropriate to the current situation, or they are far more intense
than the situation warrants. You may want to return to chapter 4 for
a review of traumatic memories (flashbacks).

Understanding Triggers
A trigger (or reactivating stimulus) is something that bears a literal
or symbolic similarity to an aspect of an unresolved traumatic
experience. It may be a present-day situation, an interaction with
another person, an object, or even an inner experience such as a
particular feeling or sensation, a smell, or a position of your body.
Parts of you then may automatically react in similar ways as during
the original traumatizing situation, that is, parts of you have
conditioned reactions that you cannot consciously control.
Being able to accept traumatic experiences as your own is not
easy, and it may take some time and work before you are ready.
This manual is meant to offer you opportunities to learn and
practice the skills you need to be able to achieve the task of fully
realizing what has happened to you. In the meantime, you may find
that you continue to have problems from time to time with being
triggered, because some dissociative parts of yourself remain stuck
in trauma-time and thus are vulnerable to reliving past experiences.
Therefore, it will be helpful for you to be able to recognize triggers
and your reactions to them in order to change these conditioned
responses.

Recognizing Triggers
It may be hard to recognize when you are triggered unless you have
an extreme reaction. But it does help to recognize some
possibilities that you might be triggered:

• Your reaction to a situation seems more intense than is

warranted, or it is significantly different than your usual
reactions.
• You are not able to step back and reflect in the situation, but
feel stuck in your reaction.
• Inner parts of you become activated to the degree that you are
aware of them.
• You have a defense reaction, that is, flight, fight, freeze, or
collapse.
• You seem to watch your reaction unfold, not feeling in
control of it, as though another part of you is having the
reaction.
• You switch to another part of yourself and lose time.
• You have a sudden flashback; these are almost always
triggered by something in the present.

Sometimes you may be able to recognize the link between a

trigger and the original traumatizing event. For example, a person
might be aware that the smell of gasoline evokes fear and panic
because of a traumatic past experience involving gasoline.
However, at other times, you may not be aware of what has
triggered you. Perhaps you have no memory of the event and thus
cannot make a connection with a trigger. Or even if you know
about it, you may not be (very) aware of the part of yourself that
has become triggered, or you may simply not understand the link
between them. As we have noted, the parts of you that function in
daily life are adept at avoiding parts stuck in trauma-time, as well
as the traumatic memories that they hold, so you may find yourself
not wanting to know why you are triggered. Unfortunately, this
avoidance has serious disadvantages. When you cannot understand
and accept your inner experiences, they become confusing and
frightening, seemingly arbitrary and out of control. This only
increases your fear of inner experiences and you then make your
life ever smaller to avoid dealing with yourself (see chapter 5 on
the phobia of inner experience). Therefore, you need to learn to
reflect on triggers and the reactions they evoke in you and other
parts of yourself.
Although it may sometimes seem as though “all of life” is a
trigger, it can be of great help to distinguish specific triggers. Then
you can notice that not all situations are equally disturbing to you
and that you have already learned to cope successfully with certain
triggers.
You may be puzzled by the fact that you can be triggered at one
time by a stimulus, but not at another time. Your vulnerability to
triggers is determined to a large degree by your physical and mental
condition in the moment. If you are more tired or spacey, sick or
seriously stressed, or faced with new challenges or problems that
seem overwhelming, you are more likely to be triggered. If parts of
you are in inner chaos and conflict, you are very prone to becoming
triggered more easily. And as you work on particular aspects of
your history, the triggers related to that time may be more active for
a while.
Triggers can involve an infinite variety of experiences or
objects, depending on what has become associated with a particular
traumatic episode. Although it is important to recognize triggers,
you do not necessarily need to know at this point in time the history
related to the trigger in order to cope differently. In the early stages
of treatment you may not yet be ready to deal with painful
memories to which they are related.
 For example, if you feel panic in crowded stores, regardless of
whether you know why, you can begin to help yourself with
practical solutions. Perhaps you might choose to shop during times
when stores are less crowded. You might make a list before you go,
so that you minimize time in the store. You can help parts of you
remain in an inner safe place while you shop. You might take your
partner or a friend with you. We will discuss strategies such as
these to cope with triggers in the following chapter, but your first
task is to be able to recognize that you have become triggered and
to notice your conditioned reactions, that is, your thoughts,
feelings, impulses, sensations, movements, and so forth. To that
end, we describe various types of triggers, which may help you
become more aware of your own.

Types of Triggers
Following you will find an explanation of different types of
triggers.
Time-related triggers. You may have heard of “anniversary
reactions,” in which a person has a predictable and involuntary
reaction on or around the anniversary of a traumatizing event. This
experience is most well known in people who have intense grief
reactions each year around the anniversary of the loss of a loved
one. But anniversary reactions may be evoked for a wide variety of
other events. At first, you may not recognize an anniversary
reaction, but you or your therapist may begin to notice that you, for
instance, become depressed, or very anxious, or feel suicidal
around the same time each year, time after time.
Time-related triggers may also involve a time of day or a
particular period of time, such as weekends or holidays (see also
chapter 16). For example, some traumatized people may become
increasingly fearful and anxious as it becomes dark each evening,
related to overwhelming experiences that may have occurred
around that time.
Place-related triggers. Many people find it hard to return to
places where they were abused or had other highly distressing
experiences. This avoidance can generalize to other places that
remind them of the original situation, prompting them to evade
more places and experiences to prevent triggering. For example, if
a person had been robbed or assaulted on a bus, he or she might be
inclined to avoid all busses. And eventually, this person may come
to avoid any public transportation, including trains, trams, and
planes.
Many traumatized people regularly report that they are upset or
overwhelmed by crowded spaces, such as shopping malls, long
checkout lines, or crowded waiting rooms. Their aversion often has
nothing to do with a traumatic memory, but rather they feel
overstimulated and trapped, which may be similar to inner
experiences they felt during traumatic events in the past.
Even though some parts may be triggered by certain places,
other parts may not be; they may even enjoy, for example, riding in
the train or flying, or being at the mall. These contradictory
experiences may set up internal conflicts, because some parts may
dismiss or even be unaware that a trigger is problematic for other
parts.
Relational triggers. Relationships themselves are often triggers.
Relationships and any perceived threat to them evoke the most
powerful feelings in everyone, for better or worse. When you have
been mistreated by others, intense feelings of abandonment,
rejection, humiliation, shame, panic, yearning, and rage are often
easily triggered by the minor ups and downs that are a natural part
of even the best of relationships. And when a serious relational
disruption occurs, it can feel catastrophic. Some parts of you may
always be on guard, looking out for any cues that perhaps you are
being rejected or criticized, and thus they may overlook important
cues to the contrary. Others may desperately seek out relationships,
not attending to whether they are healthy (see chapters 28 and 29
for more about relationships).
Many patients with complex dissociative disorders rightly felt
criticized, lonely, and misunderstood as children. Anger or critical
remarks by a partner or a friend in the present may quickly give rise
to a partial reliving of old experiences, such as intense fear of being
abandoned or misunderstood, or fear that you cannot speak your
mind without terrible consequences.
Internal triggers. People who have a dissociative disorder have
typically learned to avoid much of their inner experience in order to
avoid traumatic memories (see chapter 5). Any inner experience
may be triggering, such as the sound of another part talking or
yelling, certain emotions (anxiety, anger or shame, and so forth),
sensations (such as pain, sweating), needs (such as wanting to be
comforted), or thoughts (such as “I wish I was dead” or “I am not
happy in this relationship”).
Some parts may even provoke other parts as an internal
reenactment of old experiences. For example, a highly critical part
might scream that you are stupid when you are trying your best to
cope with a difficult problem at work. This inner experience may
be quite similar to some you may have had as a child. We will
further discuss ways to deal with this type of internal triggering
from dissociative parts of yourself in chapter 22 on anger, and
chapter 24 on shame and guilt.
Sensory triggers. Body sensations are a particular type of
internal trigger. These may resemble similar sensations that
occurred around the time of a traumatizing event. Smells are
particularly potent triggers. Other sensations include pain, the
racing heart and breathlessness of anxiety, feeling too hot or cold,
nausea, thirst, hunger, stomachache, the need to eliminate, or even
certain body postures. Some women may be triggered by the
sensations that accompany menstruation. The sense of being
touched by another person may be especially triggering from some
individuals.

Triggers for Positive Experiences

Triggers are usually thought of as negative, but some triggers evoke
positive feelings and memories. For example, looking at pictures of
a nice holiday that you enjoyed, the smell or taste of a specific
food, or particular music may all evoke positive memories and
feelings of contentment or warmth. Positive triggers are important
because they can help you find some enjoyment and calmness in
the present. In fact, your personal anchors are positive triggers that
help you stay in the present.

THE STORE:
AN EXERCISE FOR SUPPORT, STRENGTH, AND
PROTECTION
This imagery exercise is intended to help you cope with triggers by girding
yourself with resources that can help when you feel overwhelmed. Practice
this exercise often, or a similar one that fits better for you, when you are
feeling calm. Once you are familiar with the exercise, you can begin using it
when you feel stressed.

Imagine a store in which anything you want or need as a

resource for healing can be found and taken for free. This is no
ordinary store, with ordinary aisles and ordinary merchandise.
This is a magical place, a special place, beautiful and
comfortable. Perhaps you see it as a quaint village shop, or an
old bookstore with comfortable chairs and steaming pots of tea,
or a sleek high-tech store with all the latest gadgets, where
espresso and lattes are available as you browse. You can
envision it in just the right way for you. It is your store that you
create. In your shop you feel completely at ease, wandering up
and down the familiar aisles, where the lighting and
temperature are just right, where all is well and just as it should
be. Perhaps it is quiet, or perhaps your favorite music is playing
in the background. Perhaps there is even a little stage where
your favorite musicians are performing just for you. This is one
store where you really enjoy lingering, choosing just the right
items for your strength and protection. And indeed, there is an
endless selection: shields; screens; transparent bubbles; magic
stones; books of great wisdom; vials of liquid with healing
properties; protective spirit or animal guides; magic cloaks of
many colors, and some invisible to all but you; form-fitting,
lightweight suits of armor; emotional Kevlar, and on and on.
Each is an equally strong and effective protection from the
slings and arrows of life, from the vulnerability of being
triggered. You may choose as many as you like, and exchange
them as you wish. And as you wander around, or sit
comfortably in a chair, allow all parts of you to have their time in
this store, because it is for all of you.
Just to practice, try out one of the special protective suits or
cloaks. Just as a raincoat or waterproof suit keeps the water out
and allows it to slide off of you, or just as a windbreaker
protects you against icy winds, so you can imagine that you
have found just the right suit of protection for yourself in your
store. And allow each part of yourself that wishes or needs to
have their own suits, each suit just right for each part of you.
You will be amazed at how flexible and lightweight, yet sturdy
and comfortable it is. You can don it in an instant, so quickly
that no one notices. You can take it with you wherever you go,
and wear it whenever you like. Your suit or cloak is just the right
weight, the right material, the right texture and color to help you
feel completely protected from head to toe, front to back, up
and down, all around, where not a single chink or crack or hole
will allow negative forces to gain entry, and where you are
comfortably ensconced in safety and calm. You are completely
protected in body, mind, and heart. You are protected from
other people’s emotion that set you on edge, from triggers that
might evoke you, from the stresses and strains of life and living.
If you wear the suit even when you feel more tranquil and
secure, it offers you extra protection, adding even more
serenity, calm, and safety.
Now allow a situation to come to mind, one in which you felt
uneasy or insecure. Imagine wearing your suit or cloak and
walking into that situation with a sense of deep protection,
confidence, relaxation. It is as though you cannot be touched by
the situation, unaffected by the stress of it, yet still you feel very
present because you feel safe and protected. Take your time to
imagine yourself in the situation with this protective suit. And be
aware that at any moment, you may make adjustments to your
suit or return it to your store and find another. When you are
ready, you can return to your store. Look around once again,
taking all the time that you need to be familiar with every aspect
of it. This is your store. You can return whenever you need or
want. It is there for each part of you whenever it is needed. And
when you are ready you can return to the present, feeling
strong and serene, supported and safe.


Homework Sheet 14.1

Identifying Triggers
Choose a time when you were recently triggered. Reflect back on
the situation and answer the questions below, as you are able. This
reflection will help you become more aware of yourself and what
evokes you and other parts of you. If this exercise evokes too much
for you, simply stop and practice a grounding or relaxation
exercise. It is essential to pace yourself. Discuss with your therapist
how you might be able to learn more about triggers without
becoming overwhelmed.

1. Where were you and what were you doing when you were
triggered?

2. Describe the trigger, if you know.

3. What was your inner experience of being triggered (for example,

feeling like you were out of body, anxiety or panic, visual or
auditory flashbacks, nausea, loss of time)?

4. If you lost time, what is the last thing you can recall (for
example, a sound, smell, image, thought, feeling)?

5. Are you aware of any specific parts that may be involved? If so,
please describe what you understand about that part of yourself.

6. If you were with someone, what, if anything, might have been

stirred up for you in the relationship (for example, you felt hurt,
angry, invisible?)

7. Note the date, season, and time of day when you were triggered,
if you have a sense that the trigger may be time related.


Homework Sheet 14.2

Reflecting on Reactions to Triggers
In the chart below, choose a time each day this week when you
have been triggered (if you have). Do not focus on any traumatic
memories at this point, but only your reactions to them. As you
reflect on the experience, answer the questions below as best you
are able. If you are not being triggered, that is wonderful! You may
then use this chart to describe previous examples of being
triggered.


Homework Sheet 14.3

Identifying Positive Triggers
Make a list of positive triggers and what they evoke for you. Use
these experiences in your daily life to help you feel better and more
grounded.

Examples
1. Positive trigger: snowfall
Reaction: a feeling of pleasant excitement and fun memories of
playing in the snow
2. Positive trigger: the smell of freshly baked bread
Reaction: a feeling of comfort, of having pleasant and basic things in
life
3. Positive trigger: a funny joke or movie
Reaction: laughter, feeling grounded, a feeling of being lighter for a
time

1. Positive trigger:
Reaction:

2. Positive trigger:
Reaction:

3. Positive trigger:
Reaction:
 CHAPTER FIFTEEN

Coping With Triggers

AGENDA
• Welcome and reflections on previous session
• Homework discussion
• Break
• Topic: Coping With Triggers

Introduction
Reducing or Eliminating Triggers in Daily Life

• Homework

Reread the chapter.

Complete Homework Sheet 15.1, Identifying Triggers
and Coping Strategies.
Complete Homework Sheet 15.2, Skills to Cope With
Triggers.

Introduction
In the previous chapter you learned about triggers, and that parts of
you stuck in trauma-time are most vulnerable to being triggered,
unable to distinguish between the past and present. You may not
always be completely aware of these parts. The more you can
reflect on your inner world, the more effective you can be in
helping all parts of yourself cope with triggers. But of course,
managing triggers is difficult. The first steps are usually the
hardest. Do not expect yourself to completely control all your
triggers immediately. And some triggers are easier to manage than
others. Any person can be triggered by completely unexpected
situations. Just take your time and learn to be more reflective and
tolerant of your experiences.
In this chapter we focus on specific ways to deal with triggers
effectively.

Reducing or Eliminating Triggers in Daily Life

Regardless of whether you are ready to directly cope with your
traumatic memories, you must still deal with being triggered in
ways that interfere with your daily life. In the following sections we
describe specific methods to cope with triggers.

Eliminating or Avoiding Triggers

When you become more aware of your triggers, you may
temporarily eliminate or avoid certain objects or situations, and
thus become triggered less often. This should be a temporary
measure only, until you are able to resolve what is being triggered.
Otherwise you will feel the need to restrict your experiences more
and more. But once you are triggered less often, you can begin to
work on your skills and resources so you can overcome what is
upsetting you. Temporarily stow away, give away, or throw away
objects in your home that trigger you, for example, photographs,
art, a particular blanket, a knick-knack, a book. It is important to
remind yourself and other parts of you that a particular object or
situation does not have to overwhelm you the rest of your life. You
and other parts can learn to be less reactive in the present as you
begin to feel safer and calmer. It might be helpful to remind all
parts of you that the object or situation is reminiscent or
representative of something painful from your past, but it is not
dangerous itself.
When you are not able to eliminate a trigger, you might
temporarily avoid it. For instance, if you are triggered by seeing
someone drunk, avoid places where such people are likely to be
found (parties, bars, pubs, weekend nights in the city). If a part of
you is terrified of crowded areas, you can choose to shop at times
when stores are likely to be less crowded, while you are working
with that part to overcome the fear of crowds. If a part of you is
afraid of the dark but you want to see a movie, you can choose to
watch a DVD at home instead of going to the theatre. Again, these
are only meant to be temporary solutions, until such time that you
can approach and handle the cause of being triggered more
adaptively. You can also have empathy for these parts of you
instead of being angry or frustrated with them, and assure them you
are taking their needs into account as well as helping them
gradually overcome their fears or concerns.

Anticipating Triggers
If you anticipate that you might be triggered by a certain situation
that cannot be avoided, you can plan ahead to cope with it
effectively. For example, perhaps you need to make an appointment
to receive a flu shot, but some part of you is terrified of shots. You
may find the crowded waiting room intolerable, and feel exposed
and vulnerable when visiting a doctor. Nevertheless, you need your
influenza shot for your health, so this is not a situation to be
avoided.
You can prepare yourself by reflecting with all parts of you to
discover what you need to cope. You can calm and reassure parts
inside that you are getting medication that keeps you healthy: You,
as an adult, will make sure nothing bad will happen. You might
take time before the appointment to help parts of you go to an inner
safe place, or you might imagine allowing them to stay at home,
and only adult parts that can distinguish the past from the present of
yourself should go to the appointment. Some people may have
inner helper parts that can calm and reassure, but it is doubly
effective if you can join with these helpful parts in reassuring all
parts of you. You can use your own imagination to help vulnerable
parts in this way until they are able to heal.
Above all, do not ignore parts of you that are triggered by
acting “tough” and belittling these parts of yourself. You run a far
greater risk of losing control or switching than when you anticipate
what you need.
In addition to inner preparation, you might also ask for the
support of others when you are faced with a situation that triggers
you. In the aforementioned example, you might ask someone to go
with you to the doctor—someone who will keep talking with you to
help you stay present. You can ask to make your appointment the
beginning or end of the day, or immediately after lunch, so you can
be in and out without spending too much time sitting in the waiting
room.

Imaginal Rehearsal
All too often, when people imagine an upcoming situation, they
imagine themselves failing or being overwhelmed. That is, they
imagine a negative outcome. Imaginal rehearsal is the opposite:
You imagine yourself being completely successful, walking
through the situation step by step (Bandler & Grinder, 1975). Many
people find it helpful to imagine successfully negotiating through a
challenging situation ahead of time. You may begin by imagining
that you are watching yourself. For example, imagine watching
yourself walk into the doctor’s office feeling calm and adult-like.
Imagine being able to reassure yourself if you begin to feel anxious.
Imagine being wrapped in your protective suit or your favorite
colors, and not even feeling the injection. Imagine that all parts of
you feel perfectly safe in the present. Imagine having all the
support you need. Imagine supportive people being with you,
encouraging you, cheering you on. After you have successfully
“watched” this scenario, imagine it from your own perspective.
Imaginal rehearsal is more successful when you share its purpose
with all parts of you, and as many parts as possible can participate.

Recognizing Options
Often when people are triggered, they feel trapped and helpless.
Recognizing that you have options is essential to feeling more
control and choice. You might be surprised at the choices you do
not realize that you have. And you are only limited by your own
creativity! For example, continuing with the example of the flu
shot, if you become too triggered, give yourself the option of
leaving if parts of you become too afraid. Or give yourself the
option of walking outside to calm down or allowing the nurse to
help you calm down. Give yourself the option to either watch or
avert your gaze when you get the shot: whichever helps you more.
Give yourself the option of being assertive and asking the nurse or
doctor to tell you every step of the procedure ahead of time, so you
will know what to expect and can be a part of deciding how and
when the injection is given.

Neutralizing the Effects of Triggers

You can learn to create distance from the emotional and physical
experience of being triggered. Usually this method involves
imaginal techniques that you have already learned in this manual.
For example, you can use an inner safe place in which parts of you
can be protected from the overwhelming experiences of being
triggered. Parts of you may voluntarily go to sleep in their safe
place if you anticipate a time when you may be triggered, so that
only adult parts aware of the present need cope with the situation.
You can use The Store exercise in chapter 14 and imagine having
on a special suit or cloak, or a shield that triggers cannot penetrate.
Or try The Tree or The Healing Pool exercises from chapter 11 to
immediately calm all parts of yourself if you become triggered. In
chapter 18 you will find suggestions for putting your feelings in a
container such as a bank vault or a computer file.

Distinguishing the Past From the Present

It is essential for all parts of you to learn to distinguish between
here and now and then and there. For example, a particular knife or
fork from the kitchen or the color of the living room wall in the
present may remind you of a painful experience in the past, but it is
not the same knife or fork or the same living room. Of course,
before you can make a distinction between the past and present,
you must be aware that you are in the here and now. Continue using
your various anchors to the present from chapters 1 and 2. The
more quickly you can ground yourself, the easier it will be to cope
with triggers. You may also find it helpful to carry a small object,
such as a beautiful small stone, as a tangible reminder of being in
the safe present. As soon as you touch it, you can immediately feel
yourself become more present.
Once you are present, you will find it helpful to describe the
differences between an experience in the past and present in detail,
to actually say it out loud to yourself, and to keep reminding all
parts of these differences. For example:

The green color on the wall is the same as in the past, but the wall,
the room, the house, the city, the year, and even I am not the same
as in the past. The only similarity is green, only paint. I am not
there, I am here. I can see the pictures on the wall that are different
than in the past. The carpet on the floor is different. When I look
out the window, I see the scenery of the present, which is different
from the past. This green wall reminded me of something that I am
not yet ready to handle. I will put that memory in a safe place and
contain it until I am ready.

This repetition gradually helps all parts to notice these

differences, instead of only focusing on what is similar to the past.
 It is particularly important to pay attention to differences when
a person in the present reminds you of someone from the past with
whom you felt uncomfortable or unsafe. For example, if a friend
becomes irritated with you in the present, you or other parts of
yourself might automatically react with fear because an angry
person was dangerous in the past. However, you notice that your
friend’s voice is not raised, and he is not screaming or cursing. He
is speaking to you respectfully, and you know his intentions toward
you are good in general. His body language shows no indication
that he might be physically violent. These are cues that tell you this
interaction is different from the past. Draw the attention of all parts
of you to these cues and bring them back again and again to these
cues in the present. In this way all parts of you can learn that
although an aspect of the present might be similar to the past
(irritation or anger), many other aspects are different enough that
you can learn when it is safe. You are teaching parts of yourself the
early beginnings of reflection about the motivations and intentions
of others in the present.
It is also helpful to notice what is different about you, that is,
you are an adult, not a child. You are stronger, have more wisdom
and experience, and have supports and resources that you did not
have as a child.

Inner Orientation, Cooperation, and Support

You have begun to experience times of being able to orient parts of
you to the present, help parts cooperate for your well-being as a
whole person, and share mutual inner support. These skills are
essential in helping you overcome the effects of triggers. When
inner parts feel more trusting of each other to attend to, care for,
and respect one another, they will feel calmer and less afraid and
chaotic. When they are helped to become more oriented to the
present, they can reflect more on their inner experiences. And when
parts can cooperate, for example, to help other parts remain in an
inner safe place without disturbance or to avoid situations in which
you may be triggered, all parts of you will feel better. Some degree
of inner cooperation is already present when you talk inwardly to
all parts of yourself, when you remind them of the safe present,
when you create inner safe places, when you practice relaxation
exercises, and when all parts of you pay attention not only to what
is similar to the past, but more important, to what is different.
 This inner cooperation and support can grow exponentially over
time, as you will see. People with a dissociative disorder often
know at some level, or in some part of themselves, which situations
are best avoided or how a triggering situation might best be
handled. Inner dialogue and reflection among parts about the best
approach to situations is helpful, and it must go beyond merely
telling all parts to “just do it.” You are a team and must work as a
team. Be compassionate with yourself and all parts inside; and help
them to engage cooperatively with you as often as you are able. Of
course, we are aware that inner cooperation, communication, and
support take time to develop and are not always easy to achieve. It
may not always seem clear or obvious how you can accomplish
these skills. Be patient with yourself and all parts of yourself. In
chapter 27 we will return to the subject of inner cooperation, as
well as to more advanced work on distinguishing between the past
and the present.


Homework Sheet 15.1

Identifying Triggers and Coping Strategies
As in your homework from the last chapter, choose a time when
you were recently triggered and reflect back on the situation and
answer the questions below, as you are able. This reflection will
help you again practice identifying triggers but also to become
aware of what coping strategies you might already use. If this
exercise evokes too much for you, simply stop and practice a
grounding or relaxation exercise.

1. Where were you, and what were you doing?

2. Describe what triggered you, if you know.

3. What was your inner experience of being triggered (for example,

feeling like you were out of body, anxiety or panic, visual or
auditory flashbacks, nausea, loss of time)?

4. If you lost time, what is the last thing you can recall (for
example, a sound, smell, image, thought, or feeling)?

5. If you are aware of specific parts of yourself that were triggered,

describe their experience as best you can.

6. If you were with someone, what, if anything, might have been

stirred up for you in the relationship (for example, you felt hurt,
angry, invisible?)

7. Describe what you did to cope with being triggered at the time,
and what you did afterwards. You may have used some of the
coping skills discussed in this chapter or others. You may even
have coped in ways that were not healthy. Do not judge yourself;
simply describe what you did.


Homework Sheet 15.2

Skills to Cope With Triggers
Choose a time when you were recently triggered and reflect back
on the situation and answer the questions below, as you are able.
This reflection will help you become more aware of how you might
employ some of the skills you have read about in this chapter. If
this exercise evokes too much for you, simply stop and practice a
grounding or relaxation. Refer back to the chapter as needed. You
will be using one or more of the following skills:

• Eliminating or avoiding triggers

• Anticipating triggers
• Imaginal rehearsal
• Recognizing options
• Neutralizing triggers
• Distinguishing the past from the present
• Inner orientation, cooperation, and support

1. Describe an object or situation in the present that triggered you

recently.

2. Describe the reactions of you, or other parts of you, to the trigger

(for example, feeling like you were out of body, anxiety or panic,
visual or auditory flashbacks, nausea, loss of time; being frozen or
collapsed).

3. If this trigger can be eliminated or avoided, describe how you

could accomplish that for the future (for example, avoiding violent
movies, putting away a photograph or book; deciding not to visit a
particular place).

4. If you were to anticipate this trigger in the future, how might you
prepare for it? For example, helping parts be in an inner safe place,
using images of protection, or practicing imaginal rehearsal.
5. Describe in retrospect any options you had but did not realize
that you had at the time you were triggered (for example, you could
have left the situation, called a friend for support, oriented parts of
yourself to the present, or calmed and reassured them, but you did
not think of it).

6. Practice protective imagery (for example, from The Store

exercise) and containment strategies for the feelings, sensations,
and memories that are evoked when you are triggered.

7. Describe the differences between the trigger in the past and its
present-day context, for example, the bed is similar, but the room is
different; the beard on a man is similar to the past, but it is not the
same man.

8. Describe any inner orientation, communication, cooperation, and

support you were able to accomplish when you were triggered. If
you were not able, describe what stopped you and how you might
support your inner parts in the future.
 CHAPTER SIXTEEN

Planning for Difficult Times

AGENDA
• Welcome and reflections on previous session
• Homework discussion
• Topic: Planning for Difficult Times

Introduction
Planning Issues for People With a Complex
Dissociative Disorder
Difficult Holidays and Other Special Times
How to Plan for a Difficult Time
Reflections to Help With Planning for Difficult Times
Tips for Effective Planning
When Obligations to Others Conflict With Your Needs

• Homework

Reread the chapter.

Complete Homework Sheet 16.1, Preparing for a
Difficult Time.

Introduction
People with a complex dissociative disorder often have specific
periods of difficulty with depression, anxiety, fear, shame,
posttraumatic stress, or other problematic symptoms. Many of these
difficult times can be predicted based on how people have reacted
in the past to similar situations. These times might include
weekends, extended time alone, holidays, times when contact is
necessary with people who were abusive in the past, or painful
anniversaries of past events (which often are not recognized as
such). Planning is always needed for times in which you are likely
to encounter an unusual amount of triggers. When you are able to
predict that you might have a hard time, you can plan ahead to deal
with the situation effectively, instead of being blindsided by it.
These important coping skills of forward thinking and planning, the
ability to “deal with it before it happens,” are essential in daily life
and also vital in learning to help dissociative parts of yourself. This
chapter will help you learn to plan for difficult times so they are a
little easier to manage.

Planning Issues for People With a Complex

Dissociative Disorder
Planning ahead may be difficult and can be an enormous challenge
for individuals with a dissociative disorder, especially when it
involves the need for self-care and boundary setting. Such people,
or at least some parts of them, generally avoid dealing with painful
or conflicted feelings and situations. As a consequence, they often
avoid thinking about or planning ahead to help themselves better
manage a potentially difficult time. In the following sections you
will find some of the major reasons why planning is difficult when
it involves conflicted dissociative parts of yourself. You may also
have your own unique reasons that are not listed.

General Feeling of Being Overwhelmed in the Present

When people are already overwhelmed and depleted, thinking
about the future can seem like a monumental task, much less
planning for it. Thus, it is essential to do your best to care for
yourself, manage your time, get sufficient rest, and use your
relaxation skills.

Inner Chaos and Confusion

Cognitive confusion and fogginess, blankness, and inner chaos
among parts can make it difficult to think through and plan. Often
this is due to being overwhelmed in the present and/or conflicts
among dissociative parts.

Inner Conflicts Without Sufficient Capacity for Negotiation

Various dissociative parts may have conflicting needs or desires
about an upcoming time. These conflicts may make the time more
difficult than it needs to be. People may not be aware of these parts,
or they may ignore or belittle them. For example, while one part
may enjoy a free weekend, another may find it a waste of time, and
yet another may find it lonely and overwhelming. One may dread a
holiday while another comments on how ridiculous it is to dread
just another day. It can take time to learn how to be more aware of
inner conflicts among parts and how to negotiate satisfactory
outcomes. You can begin by acknowledging the conflicts and
taking them seriously, and trying to help those parts of yourself as
best you can. Gradually, negotiation will become easier.

Difficulties With Time, Time Management, and Time Loss

Most people with a complex dissociative disorder have some
difficulties with time (see chapter 10; Van der Hart & Steele,
1997). Some are forgetful and may not recall making an
appointment, or they may engage in the same activity twice, not
remembering they have already done it. Some may be so
overwhelmed or depressed that they sit and do nothing or sleep
away the day, unable to focus either on the present or the future.
Some people with DID report recurrent problems with double
bookings of appointments made by different parts of themselves or
cancellations of appointments by other parts.

Difficulties Setting Priorities

Some people find it hard to prioritize what is most important, and
for people with a dissociative disorder this may involve inner
conflicts among various parts about what is important (for instance,
feeling safe is a priority that may conflict with being in a particular
relationship, which is a different priority).

Problems With Executive Functioning

Executive functions are cognitive skills involved in our ability to
organize thoughts and activities, prioritize tasks, manage time
efficiently, and make decisions. These skills may be limited or
lacking in some traumatized people because traumatic stress
adversely affects the areas of the brain that are key to using these
functions. These problems can be overcome to a large degree, and
there are many readily available resources on the Web or in print
for coping with problems with executive skills, particularly in
material that addresses attention-deficit disorders in adults.

Difficult Holidays and Other Special Times

Specific times of day, time of year, seasons, holidays, weekends,
and anniversary dates of significance may trigger painful feelings
or traumatic memories (see chapters 14 and 15 on triggers). In
addition, free days and times such as weekends, evenings, holidays,
and vacations may be hard because they lack sufficient structure for
people who do not yet know how to manage their free time (see
chapter 11 on relaxation and free time). During such days people
may have more time to feel and think about painful issues or
memories, which they might prefer to avoid. And if they are
avoiding dealing with inner parts, these times are fertile ground for
such parts to emerge unbidden. Therefore, empathic internal
communication and collaborative planning are invaluable to
prepare for these times.
Next we discuss holidays as one example of a stressful time for
which it is helpful to plan in advance.

Managing Holidays
Holidays are painful for many people, not just those who have a
dissociative disorder. Some degree of depression, anxiety,
loneliness, hurt, and general stress are fairly common for people in
general. Everyone knows about the “holiday blues,” and at some
level most of us realize that expectations of ideal holidays rarely
match reality. Yet even when people may realize their expectations
are unrealistic, they still may be affected emotionally. And there are
added complexities for people who must make difficult decisions to
be with family who might have been abusive in the past or continue
to be abusive in the present; furthermore, some people are faced
with the prospect of being alone at an important time. Finally, there
may be pressure from those around you, or parts within you, to act
like everything is fine, when you feel anything but fine. Such
demands compound feelings of loneliness and being
misunderstood, and even of shame or despair.
Many people with a dissociative disorder did not have positive
experiences of holidays in childhood, and these memories may be
triggered, resulting in anxiety, depression, inner conflict and chaos,
and flashbacks. Inner reflection, including communication with
dissociative parts of yourself, may help you identify triggers and
help you make plans to cope with them. You might decide to
consciously avoid the trigger for the time being or help parts of
yourself cope differently. For example, you might decide to use
different holiday decorations, if the usual ones remind you of
painful times. Or you might notice the similarities and differences
between here and now and then and there, for example, the holiday
is the same, but what happens during the holiday now is quite
different from then, and you are an adult now. The problem is not
the holiday (the trigger) itself, but what it represents for you. You
might plan to find ways to contain painful memories so you can
enjoy the present holiday, and then deal with these memories at a
later time, for instance, storing them in an imagined vault, or box,
or on a computer file. It is often helpful to plan how you want to
spend a holiday instead of waiting to find out what friends and
family will do and whether they will invite you to join them. Learn
to be proactive and deal with it before it happens!

Times of Day, Anniversaries, and Seasons

Many people with a dissociative disorder struggle during other
kinds of situations that are reminders of painful events in the past.
Perhaps nights are hard because that is when they were hurt by
someone or when they feel the most lonely. Sometimes the date of
an overwhelming experience brings back all the pain. For others, a
season may be difficult, for example, summer brings up painful
reminders of events that occurred during that time of the year or,
conversely, may evoke a sad yearning for wonderful summers spent
with loving grandparents when life at home was hard.

Other Difficult Times

There are many times in daily life that may be especially stressful,
such as a big meeting at work, an ongoing conflict with someone, a
visit to the doctor, a medical or dental procedure, a separation or
divorce, being alone when you need the support of others, or
having to meet with family members whom you find difficult or
even unsafe, and many others. Some of these situations may be
challenging in their own right, while others are difficult because
they trigger you or some parts of you. We have addressed many of
these issues in other chapters, for example, dealing with doctors in
chapter 13 on self-care, coping with triggers in chapters 15 and 16,
and regulating overwhelming emotions in chapters 17 and 18.

Coping With Being Alone During Difficult Times

There may be important times when you wish to be with others but
instead find yourself alone. This happens from time to time for
almost all people. Perhaps it is a weekend or holiday, your birthday,
or a difficult anniversary for you. The loneliness that is evoked can
be profound and painful.
Make efforts to plan for these times. Even though you are alone,
you do not have to feel lonely. Use your relaxation kit (chapter 11)
and plan healthy activities to occupy yourself. Make a list of
activities that you or some parts of you would like to do with and
without other people. Try choosing a couple of activities that are
agreeable to your whole self. If you cannot be with someone during
your difficult time, plan to get together with someone a little later.
You can always celebrate holidays or birthdays on a different day if
you are flexible. After all, it is the enjoyment of the day, not the
date itself that is important. If you are alone during a holiday or
other important time, volunteer somewhere or make other active
plans instead of sitting at home doing nothing and feeling lonely.
You will find more help in dealing with being alone and lonely in
chapter 30.
Regardless of the type of situation, if you think you might have
a hard time, the planning process is similar, with certain predictable
steps, which we discuss next.

How to Plan for a Difficult Time

If you know of an upcoming time that will likely be difficult for
you in some way, begin early with inner reflection and
communication among parts of yourself. Reflect on what happens
for you during those times, noticing what you feel and think, how
your body responds to the stress (for instance, freezing or agitated),
and how various parts of you react. The awareness you gain from
reflection allows you to make different choices instead of feeling
hopelessly captive in your experience.
For example, if you are aware a part of you always criticizes
you during these times, you might be able to communicate more
with this part of yourself to understand why. Perhaps this part
believes you will fail and criticizes you in the hopes that you will
try harder, or perhaps it uses anger to avoid shame or fear about the
situation. If you know you always freeze, you might be able to
begin to notice and to change that physical reaction instead of being
stuck in it. If you can be aware that you are feeling hopeless, you
might be able to provide yourself with comfort, meaningful contact
with others, and inner support for parts of yourself.
You may dialogue with parts of yourself, write in a journal or
on the computer, or imagine an inner meeting. If you find these
tasks difficult, ask your therapist to help you. Do not wait until the
day before to communicate internally about upcoming difficult
times. Give yourself sufficient space to think it through, to reflect,
and to make a plan that will help you, so you can “deal with it
before it happens.” Even if you do not have “direct”
communication with parts, you may already be aware of certain
activities, people, foods, and so forth that might trigger you, as well
as some ways to help yourself be more comfortable and safe.
In the next section you will find some questions that will help
you reflect on how you, including all parts of you, can best plan for
difficult times. Find a quiet time at home to reflect on these
questions. Try to take into account thoughts and ideas from as
many parts as possible, because various parts of you may perceive
the situation differently from each other.

Reflections to Help With Planning for Difficult Times

• What times tend to be your most difficult?

• When you have a difficult time, what happens? For example,
what do you feel and think, how does your body react?
• How do you usually make a plan? For instance, do you think
it through, avoid it, prefer to be completely spontaneous, talk
about it with others?
• What obstacles do you encounter while planning? For
instance, beginning a plan, identifying the steps needed to
complete a plan, getting lost in too many choices or details,
inner criticism or conflicts among parts, trouble completing a
plan.
• What techniques and skills do you already use to help
yourself with planning? You may also check on the Internet,
look for books on planning (and executive functioning), or
ask for help from your therapist or other supportive people.
• What has helped you in the past with difficult times?
• List any triggers for which you know you need to prepare
yourself.
 • What are the fears and concerns of various parts of yourself
about a particular time?
• How might you ensure your emotional and physical safety
during this time?
• What obligations might you have to others during this time?
Do these obligations conflict with your own self-care?
• Are there relational limits or boundaries that you need to set?
If so, what would help you set them?
• Are particular parts of yourself especially vulnerable during
this time? If so, what do they need to feel safe, supported,
and cared about by you?
• Notice whether you prefer activities with other people during
difficult times or if being alone is more helpful.

Tips for Effective Planning

• Put your plan in perspective. The need to plan is usually not

an emergency, so you do not have to do it urgently. Give
yourself time to think and to check in with yourself.
• Try to let go of the belief that there is only one single “right”
solution or choice. There are almost always many “right”
pathways, and if you make a mistake, you can deal with it.
Many plans involve a combination of pros and cons, so often
there is not a “perfect” solution, but rather one which likely
requires some compromises.
• Most importantly, include all parts of yourself in your
planning. Attend to their concerns, needs, and desires without
judgment.
• Listen to both your head and your heart, that is, reflect.
Sometimes your logic and your emotions (or “gut”) tell you
something entirely different. Various dissociative parts
typically base a choice either on too much feeling or on
avoidance of feelings and needs, and they often do not know
enough about the present. If all parts of you can work
together to learn more about the present, acknowledge
feelings, needs, and wants, and offer inner empathy and
support, making plans can be a lot easier and clearer.
• Think before you act. Take your time, even if you feel
“urgent.” Imagine being in your safe space or use a relaxation
 exercise to get yourself in an alert, calm space. Let all parts
of yourself know they will be acknowledged and considered
as you make your plans.
• Imagine how your plan will affect you and parts of yourself.
You are learning how to take care of yourself, which means
you need to take yourself into consideration, as well as
others. This is not selfish, but rather good self-care. After you
anticipate how the plan will affect you and other parts of
yourself, then you can take others into consideration.
• Ask trusted others for feedback, but make your own plans,
taking their advice into consideration.
• Be willing to modify your plans if they are not working.
Making small changes along the way often helps you
accomplish your final plan better than rigidly sticking to a
plan.

When Obligations to Others Conflict With Your

Needs
You may find yourself in conflict during a difficult time between
your own needs and those of others. For example, you may have an
obligation to attend a family function that you know will be very
stressful for you. You prefer not to go, but you must. This may
provoke intense inner conflicts among parts inside. Next you will
find some suggestions for dealing with these conflicts in such a
way that you are able to take care of yourself. You must learn to set
healthy boundaries and negotiate compromises that work for you
and all parts of you (see chapters 30 and 31 on assertiveness and
personal boundaries).

• Negotiate to limit visits with others who are difficult, for

example, visit for an hour instead of an entire evening, or a
day instead of a weekend. Announce your time limit in
advance or at the beginning of the visit. If needed, set the
alarm on your watch or phone for the right time so you will
not forget, or have a trusted person call you at that time.
• Stay in a hotel rather than in the home of a person with whom
you have a difficult time.
• Invite a friend to be with you for support.
• Make plans to leave early if needed.
• Have your own transportation so you do not have to rely on
someone else.
• Use imaginary rehearsal, protective suits, and inner safe
places.
• Make quiet times for yourself during difficult visits by taking
walks, going to your room to read or rest, or going to a movie
or other activity.
• Make time for inner reflection and check-ins with all parts of
you. Treat their needs seriously and with compassion.


Homework Sheet 16.1

Preparing for a Difficult Time
Choose a difficult time that you predict is likely to occur (not your
most difficult, but one that you feel ready to tackle). Record your
reflections below regarding this difficult time (you may refer back
to the reflections to help you plan). If possible, allow parts of you
to participate without making any judgments about them. Try to
develop a plan to address your difficult time. It is OK to start with
very small steps. If you were able to try the plan after you made it,
describe what happened. If you were not able to try the plan (or
come up with a plan), please describe what made it difficult.

1. Describe the difficult time on which you have chosen to work in

this exercise.

2. Describe what you are most concerned about during this time
(for example, having flashbacks, being overwhelmed, being afraid,
freezing and going blank).

3. If you are aware of any parts of yourself that are particularly

vulnerable during this time, describe what might happen for them
(for example, a part may want to engage in self-harm or may feel
suicidal; it may want to be with someone who is hurtful to you; or it
may be terrified, ashamed, or become enraged).

4. Begin your planning by finding a quiet time, free of distraction

and chaos. Use some of the relaxation exercises in chapter 11 to
help you be calm and clear headed. Also use your inner safe
place(s) to help all parts of you feel safe and secure. It is essential
to stay focused on the present, not on the imagined catastrophic
future.

5. Next, check in with all parts of yourself to survey your needs and
desires for this time and describe them below. It is fine if various
parts have conflicts: Do not judge them or worry about the conflict,
but rather simply write down what each part of you wants or needs
during the difficult time. For example, one part may want to self-
harm, while another part wants to hide; yet another part may want
to explode in anger, while another part wants to be extra good so
that she might be loved by someone.

6. You may be able to find some common ground among parts in

these conflicts you have shared in #5 above. For example, if a part
wants to self-harm, you likely are feeling overwhelmed with some
emotion, and the self-injury may be a way to reduce the sense of
being overwhelmed. And certainly all parts could agree that being
less overwhelmed might be a common goal each of you could work
toward. Likewise, if one part is terrified and another part is furious
about this “cry baby,” it is possible that both parts need and want
safety. The one is expressing fear, while the other is acting “tough”
to protect vulnerability: Both are simply different ways to respond
to threat. And all parts might agree that feeling safe is a worthy
common goal.
Describe one or two inner conflicts (if you have any) about your
difficult time, using the examples above as a guide. After you
describe the conflict, see if you can determine the underlying
common goal among parts. If you need help, make sure you take
time in therapy to understand these conflicts and any possible
underlying common goals.

7. Describe your plan for being emotionally and physically safe

during your difficult time, using inner consultation and, if needed,
help from trusted others.

8. Describe the resources you or parts of you may need to cope with
your difficult time. For example, parts may need to feel safe or
comforted, may need to remain in an inner safe place, may need to
know the adult part of you is capable of dealing with the situation,
or that a safe person is available to talk, if needed.

9. Finally, describe what you will do if you become overwhelmed.

For example, you can leave, take a time-out and go for a walk, call
a friend, take time to go to an inner safe space, practice relaxation
exercises, or take prescribed medication to calm you.
 PART FOUR
SKILLS REVIEW
You have learned a number of skills in this section of the manual.
Below you will find a review of those skills and an opportunity to
develop them further. As you review, we encourage you to return to
the chapters to read them again and repractice the homework a little
at a time. Remember that regular, daily practice is essential to learn
new skills.
For each skill set below, answer the following questions:

1. In what situation(s) did you practice this skill?

2. How did this skill help you?
3. What, if any, difficulties have you had in practicing this
skill?
4. What additional help or resources might you need to feel
more successful in mastering this skill?

Chapter 14, The Store Exercise

1.

2.

3.

4.

Chapter 15, Identifying and Coping With Triggers

1.

2.
3.

4.

Chapter 16, Strategies for Effective Planning for Difficult Times

1.

2.

3.

4.
 PART FIVE

Understanding Emotions and

Cognitions
 CHAPTER SEVENTEEN

Understanding Emotions

AGENDA
• Welcome and reflections on previous session
• Homework discussion
• Topic: Understanding Emotions

Introduction
Basic Emotions and Their Functions
Problems With Emotions for People With a Complex
Dissociative Disorder

• Mindfulness exercise
• Homework

Reread the chapter.

Practice the Mindfulness exercise at home.
Complete Homework Sheet 17.1, Identifying and
Understanding Emotions.
Complete Homework Sheet 17.2, Sensory Experience
of an Emotion.

Introduction
Emotions are part of our basic functioning as humans. They are
present in everyone, and they are there to guide us and help us
make decisions. Emotions are felt in the body; they involve somatic
sensations, specific postures or movements, and tendencies toward
certain actions. They are also understood as signals to behave in
certain ways during particular circumstances. Generally emotions
are not voluntary, that is, you cannot “make” yourself feel a
particular emotion. They are a bit like internal weather, coming and
going, changing from time to time, flowing from one to the other,
sometimes stormy, sometimes calm. This internal weather is as
normal and expected as outside weather. And like weather,
emotions are influenced by various environmental stimuli, either
internal or external effects. Emotions are spontaneous (involuntary)
reactions to events outside and inside ourselves. They are primary
guides that help us best adapt our behavior to what is happening in
the present. For example, love helps us be closer to someone we
care about; fear helps us avoid a dangerous situation; joy helps us
seek out pleasant experiences.
Because emotions are basic to our functioning, it is essential to
understand and learn to “read” them. The first step is being able to
name and recognize basic emotions, and then to understand their
functions and how to respond to them.

Basic Emotions and Their Functions

There are many lists of basic emotions. We have chosen to describe
eight that are based on our evolution from animal emotions and are
found universally in people around the world. These emotions are
paired in a range from mild to intense.

1. Interest–Excitement
2. Enjoyment–Joy
3. Surprise–Startle
4. Distress–Anguish
5. Anger–Rage
6. Fear–Terror
7. Shame–Humiliation
8. Disgust

Judging Emotions
Although we often tend to view emotions as good or bad, this is not
a helpful judgment. Emotions are neither good nor bad; they simply
are part of our functioning as humans. It is true that we recognize
some emotions as pleasant and others as unpleasant or painful, but
you will find it very useful to focus more on the purposes and
meanings of an emotion rather than judging them. This is a step
toward accepting them as part of you and part of life.

Emotions Help Us Meet Our Needs

One major function of emotion is to motivate and initiate behavior
that is directed toward specific goals, that is, behavior that can meet
our needs. For example, anger directs us to fight when we are
provoked, hopefully keeping us safe; fear prompts us to run away
or avoid something that is frightening or threatening; love directs us
to behave in ways that draw us closer to the ones we love, because
we need safe relationships.
Emotions are not really separate “things”; they are part of
bundled experiences that include not only emotions, sensations,
thoughts, and physical actions but also our perceptions of what is
happening in the present and our predictions of what will happen if
we act in a certain way. Emotions are as essential as thinking and
behaving to our survival. However, when the ability to regulate and
tolerate emotions is disrupted or inadequate, this entire bundled
experience becomes difficult to manage.

Two Kinds of Emotional Experiences

Some feelings or emotions are involuntary reactions to events that
happen around you (for example, feeling joy because someone is
especially nice to you; anger because someone criticizes you or
forgets a date you made; fear because something startles you).
Other emotions are primarily a reaction to your own thoughts,
actions, and feelings (for instance, being ashamed of your body
because an inner voice tells you that you are ugly; feeling
embarrassed that you feel sad; feeling guilty or afraid because you
are mad with someone). These “feelings about feelings,” that is,
emotions about our inner experience, particularly those that involve
variations of shame or pride, are called self-conscious emotions
(Tracy, Robins, & Tangney, 2007). They can often be problematic,
because they are paired with inner negative judgments about what
we experience.

Feedback Loops of Perceptions, Thoughts, Feelings, and

Behaviors
As noted earlier, our emotions are intimately connected with our
thoughts, behaviors, sensations, and the ways in which we perceive
the world. These experiences are not actually separate, but rather
bundled together, in continuous feedback loops with each other.
For example, when people feel afraid, they will tend to view the
world through the lens of fear, perceiving many things as
threatening, when daily life may not be dangerous in reality. These
perceptions are related to fear-related thoughts and beliefs, for
example, “That man is frowning; he must be angry with me; anger
is dangerous; I must get away.” These thoughts and beliefs
heighten the perception of danger, which heighten the feelings of
fear, which heightens thoughts of danger, and so on. And
perceptions, emotions, and thoughts induce decisions to act in
certain ways. Eventually, people may become so sensitively
conditioned to an emotion such as fear that merely having a
physical sensation of fear, such as a sinking feeling in the stomach,
may prompt them to believe danger is near and to act in a fearful
way.

Problems With Emotions for People With a Complex

Dissociative Disorder
People with a complex dissociative disorder were often confronted
as children with situations that evoked extreme and overwhelming
emotions. Generally young children learn from their caregivers
how to understand and regulate emotions. People with a
dissociative disorder often grew up in families in which it was not
acceptable to show or discuss certain emotions. In some cases, it
was actually dangerous to express feelings, resulting in punishment,
ridicule, or complete disregard. Parents or caregivers of people with
a complex dissociative disorder typically had a problem with
emotions themselves and were thus unable to teach their children
adaptive and healthy skills to deal with emotions. These children
learn to avoid or disregard their own feelings. They also have
difficulty reflecting, that is, accurately reading other people’s
emotions and intentions in the present, generally assuming
something negative rather than positive.

Intense Emotions Are Often Dissociated

People with a dissociative disorder have compartmentalized,
intolerable, intense emotions in various parts of their personality.
Sometimes parts that function in daily life do not experience much
emotion and have learned to avoid feeling much. They may
experience feelings as “all or nothing,” that is, far too intense or not
at all. Some dissociative parts of the personality, living in trauma-
time, may experience the same emotion no matter the situation,
such as fear, rage, shame, sadness, yearning, and even some
positive ones just as joy. Other parts have a broader range of
feelings. Because emotions are often held in certain parts of the
personality, different parts can have highly contradictory
perceptions, emotions, and reactions to the same situation. As an
example, you may be in your therapist’s office and hear a door
slam in the hallway. You jump and are startled, but the adult part of
you is able to think, “It’s OK. It’s just a door closing.” Yet a very
frightened part of you becomes more and more upset and freezes or
wants to run out of the room, because that part is not yet oriented to
the present and still feels in great danger as though the past were
the present. Intense fear continues to be dissociated in that part of
you, while you may not feel it at all. You, or other parts of you,
may be highly critical of the scared part of yourself.
You may become so fearful or ashamed of so many emotions,
as well as the physical sensations that are a natural part of
emotions, that you have learned to avoid (some of) your inner
experience at all costs (see chapter 5 on the phobia of inner
experience).

Negative Judgments of Emotions Among Dissociative Parts

Dissociative parts of an individual often make negative emotional
judgments about each other. For example, one part may feel
disgusted because another part feels needy or dependent; or one
part feels angry because another part is afraid to try new things.
Some parts avoid feeling anything at all and believe emotions are a
waste of time. Some people hear these comments in their head or
“sense” them in the background. These “feelings about feelings”
are often highly problematic, because they generally include harsh,
negative judgments about basic emotions, which, in fact, are merely
an inevitable part of being human.

Fear of Losing Control

The major parts of you that function in daily life may have little
idea of why a given feeling occurs, almost as though it comes “out
of the blue.” Thus, people with a dissociative disorder may
experience anxiety or fear of losing control of their behavior or
feelings to other parts of themselves. In addition, emotions can be
experienced as so overwhelming that some people describe it as
“falling apart,” “exploding,” “crumbling,” or other metaphors for
intense loss of control.
Difficulty Attending to Emotional Signals in the Present
We all must attend to the signals that emotions give us. Otherwise
the emotion is likely to intensify or evolve into something else even
more difficult to manage. Many people find it easy to ignore their
feelings. But an ignored minor feeling may escalate to an intense
one, for example, irritation at someone who is bothering you may
build to outright anger if you do not address it. You might then
explode in anger with your friend or partner, and the other person
will have no idea why, because you never said anything about
being irritated. If you had been able to attend to the signal of
irritation, you may have been able to speak up respectfully, set
good boundaries, and never come to the point of anger.
Most people with a dissociative disorder have not learned to
read their emotional signals, only recognizing that they feel
globally overwhelmed, or awful, or bad, or tense. They are not yet
able to distinguish the physical and mental signals associated with
specific emotions, and how they might differ from the signals of
other emotions. They must first learn to read and interpret their
emotional signals and match them to particular emotions. Reading
emotions may be complicated by the fact that some parts have an
emotion, while others may not experience it. The part that does not
experience the emotion may only be aware of a vague unease or
restlessness. This is one reason why it is vital to develop more
internal awareness about your emotions and dissociative parts of
yourself.

Triggers May Evoke Overwhelming Emotions

As we noted earlier in the chapters on triggers, they may
instantaneously evoke powerful and overwhelming emotions.
Various dissociative parts tend to have their own particular set of
emotions related to traumatizing events, and thus they will be
triggered to experience those emotions, without regard to the
present situation. In fact, such parts often do not even experience
much of the present. Thus, while one part oriented more in the
present may be feeling fine, another part that is stuck in the past
might be quite fearful or angry. The emotions of dissociative parts
can intrude into present experience so that a person begins to feel
fear, anger, or shame that is not related to the here and now. These
feelings, stemming from dissociative parts, can be confusing and
frightening, leading the person to try to avoid emotions, as well as
situations in which these emotions are reactivated.

MINDFULNESS EXERCISE
Emotions can best be understood and dealt with when you are fully
engaged in the present moment and able to attend to your inner
experience while staying in the here and now. The following
exercise is designed to help you practice being present and mindful.
It will be most helpful if all parts of you can participate; otherwise
your attention is divided rather than concentrated on the present.
You will need a small piece of food that you enjoy, such as a
raisin or other piece of fruit, a piece of candy or cookie, cheese or
nuts, or a slice of vegetable.
Take the food and put it in the palm of your hand or
between your finger and thumb. Look at it carefully. Give it your
full attention and examine it as though you have never seen
anything like it before. Roll it gently between your thumb and
forefinger. Explore it with your fingers. Look carefully at the
parts that might catch the light, and at all the little grooves and
ridges or irregularities. Explore every single nook and cranny of
it.
And if, while you are doing this exercise, thoughts enter
your mind such as “This is stupid!” or “What on earth is the use
of this exercise?” or if other thoughts about another topic come,
simply acknowledge them and redirect your attention back to
your food. Now smell it, holding it right under your nose, and
with each breath you take, notice the smell. Slowly move it
towards your mouth. You may feel your mouth beginning to
water. Put it in your mouth and notice what your mouth feels
like, with the food in it. Let it lie on your tongue a little. Then bite
down on it deliberately, noticing the taste that is released. Chew
on it slowly, notice whether more saliva enters your mouth, and
whether the food gradually begins to feel different in your
mouth. Chew slowly, savoring each bite. When you are ready to
swallow your food, be aware of it going down your throat and
into your stomach. Notice that in your mouth the last remnants
of the taste of the food may still linger.

Each day this week, practice eating something with complete

attention: a piece of cheese, an apple, a piece of candy. Practice
with a food that you like.
You can expand this exercise to include other routine actions,
such as brushing your teeth, shopping, driving, getting dressed, and
so forth. The point is to be completely focused on the present
experience, even when there does not seem to be any important
meaning to it. Such exercises are meant to help you learn to be
present and attentive to yourself and your environment in the
moment, a necessary skill for reflecting and keeping yourself
grounded.


Homework Sheet 17.1

Identifying and Understanding Emotions

1. Make sure you can identify in yourself or in others the eight

basic emotions listed in the beginning of the chapter. Name one or
two emotions below with which you feel comfortable.

2. Name one or two emotions that you never or very rarely

experience, or of which you are afraid or ashamed.

3. Describe an impulsive urge to act (do something) that you might

experience when you are faced with a difficult emotion. For
example, when you feel lonely, you feel the need to make the
feeling go away by any means possible, even though you know that
the behavior is not good for you in the long run, such as drinking,
self-harm, (binge) eating.

4. List one or two healthy ways of coping with the feeling you
described in #3 above, even if you have not been able to use them
yet.

5. Name any emotions you might judge as “bad” in yourself or

others and state why you think they are negative.

6. Do you find that pleasant feelings such as happiness, pride, fun,

or joy are negative for you? If so, describe what is negative for you
about those feelings.

7. Name any emotions that some parts of you might experience and
other parts do not. Describe your reaction to those emotions.
Describe the reactions of other parts of you to those emotions.
8. Please describe as best you can what you are concerned about or
fear if you experience a certain emotion that you now avoid.


Homework Sheet 17.2

Sensory Experience of an Emotion
Choose one emotion and describe how you experience it in as much
detail as possible. Feel free to use metaphors, images, and
descriptions of sensory experiences. Use the suggestions below as a
guide. There are no right or wrong ways to describe your emotion.

• Sensations that accompany emotion: tingly, tense, warm,

cold, shivery, sweaty, dizzy, burning
• Colors, such as ice-blue, red-hot, sunny yellow, dreary grey,
pitch-black
• Sensations such as bitter, sweet, sour, rough, soft, hard,
smooth
• Shapes such as round, square, twisty, ball, triangle, rope, blob
• Metaphors such as “like a storm”; “like a big black hole in
my chest”; “like a tornado”
• Creative arts: painting, drawing, doodling, mandalas, collages
• Writing: keep a journal about your feelings or write a story or
poetry
• Music: make a collection of music that expresses your
emotion
• Movement: explore finding a particular posture or movement
that symbolizes your emotion

As you reflect on the sensory experiences above, explore how you

might be able to change them to feel better. For example, if you
experience an emotion as a hard black ball in the pit of your
stomach, ask yourself what the ball wants to do or what it needs.
Does it want to be thrown? To change color? Does it want warmth?
To be held in your hands? To dissolve into light? Does it have
something to say? Does it want to uncurl and stretch out? Does it
prompt a movement in your body, a change in posture? Be creative
and trust yourself, and get help if you feel stuck in your
exploration. Also make sure you are staying within what is
tolerable as you explore. If you have trouble doing so, stop and ask
for help from your therapist.
 CHAPTER EIGHTEEN

The Window of Tolerance:

Learning to Regulate Yourself

AGENDA
• Welcome and reflections on previous session
• Homework discussion
• Break
• Topic: The Window of Tolerance: Learning to Regulate
Yourself

Introduction
The Window of Tolerance for Arousal
Experiencing Too Much: Hyperarousal
Tips for Coping With Experiencing Too Much
Experiencing Too Little: Hypoarousal
Tips for Coping With Experiencing Too Little
• Homework

Reread the chapter.

Complete Homework Sheet 18.1, Learning About Your
Window of Tolerance.
Complete Homework Sheet 18.2, Your Tips for
Coping With Feeling Too Much or Too Little.

Introduction
As we noted in the previous chapter, emotion regulation is an
essential part of healing. However, many people with a dissociative
disorder tend to experience too much or too little in many different
areas of life, not only with emotions. They may feel every little
ache and pain or change in their body (too much), or they may not
feel pain when injured or feel physically numb all over (too little).
They may seek out experiences that may be risky (thrill seeking) or
avoid new life experiences altogether. They may overthink and be
unable to turn off their thoughts, while others may be unable to
think much at all and feel blank. Some are highly sensitive to
changes in their surroundings, noticing every little thing such that it
becomes hard to concentrate, while others are very inattentive to
their surroundings. And of course, dissociative parts intrude into
the present with unregulated experiences, contributing to feeling
too much or too little.
Feeling too much and too little are actually two sides of the
same coin: Both indicate difficulties with regulation of
physiological arousal. Your arousal level simply indicates how
physically and emotionally responsive or even reactive you, or
certain parts of you, are to certain stimuli. In particular, you may
become dysregulated when you react to stimuli that are especially
emotional or stressful for you, such as learning a difficult new skill,
having an argument with your partner or friend, driving in traffic,
having an unpleasant feeling, or remembering something painful. In
order to function at our best, we all need an optimal arousal level—
not too high and not too low, depending on the level needed for the
current circumstance. In this chapter you will begin to learn how to
regulate or modulate your arousal to manageable levels.

The Window of Tolerance for Arousal

A major goal in therapy is to support you, and all parts of yourself,
to learn how to experience “enough,” rather than too much or too
little. This range of optimal arousal is called your window of
tolerance (Ogden et al., 2006; Siegel, 1999; Van der Hart et al.,
2006) (see figure 18.1). It is the range of experiential intensity that
is tolerable for each part of you and within which you can learn,
have an inner sense of safety, and be engaged with life. You may
know from experience that you learn most effectively and feel most
comfortable when you are not too agitated or anxious, nor too tired,
sleepy, or shut down emotionally. This is true for all parts of you.
When you, or other parts of yourself, are outside your window
of tolerance, you experience too much arousal, termed
hyperarousal, or not enough, termed hypoarousal. Sometimes your
window of tolerance might be quite small, like a window that is
barely cracked open. Then you, or some parts of yourself, can be
overwhelmed quickly and feel out of control or even completely
shut down. In that case, your task is to widen your window of
tolerance a little bit at a time until it is sufficient for coping with
daily life.
Each of us has our rather unique range of what we can tolerate;
our window of tolerance is to some degree defined by our inborn
temperament and natural level of physiological reactivity. But it is
also defined by experiences. When you have been chronically
overwhelmed, your ability to regulate your physiological arousal is
eventually compromised.

Figure 18.1. Window of Tolerance. Adapted from Ogden et al., 2006; Siegel,
1999; and Van der Hart et al., 2006.

Auto- and Relational Regulation

People regulate themselves by using a combination of relational
and self-regulation. The first is referred to as interactive regulation,
and the second, auto-regulation (Schore, 2001). Early caregivers
ideally help soothe and regulate an infant or young child by
nurturing, encouraging, attending to emotional and physical needs,
and comforting. This lays the groundwork for individuals to be able
to regulate themselves as they grow and develop. As adults, we call
upon others to support us when we are upset, because it can be
comforting to have another person present, and he or she helps us
view our problems from other helpful perspectives. And at times,
others are not available or needed. Then we are able to regulate
ourselves by reassuring ourselves, slowing down to reflect,
practicing calming exercises, or doing things that help ourselves
feel better.
The ability to employ a balance of auto- and relational
regulation is important. However, some people find it hard to rely
on others for any kind of support, that is, they do not use relational
regulation. Others find it hard to rely on themselves, that is, they do
not use auto-regulation. Both groups are at a significant
disadvantage, since we all encounter situations in which one way of
regulating is not sufficient or appropriate. We will discuss more
about auto- and relational regulation in chapter 29 on resolving
relational conflicts.

Lack of Reflection
A major difficulty in emotional dysregulation is that you are, at
times, unable to reflect on what you are feeling, but instead are just
“in” the feeling, acting blindly and not able to think clearly. You
may find that emotions from dissociative parts of yourself intrude
into your awareness. You may not always know where these
emotions are coming from, as though they are “out of the blue,”
and this adds to how overwhelming and frightening they can feel.

Avoidance of Emotion
Most people with complex dissociative disorders are very adept at
avoiding emotions. And there are certainly times when it is
important to focus on the task at hand and wait to deal with your
emotions until a later time. Although avoiding overwhelming or
intense feelings may help you function in daily life in the short run,
it also leaves you and other parts of you devoid of rich and
meaningful connections to yourself, to safe others, and to
experiences that make life worth living. And you also have little
ability to resolve painful or traumatic experiences.
Perhaps only certain experiences, such as having flashbacks, or
the threat of losing a relationship, push you, or some parts of you,
out of your optimal level of arousal. But the more afraid or
ashamed you are of your inner experiences, the more avoidant of
inner parts of yourself, the less ability to reflect, and the more
unresolved conflicts or traumatic memories you have, the harder it
is to stay within your window of tolerance. Thus, being able to
reflect is of prime importance in helping yourself learn to cope with
your emotions (review chapter 6 on learning to reflect).
As a first step, you need to find your window of tolerance and
learn to stay within it more consistently, and then gradually learn to
widen your tolerance level, like fully opening a window that had
only been cracked open previously. Each part of you will need to
learn to become more regulated. Once your tolerance level as a
whole person is wider, you can have a much broader range of
experiences that do not overload you. Overwhelmed parts of
yourself can feel calmer and more focused, while numb or avoidant
parts feel more capable of tolerating emotions and other inner
experiences. Thus, all parts of you gradually learn how to regulate
emotions and arousal levels, and each part of you can learn to help
other parts so that you, as a whole person, learn to deal with
emotions and all other experiences in ways that are more
constructive and adaptive. And as you learn not to judge your
emotions and other inner experiences and are able to reflect on
them without so much avoidance, you will find your window of
tolerance will increase, that is, you have more tolerance for a wider
range of experiential intensity.
A number of exercises in earlier sessions are actually designed
to help with emotion regulation and forming a healthy window of
tolerance, such as learning to reflect (chapter 6) and creating an
inner sense of safety for all parts of yourself (chapter 8). The
chapter on sleep (chapter 9) contains methods to soothe yourself
when you wake up feeling anxious or scared during the night. The
relaxation kit (chapter 11) furnishes you with a list of activities and
ways that help you and all parts of you feel more pleasant and
relaxed.
Next we explore some of the problems and solutions for
experiencing too much and too little.

Experiencing Too Much: Hyperarousal

Typically, some dissociative parts of yourself chronically
experience too much, that is, are hyperaroused, because they are
stuck in traumatic experiences and feel overwhelmed by fear, pain,
shame, and so forth. Or perhaps you, as a whole person, generally
feel so sensitive and edgy that it is very easy for you to become
overwhelmed and upset in daily life, even when you are not
bothered by traumatic memories. You, or some parts of you, might
be upset by situations that generally are of little consequence to
others, particularly small relational upsets or conflicts, or a last
minute change of plans. Once you are upset—agitated, anxious,
scared, or angry—it might be hard to calm yourself down (auto-
regulation). Time may seem slowed down as though you will be
upset forever, and you cannot remember being calm. This makes
you even more upset and urgent to stop what you are feeling.
When you are overwhelmed, your judgment is not at its best
and you, or another part of you, may impulsively try to stop the
intensity of your feelings by acting in ways that may not be in your
own best interest in the long run. For instance, people may drink,
use drugs, harm themselves physically, get into fights, say things
they later regret, or isolate from others. You may find yourself
puzzled about why you are so upset and cannot seem to understand
what happened: This sometimes occurs when a dissociative part of
you has become triggered without your awareness.

Tips for Coping With Experiencing Too Much

There are a number of ways to help yourself when you are feeling
overwhelmed. You can temporarily distract yourself and all parts of
yourself. You can contain particular feelings or memories or parts
of yourself in a safe place. You can express your emotions
appropriately. You can reassure and soothe parts of yourself. And
you can practice grounding exercises to help keep you in the
present.
You will receive the most benefit from the following tips when
you are able to reflect on what has evoked your hyperarousal and
begin to develop awareness of the struggles of various parts of you
that contribute to feeling too much. Empathic understanding of
your inner struggles and a willingness to seek out healthy coping
strategies to help all parts of yourself are essential to your healing.
Without inner awareness and empathy, most coping strategies are
not very effective.

Distraction
Temporary distractions help everyone who is feeling overwhelmed
from time to time. But it is important for all parts of you to
understand that conscious and voluntary distraction as a temporary
coping strategy is not the same as persistently avoiding the needs of
parts of you. Temporary distraction is just a way to slow down your
hyperarousal, like using a “reset” button. It gives you some time
where you can take a deep breath and rest, so you feel more able
and ready to cope with your feelings. An apt analogy is staying
busy to take your mind off of a strained muscle while you continue
to do the right things to help it heal, since focusing on the pain will
not alleviate it and will often make it seem worse. You do not
ignore the need to tend to your injury, but once you have done all
you can, you may distract yourself as you heal.
Distract yourself with healthy activities and support all parts of
yourself to refocus on something other than what you are feeling.
However, avoid working too much or engaging in other compulsive
distractions that will further stress you. When you distract yourself,
always make a promise to yourself that you will return later to what
is overwhelming, as soon as you are able.
What works for distraction may vary according to the way in
which you are feeling overwhelmed. For example, if you feel
overwhelmed with anger you might find a physical activity like
walking, running, or gardening helpful. But if you, or parts of you,
feel intensely sad, you might chose a soothing activity like
watching a nice movie, reading a (children’s) book, listening to
calm music, or going to your safe inner place. Try choosing
activities that match what you are feeling and that are agreeable to
all parts of you. Following are additional suggestions for distracting
activities.

• Exercise or take a brisk walk; changing your physiology can

change how you feel. Encourage all parts of yourself to
experience the walk.
• Listen to music while singing the lyrics.
• Do something pleasant or fun that all parts of you can enjoy.
• Call a friend and get together. Talking with another person
(not about the problem that is overwhelming you) can take
your mind of yourself for a while.
• Engage in an activity that requires concentration, for
example, a hobby, a crossword puzzle, or a computer game.
Try to encourage all parts of yourself to concentrate on the
same thing at the same time.
• Read an interesting or nice book that is not upsetting to any
part of you.
• Watch a comedy program or read a funny book. Again,
encourage all parts of you to focus on the same activity at the
same time. Laughter is a great distracter, and it helps you feel
better, too.
Containment
Contain, but do not ignore, feelings and parts of yourself.
Containment is entirely different from “getting rid” of your
feelings. When you contain a feeling or memory, and thus often a
dissociative part of yourself, you are saying to yourself, “Not now,
but I will return to this later.” You are making a promise to all
parts of yourself to make the time and energy to deal with it in the
right place at the right time. Be sure to take the time to check for
internal agreement among parts to contain an experience
temporarily.
You can use countless containment images: a bank vault,
floating up in a balloon floating high in the air, a submarine, a
computer file, a video, and so on. Use your own images that fit for
you or parts of you.
A different way to contain is to write or to use art to express
what you are experiencing. If this evokes too much for you, there
are other ways to contain. But some people find it helps to put their
experience on paper or canvas and then leave it there for later. You
may allow some parts of you to use this method if it is helpful,
while other parts need not be present, for example, by staying in
their inner safe place. You can put away these writings or drawings
or take them to your therapy appointments to help you move
forward in your healing.

Calming and Soothing Yourself

When you soothe and reassure yourself, you are not telling yourself
to stop having negative feelings, for example, “Shut up and don’t
cry. Put your happy face on.” This critical approach does not really
make any part of you feel better, even though it may be a long-
standing habit. Soothing and reassurance are much more effective
in calming all parts of you. Soothing includes an empathic
acknowledgement of the feeling, for example:
I am feeling sad and angry, and that is a hard combination. I am doing my
best to deal with these difficult feelings. It is in the best interest of all parts for
me to focus on what I am doing right now and then deal with them when I get
to therapy. That way I feel good about how I function in life and also have
support to work on these feelings.
This empathic acceptance also includes supporting all parts of
yourself, for example:
Since I am feeling so bad, I will do something nice for myself that all parts
can enjoy. It is OK for any part of me to have feelings, but I don’t want them
to overwhelm any part of myself. I will take care of all parts of me.
Following are some tips that help you to calm and soothe all
parts of yourself:

• Listen to all parts of yourself and try to reassure and comfort

any parts that may be anxious or upset; a little inner
communication and empathy go a long way.
• Practice calming, deep breathing exercises. Imagine that all
parts of you are breathing together, in perfect synchronization
in your safe place.
• Invite upset parts of yourself to go to a quiet, undisturbed
safe space where they can be soothed and helped, while
promising you will return to what is bothering them as soon
as you are able.
• It may also be helpful for you to take a short “time-out” to
rest.
• Ask a helpful inner part of yourself to support parts that are
anxious or upset.
• Try to slow your thoughts down and each time you notice
you are thinking about the problem, shift your thoughts to
something else. Help parts of you share thoughts at a
reasonable pace.
• Get some rest. Encourage all parts of yourself to rest. If parts
are critical, for example, “You are lazy and need to be doing
more,” try to negotiate with those parts of yourself for a
period of rest to see if it actually helps calm you down.
• Listen to soothing music and take into consideration what all
parts of you might find calming.

Grounding and Reassurance

• Use all five senses to ground yourself and be aware of the

present moment. Say out loud to yourself what you notice
with your senses.
• Try just noticing the experience of being overwhelmed, slow
your breathing down, and each time you feel the urge to do
something about the experience, allow that feeling or thought
to pass through you mind, like a train that does not stop a the
train station.
• Remind all parts of you that feelings are normal, a part of
 life, and that it is safe to feel intensely in the present.
• Remind all parts of you that all experiences, no matter how
unpleasant or intense have a beginning, middle, and an end.
• Notice what was happening when you began to feel
overwhelmed. This may help you determine what triggered
you (see chapters 14 and 15 on triggers). It also reminds you
that the feeling had a beginning, and before which you were
feeling something else.
• Recall times in the past when the feeling finally passed, that
is, remember its ending, as a reminder that this feeling will
also end in time.
• Ask your therapist to help you with additional ways to cope.
• Talk to people you know and become curious about how they
handle intense emotions and what they do to calm themselves
down. You can learn from their experiences.

Experiencing Too Little: Hypoarousal

To avoid feeling the kind of intense hyperarousal described earlier,
you, or some parts of yourself, may cope through avoidance and
numbing; thus, you experience too little at times. This is called
hypoarousal. You, or avoidant parts of you, may evade situations
that would evoke too much feeling, which often means you avoid
being too close to people, since relationships evoke some of our
most intense feelings, positive and negative. Sometimes a part of
you may completely shut down for brief periods, going to sleep or
being unable to think. Some people may even become
unresponsive, unable to hear or respond to someone speaking with
them. You might tend to avoid thinking about anything painful or
unpleasant, which means you are not able to resolve issues that
involve pain and conflict.
Dissociative parts of yourself that feel numb and detached may
have little to no empathy for, or even awareness of, other parts of
yourself that very much need support and help with feeling too
much. It becomes easy for these parts to label certain feelings or
experiences as “bad,” and thus to be avoided (see chapters 16 and
17). Such avoidance strongly maintains dissociation and prevents
healing.
Tips for Coping With Experiencing Too Little

• Because shutting down is often the result of feeling

overwhelmed, most of the interventions used for feeling too
much are also appropriate.
• You, or a part of you, may tend toward hypoarousal when
you are stressed. A major solution is to first become
physically and then mentally active. If you, or a part of you,
feel sleepy when you are faced with something
overwhelming, try to get up and get moving. You must resist
the tendency to become more and more still.
• Help inner parts feel safer in the present by reassuring,
calming, and orienting.
• Try a brief, vigorous activity to get your heart pumping and
your energy level up, for example, jumping jacks, push-ups,
or running in place.
• Do not allow your eyes to focus in one place, or you will
trance out. Notice your environment. Use all five senses and
name the things you notice out loud, in order to ground
yourself in the present. If a part of you tends to trance out,
you may try putting a little temporary distance between you
and that part of yourself, for example, imagining actual
physical distance between you or allowing that part of you to
go to a safe space.
• Use mental stimulation to get your brain more engaged and
active, for example, count backward from 100 by threes or
sevens, or go outside and count trees or cars.
• If you have a feeling of being paralyzed, ask inside whether a
part of yourself can help you move. You can start with a very
small movement, such as moving your little finger just a bit,
blinking your eyes, or twitching your nose. Next try to make
other small movements in another part of your body. Focus
on moving as much as possible. Think of someone whom you
may trust—a friend, your therapist, your partner—and
imagine that person helping you. Sometimes a particular part
of you is immobilized and other parts of you can help by
tending respectfully and empathically to that part, giving
orienting information, comfort, and safety.
• If you feel cold or freezing (a common experience in
hypoarousal), try a warm bath or shower (not too hot). Or
 wrap yourself in a blanket and place a hot water bottle or
heating pad on your stomach to warm your core. Then
imagine soothing inner parts as you warm up, using some of
the other resources available to you.
• If you, or a part of you, have physical numbness, note where
in your body it begins and ends, or whether you are
completely numb. Many people have at least small areas of
their body where they can feel. If you have such a place (for
example, your forearm), touch it gently and intentionally,
saying to yourself, “I am touching my forearm.” Scratch your
back with a soft, long brush; rub up against the door frame as
a bear rubs up against a tree; or wrap in a blanket to feel your
skin.
• If you are emotionally numb, notice whether you can feel just
a little bit of emotion, perhaps a 1 or 2 on a scale of 10.
Concentrate on the feeling, say it out loud, and draw the
attention of all parts of yourself to it. Remind yourself that
emotions can be safe; they are merely signals.
• You might ask whether any part of you could “share” a little
emotion with you, no more than you think you can tolerate,
for example, a teaspoon, a cup, or 5%. Also set a time limit,
so you can feel a little of the emotion just for a moment, say
to the count of 5, or 10 seconds or 30 seconds. As you feel
more able, you can increase both the amount and time you
experience an emotion. Notice as much of your inner
experience during this time as possible: what you think, feel,
sense, what you predict.
• If you are aware of certain parts of yourself that are severely
shut down, see if you can become more curious about what
they might need in order to be less shut down, and how you
might provide for some of those needs. Sometimes merely
the reassurance that you are really interested in tending to
them is enough to help these parts become more present and
alert.


Homework Sheet 18.1

Learning About Your Window of Tolerance

1. Place your current arousal level on a scale of 1 to 10, with 1

being the most extreme hypoarousal (feeling too little) and 10 being
the most extreme hyperarousal (feeling too much). On the scale
below, mark the range of your optimal level of arousal (not too
much or too little), that is, the range that is tolerable and relatively
comfortable. This is entirely subjective. There is no “right” answer.
For example, you might mark an area between 3 and 7, or 4 and 6.
Next, circle the points at which you might begin to work on
keeping yourself from going too high or low on the scale. For
example, if your range is 3–7, perhaps these points might be 2 and
6. Where on this scale would you need to stop what you were doing
to find a way to return to your optimal level of arousal?
Also notice whether any parts of you might have a different
window of tolerance.

2. Next, describe how you know you are within your optimal
arousal zone. For example, perhaps you feel calm, alert, relaxed,
pleasant, or energized. Perhaps you feel warmth or coolness in your
body, a sense of competence, a quiet or active mind. Your inner
experience when you are within your window of tolerance is like a
bookmark. You can memorize that experience, almost as though
you were taking a picture of it with your body, and return to it as
often as you need.

3. Finally, reflect on what helps you know you are about to, or
already have gone outside of your window of tolerance. For
example, you feel a whole-body tension, thoughts become
disorganized, your mind goes blank, you hyperventilate, parts
become noisy or you feel inner chaos, or you become drowsy. If
you can recognize these markers as they happen, you can stop what
you are doing and get yourself more grounded.


Homework Sheet 18.2

Your Tips for Coping With Feeling Too Much or Too Little
Make your own list of tips for dealing with too little feeling and
dealing with too much. Try to include all parts of yourself in this
exercise. You might be pleasantly surprised to find that you are
already using some skills or that some parts of you might have
some helpful ideas.

Helpful Tips for When I Am Feeling Too Much

1.

2.

3.

4.

5.

Helpful Tips for When I Am Feeling Too Little

1.

2.

3.

4.

5.
 CHAPTER NINETEEN

Understanding Core Beliefs

AGENDA
• Welcome and reflections on previous session
• Homework discussion
• Break
• Topic: Understanding Core Beliefs

Introduction
The Origins of Core Beliefs
Negative Core Beliefs in People With a Complex
Dissociative Disorder
Realistic and Healthy Core Beliefs
• Homework

Reread the chapter.

Complete Homework Sheet 19.1, Identifying Negative
Core Beliefs.
Complete Homework Sheet 19.2, Developing Realistic
and Healthy Core Beliefs.

Introduction
In chapter 17 you learned that unduly negative thoughts and beliefs
can play an important role in maintaining overwhelming and
dysfunctional emotions. Positive thoughts and beliefs that are
realistic can reinforce positive self-perception and contentment,
satisfaction, happiness, curiosity, and connection with others.
Persistent negative thoughts can evoke or reinforce feelings of
depression, anxiety, grief, anger, guilt, shame, or fear. And in turn,
these feelings reinforce yet more negative thoughts and beliefs.
When we are in a bad mood, our thoughts are more negative, and
thus we are more likely to see things in a negative light. This
interconnection among thoughts, emotions, perceptions,
predictions, and related decisions creates a cycle that supports our
unique experience of self, others, and the world, whether that is
largely negative or positive. Once a negative cycle begins and is
reinforced by negative situations, it becomes more difficult to
balance our perspective. And for people with a dissociative
disorder, various parts will have different perspective and beliefs.
In this chapter you will be working toward gaining a greater
understanding of some of your basic thoughts and belief systems
that originated in the traumatic past but which are not helpful in
your current life. Exploring and challenging these thoughts and
beliefs can be an effective point of entry for positive change.

The Origins of Core Beliefs

Our most basic, or core beliefs, are those which provide the
foundation for our view of self, others, and the world. They often
define what we believe about safety, trust, belonging, self-esteem,
competence, vulnerability, needs, and risk taking (Janoff-Bulman,
1992). For example, a realistic positive core belief might be: “Most
people are good and well intentioned, though they are not perfect;
however, a few people are truly dangerous and should be avoided.”
A negative core belief might be: “No one can ever be fully trusted
because they are looking out only for themselves; I should avoid
getting close to anyone for any reason.”
We all develop certain core beliefs whether they are negative or
positive. For those who have a dissociative disorder, various
dissociative parts of yourself may have different core beliefs, and
these may create much inner conflict (Fine, 1988, 1996). We will
discuss more about these conflicts in the next section.
Core beliefs have their origin in childhood and a few can
develop later in life based on powerful events. They can be
changed, but often people are not consciously aware of them.
Instead they might have automatic thoughts that seem true but
which they do not closely examine. For example, many traumatized
individuals have automatic thoughts such as “No one loves me. I am
worthless and stupid. I always fail at whatever I try. I am so ugly. It
is ridiculous that I need help: I am just weak and whiny.” Positive
change requires being able be aware of and reflect on core beliefs.
A number of factors play a role in the development of core
beliefs. Your inborn temperament affects the way in which you
naturally view the world. A person who is naturally introverted and
likes routine is likely to have somewhat different beliefs than one
who is extroverted and likes to take a lot of risks. Some people are
naturally more sensitive, while others seem less vulnerable to hurts
and abrupt changes. Some people naturally feel quite intensely,
while others have a more narrow range of feeling. These
differences can influence a wide range of core beliefs.
In addition, each family has collective core beliefs that are
passed down to the child, whether explicitly or unconsciously. For
example, if the implicit message in a family is that one should
never make mistakes, a child will develop the conviction that he or
she should always be perfect. Gradually such a child will develop
fears of making any kind of mistake, will become afraid of trying
new things, and will not be easily satisfied with whatever he or she
accomplishes. If the family core belief is that children are
important, competent, and lovable, a child will grow up with
confidence and feel secure in relationships. Core beliefs can also
develop based on whether early relationships are secure and
enduring. For instance, suddenly losing a parent at a young age
may result in feelings of abandonment and the belief that something
disastrous can suddenly happen, and that you can lose people you
love at any moment. Likewise, being abused by a caregiver at a
young age may result in strong beliefs that you cannot trust anyone,
ever.

Negative Core Beliefs in People With

a Complex Dissociative Disorder
Chronically traumatized people often suffer from persistent
negative core beliefs. These are deeply rooted convictions that
typically involve all-or-nothing thinking without balance or nuance:
“Things never work out for me,” “People always hurt me,” “I am
completely stupid and unlovable,” or “There is no safe place.”
These beliefs often contain words like always, never, or none. Such
thoughts and beliefs can profoundly influence, reinforce, and
intensify negative emotions. Negative core beliefs are reinforced
over time by negative emotions, perceptions, and predictions, and
by additional negative life experiences. The same is true for
positive core beliefs and attendant perceptions, emotions, and
experiences.
People with a dissociative disorder may find that their beliefs,
thoughts, and convictions may change suddenly or be in conflict,
since various dissociative parts may have different core beliefs
(Fine, 1988, 1996). Some thoughts and convictions are so
fundamental to the individual’s life experience that all dissociative
parts share them, for instance, “I cannot trust anyone” or “I will
never be safe.”
Individual differences in beliefs among dissociative parts are
related to the fact that each part has somewhat different life
experiences. Parts of you that deal with tasks and functions in daily
life are sometimes better able to observe and interpret the reality of
the present moment, without being influenced by too many old
thoughts or convictions. These parts have more distance from the
past, largely because they avoid it. Most dissociative parts that are
stuck in trauma-time suffer from negative, undermining thoughts
and convictions, because they view the world only through their
past experiences, without considering that the present may be quite
different. As a result, the reality of the present moment can easily
be distorted and relived in similar ways as the past as parts intrude
into daily life: This is what we have called living in trauma-time.
Even if there is some factual acknowledgment that the present is
different from the past, these core beliefs often seem so compelling
that they drown out current reality. Talking inwardly to these parts
and helping them by respectfully challenging their deep-rooted
convictions is a start, beginning with orienting them to present-day
realities. Correcting core beliefs is not easy and will take some
persistent work, but you can be successful over time.
Core beliefs affect your ability to reflect on your experiences.
For example, suppose you are walking down the street and see a
friend on the other side, walking in your direction. You wait for her
to say hello, but she just keeps walking without acknowledging you
at all. You could consider many different possibilities for what she
was thinking, and not just assume that she did not care about or was
angry with you. Depending on your core beliefs and your
perceptions, you or different parts of you may have some or all of
the following thoughts: (a) This person is preoccupied and did not
even see me; (b) This person is deliberately ignoring me; (c) This
person seems angry (with me); (d) She is walking fast to get away
from having to talk with me; (e) She feels hurt that I did not say
hello.
It is important for you to consider the possible intentions of
others, rather than jumping to the same conclusions based on
certain core beliefs, such as “People never like me.” Do your core
beliefs allow you to assume that people generally have no reason to
dislike or ignore you, and that most people are well intentioned? Or
do you believe that most people do not care about you and are just
out to get what they want from you? Perhaps different parts of you
might have different beliefs. Regarding the earlier example, some
part of you may think, “See! She ignored me. Nobody likes me. I am
worthless and will always be alone.” Yet another part of you has an
entirely different perception: “This isn’t about me at all. She
probably didn’t even see me.” These two very different sets of
thoughts, beliefs, and perceptions have different emotional tones:
one is highly negative, and one is positive or at least neutral. The
first statement reinforces old negative beliefs, whereas the second
statement supports a more positive and realistic view of the world.

Realistic and Healthy Core Beliefs

There are a number of generally accepted healthy core beliefs that
allow for a more balanced view of self, others, and the world. They
are more flexible and realistic. A healthy core belief is based on
both the positives and negatives of reality. For example: “I prefer
not to make mistakes, but I know I will, because no one is perfect.
When I do, I will work to correct it and not be too hard on myself.”
Or “Everyone needs help from others from time to time. Needing
help does not mean I am weak or lazy; it means I am human.” Or “I
can allow myself to relax and have a good time, just as I allow
myself to work hard when I need to.”
Of course, not everyone can always live in accordance with all
their beliefs or put them into practice every moment. You may be
quite convinced that something is healthy and good, but this does
not mean that you can always “practice what you preach.” But the
more you practice, the more healthy beliefs can become part of
your life. In Homework Sheet 19.2 you will find a list of some
realistic and healthy core beliefs, which might be helpful in
formulating your own.


Homework Sheet 19.1

Identifying Negative Core Beliefs
Below you will find lists of negative core beliefs about yourself,
about others, and about the world. Read each list and check or
circle five beliefs that affect you or parts of you most often.

Negative Core Beliefs About Yourself

• I am a failure; I never succeed in anything.

• I am an outsider and have no place to belong.
• I cannot connect with other people.
• I am utterly worthless.
• I am a bad person, ashamed of who I am.
• I am a weak person, always dependent on others.
• I should have never been born.

Negative Core Beliefs About Others

• Other people will always betray or hurt me.

• People are dangerous.
• Even if someone is nice, he or she is just waiting for the right
time to trick me.
• Nobody understands me.
• Nobody will ever love me.
• People will always take advantage of others.
• People will always abandon or reject others.
• People are only out for themselves.

Negative Core Beliefs About the World

• The world is a dangerous place.

• At any moment something terrible can happen.
• The world is always unpredictable.
• There is no place for me in the world.
• The world is full of pain and misery, nothing more.

List any other negative core beliefs not listed above that affect you
or other parts of you.
1.

2.

3.

4.

5.

Notice whether all parts of you share the core beliefs that you
checked or wrote in above, or whether only some parts do. Choose
one of the beliefs and take some time to have an inner dialogue
about whether it is always correct in the present. Describe your
experience during this inner discussion. If you are not able to have
such a dialogue, please describe what stopped you from doing so.


Homework Sheet 19.2

Developing Realistic and Healthy Core Beliefs
Below you will find lists of healthy beliefs about yourself, others,
and the world. Please read each list and then complete the
homework below.

Healthy Core Beliefs About Self

• Pleasure and relaxation are normal, acceptable, and essential

life experiences.
• I accept myself the way I am. I have my stronger and weaker
points just like everyone else, and there is room for
improvement and growth in my life.
• I can set healthy limits and boundaries with other people.
• I am competent in being able to solve everyday problems by
myself most of the time.
• It is OK to ask for help when I need it, and I can manage
when help is not available.
• I can be in charge of my own life. I do not always have to
give in to what others want if it is not good for me.
• I feel I belong in the world and with others.
• It is OK that I don’t know everything.
• I don’t have to be perfect, just human.
• I am a decent human being.

Healthy Core Beliefs About Others

• Most people are decent and trustworthy; a few are not.

• Others are willing and available to help if I need support or
assistance.
• People care about and understand me for the most part.
• Important relationships can be stable and good, though not
perfect. Conflicts can be resolved.
• I can choose to be with safe people and avoid those who are
not.

Healthy Core Beliefs About the World