Kid's Korner

Proposal to the Field: Fourth Phase in Treatment of Dissociation Protocol

Author Michele, with therapy dog Boaz

In the field of complex trauma and dissociative disorders we are accustomed to conceptualizing our work through the lens of a three-phase treatment model which includes: safety and stabilization, processing of traumatic memories and integration/new life as one integrated self. However, in my clinical practice I have found it useful to conceptualize the treatment as four-phases with a distinct phase focused on life post integration. Often, when working with children, I find that  children and parents need additional therapeutic resourcing during this time.

In Chapter 13 of her book, Healing the Fractured Child, Waters (2016) includes post integration as a treatment component. Albeit, integration is our treatment goal, but bridging the chasm between age regressive coping/social skills and the child’s biological age is just beginning. This vital post-integration work can get lost amidst the celebration and the child’s new awareness of life as one. Often, parents expect their child to “shape up and fly right” and wonder why the child struggles socially, emotionally, academically, and/or relationally. I use the Star Theoretical Model (Waters, 2016, pp. 32-39) to reiterate why the child may be stuck at any given stage. Personalizing this with the ages and roles of the parts of self helps put this into context for parents/caregivers. I suggest to parents that practicing the types of age-appropriate parenting techniques for younger children may be more effective, at times, during the post integration phase. I find that frequent reminders that the child is learning a specific skill for the first time nurtures patience and better understanding.

Preparing parents/caregivers and children for this fourth phase allows them to visualize the integrated life, from their perspectives, when introducing the four-phase treatment protocol and healing process. This may be best during the initial phone call, if the parent sounds hopeless, but if not then, certainly at the intake with the parents. Emphasis on the fourth phase treatment goals can bolster family members, who may be in their own recovery mode, at this point in the healing journey.

Depending on the family structure, an educational family session may be a good time to discuss the four phases. I add a brief video about the impact of pre-birth trauma, to help family members better understand real life manifestation and presenting symptoms. My goal is to build a stronger support system. I also teach emotional resourcing techniques during the family session, so that the child is not singled out at home. The resourcing is beneficial for everyone and provides opportunities to build unity among family members…as well as a glimpse of life with an integrated child!

Post integration presents new challenges and often parents/caregivers tell me they are not quite sure what to do with this new person. Siblings, too, struggle with unfamiliar family dynamics and may attempt to maintain the previous chaos, which had become their norm. Coaching family members in relating to the child in healthier ways, seeing the child for who the child is, rather than based on behaviors may help everyone more easily transition into functioning, as they previously envisioned during phase one. The fourth phase is an excellent time for another family session! One of my favorite pre/post integration family activities is “Build a House.” The family members build a house out of colored wood blocks, while seated on pillows, on the floor. This provides an opportunity for each to process their current experiences in a creative setting, as well as narrate the significance of their created portion of the house.

Giving time to a ‘fourth phase’ of treatment may also be instrumental in the reduction of relapse. As children navigate life as one integrated self, daily stressors can be overwhelming and major events, such as a death in the family, can lead to re-fragmentation. Waters (2016) enumerates several possible precursors, as well as case studies of children who dissociated, post-integration. Hidden and previously known self-states may emerge or re-emerge, due to environmental triggers or incomplete trauma processing (p. 412 – 415).

The deficit in the development of age-appropriate social/coping skills can be more effectively addressed in the post-integration phase. Parents/caregivers can better support their child in practicing the specified skills, with more patience and understanding. All will enter into this phase with the expectations that challenges in these areas are part of the process. Kids love to create their toolboxes and fill them with reminders of the more effective ways of managing their emotions. Parents/caregivers feel more confident about their parenting skills, as they employ the recommended techniques, with greater success.

In the following vignette, all identifying information has been changed and permission was granted by the client and family for use in this article. Kelly began treatment at age 9 and I diagnosed him with Dissociative Identity Disorder. He had experienced trauma pre-birth, through his mother’s medical complications in the third trimester. Kelly had complex medical issues, unrelated to his mother’s, that presented when he was 4-5 months old. The medical diagnostic period was lengthy and he experienced high levels of emotional, as well as physical distress.

From the time of intake throughout the treatment process, Kelly’s parents were very supportive, participated in sessions as needed, implemented the specialized parenting techniques, and carried the integration metaphor (Waters, 2016, p. 400 – 404) of Kelly’s favorite food, throughout the 3 phases of treatment. After approximately 2 years of treatment, Kelly spontaneously integrated, and reported he was “one Kelly” during the subsequent session check-in.

Delineating the fourth phase, provides opportunity for the children and their families to enter on a note of celebration. This can, also, be utilized for assessment purposes. Integration celebrations (Waters, 2016) can be based on the themes that represent oneness, such as sports teams, favorite foods, etc., which were carried through phases one, two, and three. Kelly, his parents, and I planned the family celebration surrounding his favorite food. Kelly’s 5-year-old sibling also attended the party. I included Theraplay Principles and Techniques (Booth & Jernberg, 2010), to assess family dynamics in a play-based, interactive setting. Kelly presented with age appropriate, as well as age regressive behaviors. This was good information that aided in guiding me to address the areas of delayed development.

Kelly’s mother also reported each week on her observations at home and those of school personnel, which was helpful in monitoring Kelly’s progress in different settings. His parents often participated in sessions that focused on continued strengthening of emotional management/self-regulation skills. In these Post-Integration sessions, we practiced the previously learned techniques that the parents would continue to coach Kelly in using, as needed. Kelly decorated his papier-mache “toolbox” and placed various reminders of his healthier coping skills inside. We reviewed the compilation of drawings, photos of sand trays, artwork, and various activities for final selections to add to his take-home binder.

For Kelly’s family, application of Satir’s view, “that the family needed to be treated as a unit when a child presents as the problematic client,” (Satir, 1983, cited in Waters, 2016) focused on relationship repair, as well as learning to share toys, time, and attention. Theraplay Principles and Techniques were used in Kelly’s family sessions, which included activities in the domains of Structure, Challenge, Nurturing, and Engagement (Booth & Jernberg, 2010). During individual sessions, Kelly created hand-made cards, letters, and artwork to express his apologies to various family members, for some of his past behaviors. Kelly became quite skilled at journaling challenging incidents, his feelings, and emotional management skills that he had used successfully.

During the fourth phase, children can look forward to diminishing frequency of sessions, as they master age appropriate life skills. Session frequency will be reduced to bi-weekly, then monthly check-ins, and, finally, graduation (termination). The length of the termination process depends on the child’s progress, as well as that of their families. I like to celebrate graduation with a special treat and final compilation of their take-home healing journey binder, which reminds them of their strengths, courage, healing and hope for overcoming future challenges. Of course, the kids and parents know they can always return for a tune-up, if needed.

Post-Integration, as a fourth phase, has many benefits. It prepares the child and family members for a new normal, provides for more focused time on healthier emotional management skill building, family relationship repair work and transitioning to termination. Closure to such intensive treatment also feels more complete with a fourth phase.

Thank you for consideration and investing your valuable time in reading this. Your feedback is most welcome and respected. Please feel free to email me at:


Waters, F. S. (2016). Healing the fractured child: diagnosis and treatment of youth with dissociation. New York: Springer Publishing Company.

Booth, P. B., Jernberg, A. M. (2010) Theraplay: helping parents and children build better relationships through attachment-based play. San Francisco: Jossey Bass Publishing Company

Satir, V. (1983). Conjoint family therapy (3rd ed.). Palo Alto: Science and Behavior Books