integration

In the case of our patient, Cain, the unresolved psychological trauma initially surfaced unconsciously in the form of somatic symptoms, such as the knots in his stomach, elevated heart rate, and shortness of breath in social situations. Upon re-collecting the traumatic memory, unconscious material becomes conscious, and the memory is gathered together with the emotional experience it was originally associated with before being split off, or dis-integrated (Ecker, Ticic, & Hulley, 2012; Lane, Ryan, Nadel, & Greenberg, 2015).

It’s common for people to unintentionally dissociate from traumatic memories, as in the story of the young girl stopped by an angel from delivering her dead father coffee. Culturally, we support the avoidance of integration by saying things like, “leave the past behind” or “don’t dwell on the past”. In this way, we become vitally disconnected from the most important parts of our story. Moreover, it can be difficult for people with unintegrated traumatic experiences to be fully authentic. They often report a sense of “something missing” and can’t help but to lack the capacity to be fully themselves.

For Cain, the process of integration began in the prior stage of therapy, when he was challenged to re-collect the memory associated with his presenting symptoms (i.e., “knots” in his stomach). At first, the traumatic material completely overwhelmed him. The focus then was to help him find the ground, to hold himself together, so that he could move forward in the developmental process to become a whole personality.

The only way to develop beyond our limitations is to reflect, to learn, and outgrow them (Mezirow, 1997; Schön, 1983). As a story-teller species, re-telling our story is the most effective way of doing this (McAdams, 2001; Pennebaker & Chung, 2011). Cain’s first attempts at telling his story are overwhelming, but eventually the traumatic material will be integrated and incorporated into a cohesive narrative. He’ll become a fully embodied story, a hero in his own right, for facing the Hell inside of him and overcoming it.

The therapist assists the patient for as long as it takes, sometimes months, until he can tell the story without falling apart. It’s imperative that the therapist remain focused on this. It’s all to easy for a novice therapist to see a person get overwhelmed at the telling of a traumatic event and to think, ‘It’s too much! I won’t ask them to do that again.” Moreover, one pass at the story isn’t enough, either (Pennebaker & Chung, 2011; White & Epston, 1990). That’s avoidance, and patients do a good job of that on their own.

The therapist’s role is to educate and expose. At this stage of the therapeutic process, the therapist educates the patient on the importance of telling their story and that integration can take many months (Lane et al., 2015; van der Kolk, 1994). The therapist must take copious notes regarding the stories their patients tell that hurt the most, and make sure to inform the patient they’ll be returning to those stories, again and again.

Remember, not every patient knows the story, or stories, that need exposure and processing. When a patient presents with anxiety or depression, the therapist helps the patient connect to that feeling in the body, whether it be a tightness or heaviness, and ground them with a simple meditative technique, trusting the psyche to reveal the memories that need attention.