Combining
Ego State Psychology
with EMDR enables
psychotherapists to
better deal with the
complex consequences of
psychological trauma
by
Carol Forgash LCSD BCD
CONTENTS...
Summary
In
this adaptation of her
keynote address
presented at the
European EMDR Annual
Conference in Frankfurt,
Germany, in May, 2002,
psychotherapist Carol
Forgash explains that
the context of
psychotherapeutics has
changed since the early
years of EMDR. This
change supports the
combining of EMDR with
ego state psychology to
better deal with the
complex consequences of
serious trauma. Forgash
proposes that ego state
conceptualizations
provide a constructive,
efficient, and
accessible means for
therapist and client to
work through these
complexities.
Historical
Perspectives on
Traumatology
In
this paper I will
describe how a
combination of EMDR and
ego state therapy, along
with interventions used
to treat dissociation,
can be used to treat
complex posttraumatic
stress disorder,
resulting in a treatment
model that is more
powerful than the use of
any of these methods
alone. I will
particularly emphasize
the extended
stabilization and
preparation phase that
is necessary before
beginning EMDR work with
clients with complex
PTSD.
We
begin by reviewing the
history of traumatology
so that the present
context and need for a
new treatment method may
be better understood.
The
effects of trauma have
been known since the end
of the 19th century. And
yet, that important
knowledge was
subsequently "forgotten"
for many years and was
not available to
clinicians. Judith
Herman, in her book
Trauma and Recovery
(1992), describes
society's tendency to
sometimes remember what
trauma is and what it
does to individuals,
groups, and
institutions, and then
to forget those
important concepts. This
is of course a shift
from awareness of
reality into denial and
dissociation-exactly
what our clients with
complex PTSD and
dissociative disorders
do! They want
desperately to remember
their traumas, but when
they do, they want just
as desperately to
forget.
Therefore we have
needed, over the past 25
years, to rediscover
what was already known
about trauma-concepts
that were as correct
then as they are now-and
to relearn to apply that
information.
Secrecy,
avoidance,
and denial
- common reactions to
trauma - are all too
prevalent in the public
and private domains.
Arne Hoffman and Peter
Liebermann, in their
presentation at the 2001
ISSD conference (New
Orleans), spoke of this
as a "collective
dissociation." They
added that when this
happens, there is
frequently also
concomitant loss of
empathy for others-in
this case, for trauma
victims. The mental
health profession is not
immune to this
phenomenon. Fortunately,
over the last 25 years
we appear to have
returned to the
remembering and
discovery phase.
One
hundred years ago Janet
and Freud began to study
and develop theories
about childhood sexual
abuse. This was the
first important research
into trauma. We know
that Freud later
retracted his seduction
theory due to many
factors. Clearly, it was
threatening material.
After
World War I, theorists,
researchers, and
clinicians began
studying the effects of
combat on soldiers.
Their conclusions about
the trauma of war were
equally unpopular and
virtually disappeared
for 75 years. Society
treated trauma survivors
with a lack of empathy
that mirrored these
clients' feelings about
themselves. They are
different, hard to deal
with, and remind us of
the results of human
cruelty that we don't
want to see.
Listen
to the descriptive
language used in the
past century to describe
casualties of war and
abuse: They have been
called "malingering,"
"lying," "cowardly,"
"factitious,"
"schizoid,"
"hypochondriac," and
even "slutty." It has
been said that they
deserve what they get;
they exaggerate; they're
bad, lazy, borderline,
impossible clients. This
unempathic language,
reported to me by my own
clients and spoken by
family, military
officials, health
professionals, and
mental health
clinicians, doomed
people to further
suffering. This language
has also affected and
threatened those of us
who do this work. In the
United States, the False
Memory Syndrome
Foundation spent much of
the 1990s suing
therapists for allegedly
implanting false
memories in their
clients. The work we do
with our clients
diagnosed with complex
PTSD must remedy these
historical biases.
From
the Beginnings of EMDR
to the Present
In
1995, when I was trained
in EMDR, the compelling
question about treating
the dissociative
disorders and PTSD with
EMDR was, "Can you use
EMDR to safely treat
complex, chronic
posttraumatic stress
disorder and the range
of dissociative
disorders?" The answer
was, as Sandra Paulsen
(1995) wrote in one of
the first publications
on the use of EMDR for
the treatment of
dissociation: Yes, but
cautiously. It was to be
used for the
reprocessing of trauma.
As we now know, this was
a sensible goal given
the state of the art and
development of EMDR at
that time. Paulsen
called EMDR a "divining
rod" for dissociation,
to be used carefully.
At the
EMDR level 1 training we
were reminded not to
treat people presenting
with dissociation unless
we had sufficient prior
knowledge and
experience. After that
training I returned to
an office filled with
dissociative survivors
of child sexual abuse.
After 15 years as a
trauma specialist, I
knew how to use the
prevailing treatment
modalities, but I knew
nothing about the
potential impact of EMDR
in ameliorating the
problems of these
clients diagnosed with
DDNOS or DESNOS. Many
clinicians found, to
their distress, that if
the EMDR trauma protocol
was used with
dissociative clients
without the prior
development of a secure
therapeutic
relationship, and
without screening for
dissociation and
extensive preparation
for trauma work,
destabilization and
increased dissociation
would follow. Clearly a
new treatment approach
was needed to meet the
needs of this large
population of trauma
survivors who did poorly
with the standard EMDR
protocol.
Now,
15 years after the
introduction of EMDR by
Francine Shapiro, we
have made further
strides in understanding
the treatment of severe
trauma. There is much in
the way of new
biopsychosocial research
and clinical studies to
inform our
questioning-material
that is beyond the scope
of this paper. There is
current research into
understanding the
effects of trauma; the
relationship between
early attachment
conditions and the later
development of PTSD; the
disorders of affect
regulation that follow
abuse; the
manifestations of
dissociation in PTSD;
the neurobiology of PTSD
and dissociation; and so
on.
Why
EMDR and Ego State
Therapy?
As
clinicians, we want to
know how to use EMDR
most effectively and
efficiently in the
treatment of complex
PTSD and the
dissociative disorders.
We need to ask, What can
be achieved in
treatment? What kinds of
resolution and changes
can we expect? How can
we be most helpful as
therapists? Do we want
to merely eliminate
symptoms, or help people
with these most
complicated diagnoses
find a way out of
suffering?
I
propose that we utilize
EMDR and ego state
treatment to help trauma
survivors develop more
functional inner
boundaries, ego state
systems, stability,
mastery of life skills,
and most importantly,
empathy for themselves.
We want to help them
move from victim status
to thriving and leading
a full life.
Integrating ego state
work with EMDR can allow
us to achieve goals
beyond elimination of
PTSD and dissociative
symptoms. In the model I
describe here, the
standard EMDR protocol
is blended with
effective interventions
and phased treatment
approaches often used to
treat dissociative and
posttraumatic stress
disorders, and ego state
psychotherapy
strategies. Working with
our clients in this way,
and from a position of
empathy and
understanding of the
legacies of trauma, we
can help them resolve
their most critical
issues and go on to
develop and utilize a
blueprint for healthy
living.
Introduction to Ego
State Therapy
Ego
state theory was
developed initially by
Paul Federn (1932, 1943)
and extended by John
Watkins and Helen
Watkins (1995), Richard
Erskine (1997), Eric
Berne (1963), and
Richard Schwartz (1997).
It posits the existence
of an internal family
variously termed
parts,
ego or
self states, or
selves,
or conceived of as
neural or memory
networks.
The
ego state system can be
thought of as a
segmentation of the
personality into self
states or parts at
points along the
dissociation continuum
that comes about due to
normal differentiation,
introjection, or trauma,
Ego
states may be described
as an organized system
of behaviors and
experiences that have
varying boundaries. The
states may be organized
to enhance adaptability
in coping with events or
problems. Some ego
states are delineated by
time dimensions: a
five-year-old, teenager,
or infant, for example.
Others are delineated by
function, trait, or
role, for example
self-hater, nurturer,
critic, executive,
bratty kid, daredevil,
curious, nature lover,
parent, grandparent, and
so on.
Ego
states may have
normative imaginal or
creative functions, such
as daydreaming. However,
ego states formed in
childhood may function
maladaptively in present
life situations. They
seek to protect their
existence and roles,
even if those are
counterproductive. This
is similar to
organizational
maintenance theory: no
corporation willingly
goes out of business.
Ego states can conflict
with each other, leading
to intrapsychic
conflict. Finally, they
have the capacity to
change, combine, grow,
and adapt.
Ego
state work utilizes
individual, group, and
family therapy
techniques for the
resolution of conflicts
among the ego states
that constitute the
internal family. The ego
state techniques and
procedures I will
describe draw upon the
work of Kluft (1993),
Fine (1993), and others.
They were developed to
treat dissociative
identity disorder
specifically, but have
been successfully
extended to treat the
range of dissociative
disorders. A number of
EMDR therapists have
presented and written
about their use of this
integrated treatment
with varied populations.
They include Bergmann
(2000), Forgash (2002),
Grand (2001), Knipe
(2001), Paulsen (1995),
Phillips (2000), Schmidt
(1998), and Twombly
(2000).
A
Portrait of Complex
Posttraumatic Stress
Disorder
If we
look at the symptoms of
posttraumatic stress
disorder we can begin to
get a sense of what the
client with complex PTSD
and dissociation brings
into treatment. The
following is a sample
scenario of childhood
trauma with negative
consequences, leading to
complex PTSD.
A
trauma such as a
disaster or major loss
occurs and no parental
help is available. There
is no comforting or
mirroring by a parent or
other attachment figure.
No systemic
self-soothing or empathy
is available internally
or externally with any
consistency. Chaos and
instability follow.
Dissociation or freezing
occurs. This can lead to
a sense of nothingness
or emptiness.
The
trauma may be repeated
or become episodic,
perhaps involving
ongoing physical damage.
In response to repeated
severe trauma a network
of dissociated ego
states or neural
networks may form, and
dissociation, amnesia,
and somatization may
ensue. A possible
explanation for this is
that the traumatic
material is dissociated
and moved to
disconnected neural
networks. Memories and
behaviors associated
with the trauma are
sometimes stored in
fragments and therefore
not available for
information processing.
When the client is cued
or triggered, these
distressing memories can
invade the person's
consciousness. These
trauma victims suffer
from emotional
dysregulation and cannot
close down the
disturbances when
triggered.
Following are the main
diagnostic symptoms of
PTSD that these clients
frequently present:
intrusive recollections
of the trauma, a sense
of reliving traumatic
events, hypervigilance,
exaggerated startle
response, flashbacks,
nightmares, night
terrors, sleep
disorders, irritability
or agitated behavior,
difficulty
concentrating, anger
dyscontrol, avoidance of
people and triggers that
are reminders of the
trauma, a range of
dissociative symptoms,
numbing, flat affect,
anhedonia, distress
following internal or
external triggers,
feelings of isolation,
detachment, and lack of
trust.
Others
symptoms commonly seen
include phobias,
obsessive-compulsive
disorder, ill health,
hopelessness, learned
helplessness, affect
intolerance,
self-injurious
behaviors, and
risk-taking behavior.
Diagnoses of Axis 2
disorders and anxiety
and mood disorders are
frequently seen in this
population.
Additional problems
described by Judith
Herman (1992), who
developed the concept of
complex PTSD, are
explained as "profound
systemic alterations."
Those include
alterations in systems
of meaning (loss of
sustaining faith and a
sense of hopelessness
and despair);
alterations in relations
with others (failure to
protect oneself,
isolation, withdrawal,
and disruption or
avoidance of intimate
relationships);
alterations in
perceptions of the
perpetrator (power
imbalance, the victim
taking on responsibility
for abuse, Stockholm
Syndrome). Additionally,
there are
self-perception
alterations: guilt,
shame, self-blame, and
stigma.
So
many natural processes
and developmental stages
become disrupted,
delayed, and negatively
impacted by childhood
trauma, war, atrocities
carried out on
individuals and groups,
familial abuse, losses,
and natural disasters.
Often there are feelings
of disrespect and
betrayal. These
disruptions can lead to
poor functioning as an
adult. In many areas,
full potential of the
self has not been
reached. Clients with
these problems often
present with intricate
layers of symptoms and
problems that seem
daunting to therapists.
According to van der
Kolk, McFarlane, and
Weisaeth (1996) a
central feature of PTSD
is a loss of the ability
to physiologically
modulate stress
responses. This can lead
to a diminished capacity
to utilize bodily
signals and may also be
responsible for immune
system impairment as
well. It is well
documented that the
chronic PTSD population
suffers greatly from a
variety of
stress-related illnesses
and syndromes.
Treatment Goals
A
successful EMDR and ego
state integrated
treatment model permits
our overarching goals of
treatment to become more
expansive. These goals
include helping clients
in a number of crucial
areas:
-
To provide safety
and develop
stability in
treatment and in
current life
experiences.
-
To
help clients become
affect tolerant and able
to regulate emotional
responses.
-
To reprocess trauma
and manage and
eliminate symptoms
of PTSD and DD.
-
To repair damage to
boundaries and the
internal structure.
-
To resolve
relational and trust
issues (attachment
breaks and losses,
fears of intimacy).
-
To enable the person
to develop empathy
for self and the
internal family
system.
-
To help clients
reach their
potential in a
number of crucial
areas, including the
ability to meet
their own needs more
effectively and to
become effective
parents to
themselves.
These
goals are also described
from an attachment
perspective by Barach
and Comstock (1996), who
emphasize stabilizing
self-other object
representation through
facilitation of the
development of an
internal "secure base."
The
Treatment Challenge of
Complex PTSD
Organization of Psychic
Processes Viewed
Historically
Michael Levine speaking
at a 2002 literary forum
about trauma survivors'
attempts to write about
their experiences of
horror, referred to
Freud's writings on
hysteria and suggested
that trauma survivors
frequently engage in a
traumatic repetition in
which the self attempts
to return to, transform,
and gain some control
over a traumatic past.
Levine said that the
survivor has to deal
with competing drives:
wishing to return to the
same place, and also
wishing to go to another
place, one where the
trauma has been at least
partly changed. Yet the
survivor who cannot
arrive at this new place
may become trapped in a
black despair from which
there seems to be no
exit.
Once
again we turn to Janet
(1919), who wrote that
traumatized clients have
lost the ability to
progress in the
evolution of their
lives. They cannot
integrate traumatic
memories, and further
lose their capacity to
assimilate new
experiences as well.
According to Allan
Schore (1994), Janet
postulated that
traumatized people may
have immature
personality organization
with vulnerable and
inefficient coping
capacities. Their
response to stress is
expressed in alternating
experiences of
hyperarousal and
dissociation.
Specific Ego State
System Concerns
Here
is the crux of the
matter: treatment of
trauma survivors and the
ego state issues that
come into play in their
therapy are complex
issues for therapists to
grapple with. If we
ignore them it will be
to the detriment of the
client.
Trauma
victims commonly have an
internal ego state
system with parts that
function maladaptively
in the present. Parts
may become
pathologically
dissociated, with
serious conflict among
some of the parts. Some
parts may fear
annihilation if they
lose their perceived
roles and know that they
are not honored or
respected for their
original role as system
protectors. We need to
recognize those parts.
Some ego states (as well
as the client) may not
be aware of the
existence of other
parts, and may not be
orientated to the
present (time, place,
year). There may be no
co-consciousness--that
is, the client may not
be aware of ego states
and their influence, and
the parts may not be
aware of each other.
Clients may only have
perceptions of
differentness and
alienation from others
and almost certainly are
ignorant as to the
causes of their present
problems.
Challenges within the
Therapeutic Relationship
and Process
Additionally, the
intrusive and
dissociative aspects of
posttraumatic stress
symptoms produce
treatment difficulties
that can include
destabilization and
dissociative episodes as
well as resistances that
therapists are not
commonly trained to
recognize in non-ego
state psychotherapy.
These resistances may
involve ego states who
fear exposure for
violating taboos against
"telling." Fearful
anticipation of painful,
punitive sequelae to
disclosure of
abuse-secondary to the
experience of
abandonment by parental
figures, siblings, other
relatives, and even by
parts of the ego state
system-may become a
major treatment
obstacle. Such a painful
consequence is often
what the client expects
due to past threats or
actual experience with
abusers or other family
members. The client may
experience overwhelming
shame, guilt, distrust,
and fear of rejection by
the therapist.
Many
clients are aware of
their problems with
affect dysregulation and
fear being flooded by
feelings and memories
coming up in treatment
that will prevent them
from functioning.
Therapists, even those
who are EMDR trained,
are often not aware of
containment techniques
and stress management
strategies that the
client needs to learn
prior to working with
traumas. If these fears
persist with no
reduction, or in fact
escalate into higher
levels of distress,
clients may experience
increased levels of
frustration, feelings of
defeat, depression, and
anxiety. Loss of belief
in the efficacy of
therapy can follow. We
will be perceived as not
helpful or as unempathic.
It is important to note
that many of these
clients have already
been given multiple and
conflicting diagnoses
and have experienced
many failed prior
therapies.
Implementing Integrated
EMDR and Ego State
Therapy
Using
an integrated EMDR and
ego state model allows
us to diagnose readiness
for trauma work,
stability, and specific
needs of the individual
with a complicated
trauma history.
Eventually we can work
with issues and problems
involving trauma and
dissociation with safety
and precision. Protocols
in this model are
individually tailored
and ego-state specific.
SUDS levels can go to
zero and remain there.
This is a longer EMDR
treatment model, one in
which deep work can be
accomplished.
In
contrast, in
conventional EMDR
treatment with clients
who are diagnosed with
PTSD, dissociative
disorders, or
personality disorders,
ego state treatment
usually has not been
integrated into the
treatment planning or
into the protocol. If
uncovering work or
desensitizing and
reprocessing work is
prematurely attempted,
these clients will often
destabilize or
experience other
treatment difficulties.
Therapists report that
there are many
processing sessions
where SUDS levels don't
go down, or if they do,
they do not stay down
and symptoms continue.
This is due to the
presence of one or more
unacknowledged ego
states who have not been
included in treatment.
Over time, this
interferes with
treatment and with the
therapeutic
relationship. With the
integration of ego state
work at an appropriate
point in the preparation
phase of treatment,
these problems can be
resolved.
Levels of Dissociation
The
standard EMDR protocols
only address the primary
and secondary
dissociation that
frequently accompany and
follow traumatic events.
These two types of
dissociative symptoms
typically are symptoms
of posttraumatic stress
disorder.
Primary dissociation
consists of flashbacks,
intrusive thoughts, and
somatic symptoms.
Secondary dissociation
consists of
depersonalization and
derealization.
In
contrast to the former,
tertiary dissociation,
which is addressed by
the proposed treatment
model, includes the
formation of a range ego
states, from normal
functional parts to less
functional self
fragments or alters.
Tertiary dissociation is
considered
ubiquitous--Bromberg
(1994) and Watkins and
Watkins (1996) describe
the formation of ego
states as a line of
normal human
development.
In the
EMDR treatment of
dissociated, traumatized
clients who are dealing
with these less
functional parts, ego
state work needs to be
an essential part of the
preparation stage. If it
is not, as mentioned
above, there may be
diminished response or
non-response to
treatment.
The
Preparation Phase
Particular importance
must be placed on the
preparation phase, which
becomes greatly extended
to meet the needs of the
client with complex PTSD
and dissociation. In
this phase we will lay
the foundation for a new
and respectful building
of relationships:
between the client and
therapist, the client
and the internal system,
and among the parts. In
the 21st century, we
return to the Janet's
late-19th-century phased
treatment in which
stabilization must
precede trauma
treatment. In fact, the
techniques that are a
fundamental part of the
preparation phase will
continue to be necessary
throughout the treatment
relationship.
An
essential goal of the
preparation phase is to
enhance the evolution of
the internal system. One
of my clients called
this work a "second
course in childhood" for
her. In this phase a
strategic and procedural
approach is individually
tailored to each client.
The work allows for the
building up of
structures that were
disabled and broken down
by issues such as
trauma, losses, or
unstable family life. We
initiate systematic and
consistent sequencing of
developmental work,
starting where the
client is. The client is
eventually able to deal
more safely with
traumatic material
because of the extensive
preparation involving
work toward affect and
dissociative symptom
management. This work
can lead to mastery and
control in present life.
It is
a clinical decision when
in this phase to
introduce ego state
concepts as well as
information about EMDR.
Screening for the range
of dissociative symptoms
and assessing the client
for stability are key to
the decision to proceed.
There are many
stabilizing
interventions that can
be taught prior to the
introduction of ego
state work if the client
is too dissociative or
unstable to attempt
parts work. Elements of
the EMDR protocol can be
introduced as a
framework for discussion
about the client's
problems and traumas
that eventually will be
reprocessed after
stability is achieved.
Bear
in mind that we utilize
a psychoeducational
approach to create the
environment for ego
state work. Providing
information about the
ego state system gives
the client a framework
for understanding the
effects of trauma. In
order to normalize ego
state concepts it is
best to use descriptive
vocabulary that fits the
client's language: words
and phrases such as
states of mind,
fragments,
internal objects,
internal family
system,
part selves,
and inner
children. This
will usually be
perceived as respectful.
For some clients,
concretizing this system
via mapping, listing,
drawing pictures of the
parts, or creating an
internal landscape is
helpful. The time in
which this can be
accomplished varies.
Humor helps! One of my
clients with 11 years of
analysis, when asked
about internal parts,
said, "Oh, you mean the
Committee. You know,
Freud was right on
target, but why did he
stop at three parts?"
Co-consciousness begins
to be developed in this
phase as the parts feel
safer about being
"known" to the client.
In
this integrated approach
key components of the
preparation phase
include readiness
activities, creation of
a home base and
workplace, and orienting
the ego state system to
present reality. Somatic
work, managing symptoms,
creating safety, and
constructive avoidance
are also key concepts.
If
possible, dual attention
stimuli (DAS) or
bilateral stimulation
such as eye movements,
tapping, and audio
stimulation should be
introduced during this
phase. DAS can be used
throughout sessions
while working on
readiness activities
with clients who are
sufficiently grounded.
For more vulnerable
clients, bilateral
stimulation will be used
only to reinforce and
strengthen readiness
activities if and when
the client system can
tolerate it without
distress. Bilateral
stimulation seems to
increase focus and
reinforce stability and
activities related to
safe place development,
resource development,
ego strengthening, and
stress reduction. With
more dissociated people,
use of DAS may have to
be postponed.
Getting Acquainted with
the Ego State System
Those
voices or inner
conversations described
by our clients are those
of their internal parts.
They appear to clients
to be in a chaotic
situation that often
echoes their families
and childhood homes. It
makes sense that they
are "living" in the
client's mind or brain,
even if the client is
not happy with that idea
and doesn't particularly
want to interact with
the parts. This work
marks the beginning of
building functional
structure and
differentiation.
The
client needs to meet the
ego states. The client
and the system may know
directly or only
indirectly of each
other's existence and
roles. The when and
where of this meeting
will be client specific.
Clients may feel as if
they are taking in very
abused foster children.
Their attitudes toward
the parts vary. We must
accurately gauge empathy
for the system parts and
developmental readiness
for this work by
listening to language
and watching body
language. Do we hear the
parts describe
themselves with
self-hatred, loathing,
loneliness, and
isolation? We note if
the client's descriptive
language is abusive,
empathic, distant, or
stern.
Clients are informed
about the ways in which
they are likely to be
misinterpreted by the
system: like actual
children, the parts may
be listening when
clients least expect it.
Even if they are angry
at these parts, they may
be able and willing to
modify their language.
They need to criticize
the behavior, not the
part. We note if there
are stern, harsh critics
or perfectionists in the
group. Bullies can be
seen as once having had
a protector role. It is
important to tell the
client that having an
inner critical voice
could prevent punishment
in childhood. In helping
the client learn about
the parts, interweaves
are used: "How old were
you when that part had
to take on that critical
function? What was going
on in your life? What
was good about having
that part function in
that way?"
Creating a Home Base and
a Workplace
The
creation of a home base
is a new idea for many
survivors. It can offer
safety, privacy, and
relaxation for the
internal parts system.
This is a different
place from the adult
client's safe place. An
explanation I use is
that metaphorically
speaking, the ego states
"have to be somewhere."
Home
base is also a metaphor
for privacy, with doors
and boundaries for some
clients who had none, or
have lost them. For some
clients and their parts,
a home base is
impossible in the
beginning because no
place is safe. When the
client first develops
this space, it may look
barren and unprotective.
Alternatively, the home
base may have to be part
of the client's actual
home. Once found, some
parts want to stay close
by, while others may
refuse to go to the home
base initially. Some
parts can be shunned by
others and may need a
separate space or one
connected by a hall or
breezeway. This usually
evolves positively over
time.
A
workplace where ego
states can be accessed
and therapy sessions
with the ego states can
take place is also
created. Clients may be
comfortable including a
conference room in their
home base. They may wish
to use the therapist's
office setting or a
familiar place for the
workplace. There are
many techniques for
accessing ego states:
the round table (also
known as a conference
table), the Gestalt
empty chair, and so on.
Some
parts will not be
visible, especially at
first. Some are "ghosts"
and shadows; some will
just be sensed. This is
to be expected and
respected, never forced.
Orientation to Present
Reality (OPR)
The
exercise called
Orientation to Present
Reality (OPR) helps the
ego states learn about
present time and place
and can enhance feelings
of reality and security
and a sense of
appropriate caring by
the adult. Parts can use
an imaginal screen in
their workplace to view
images that may be of
your office or the adult
clients and their
present age, body,
gender, roles, and so
on. A video tour of the
adult's home, job,
present life, family,
and so on is helpful.
This sets the stage for
an acceptance of reality
and changed conditions.
For example the ego
state system may need to
learn that perpetrators
are dead, that the
adults lives
independently, and so
forth. This information
can be shocking. This
OPR work is titrated as
needed. OPR might need
to be repeated many
times during treatment,
as parts who need
orientation or
reorientation may appear
at any phase
Somatic Work
Recognition of physical
sensations is an
important part of the
preparation phase. The
emphasis that EMDR
places on identifying
and recognizing body
sensations normalizes
the presence of physical
sensations that are
often troubling to the
ego state system.
Clients will
subsequently be less
fearful of processing
sensations, symptoms,
and the memories to
which they are tied. In
the preparation phase
there is an emphasis on
somatosensory exercises
(see Levine, 1997) that
utilize identification
of positive body
sensations (calm,
serene, tension free,
and relaxed) as
resources. This can be
enhanced with bilateral
stimulation for clients
who have difficulty
identifying these
sensations. The client
learns to focus on the
positive body resource.
The body is felt as a
physical safe place, to
be returned to whenever
necessary. This helps
clients master the
ability to consciously
distance themselves from
often overwhelming
memories, events, and
emotions. In this way,
clients develop an
interior safe space.
This work prevents
hyperarousal and numbing
episodes and eventually
allows clients to stay
in their body even when
processing difficult
material.
Helping Clients Manage
Affect and Dissociation
Management of affect and
dissociation is an
aspect of parenting work
that continues to grow
throughout treatment. We
are providing clients
with tools to create
safety for the ego state
system both in session
and in between sessions.
Containment:
We teach the concept of
containers for troubling
or overwhelming
emotions, thoughts, and
sensations and encourage
the imaginal development
of containers such as
safes, closets, boxes,
and bubbles to hold this
material temporarily.
Clients must learn that
containment is different
from the old behavior of
"stuffing," or
repressing feelings.
This temporarily
contained material will
be brought back to
sessions, not hidden
permanently.
Self-soothing
activities:
Clients need to learn
self-soothing in order
to manage affect both
during and between
sessions. First we teach
them to ask the ego
states what they need to
be comfortable. This
could be a blanket or a
hug. Grounding and
centering procedures are
helpful for clients who
dissociate. This is
especially important if
dissociation occurs
while driving. While
driving clients need to
be able to feel the
steering wheel in their
hands, or differentiate
between different
textures and materials
in the car. If they
cannot, they need to
learn to pull off the
road until they feel
more present.
Other
self-soothing activities
include stress reduction
activities, safe place
imagery, progressive
relaxation techniques,
and conscious distancing
techniques. One
distancing mechanism is
the "affect dial," which
can be imagined as the
on/off button on a radio
or a television remote
control. This can be
utilized by the ego
states to turn off
overwhelming images,
thoughts, and emotions.
Regular practice is
important.
Clients should be
reminded to encourage
their ego states to
remain at the home base
in between sessions to
avoid dissociation. We
encourage clients to
develop a "check in"
system by the adult ego
state. Consistent
caretaking of the ego
states is encouraged, as
is dialogue with the
parts to problem solve
or to discuss internal
or external change.
These activities help
clients develop parental
responsibility over
time.
Stop
Signals:
The client and the ego
state system need to
develop a stop signal to
stop work if the system
is experiencing distress
during a session.
All
sessions during the
preparation phase end
with debriefing,
containment work,
relaxation, and
somatosensory work. All
of the above
interventions and
activates of the
preparation phase are
enhanced with DAS if
this is seen as safe by
the system.
Constructive avoidance:
This is a technique for
managing current life
stressors. The adult
client needs to be able
to function in life
while therapy work is
proceeding. The teaching
point here is that we
don't expose immature or
unhealed parts to
potentially triggering
or frightening events
(medical procedures,
sexual intimacy) or to
situations for which
they have no
understanding or skills
(public speaking,
employment interviews,
or arguments with
spouses). It is helpful
for the client to
explain the upcoming
situation to the parts:
the time and place of
the event, what will be
happening. The client
then encourages the
parts to stay in the
home base until the
adult says, "I'm home"
or "It's over." This
presents a very
different reality than
that learned in the
family of origin where
the needs of the child
were not considered.
What
Does the System Need to
Proceed into Trauma
Work?
Negotiating ongoing
permission and system
wide consensus for the
part or parts to work on
traumatic events is
always necessary. We
work on continuing to
develop benevolent
communication and
developing resources (or
rediscovering them).
Exploring conflicts and
resolving issues is
ongoing work. Clients
continue to explore
their ability,
resistance, and
motivation to work with
the ego state system.
Resource building
continues throughout.
Providing information
encourages security and
trust. The system should
be reassured whenever
necessary that ego
states cannot and will
not be killed off. If
they choose to change
roles and jobs, they
will still be necessary
to the existence of the
ego state system.
The
therapist must form
alliances with the ego
states during the
treatment. This
particularly applies to
angry, self-hating,
destructive, or punitive
parts. Identifying them
and acknowledging their
pain, qualities, and
roles is crucial to
successful treatment.
This encourages the
clients to look at parts
through new lenses. As
therapists we provide
continuous reassurance,
education, and respect.
The pace of the work is
always set by the
system.
Appreciating differences
among clients in
developmental abilities,
readiness, and so on is
an important part of our
work. We can then time
our interventions based
on accurate ongoing
assessment.
The
client and ego state(s)
can develop and view
targets together. They
may spontaneously
combine in a temporary
merger for strength and
security (also called
"blending"). This leads
to the formation of
internal alliances. We
keep encouraging
self-nurturing and
parenting.
This
desensitization and
reprocessing work is
utilized in combination
with techniques and
strategies common to
dissociative disorder
treatment to provide
safety during treatment.
It is important to use
fractionated work with
frequent breaks. This is
not one- to
three-session EMDR, but
long-term work.
When
the timing is
appropriate, the
therapist must always
obtain permission to
begin processing. This
may require negotiation
at several stages of the
treatment. The system is
informed that all of the
parts do not have to be
present during
processing. They can
choose to stay away or
not participate. They
can stay present, but
have speakers and
microphones that they
can turn off to distance
themselves from the
processing. The only
agreement necessary is
that they not sabotage
the work taking place.
If they cannot commit to
this promise,
desensitization has to
wait until the problem
is resolved through
discussion and
negotiation.
Elements of Trauma
Treatment
In
working with clients
with complex PTSD, the
following special
considerations need to
be accommodated during
the trauma treatment.
Target
choices:
Targets can focus on
events, memories, and
body parts. They may be
specific to one or more
ego states. Each ego
state may require a
separate VOC, SUD, NC,
and PC.
Assessment:
The therapist will need
to assess whether the
client has gained the
necessary resources and
ego strengths to begin
trauma processing. If
the work was started
prematurely, we return
to readiness work and
resume when the system
is ready.
DAS:
Length of sets and type
of stimuli are also
selected by consensus,
both between therapist
and client and among the
ego states.
Interweaves:
In some situations,
interweaves can be
lengthy, continuing over
many sessions. They can
include resource
building, ego state
work, and cognitive,
somatic, and
psychodynamic
interweaves. Body
processing can be
lengthy, with frequent
returns to target. In a
typical session,
fractionated work (on a
fragment of the event)
is usually necessary to
prevent flooding or over
stimulating the system.
Structuring sessions:
Processing may take only
a small amount of
session time. It may be
typical to begin with a
discussion of the
client's week between
sessions and a safe
place exercise; then
there will be a short
amount of trauma
processing in the middle
section of the session,
and the session will end
with debriefing,
relaxing, and
containing. The work is
paced by the parts
system, which now is
competent to tolerate
processing and can make
use of containment,
debriefing, and other
management techniques.
Safety techniques are
rehearsed when
necessary. Processing
stops to orient "new"
ego states and to solve
conflicts, or if
overwhelming reactions
to trauma material are
encountered.
Ego state
changes:
Individual and system
wide ego state changes
can be expected. As
desensitization and
processing proceed
adaptively, ego states
change or merge. They
observe and help the
desensitization and
reprocessing. Several
ego states may watch the
session or be
supportive. Working with
several states
simultaneously means
that there may be
parallel processing of
different perspectives
of the event. Long-range
systemic changes are
seen as a result of EMDR
and ego state treatment.
Ego States evolve and
change roles during the
EMDR protocol.
Conclusion
We
have seen that extending
the length and scope of
the stabilization and
preparation phase of the
standard EMDR protocol
and adding ego state
work allows clients who
might otherwise have
been deemed ineligible
for EMDR to profit from
trauma work.
During
the important
preparation work clients
come to an awareness and
acceptance of their ego
state system and develop
the ability to
self-soothe. The system
can now deal effectively
with issues of safety,
responsibility, and
choice from the position
of empathic
understanding The client
acts more independently,
tries out new
situations-sometimes in
the presence of the ego
state system-and then
develops a future
template for positive
behaviors. The client
practices new skills in
real-life situations. We
end the work, not as it
was begun, but with a
more evolved,
self-loving human being
who is interested in
living life fully. We
have come more than full
circle.
In
conclusion, within this
integrated treatment
model, the internal
family system is
recognized for having
played purposeful,
honorable roles during
the earlier times of
terror and chaos. In the
course of treatment, the
ego states have been
treated with care and
respect and given
structure and healthy
boundaries. The
traumatic material has
been reprocessed. The
system can now implement
a more effective
blueprint for living.
EMDR therapists are thus
able to provide
effective treatment to
address complex
traumatic stress
disorder and its
sequelae in our clients.
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Note
I
would like to thank Tom
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paper and Margaret
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for editing it.
Publication history:
first published
2004-05-17; rev.
20004-08-06.
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