Trauma & Attachment Therapy

Interesting 45-minute documentary of DID woman who got her father put in jail.

https://www.youtube.com/watch?v=lsXFcbPbvI4

Interesting, somewhat sensationalized, video from the Australian 60 Minutes show, about a woman who went to the cops and won in court.

The story is brutal, as is often the case for people with massive dissociation. The outcome is lovely.

Check it out!

Easy Ego State Intervention Workshops

Dear Readers,

Ego state work has been around since before Freud, and in latter years, has been the main stay of many practices. Interventions can range from "How old did you feel when you were yelling at your wife?" to "Let's identify those dissociative states that take over your body." I've been working with this stuff since I became a therapist, 38 years ago, and have read, been taught, taught, and written about it, extensively. It's one of the most versatile tools and lenses through which to see clients that I have.

In January, I expanded my 2-day Ego State training to 3 days and presented it in near London, England. there was time for practice, demonstrations, and some case consultations. Participants raved about the workshop, saying things like "I know MY parts now!" "I know exactly what to do with many of my clients!" "This is the most practical workshop I've taken!" There is special info for EMDR practitioners, but you don't have to know EMDR to take the workshop and get credit. EMDR practitioners get 12 hours for EMDRIA and 12 for their profession. Others get it for their profession.

I'm  giving it several times this year. 

• 4 days in Milan,Italy.  May 10 -13 https://www.international-isc.com/wp-content/uploads/2017/12/brochure-shapiro-ing.pdf
• 3 days in Seattle, WA, June 8 - 10 https://www.eventbrite.com/e/easy-ego-state-interventions-seattle-tickets-44375863402  
• 2 days in Des Moines, Iowa October 20 and 21st, link to follow
• 3 days in Boston November 9-11, link to follow

Here is what I cover:

• Distinguishing Healthy/Flexible and Dissociative Ego States (and map your own)
• Overview of Ego State Interventions
• Identify Vagal States
• Use Embodied Ego State Interventions (includes practice)
• Clearing Trauma (includes practice)
• Theory of Structural Dissociation
• For EMDR practitioners, distinguish when EMDR, when EMDR and when both are the treatments of choice
• Tools to work with sexual abuse, and then bring back healthy current sexuality
• Work with Attachment Issues, including April Steele’s Building a Secure Self (practice)
• Couples Therapy
• Calming Over-Active Immune Systems, Multiple-Chemical Sensitivity (possible demo, if someone has one)
• Pain Protocol
• Shame (practice)
• Suicidal clients
• Resourcing (including installing your own “team”)
• Healing Personality Disorders
• Working with Dissociative Identity Disorder

If you can't get to a workshop, you might read Easy Ego State Interventions or sign up for one of the many good trainings on this subject. It's good stuff to know!

Installing the Future

Dissociative people often lack coherent narratives of their pasts (Mary Main & Dan Siegel). I'm finding that they often lack coherent visions of their futures. Today I "installed the future" in a formerly dissociative client, who has given me permission to tell this story. 

When "Linda" was 6 weeks old, her mother became gravely ill and was hospitalized for several weeks. Linda was passed around to different relatives, none of them parents, until her mother returned home. After that Linda, was different, sometimes frantic, sometimes shut down. As a teenager, she was in and out of mental hospitals, overdosing on drugs, and acting out in big ways. Later she settled into a long-term relationship with some good earned attachment, became a respected professional and had two kids.  She came to me two years ago, functional, but prone to huge swings in mood, perspective, and ego states: DDNOS in presentation, possibly DID.  

After two years of intensive EMDR, Ego State Work, Brainspotting, and great therapeutic alliance, Linda, in her late 30's, is stable, adult, and integrated. A few months ago, after a violent death in her family, Linda had the normal reaction of fearing for her own mortality. In discussion, she revealed that she couldn't see her future. Her future felt like one second away, even thinking of herself as 90 years old, felt like a momentary blip. Her past, too, felt like a blip. Dissociation had stolen a coherent sense of time.

I stole a piece from Lifespan Integration (Peggy Pace), which leads kid parts up past years, year by year to the present. Instead of doing it in the past, I led Linda through the years from now until her 90's, including the changes in her body, her kids, her partner, her parents, her work life, her age-appropriate world view, and technology. In 20 minutes we visited developmental stages from now until old, old age, while I administered bilateral stimulation.

When we were done, she said something like, "Wow, that was great! You've given me the future. I feel much calmer. For the first time in my life I can imagine what it would be like. It's not just a blank, like my childhood. . . I feel safer and less afraid of dying, since I can imagine living. I know that anything could happen, but I had no alternative in my mind to something happening. Thanks!"

At the end of session, we agreed to go back and use Lifespan and the bilateral stimulation to bring coherence to her life, up until now.

In Ego State Therapy, Let the Client Run the Internal Show.

Twenty-seven years ago, when I worked with my first DID client, I became the "go to" person for soothing the young, distressed ego states. As a result, I was on-call 24/7, never took longer than a week's vacation, and was constantly fielding emergencies. Finally, a savvy consultant told me to put the "oldest, wisest part" of the client in charge of all distressed, younger, or destructive alters. What a relief! Within three sessions, the client could self-soothe, make adult decisions, and deal with new alters as they popped up. (This was a complex ritual abuse case with lots and lots of parts.) Therapy sessions became case consultions. I worked with the most adult parts of my client to create safety, internal communication between parts, internal and external boundaries, and good, safe rituals of orienting "new" parts to the present and giving them the rules.  The therapy wasn't over then, it lasted 10 years, through trauma processing (which got more efficient when I learned EMDR), lots of sorting out "then" from now, the grief process about her awful losses, and coming to terms with her current life.   The client still contacts me every 9 months or so for a tune-up session.

So, all of you who work with parts: If you help the oldest, wisest, most nurturing parts run the show, the client gets to do more of the work, feel effective and in charge of his or her life, self-soothe, and heal faster. If you want to communicate with younger parts, ask an adult, the adult, or the "team" to ask about or talk to the part. "Can you go inside and tell me how that 2-year-old part is doing now? . . .Can you remind her that you are always there for her so she's never alone again? . . . That she's safe now. . . And that she lives with you in your nice house. . . ."

I do ego state work with 85% of my clients and I rarely speak directly to any but the presenting adult. The only time I do, once a decade, is when I'm working with a new client, who pops into a part I don't know that's amnestic for the rest of life. (The ultimate "Oh S--t!" moment of therapy.) Then I introduce myself, if the part doesn't know, explain that we're in my office, and gather information: age, name, and what it needs, or what it does and "Did you know that you're part of John?". Then ask for "Adult client", to come back. Sometimes, with a count of three. It's always worked. If the presenting client doesn't remember the situation, I offer to set up an introduction. When I do, I refer to the presenting adult, team, etc. as the boss.

Most ego state work is much less dramatic. I often ask people to tell me how old something feels and if they can talk to that 3-year-old, 5 y.o., etc. part. Most people can do this. It doesn't take formal dissociation. For the dissociative disorders of complex PTSD, Axis 2 diagnoses, DDNOS, and DID, formal ego state work, combined with EMDR or Brainspotting or Somatic work for trauma, in conjunction with attachment-based therapies are always called for.

Therapeutic Metaphors from Star Trek and other Popular Culture

Utilization is the idea that therapists should use the culture and the language that their clients already use. If your client has watched Star Trek, they already know how to utilize these great tools. 

• Safe place: "Do you know what a containment field is on Star Trek? Great! So imagine your safe place has a containment field around it. No one can see it, no one can get through it, and it will keep you completely safe from harm."
• 
  
• Sharing between Parts with highly dissociated clients: "We've cleared a lot of the trauma that that part holds. Does the Adult part feel ready to know what happened back then? Good. Then let the child do a Vulcan mind-meld with the adult and share the information about what happened and what it was like for her. Let me know when the transfer of information is complete."
• "So lets bring this to the Holodeck and run through the event so you can control how it turns out this time."
• Practicing: "So lets create this situation on the Holodeck, you can direct the Holodeck to create facsimiles of all the players and you can practice how you want to talk to that person/ those people until you feel that you know exactly how to do it in real life."
• "Now imagine transporting that 5-year-old self out of that bed and out of that time, letting her rematerialize right here and right now. Is she here? Then let her know who you are and where she is and that she's finally safe from that guy."
• Other magic:
• "What would Harry Potter do? What spell would you cast?"
• "Imagine you had Superman's/Wonder Woman's strength? What would you do then?"
• "So could you go back in time with Doctor Who and rescue that child?" (For Brits)

My clients are delighted when I speak their language and use what's already in their brains. If they've spent years with Star Trek or Doctor Who or the mutants in Heroes, their mirror neurons have already had them doing the magical activities, and are ready to take them into a different reality. 

Years ago, a cult-abused DID client cured her insomnia by imagining a Star Trek containment field around her bed, which she turned on before sleep. Later, after years of trauma-clearing and Vulcan mind-melds between related parts, she did a mind-meld between all remaining parts and integrated (mostly) in my office. 

  

Kathy Steele: Neurobiology of DID, on Science Friday

Kathy Steele, cocreator of the Structural Dissociation Theory, patiently defends the existence of Dissociative Identity Disorder to Ira Flatow and Numan Gharaibeh (a clueless psychiatrist) on NPR's Science Friday. Worth a listen: http://www.sciencefriday.com/program/archives/200911133 

I've run into this blindness before, mostly in analytically trained psychiatrists, despite all evidence.

UCLA 2009 Trauma Conference Day 1, van der Kolk & Shapiro

Day 1: Bessel van der Kolk is lovely. He's humble, he's funny, and he is the premiere researcher on the neurobiology and/or efficacy of trauma treatments in the world. And cute and brilliant, of course.

Here are nearly random gems from 3 hours of notes:

With trauma, there are no stories, only sensory experience: images, affect, and tactile, olfactory, and auditory experience. Bleure (1920): People can't hold the memory of the trauma--can't tell the story. The solution is taking action against the person who hurt you or telling the story over and over. (Prolonged exposure). Bessel says "No. Telling the story is not enough!" Later: "When people are into their trauma, they cannot talk about it. They become dumbfounded." Because Broca's area in the brain shuts down. "When the left brain shuts down, we must shift to right brain processing."

"Our job as trauma therapists is to bring the frontal lobe on line." (He said that GW Bush showed himself to be a "limbic" president with his "Let's kill them all" speech after 9/11. "A dangerous limbic-run man.")

The body relives and reinstates the initial trauma state, even the stress hormones.

Exposure therapy "blasts people's brains with the trauma and drives them crazy. That's supposed to be good for people?" And said the CBT literature is full of the treatment triggering suicide attempts, substance abuse, and worse symptoms.

He talked about his amazing EMDR vs Prozac study. 80% of adult onset trauma completely cleared PTSD & Depression after 8 weeks of tx. Prozac people felt better until they stopped taking the drugs. EMDR folks got better and better for months after tx and stayed that way. Cool study and he had trouble getting published despite 3X the success of CBT. Politics.) http://www.emdr.dk/artikler/07_kolk.pdf

Bessel and many of the top child psychiatrists and psychologists are lobbying for an new DSM 5 diagnosis: Developmental Trauma Disorder:  http://www.traumacenter.org/products/pdf_files/Preprint_Dev_Trauma_Disorder.pdf 

It's much needed. I have so many clients who need this diagnosis! (gai

Developmental Trauma Disorder

A. Exposure

1. Multiple or chronic exposure to one or more forms of developmentally adverse

interpersonal trauma (abandonment, betrayal, physical assaults, sexual assaults, threats to

bodily integrity, coercive practices, emotional abuse, witnessing violence and death).

2. Subjective Experience (rage, betrayal, fear, resignation, defeat, shame).

B. Triggered pattern of repeated dysregulation in response to trauma cues

Dysregulation (high or low) in presence of cues. Changes persist and do not return to

baseline; not reduced in intensity by conscious awareness.

•Affective

•Somatic (physiological, motoric, medical)

•Behavioral (e.g. re-enactment, cutting)

•Cognitive (thinking that it is happening again, confusion, dissociation,

depersonalization).

•Relational (clinging, oppositional, distrustful, compliant).

• Self-attribution (self-hate and blame).

C. Persistently Altered Attributions and Expectancies

•Negative self-attribution

•Distrust protective caretaker

•Loss of expectancy of protection by others

•Loss of trust in social agencies to protect

•Lack of recourse to social justice/retribution

•Inevitability of future victimization

15

D. Functional Impairment

•Educational

•Family

•Peer

•Legal

•Vocational

---------------------------------------------------------------------------------

Bessel talked about vagal nerves (see Porges--later) and said that you can change the way you feel by changing the state of your body (thus our affinity for alcohol, drugs, and sugar.) Drugs, tai chi, karate, yoga, meditation and exercise manipulate the vagus nerves. Do yoga, etc. to affect the state of your body.

"Emotional Regulation is the most important issue in psychotherapy."

Cloitre 2007: '"If treatment relationship lead to affect regulation, the patient gets better."

In a study with chronically traumatized clients: 8 weeks of Yoga class beet 8 weeks of CBT with 28 hours of homework.

In PTSD, the thalamus goes offline. The thalamus orients you to where and when you are in a autobiographical context. Much of the brain goes offline when immobilized and there are no available receptors for attachment or problem-solving.

"Thinking has no avenues of access to the emotional brain. (You can't talk yourself into loving Dick Cheney, whatever the incentive.) . . . Traumatized people don't have a sense of being deeply present because the anterior singulate is off-line. . . Keep clients oriented to 'now' in themselves: 'How does your body experience that feeling?' . . .Help clients process what's inside of their here and now consciousness."

Trauma survivors see the trauma or the "bad thing" as outside of themselves, not as their own response to something that happened. "Bring attention to the body, to internal landscape: What's the sensation? Where do you feel it? What happens if you try something? Take a deep breath, right now. Do TFT tapping on the collarbone spot. . . Notice what comes up and remember how it will come to an end. How can we give the miserable, alone, frightened part of you some company? . . . Tell her you know how terribly lonely it was."

"You can't do trauma work without people deeply observing their own level of consciousness and then deeply connecting on the outside with you."

"The emotional brain runs the show." Feelings should be guides rather than a source of terror.

Bessel spoke of the importance of EMDR and Somatic therapies in working with trauma and showed a moving video of a formerly DID client who was "organized" by neurofeedback. "EMDR is the opening for understanding trauma. You can't do trauma treatment without EMDR or something else that knits the sensory experiences together."

Part II: Francine Shapiro, the brilliant maven of EMDR, looking well and energetic.

Much of what Francine said was material you can find at emdria.com or the EMDR Institute website: The Adaptive Information Processing model and the steps of EMDR treatment. Today I heard her say some different things: The importance of targeting the "small t" traumas. Much of the trauma that can severely impact a life does not fit the criteria for PTSD. She gave many examples of people who developmentally stopped at some distressing, non-life threatening event, until an EMDR session, years later, released them. (It happens. I've seen it many times.)

"Neurophysiology does not equal destiny." There is neuroplasticity in adult brains. Shrunken hippocampi grow again, after the trauma is resolved. Don't give up! A study: 8 sessions of EMDR, 20% increase in hippocampal growth.

Beliefs are a manifestation of trauma. CBT/Exposure = extinction. EMDR = reconsolidation. In prolonged exposure, the memory of the rape doesn't change, but get a competing new memory. But the clients relapse when around a trigger, because the old memory is still there. EMDR reconsolidates memory changes, so the initial triggers won't work.

"Processing dysfunctional and positive memories are the focus of EMDR treatment. Process the negative and integrate the positive. Every positive attunment or modeling by the therapist links the positive information in. . . You need to have positive adaptive memory networks for tx to work."

Process: Family of origin issues, memories that are encoded; Defenses, i.d. the earliest childhood event that caused that pathway to develop; cognition, process the memories that created the cognition--the cause is the encoded earlier event; Somatic/Emotive, "When's the 1st time you felt that way?"; Developmental, "What events derailed attachment?"

(I'm getting too tired to give you all the rest, so I'll hit a few highlights:)

ADHD: some of it is PTSD, some real ADHD.

Body dysmorphia: usually from childhood humiliation, sometimes just one comment. Clears with a few sessions. (There's a chapter in Solutions II about this.)

Small t traumas cause more pathologies than PTSD.

Axis II (personality dx's) are a constellation of attributes, each rooted in earlier events.

Borderline Personality Dx: Cool stuff-- too much to write. But Axis II is moveable and cureable if you go after the childhood antecedents. (I know because I have ex-borderline clients and ex-narcissists.)

If you are treating kids, treat the parents attachment issues and the kids get better. Include in this: targeting the non-bonding event with the child, then make a story about an easy pregnancy, each trimester, an easy delivery, the first breath, first hours, coming home -- better than real life, and install it.

In family systems, you can treat the family of origin issues in every one, all the behavior. Teach skills after the trauma is gone, when it can sink in.

Depression. Yes, See the first 5 chapters in Solutions II.

Phantom Limb Pain. Yes. See the PLP chapter in Solutions I--Wilson

Grief: "There is more positive recall of the loved one after EMDR (for traumatic grief) than after CBT. (Sprang, 2001)

EMDR increases resilency and engenders a new sense of self.

 

 

"The Post-Traumatic Stress Disorder Sourcebook"

I'm reading piles of books in preparation for writing a trauma therapy survey book. My friend and colleague, Barbara Hinsz lent me Glenn Schiraldi's The Post-Traumatic Stress Disorder Sourcebook. (McGraw-Hill, 2000) It's a great self-help book, one of the best I've seen. Schiraldi's a good writer. I never wanted to fix his sentences. He's simple without being simplistic. He gives a great description of dissociation. He talks clearly and cleanly about therapy. (Giving CBT, EMDR, Counting, and TFT good "marks", describes many other self-help and therapeutic techniques, and gives the same warnings I do about prolonged exposure.)

If you have a client who wants more information and some good self-help advice as an adjunct to therapy, suggest this good and wise book. And if you have suffered a trauma, and are still feeling the after-effects, read this book. I just bought one for myself.

Psychology on TV: The Mentalist & My Own Worst Enemy

    The Mentalist & My Own Worst Enemy portray very different uses of hypnosis and psychological strategies. Tim Kang is Kendall Cho, the stage hypnotist turned California Bureau of Investigation adjunct. While his skeptical colleagues look on, Cho uses (Milton) Ericksonian hypnotic techniques to befuddle, assist recall, and produce telling reactions in witnesses and "persons of interest" in California state cases. I enjoyed watching his technique. The advisors to this program must be having a great time. By the second show, I was already tired of the skeptical administrator vs. earnest investigator dynamic. And the two cases I've seen Cho crack had a high "ick" factor. I may not watch it every week, but the protaganist is handsome, the hypnotic technique stellar, and about half the scenes are on the beach.

    Worst Enemy stars Christian Slater as an MK-Ultra operative (Edward) and a married efficiency expert (Henry), who share a body and didn't know each other. MK-Ultra was a CIA-based mind control project that ran for at least 20 years. There were centers scattered around the US and Canada in which people, including children, were tortured and given drugs in order to cause tightly-controlled dissociation. According to Wikipedia, http://en.wikipedia.org/wiki/Project_MKULTRA ,it's still going on. There was a center in Seattle, at the Pacific Medical Center. I knew a man whose father, a psychiatrist, worked there. The psychiatrist later commit suicide and said, in his note to his family, that he couldn't continue torturing children and wouldn't have been allowed to quit.

The switching techniques in Worst Enemy are flashy and high tech. In the first episode, they stop working and Henry, the innocent "normal" part starts showing up in high risk explosive situations, while Edward, the brilliant, psychopathic spy part, shows up in Henry's life, with Henry's wife. They figure out how to leave video notes for each other and the series is set.

I've worked with only one survivor of the Ultra experiments. I can't talk about the person, but I can say that most of these folks are poly-fragmented DID with huge memory gaps. They often seem to be victims of ritual abuse (and some were) and some of them, because of what they experienced in their "training" think that they were abducted by aliens. There are clinicians who know how to deprogram them using specific protocols developed by Jim McCarthy, a sociologist, who, while studying cult deprogramming, ran into MKUltra survivors, and figured out how to help them. There is a 1997 movie, Conspiracy Theory, with Mel Gibson, that portrays an MKUltra operative. The movie does a pretty good job of portraying the messes that these people become. If you think you've got a client like this, get some training about them, or refer to someone who knows how to work them. The work is very specific and very complex.

In the mean time, because of my interest in Dissociative Identity Disorder and hypnosis, I've got both of these shows on permanent Tivo.

New Sybil movie. DID in the media.

CBS aired a new Sybil on Saturday, starring Jessica Lange as the therapist and Tammy Blanchard as Sybil. It was less fantastic and spooky than the original Joanne Woodward/Sally Field movie, and was a realistic depiction of a poly-fragmented DID person. The movie depicted realistic switching behavior, flashbacks, losing time, and amnesia between parts. It showed recurrent triggering that brought out different parts.The therapist was as competent as she could be, with no training, and fiercely attacked by colleagues for "making a multiple". The movie showed the kind of early abuse that creates DID. My husband kept saying, "How can that happen to a child?" And I kept saying, "I hear this at work, nearly every day."

It was worth watching: the acting was great, the depiction realistic, and the state of therapy pretty bad. Unfortunately, CBS isn't making it available for replay on its website, or I'd provide a link.