Trauma & Attachment Therapy

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.

Defining Rape and Sexual Assault

I've been working with survivors of rape and sexual assault since I started in the mental health field. Here are my definitions:

Rape: The sexual use, involving penile, digital (fingers) or objects on a woman's, man's or child's body without that person's consent, with forced consent (threats) or if that person cannot conset due to age, mental disability, state of drunkeness or druggedness, or relative social position to the rapist (employee, slave, patient, lower rank, parishoner, etc.)  

Rape can include penis in vagina, anus, or mouth, or forced masturbation. It can include objects. It can include rubbing genitals on a person with clothes in between. Women can, but rarely do, rape people by forcing them to touch or otherwise sexually interact. People of any age can be raped. People in an otherwise consensual sexual relationship can be raped, if they say "no" or are asleep or passed out, and their partner is sexual with them without their consent. 

Sexual Assault: Unsolicited, unwanted touching, grabbing, or other sexualized physical utilization of another person. All rape is sexual assault. Not all sexual assault is rape.

Molestation: See Sexual Assault. Often used when describing either the Sexual Assault or Rape of children. I wish this word would go away. I'd prefer "Child Rapist" to "Child Molester" since it's the true definition of what happened.

Effects of Rape and Sexual Assault: It depends on what happened, by whom, and to whom.

• Adults who are raped by strangers tend to experience full-blown Post Traumatic Stress Disorder. No matter the circumstance, they tend to feel dirty, culpable, and ashamed. It ruins, at least for a while, their healthy sex lives, their sense of safety and trust in the world, and their image of an autonomous, safe self. If the adults had a history of childhood sexual abuse, the new rape often brings forth the same feelings, ego states, and flashbacks of the earlier time. Sexual situations with beloved partners can bring up flashbacks of the rape. Men who are raped can have a sense of loss of maleness and a whole other level of loss of self.
• Children who are raped by strangers tend to experience all of the above including a pervasive sense of "badness", and without treatment may carry that sense of shame and fear of sexual situations to adulthood
• Date rape: Rape by someone in dating situation, when the victim has said no or cannot show consent, brings another layer of self-blame, lack of trust, questioning of "fault", and social complications. ("I shouldn't have worn a short skirt; drunk so much; gone out with someone I didn't know well; etc.") along with PTSD.
• Rape of a child or teenager by a parent, coach, teacher, older sibling, uncle, step-parent: Kids can't give consent, even if it's "friendly", it's rape. The worst thing I often hear is "It's (being an object of sex) what I'm for." Child rape by a person on whom the child relies for protection creates huge issues of identity, safety, goodness, worth, and sexuality.  Some kids, after chronic sexual abuse/rape, become prostitutes. 75 - 95% or prostitutes were sexually abused as children.  http://www.womenslaw.org/simple.php?sitemap_id=148. Many have flashbacks for the rest of their lives, unless treated. Many are not believed by their families. (The response of the family and/or institution in which the abuse occurred is strongly correlated with healing, or not, after the rape.) Kids who are raped tend to freeze, then go limp during the act. Afterwards, any sexual threat or even solicitation can bring the same passive, obedient response, making further exploitation more likely. Some re-enact their role with sexual acting out, a warped attempt of mastery of the situation. Most, but not all, people involved in sadomasochist "scenes" were sexually abused/raped as children. Child rape by trusted adults is a factor in most serious dissociative and Borderline Personality Disorder diagnoses. 

Complicating factors:

•     Not all rape is violent or actively coercive. When attachment bonds are used to manipulate kids or adults into sexual activity it confuses the issue of desire, identity, and fault.
• People can be physically aroused and even orgasm during a rape -- by the mechanics of the act. It still doesn't mean they wanted it. This is a huge issue in therapy.

Treatment: Many psychotherapies are helpful with rape and sexual assault survivors. My favorites are EMDR, Somatic Therapies, and, with victims of child rape and long-term abuse, Ego State Therapies. With permission, my favorite phone message from a client, after 3 sessions of EMDR for childhood sexual abuse: "Robin, I just called to tell you that I had sex with my husband today and it was great. After 12 years of marriage, this was the first time we made love and my grandfather wasn't in the room! Thank you!" 
 

Politics: Misinformation by the anti-choice people has muddied this issue. Some of them don't want women to have abortions. Some don't want women to be able to get pregnant from rape, necessitating the need for discussion of incest and rape exceptions in laws. Women who are ovulating can get pregnant from rape. It's a fact. "Legitimate Rape" appears to mean a violent rape by a stranger, only one kind of rape. 

A Song: Illegitimate Rape. the only good thing to come out of this political kerfuffle: http://youtu.be/mg_4O6XmKAQ

Penn State: Was the abuse too horrible to acknowledge?

Here are two similar views of the Penn State child abuse debacle. One from the anonymous humble2humble blog (obviously by a man of faith who understands child abuse): http://humble2humble.blogspot.com/2011_11_01_archive.html. The second is by David Brooks, from yesterday's NYT's: http://www.nytimes.com/2011/11/15/opinion/brooks-lets-all-feel-superior.html

Both speak to the commonality of denial and avoidance. Both are great writing. What do you think?

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.

Dissociation Often Caused By Disrupted Attachment

Andrew Leeds' Sonoma Psychotherapy Training Institute posted a great article on its blog: Developmental Pathways to Dissociation. They quote Dutra, Bianchi, Siegel, and Lyons-Ruth saying that ". . . lack of positive maternal affective involvement, maternal flatness of affect, and overall disrupted maternal communication were the strongest predictors of dissociation in young adulthood." Read the whole article here:  http://www.sonomapti.com/sonomaptiblog_files/developmental_pathways_to_dissociation.html

Trauma and Trauma Therapy: Interview on "Public Exposure"

I was interviewed by Stan Emert on his cable TV show, "Public Exposure" a few weeks ago. Here is the YouTube link to the show:  http://youtu.be/KsFoHFQxx4o  Topics include trauma definitions, PTSD, EMDR, Ego State Therapy, and a minute of traumatic grief.

Due to a neck injury, I've been unable to spend more than a few minutes at a keyboard in the last few months. I hope to resume posting on this blog after I learn to write with Dragon, a voice-recognition program.

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. 

  

A Meditation for Clients Who Have Complex Trauma

This meditation was generously shared by someone else's client who was neglected and abused as a child. She does it as part of breathing practice: breathing in each true line. In it she speaks to different parts of self and all parts of self, counteracting distressing and untrue beliefs and orienting parts to the present. The changes in type, underlining, etc. are as I received them.

To the writer: I don't know you, but I thank you on behalf of all the therapists who are going to borrow this for their clients who need to learn the same things that you are already learning. Thank you!

Breathing Meditation

1.  I am here now, in my body,

2.  quiet and calm.

 

3.  It’s OK to know.

4.  It was not my fault, ever;

5.  I had no choice and did nothing wrong.

6.  I was not a bad girl;

7.  I was good.

8.  I am good.

9.  It’s OK to know.

10. It was not her fault, ever;

  [multiple “hers”]

11. she had no choice

  and did nothing wrong.

12. She was not a bad girl;

13. She was good.

14. I am good.

15. It’s OK to know.

16. It is not your fault, ever;

17. you have no choice

  and are doing nothing wrong.

18. You are not bad,

  even though it sometimes feels good.

19. You are good,

  even when it feels good.

20. You are good

  even when it’s confusing

  and you think maybe you like it.

21. You are good

  even when you’re sure you’re bad.

22. You are always good.

23. I am good.

24. There has never been anyone there to help you.

25. You have been so lonely.

26. I see you now.

27. You are not alone anymore.

28. I can help you now.

29. It is OK for both of us to know.

30. It is OK for all of us to know.

31. It is OK for all of you to be known.

32. It is OK for me to know all of you.

33. We did nothing wrong.

34. Bad, confusing things were done to us.

35. I have compassion and tenderness

  for all of myself.

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.

Self Care for Trauma Therapists

As trauma therapists, we are privileged to watch our clients’ trauma fade from terrible, here-and-now experiences to mere memories; their dissociation shift to integrated presence, and their pain disappear. We are also privy to the gut-wrenching details of rape, accidents, war, and story after story of child abuse, domestic violence, and horrible neglect. The more terrible the abuse and the more dissociated the clients, the more they project the actual emotions of their trauma into us. Some therapists become grim. Some avoid complex trauma clients. Some help their clients avoid expressing affect in the sessions. Some burn out and leave the profession. Here are some ways to keep yourself whole while doing this important work.

1.   Do your own work. If you’re not able to tolerate your own history and your current affect, you won’t be able to tolerate the despair, rage, shame, and grief that move through many trauma survivors.

2.   Learn mindfulness. Meditate, do yoga, do chi gong, do breathing exercises. It will help you “stay in the chair” while witnessing whatever is there to see. Learn to breathe and ground yourself while being with anything.

3.   Know yourself. If you start a session in a state of equilibrium, and you start feeling rage or exhaustion in the session, guess that it may be the client’s rage or dissociation. If you then say “What are you feeling right now? There’s something in the room.” The client is likely to say, “Oh, I’m angry, I guess it’s about X.” or “Oh, I was just spacing out.” When you know where you are, you’ll know when you are being drawn into someone else’s experience and use it for their benefit.

4.   Know the signs of burn out:

a.   You aren’t excited to go to work.

b.   You talk only about work and have no other interests.

c.    You treat everyone on earth like a client.

d.   You dream about clients, all the time.

e.    You’re angry at clients for being the way they are.

f.     You feel shame for your human limitations.

g.   You have vicarious PTSD: flashbacks, anxiety, depression, avoidance around client material.

h.   You want to drink, gamble, or otherwise dissociate after work.

5.   Get support.

a.   Join a supportive consultation group. (Not just about the technique, but about you, too. And no shaming allowed.)

b.   You might get individual consultation for the most troubling cases. As a consultant, I’m going step-by-step with a few consultees with their most fragile, barely tractable cases. It’s good for the therapists and good for the clients.

c.    Increase your therapeutic arsenal. If what you’re doing isn’t working, find something else that does.

d.   Do your own work. Hire a good trauma therapist who can help you clear your vicarious trauma.

6.   Develop other interests that have nothing to do with therapy. Make sure some of them involve unmitigated joy.

7.   Do things that bring you into your body: Run, stretch, work out, dance, do yoga.

8.   If you have any control over your schedule, limit the number of the most complex, dissociated, abused, unstable clients. And don’t put them all on one day.

9.   You will probably learn your tolerance the way most of us do, by exceeding it. Once you know, keep your own boundaries. Follow the Platinum Rule: “Fill your own cup first, then give away what’s left over.” And another rule, “To Thine Own Self Be Nice.” Trauma is compelling, but don’t let it run your entire life.

10.  Watch out for grandiosity. You can’t fix everything. Know your limits.

11.  If you have a spiritual practice, use it to support your work. Ask whatever higher power you have for help when stuck.

 

 

Narcolepsy and EMDR Processing

A client has given me permission to post about her situation: the effects of Provigil, Prozac, and time on trauma processing:

 

Round 1, 15 years ago: She was bright, effusive, and had the odd habits of jerking her head up to look around and writing down everything I said. We worked for eight months using EMDR to clear the PTSD from the physically and emotionally abusive marriage that she had escaped 17 years before. She seemed dissociative, but in a strange way, staring off, then going to the head jerk. The EMDR worked, the flashbacks stopped, the client, satisfied, went off.

 

Round 2, 10 years ago: After her narcolepsy diagnosis, she started taking Provigil. A few days later, the flashbacks from the abuse began again, and she returned to therapy. We went after the abuse, in greater depth as more details arose. Again, we cleared all we could find, and she left therapy feeling good.

 

Rounds 3 – 5: I saw the client through the illness and death of a sweet boyfriend, and various stressful work situations. Then as she became more constitutionally anxious, then obsessive, which became manageable when she started Prozac.

 

Round 6: last week: Planning her 45^th high school reunion, to which her abusive ex-husband had been invited, brought up the next round of distress over the marital abuse. SUD 10, when she thought of him. She processed through fear and rage, bringing up memories that had not arisen in rounds 1 or 2. She left, after a 60 minute session, feeling safe, calm, and able to ignore him, if he came to her reunion.

 

She and I think that whether or not her narcolepsy was a dissociative response, the Provigil allowed her brain to stay on task with the trauma processing, and that the Prozac with the Provigil keeps even more of her brain online and on task in trauma processing. She and I would love to hear if other people have had similar reactions with these medications affecting the depth of trauma processing.

Addiction, a form of dissociation, II

Ulrich Lanius, a clincial psychologist, researcher, therapist, and writer in Vancouver sent me this:

"The connection between dissocation, depression and addiction is a fascinating one and more likely than not  related to attachment. An article written by Bessel van der Kolk some insight into this:

http://www.cirp.org/library/psych/vanderkolk/

For more intensive reading, Alan Schore describes the effect between attachment and infant trauma and how they lead to traumatic stress syndromes:

http://www.trauma-pages.com/a/schore-2001b.php

There is little doubt that dissociation is in part mediated by an excessive release of endogenous opiates/endorphins. Animal studies that mimic neglect also suggest that animals that have experienced lack of caregiving have fewer opiate receptors. This likely  leads to lack of pleasure and sometimes intolerance of positive emotions, a common phenomenon in human beings that have experienced attachment trauma and who suffer from depression.

Addictions can be seen as an attempt by the addict to make up for impaired functioning of their own opiate system. Except that the pleasure derived is short lasting and commonly leads to negative outcomes in the long run, health or otherwise.

Another exciting development in the research on opiates are the effects of opiate antagonists on immmune system disorders but also potentially positive effects on depression. A review paper can be found here:

www.ldn4cancer.com/techpapers/ldn_for_disease_prevention_quality_of_life.pdf  "

Thanks Ulrich!

Is addiction a form of dissociation?

I read an article about how naltrexone, an opiate suppressant, curbs the urge to engage in kleptomania. I've had dissociative clients who have successfully used naloxone and naltraxone to vanquish their endogenous (internal) opiates, in order to be able to stay present and process traumatic events, instead of switching or spacing out completely. (See EMDR Processing w/ Dissociative Clients: Adjunctive Use of Opioid Antagonists by Ulrich Lanius, in EMDR Solutions: Pathways to Healing, 2005). I've also had success using ego state work with addicts, alcoholics, and people with compulsive/addictive behaviors. Here's my theory: Opiate Antagonists work on dissociation because much of dissociation is run by endogenous opiates. When addicts think of their drug or behavior of choice, they begin to enjoy their endogenous opiates. When they engage in their drug or behavior it gives them an even better high. The neural pathways to the repetitive addictive behavior become wide and strong, until they become ego states. When people in recovery talk about "my addict", they refer to this strong ego state. Integrate the ego state and help heal the addiction.

So how does this work? Have clients bring up the last time they were frantic to use, or the last time they did use. "Where do you feel that inside? What's the feeling? Float back to the first time you had that feeling. How old is that? What was happening then? Can you bring your adult back to that time/that kid? What do you need to tell that child? You're with her. You can fly her up to the present time. She's with you all the time, now, and you're with her. Can you tell her that now, as a competent adult, you can tolerate those enormous feelings? Can you show her how you have learned to soothe yourself without that drug/behavior? How's that kid doing now? (Do whatever it takes to calm her down.) And are you ready to hug her into you now and forever?"

There is usually a frantic little child and often an angry/protective teenage part. Sometimes there are several "parts" involved in different pieces of the addiction. It has worked on several clients.

A.J. Popky and Jim Knipe have protocols that seem to fit my opiate theory. Popky developed the Level of Urge to Use. Knipe spun off the Level of Urge to Avoid. In both of these you have the person imagine whatever triggers them to use a drug or to avoid a task and to feel how good it would feel to use or avoid. Then you do eye movements and watch the good feeling start to fade away. (DeTUR, an Urge Reduction Protocol for Addictions and Dysfunctional Behaviors by Popky, and Targeting Positive Affect to Clear the Pain of Unrequited Love, Codependence, Avoidance, and Procrastination-- both in EMDR Solutions: Pathways to Healing, 2005, Norton.) You target inappropriate positive affect in both cases. When the positive affect (the good endogenous drugs) fade, you target the distressing affect underneath, and the trigger stops being a trigger. I've done this many times, for many addicts. It works amazingly well.

I've watched clients and people in my private life turn into unrecognizable demons, sociopaths, and screaming or pleading children while in thrall to their addictions. The dissociation/opiate theory explains these behavioral shifts. Please comment and give me your opinion about this theory.

UCLA Trauma Conference Day 2: Dan Siegel, Mindfulness

Daniel Siegel: A System's View of Disintegration & Integration

(He's still cute, he's still brilliant, he speaks in easy-to-remember aphorisms and he's still heartful. What's not to like?)

"Integration is the linking of differentiated parts. The concept is useful for assessment, tx planning and therapy. . .Presence is absent in trauma survivors. Presence begins with us as therapists."

P.A.R.T.T.T.T  
when fully
Present we can
Attune to the client or others and
Resonate with others and develop
Trust which is important because it activates the smart ventral vagus so the social engagement system turns on so that we can
Track what's going on in moment to moment experience which allows the
Truth to come out and creates
Transformation/healing.

We help clients become open systems: self-organized: chaotic moving toward complexity, flexibility and adaptable: energized and coherent. System acheives complexity by linkiing differentiated parts. Coherence comes from integration. (Thank God for systems theory in social work school in 1979! I understand this stuff!) When not integrated we move toward rigidity (avoidance), chaos (flooding) or both.  It's all about the mind regulating the energy and information flow. "The mind is in the whole body and among people: it's embedded socially/relationally and embodied." "What I am is a process of regulating energy and information flow, not limited to our bodies and right now and this relationship. The ripple effects after we leave or die are also who we are." (My woo-woo teacher says the same thing. So does Hillel, sort of.)

Calming exercise: Put one hand on your heart, the other on your abdomen. Hold them there for a while. Try switching hands to see if you prefer one over the other. Most people do.

Your right hemisphere contains the storage of autobiographical information. PTSD is impaired integration. Long story about how a past trauma impeded on the present and how mindfulness allowed him to integrate the past event and stop reacting to the trigger.

"There's a distinction between awareness and mental activity: Awareness is the infinite possibility of neural firings."

In trauma, mental activies get locked into rigidity and chaos and pull humans into limited possibility. With unresolved trauma, rigidity and chaos imprison the person's possibilities. Good therapy transforms the brain of the the client to totally shift their center of attention and stay present to the self and watch self and make sense of it. The labeling of the internal state downregulates the limbic system. The client knows that "this" is not "that". Integration is the capacity to sit with core awareness and sit with anything that comes in. You can use mindfulness practice to help people distinguish between mental activity and true awareness. Ventral integration--being touch with the bodily state: Track it and you transform. Supress it and it screws you up.

"Liberate the innate drive of a complex system to integrate. Interpersonal integration: We are designed to be interdependent and interconnected. There's hope for we as humans to move from chaotic & rigid states to integration, kindness, and peace.

(Thank you, Rebbe Dan.)

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After Dan, Martha Stark, a child psychiatrist spoke about Optimal vs Traumatic Stress. Traumatic Stress overwhelms and disrupts. Optimal Stress provides the impetus for transformation and growth. Optimal Stress--you need enough to stimulate adaptation and growth but not enough to overwhelm the system. In therapy, challenge when possible and support when necessary. (My brain was full and I took a walk.)

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The Question and Answer period at the end of the day was worth the price of admission:

Dan Siegel: Txist attunement helps clients widen their ability to be with emotions and curiosity; integrates the experience; brings openess; widens the window of affect tolerance and acceptance and love, and moves away from rigidity and chaos. Be safe but not too safe: push the limits of the window of tolerance.

Francine Shapiro: Schizophrenia is sometimes misdiagnosed. Not all psychosis is genetic. Some is trauma-based, early and not-so-early childhood. If you target the negative experience, set up information processing. If they have positive networks to go to, the trauma will clear. Do processing if the client can stay present during processing (maintaining a dual awareness) and have positive experiences to call on. Otherwise spend as much time as you need to set up those positive networks. Truly schizophrenic people can be traumatized by their disease or by abuse, or disrupted attachment. Go after those targets if the client is resourced enough.

Pat Ogden, to Dan: Too much attention to mindfulness doesn't develop relational capacities. Dan to Pat: If you improve mindfulness, people have the capacity to connect. Capacity for the parent to be with his/her own self and material predicts the kid's secure attachment.  Teach people to harness the social capacity of their brains.

Steve Porges: We've developed to deal with humans, but school teaches/rewards dealing with objects. Psychiatry depersonalizes relationships. We need to teach social interaction: develop exercises. Play tempers mobilization states. We need more exercise that is face-to-face. Treadmill running teaches mobilization, badly. (I disagree.)

Bessel van der Kolk: Med school kills empathy in trainees. (Cited research)

Francine: EMDR and Dreams. Same brain process. (Robert Stickgold) Customize sets by attuning to clients needs. Goal is to take the REM state further than it goes in sleep. Images change in each set as new positive information comes in. . . Early therapeutic intervention for early humiliation would help people immensely. We need to teach parents and educators the impact of humiliation. (Jim Knipe and I wrote chapters about using EMDR on these issues to clear depressionin Solutions II.) The window of tolerance closes because of these childhood negative experiences.

Bessel: EMDR is hypnagogic, like sleep with very rapid associative processing. . . But people need to move, to play. EMDR has no movement. People need to complete the movement. But, research shows that EMDR clears 83% of the trauma. Movement-based treatment doesn't have the same success.

Martha Stark: Did EMDR with an insomniac client over a suicide attempt. In processing she remembered that at the last minute she saved herself, and the meaning about self changed for the better. Her insomnia disappeared and she started to remember her dreams.

Skipping some -- too tired.

Dan: Mindfulness creates secure attachment to the self. It's a way of being. Mindful awareness is brain hygiene, not a religion, should teach it in schools, to doctors, and create empathetic practitioners.

More in the next few days. Steve Porges read this blog and told the other presenters about it. I got some interesting attention today.

 

 

UCLA Trauma Conference 3/7/09 Day2: Porges

Stephen Porges, Demystifying the Mechanisms of Trauma: Maladaptive Consequences of Adapative Bio-Behavioral Reactions to Life Threat 

Stephen Porges knows how to connect. I could listen to him talk all day.  I explain his Poly-vagal theory to every trauma client and every consultee. Today, after he answered a difficult question, in a most kind way, my friend Barbara said, "Now, I'm in love with him."

Here's a post from exactly 2 years ago on Porges and his work. It might help to read it first. http://traumatherapy.typepad.com/trauma_attachment_therapy/2007/03/ucla_attachment.html

Here is the quick and dirty explanation of the Polyvagal (PV) Theory: "Neuroception of danger and safety or life threat trigger 3 neurological circuits." They developed at different evolutionary times. The newest one (Green Traffic light) occurs when we understand that we are in a safe environment. When it's on, we have the capacity to be socially engaged, to think, to hear and understand other humans, eat and to play. The second oldest (Yellow light) is engaged when we perceive danger, but we don't think it will kill us. In this mobilized state, we attend only to cues about danger and safety. We can't connect well, we can't even really hear people. We are scanning for danger and predators. The third state and evolutionarily oldest state (Red light) is immobilization in the face of life threat. We shut down completely, can't connect, feign death, and can't/don't have protective reflexes. (Can you say "dissociation?) 

Today, Porges said that "our nervous system reacts differently to the same stimulus, depending on our psychological state." The Polyvagal theory is about our biological quest for safety. He bemoans that these states aren't better recognized and then explained to clients, medical patients and all trauma survivors. Here are some but not all of the gems from his presentation:

People are different. The same stimuli can create different states in different people depending on a host of factors: genetics, attachment, and history. He talked about voodoo death--when people are literally scared to death, they aren't hyper-mobilized, but immobilized. Their hearts and respiration slow down to nothing and they just die, when cursed or after having broken an "unbreakable rule" and they have no ability to escape, no options, or are being held tightly.

"Immobilization with fear is a missing concept in psychology and psychiatry and medicine."

Vagal Paradox: Slow heart rate is mediated by the vagus. Sometimes too much (see voodoo death.) Heart rate variability (a good thing) is primarily mediated by the vagus and is a protective factor. "If the face is flat, the heart rate is flat. If the face is lit up, there's heart rate variability."

Singing, listening and chanting: when we feel safe and tuned into the tones we hear best, the human voice, we can't hear the low tones, the predator frequency. . . New brain circuits damp or control the old ones. We lose the adaptive urge in immobilization, pain threshholds are raised, we conserve metabolic resources and are prepared to die. (Imagine chronically abused people who live in this state, over and over.)

Yoga students with abuse history get a higherheart rate after mild exercise. No abuse hx, makes for a lower heart rate. Abuse supressed vagal regulation and lowered the threshold to be defensively reactive. Tell clients: "Your threshold to react changes and this is what happens."

Since "social behavior is a regulator of our physiology", use your self to help your clients regulate. Make the office safe. Make it quiet. Muffle the low traffic noises. Have face to face interactions that are safe.

"Face to face is play with reciprocity." What could be aggression without face to face contact becomes play. Puppies and kitties look at each other when playing. So do kids. So do people in consensual sex. People can be in a mobilized state, without fear, in play. They can be in an immobilized state without fear in play or rest. (Baby in mom's arms).

The nervous system continuously evaluates risk. Reactions to life threat is not easily reversed. These reactions can bring up rage if a client misreads the clues. (Think borderline or DID clients.)

Auditory pathways (music, voice, and song) invites proximity. It's the first route in to change the nervous system. Music therapy in the frequency of the human voice and social engagement help traumatized clients regulate themselves. So does Prana Yana breathing, with slow exhalation.

(Stephen, if you care to correct, edit, or add anything, I'd be honored. Links to articles or websites would be great, too.)

More tomorrow.

 

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

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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.

Waltzing With Bashir

Ari Folman has made a beautiful and devastating movie about trauma, dissociation, and war. As a young Israeli soldier, he was in the 1982 Lebanon war. When a friend came to him with troubling memories of that war, Folman realized that he had no memories about being in Lebanon. A therapist friend told him to ask fellow veterans about what happened and Folman interviewed people until his own memories came back. The movie is animated. It flips between "talking head" interviews with middle-aged men at home, and their younger selves in Lebanon. The animation is amazing; the music, perfect; the characterization of the various soldiers/veterans makes them totally human.

You see the trauma and the men's attempts to cope with it. One man,was considered a genius as a teen. As an adult  he hides on his Dutch farm, constantly stoned.  Some seem untouched. Others still devastated.

As the movie unwinds, you see the event begin to come together--The assassination of Bashir, the Lebanese Christian Falangist leader, led his followers to slaughter men, women, and children in a Palestinian refugee camp. The Israelis, their allies, were supporting the Falangists to "find the terrorists". By the time the Israelis understood what was going on, and the word finally got to the Israeli leadership (slowed down by idiocy and disbelief), it was too late. The last few minutes of the movie are film footage of bodies and wailing women in the camps. There is no other resolution. Nothing to make us feel good.

The movie brilliantly portrays what trauma looks like. Its director also directed the original Israeli In Treatment , which portrays among other things, the therapy of a soldier who inadvertantly bombed an orphanage. I wonder if he was compelled to do In Treatment, before he remembered what he forgot about his own war experience. Here's a link to some "stills" from the movie, and an interview with Folman.  http://lukeford.net/blog/?p=4343 My favorite lines in the interview are, "Having made WALTZ WITH BASHIR from the point of view of a common soldier, I’ve come to one conclusion: war is so useless that it‘s unbelievable. It’s nothing like you’ve seen in American movies. No glam, no glory. Just very young men going nowhere, shooting at no one they know, getting shot by no one they know, then going home and trying to forget. Sometimes they can. Most of the time they cannot."

Evidently the movie brings two distinct responses from some Israelis: "Folman should be shot as a traitor for bringing up the incident."  Or "It's good, he's finally showing the world that it wasn't our fault." My response and the response of the two Israelis with whom I watched the film, was devastation and hopelessness. In the light of our despair over the recent attack on Gaza, we were stunned. We had to walk in the cold wind, swing on swings, and watch children play in order to bring ourselves back to here and now in our safe Seattle neighborhood. Today, I'm back to thinking that the little we do as trauma therapists makes a differences. As Hillel said, "If you save one person, you save the world." I need to keep this always in mind, or I get paralyzed by the trauma we humans create.