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!

Online 2-Day Class of Easy Ego State Interventions

Hello,

I'm going to be in Massachusetts on June 14 -15 teaching my ego state class. If you want to live-stream it (or show up for it) go to this website to sign up:

http://www.markinickerson.com/registration/?action=evregister&event_id=127

Here's the program description:

Participants in Easy Ego State Interventions learn how to see clients through the lens of ego state therapy and EMDR and to distinguish healthy, flexible states from dissociative ones. Through lecture, guided experience, case examples, demonstrations, role-plays, and practice they will be able to utilize their awareness of vagal states, body types, and trauma and attachment histories to make accurate diagnoses, plan treatment, clear trauma, heal attachment issues, and enhance relationships with ego state therapy. The workshop includes content differentiating normal ego states from dissociative states; Stephen Porges’s Polyvagal theory as the basis for many states; how ego state interventions work; the Theory of Structural Dissociation; accessing functional and dysfunctional states; the 2-Hand Interweave technique; a simple trauma protocol with ego states; material on attachment to abusers and working with survivors of sexual abuse to create a healthy sex life; April Steele’s Imaginal Nurturing protocol and healing place interventions if there is a phobia of younger parts; working with relationship issues, including using adult states to pick a good partner; Calming over-active immune systems and chronic pain with EMDR and ego state work; working with personality disorders, including Borderline, and both Exhibitionist and Codependent Narcissists; and several hours on working with Dissociative Disorders including Dissociative Identity Disorder (DID). The DD work includes diagnosis, working within the Theory of Structural Dissociation, many case examples, a review of useful tools, including use of the Dissociative Table, Healing Places, and “Switching” Places. It also speaks to the self-care of therapists who work with this population. 

My History with Ego State Therapy

I wrote this as a prologue to the Greek version of Easy Ego State Interventions and realized that it will make a good post:

I have been looking through the lenses of ego state therapies since 1981. During that year, my first out of graduate school, I took a course in Eric Berne’s Transactional Analysis and learned to identify the “Parent”, “Child”, and “Adult” parts of myself and my clients. It was useful to notice when I, and other people, were coming from our kid states, our introjected parent states, or our chosen, skilled, present-oriented part of self.

In the same year, I read and took classes in various hypnotic techniques, and learned my most used ego state intervention: “Go inside, and find that part of you that (1) having that feeling/ (2) having that belief and/or (3) can tell you when in your life that belief/feeling started.”

My consultant, Thom Negri, gave our group the experience of finding our own inner children, and promising to care for and protect them.  I’ve used this intervention with nearly every client, and learned new twists from April Steele and others, which I continue to use.

Before I learned EMDR, in 1993, ego state therapy was my best tool for healing trauma. I would direct clients to compare their present-day safe selves with their past stuck-in-danger selves, and to rescue the endangered younger selves. After I learned EMDR, I continued to interweave ego state interventions with the new therapy. I, and many others, found that the more dissociation a client had, the more necessary ego state interventions were for both preparation and interventions. With some unstable clients, straight-forward ego state interventions are still the treatment of choice.

In 1988, I started working with my first client with dissociative identity disorder (DID). She had been ritually abused and had at least thirty parts, many of which had no awareness of each other, or the present day. I read every book, took every local training, and started spending more on clinical consultation than I ever collected from that client. Learning how to work with her dissociation informed my ego state work with everyone else. I began to see the “parts” in borderline personality disorder and other attachment-challenged clients. I became more adept at getting all clients to talk to their parts. And, of course, I learned just how brilliantly complicated work with a DID client could be.

In 2006, when van der Hart, Nijenhuis, and Steele’s The Haunted Self, was published, I got a lovely roadmap for perceiving and healing trauma and dissociation. A more accessible book, Treating Trauma-Related Dissociation, by Steele, Boon, and van der Hart, came out in 2017, and is now the bible for working with DID clients.

I’m grateful to be providing this work to therapists in Greece. Ego state therapy can be of use to nearly every client. Seeing and treating people through the “parts” lens is often transformational. Intractable problems can melt away when therapists see the stuck child parts in the dysfunctional adult. I hope you find this work as useful as I have.

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!

Differentiation and Integration in The Big Sick, Fun Home, and Trumpet

    In the last three days I've had the pleasure of watching the fabulous movie, The Big Sick, the incredible musical Fun Home, and reading Trumpet, A Novel. All three are great art. The first two are based on the writers' lives. All are about "coming out", or not, to one's self and one's family and culture. All show how how when people hide who they are, they are separated from the people around them and have internal parts that are dissociated from each other.

    In Big Sick, Kumail Nanjiani (who plays himself) is a Pakistani-American in love with a white, non-Muslim woman, who cannot show his parents who he is and who he loves. In Fun Home, Alison Bechdel does come out to herself and her parents. Her father, a closeted gay man, commits suicide rather than being fully known in his small town. Jackie Kay's Trumpet, is a novel about the fallout surrounding a married transgender man's outing upon death and it's effects on a variety of characters, in and outside the family. 

We all have ego states. We may have a different persona in a work situation, at home, hanging with our best friend, or dealing with an emergency.  Unless we are highly dissociated, we can move smoothly between "parts" and roles, bringing up the most germane set of skills for each situation. When we are not "acceptable" as we are, we may hide that part, even from ourself. We may repress it, or simply develop a separate persona in a separate arena--the secretive gay bars and "tea rooms" of the past, the hidden online communities for any "kink" you can imagine, of the present.  

When we accept who we are and what we are, and can be that person, we can be whole, but the process is not easy. Telling the family that we are not practicing the religion, the gender role, the choice of partner, the expected occupation can bring us disapproval (at the least), ostracism, and in some cultures, death. Even if it's "mere" disapproval, it's difficult. We are wired to please those people, to belong, and to be protected by the family. We define ourselves by how we are seen and treated. Going against that by choosing differentiation (being who and what you are even if people don't agree or approve) is scary and can bring up big shame. Not doing that, kills the possibility of true intimacy: being known. And it may separate us from ourselves.

In Big Sick, we get to see Kumail, after being accepted by another family, be able to "come out" as secular and in love with a blonde. In Fun Home, Alison goes to college, falls in love, and is able to accept herself and tell her family. Later in life, she creates a (wonderful) graphic novel about her coming out, and the tragic end of her father, who never could. In the musical, Alison as a child, a college student, and an adult sing together, bringing all parts together for a perfect integration, that brought down the house.

After 25 years of marriage and 36 years of doing therapy, I can speak to the importance of self-acceptance and true intimacy to my life and my relationship. As a bisexual person, a Jew in a Christian country, and not-very-gender conforming person, I can speak to the importance of being out and known, even when I'm not accepted. I am known by the people who want to know me. I am self-accepting (knowing that I can always improve). My husband and I strive for openness, even when the other one doesn't adore or agree with an opinion or aspect of us. 

As a therapist, it's my job to help people accept all of themselves, heal what can be healed, and bring all parts to eventual integration or integrity.

 

 

    

Healing MCS and Graft vs. Host Disease

MULTIPLE CHEMICAL SENSITIVITY CASE

On Friday and Saturday I gave a workshop about combining EMDR and Ego State Therapy. At the workshop, I did a demonstration with an attendee who was 8 months out from a horrible allergic reaction to crab meat. Since then she's had daily hives, breathing issues, and has had a very limited vegan diet.  She reacted to meat and fish,wine, air-borne odors and chemicals, and substances she can't identify.  We used EMDR to clear the first huge horrible reaction from 8 months ago. Then I asked her to imagine the control room of her immune system in her brain, and asked her who was in there running it. "A big burly guy named Bruce." I told her to put on her CEO business suit and persona, march into that control room and tell him to Stand Down, aim the immune system only at bacteria and viruses and stop being so over-protective. She immediately started to feel better. We imagined that if "Bruce" began to over-perform that she could tell him to "Stand Down" again.

The next day, she told the group that she'd felt much better, had had to tell Bruce to calm it down about 4 times and that she was no longer reactive. She'd had a glass of wine for the first time in 8 months. Last night I saw her eat her first fish in months, with no reaction. And she was having none of her life-long allergy to cats, at least not to my cat.

GRAFT VS. HOST DISEASE

About 15 years ago, I invented the above protocol when my friend Elizabeth and I were practicing on each other at a training. Over a year ago Elizabeth contracted a horrible leukemia and spent months in the hospital awaiting a good match for a stem-cell transplant. Finally, the cells arrived from Europe and the transplant was done. Elizabeth then developed Graft vs. Host disease: the new cells attacked her body and started to kill her. (GVHD has a 50% mortality rate.) The doctors gave her steroids and other drugs to knock back the immune response, but they didn't stop it and Elizabeth got sicker and sicker. She called me to the hospital. In two sessions we used the same kind of ego-state work, with nearly continuous bilateral stimulation, that we had done years ago for her MCS.

I asked her to personify her new immune system--it was a scared little boy. "Too bad you don't know what to do with anxious kids," I said to the wonderful mom and amazing child therapist."I'm holding him and telling him he's safe, he's with me, and he doesn't have to attack anything."    After a while she reported he had calmed down.

Me: "Tell him you're going on a tour of the body and you'll show him what's safe and what he needs to protect you from."

And we went through the list of bodily organs and places, while he was safely held." Elizabeth was exhausted after about 30 minutes of processing. When I checked in with her a few days later she had more energy and she said the little boy was chasing butterflies in a field and much happier, and she was much better.

The next week, she called me again. The "attack" was more localized: just to her digestive tract. And there were many boys.When I got to the hospital, I had Elizabeth round up the boys and announced we would take them on a spelunking tour through the entire "cave" of the digestive system. I turned on the tappers, and we "led" the boys through the "cave" from the throat, through the esophagus, to the stomach and all the way through the twisty-turny intestines. I told Elizabeth "tell the boys that they may not attack the walls of the "cave", or the "good" bacteria bugs that were around. These bugs are needed to help digest the food. You can pet them and play with them, but not hurt them. However, the bad bugs, like e-coli and C-Diff, are fine. You can stomp those bugs to death and have fun doing it." She felt even better, though still tired.

After that she had rapid improvement, but got traumatized by one of the doctors. He had been off that floor for a few weeks. When he saw Elizabeth with color in her face, walking the halls with a bit of vigor he was shocked. "You're still here."

"Yes, but they're going to send me home in a few days." 

"No, but I mean, you're still here."

"What do you mean?"

"People don't survive what was happening to you."

When Elizabeth got out of the hospital, I did a home visit and we cleared her response to that distressing conversation.

She's been home for months and is exercising, driving, able to hold her granddaughter (she couldn't before with depressed immune system.) And the "boys" are behaving in their new body, just as they should.  When she's got more energy, we think we'll write a journal article about GVHD and our work with it.

(I wrote a chapter about Multiple Chemical Sensitivities in EMDR Solutions II: for Depression, etc.)

 

 

 

 

Update and New Workshop

Dear Readers,

(It appears that the many links in this post aren't working. You're going to have to drag and drop into your browser if you want to see anything online. Sorry!)

It's been a busy year since I've posted anything. I blame Facebook and work in many other areas. Since my last book, Easy Ego State Interventions, was published, it and I have been getting a lot of attention, and many invitations to do workshops based on the material. At this point, I'm scheduled for Seattle, Edmonton, Omaha, and Rome. (That Rome!) And people are asking me to speak at conferences next to some of the big names in therapy. 

People and reviewers are telling me that the book is accessible and usable. They read it, and then go into session and are able to use the techniques with their garden variety clients, traumatized people, couples, and DID people. This is what I wanted, and I had to fight my publisher to do it. "It's not long enough!" "It doesn't have research!" "Ego states aren't a 'thing' anymore." (Oh yes they are, a BIG thing!)

I'll be doing a Easy Ego State Interventions Workshop on September 16 & 17, 9 - 4:30 in Seattle. If you'd like to see what the fuss is about, you can sign up at http://emdrsolutions.com/events/ . Or you can download or even buy the book at https://www.amazon.com/Easy-Ego-State-Interventions-Strategies/dp/0393709272 . I did the first workshop, in Ottawa, without EMDRIA credits. This one will give EMDRIA credits to people who do EMDR, and can work very well, and give credits to people who don't know EMDR, if you can stand a little talk about a therapy technique you don't do. I included some case consultation in the workshop, the first go-round, and it worked very well, so I'll be leaving a bit of room for some in this workshop.

The more therapies I learn, the better therapy I do. I'm still enjoying my studies with the CIMBS technique (Complex Integration of Multiple Brain Systems). http://www.complexintegrationmbs.com/ I'm in my third year of training and learning even more how to collaborate with clients to rewire their brains for better attachment, more directedness, less shame, more motivation, and a more positive outlook. Terry Sheldon and Beatriz Winstanley Sheldon have developed an amazing therapy and are teaching it to people in Seattle, Vancouver, and ever more places. I mix their technique with EMDR, Ego State and Somatic therapies, the hypnotic stuff I started with, and more, and am loving this work even more!  And please don't send me new clients. After 35 years in practice, I get way too many referrals and hardly ever can take any new people.

What else am I up to? I'm consulting to a bunch of groups and individuals, mostly EMDR-oriented, in person, and on Skype and phone with people from all over the States and Canada. I think it's the most fun--supporting colleagues to do help their clients. I love watching therapists grow. And in the groups, facilitating the supportive environment that helps that growth to happen. 

I'm still teaching the Washington State mandated Suicide, Assessment and Treatment class. Some people have taken my class two times, or come to mine after taking others. Their feedback is that mine is more user-friendly, practical, and, somehow, more fun. I enjoy doing it, and try to tailor each class to the special client populations of the participants. (That's easier when there's 20 people, harder when there's 60.) The next one is in Seattle on October first: http://wacoalition.org/suicide_prev_wkshp.html  

People are asking me about another book, but I'm not feeling one asking to be written. I'd like to get back to this blog and to write only when I feel like it. Every book, becomes "that #$%&ing book", near the end. I want to stick to the short form, before I put my schedule and my body through the contortions of writing a fifth book.

I hope you all are having a great summer! 

Expect posts!

Robin

 

 

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

Using Brainspotting to Resource Positive States

David Grand's Brainspotting is a powerful technique for clearing trauma and strengthening internal resources. It started as an offshoot of EMDR and has become, through the innovations of Grand and Lisa Schwartz, its own effective therapy. Here are two ways I've been using it for resourcing.

1. With fragile, dissociated, stressed, and deeply anxious or depressed clients. I use the Brainspotting "Inside Window" technique to find the "Resource Spot" (this is straight out of the training): I have clients scan their bodies for a place that's grounded, strong, relaxed, connected. We check to see if the place and the feeling are stronger while looking through the right or the left eye; while looking up, down, or straight out; and to the right, left, or straight ahead. When they find their "Spot", I turn on the tappers (Grand and Schwartz use bilateral music) until the feeling is strong. My twist on this technique is to have clients imagine finding the spot when they're stressed or anxious during the week. (Except when driving!). It creates a nice state shift, though not the clearing that is possible with application of the full Brainspotting Protocol.

2. Throughout the years, I've had several clients who report a time in their childhood (often after a move or a divorce or the introduction of a nasty step-parent) when they lost the happy, connected kid, they used to be. I've used several techniques to access the old, happy, state. Yesterday, I used Brainspotting and Ego State work to quickly access and integrate that old state. I asked, "What was that kid like, before the move?"  Client: "Playful, loving, adventurous, caring, sweet. Normal." ""When you think of her, what do you feel in your body? Where? Cover your right eye, is that feeling stronger? It's gone. Cover the other eye. There it is! Stronger looking up, down, or straight on? Up. Right, left, or middle? Middle. (Applied continual bilateral theratappers while we strengthened the sense of that kid, connected with some of her favorite things back then, connected with things the kid part would like about the current, modern life (martial arts, kids, and more), and I asked the client if it was time to bring the sense of that child up to now. "So reach back into the past, and when that kid grabs your hand, pull her up to here and now. . . Is she sitting on you or next to you?  Put your arm around her. How is she doing? Happy and calm. Great, is it time to hug her inside of you? Yes! When the child was inside, we thought of ways the client could access the playfulness, strong sense of self, and adventurouness during a typical week, and imagined that during continual bilateral stimulation.  

If you are interested in Brainspotting, David Grand and Lisa Schwarz have some great trainings coming up. I'll be doing a one-day intro class on January 22, in Seattle. If you want the real deal, with the latest innovations, learn from the masters at http://www.brainspotting.pro/trainings.

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.

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. 

  

Trauma Treatment Handbook: Protocols Across the Spectrum

My copy of the new book arrived today. Here is what Diana Fosha says about it:

"This is a thorough, accessible, and very practical book, filled with resources and sound ideas, filtered through the intelligence and experience of a savvy, compassionate, down-to-earth, and very experienced clinician. It is like a travel guide to the land of trauma and trauma treatment: if you are new to it, it will orient you to all there is to do and see; if you're a frequent traveler, it is a worthwhile reminder of all that is out there, above and beyond the familiar places you always visit. Once could ask for a better guide. I highly recommend it."

I explain trauma, complex trauma, dissociation and how to assess them and prepare for treatment, and all the kinds of treatment that I know about from the main-stream to the obscure. I talk about working with military, sexually-abused, and relationally traumatized people, and how to take care of yourself while doing the work.

 Some of my heroes comment on it. Dan Siegel wrote the introduction, despite my lack of research. Diana Fosha, Stephen Porges, Kathy Steele, and Onno van der Hart wrote very nice blurbs on the back. I'm humbled by their support.

This is the first book written completely by me. I'm amazed to be responsible for synthesizing so many people's therapies in one book. The design is great, and the photos, by Doug Plummer (my beloved) are gorgeous.

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.

Lessons Learned While Writing A Book for Psychotherapists

I'm 13 chapters into writing Trauma Treatments Handbook, Across the Spectrum. Here's the advice I'd give anyone doing the same thing:

• Get a second screen for your computer. Keep the reference page, internet search materials, etc. open on the second screen. It will save you days of searching for the right open file.
• Start the reference list on the first day of writing. Write the reference first, then refer to it in the text. Do it on a separate page.
• Figure out who you're writing for and address the book to them. I have a range of imaginary readers, from clueless, but bright, grad students to informed therapists. I try to keep it simple enough for the students and entertaining and interesting for the rest.
• Use your own voice and use active voice. It's hard to read academese. Don't try to impress anyone with how much you know. It's not the point. Make it accessible.

• Don't worry about people hating it. Some will. I'm writing a book that will piss off every true believer, by showing the usefulness of every trauma technique that I know about, and by talking about the shortcomings, too.

• Take some time to only write. I just took two weeks off, writing about 5 hours a day. I was able to hold all the chapters in my mind and let the obsession take over me: waking at 3 and 5 a.m. to scribble notes. Up at 6:30 with my brain ready to go, moving things from one chapter to another. I finished 4 chapters, including one very long one. My brain needed time to nail the structure of the book.

• Make a list of acronyms to put at the end of the book. I've wanted every therapy book to have them. Put them on the list the minute they pop up in the text. I'm up to 3 full, double-spaced, pages of acronyms and 9 pages of references, so far.

• Talk over difficulties with anyone who is around. Everytime I began to tell my husband about a quandry, it solved itself before I was done explaining it.

• Use the thesarus on dictionary.com

• Read many sources.

• Share milestones with your friends, virtual or in person. Let your publisher know too. They worry about books not being on time.

• If you don't know something that you want to include, ask everyone. I still don't know where Kluft said, "The first integration, isn't." Do you? Or was it Kluft?

• Enjoy the process of writing. Let the "alter" that writes take over and type. It's easier than torturing yourself over every word.

• Don't fall in love with your words. Reread. Edit. Reread. Edit. Reread. Edit. But don't worry. Your brain knows. Trust it. And trust that there will be mistakes in y our book. Despite you, your professional copy-editor and your friends.

• Back up everything to an external hard drive, every day. Every done chapter, send an email with attachments of all chapters to a few friends who don't live in your town and ask them to put the attachments on their hard drive. If you have gmail, as I do, you can send the attachments to yourself and they'll live in the gmail "cloud" of servers. Losing a book is a terrible thing. BACK IT UP!

• Exercise, get massage, socialize. You live in a body with needs. Take care of yourself.

• A book is a great excuse to neglect your blog. Sorry everyone!

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.

"Now Go Inside. . ."

David Calof has been one of my mentors for many years. He constantly asks clients to "Go inside" and find the answers to almost any question. I did three sessions today that included this powerful technique, all to grand avail:

1. "Go inside and find the answer to 'Am I lovable as I am?' The answer is no? Who believes that? She's 4 and all alone and no one is there. Does she think she's alone because she's unlovable? What does your grownup part need to tell her about her parents' capacities to be there for a kid? So it wasn't because of her lovability? Are you holding her? Does she feel lovable now? So what's the answer to 'Am I lovable as I am?'       Fantastic!"

2. "Go inside and find the part that doesn't believe it's okay to put yourself in the equation or take care of your needs, too. What do you need to say to that kid? Oh, he's telling you off! He wants you to start taking care of him first. How are you going to do that?"

3. "Go inside and get in touch with the writer. What's stopping her from giving you that 'dictation' that lets you write? Too many things on your plate. What needs to fall off the plate before you start writing again? Will you do that? By when? How's your writer now? Revving up? Cool!"