Trauma & Attachment Therapy

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!

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.

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.

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!

Trauma Lecture

I'll be giving a lecture about trauma, PTSD, Structural Dissociation, the Polyvagal theory and the use of EMDR to impact PTSD on Saturday morning, May 17 from 9:30 to 12. Frank Kokorowsk will copresent with a dynamite multi-modal trauma treatment that he's been using with homeless people. There are 2 CE's for everyone and it's sponsored by the WA State Coalition of Mental Health Professionals and Consumers our main advocacy group with the legislature.

Register at [email protected] (email your name and phone).

or go to wacoatlition.org for the website

May 17, 9:30 -12 Good Shepherd Center 4649 Sunnyside N, Seattle

Obsessive-Compulsive Personality Disorder

We all know what Obsessive-Compulsive Disorder (OCD) looks like: repetitive rituals, obsessive thoughts, and the people who are thinking or doing the compulsive thinking or behavior and know that they're not being rational. Obsessive-Compulsive Personality Order (OCPD) is something else. People with OCPD are detail oriented, to the exclusion of the big picture. They are obsessed by control. They may get involved with organizational details, the minutiae of tasks, or tasks that have very little to do with what most needs to be completed in their jobs, their studies, their homes, and in their lives. Many OCPD folks are prone to angry outbursts when their environments, kids, or coworkers don't go with the program. They may be very nice, but they're not usually capable of intimacy.They are the nightmare managers from hell. They often don't keep or rise very far in employment. though they work half again as many hours as any other employee. And nothing is ever right with anything. Expect depression, anxiety, and either massive pollyannish denial or massive criticism of everything, including you.

Avoidance of anxiety is their not-conscious organizing principal. Here's how it works: If I need to get the big job done, and I feel anxiety when I think about the big job, I'll bring my attention to this little task that's not so scary and I'll do it perfectly, for hours. Working on the little task makes me feel better. (Dan Goleman's book Vital Lies, Simple Truths: the Psychology of Self-Deception descibes the biology of this phenomenom.) When I take my attention away from that which makes me anxious, the pharmacy in my brain gives me really good drugs. This is why procrastination and self-distraction are so popular. If I don't work on the scary task, I'll feel better, instantly. If I keep doing the intricately complex avoidance behavior, my brain keeps giving me good endorphins. If I've been self-medicating since childhood, by focusing on unimportant tasks, instead of anxious or checked-out or angry or controlling or absent mom and my own loneliness, I'm going to build a big neural net of reflexive avoidance/distraction behavior.

In my opinion, here's the etiology: First, there's a mom, who for some reason can't connect well with her child. Non-connecting moms, be they passive or screaming, are frightening to kids. If a kid learns to distract him or herself by focussing on little tasks, she can dissociate/self-medicate away the terror of being all along and taking care of him or herself. What he or she doesn't learn is the non-dissociative self-soothing techniques that arise from the attachment dance of connection, backing off a bit, and reconnection. So the child's only self-regulation comes from distraction/dissociation.

How do you treat these people? Mostly, they don't come to therapy, and you won't get the chance. Good therapy is the opposite of avoidance, the pathology keeps them away. However, once in a while, someone gets "drug in" by their spouse, or employer, or even their own miserableness and the work begins.

They will try to control the session and keep you focused on the unimportant details. Don't let it happen. Get more assertive than you usually are, or you and your client will unhappily spin your wheels for months. Since I start most clients off with Maureen Kitchur's genogram-based intake with its predetermined list of "nosy, snoopy questions", (EMDR Solutions) I'm able to keep the initial sessions on task, and then share what I think much of the therapy will be. Then work on four things:

1. Staying on Task in the sessions: Make and keep a strong alliance. Show your compassion and your grit. When they change the subject to some small distress of the day, say "Oh that's so upsetting when that happens! Let's go back and get the underlying material, so this won't have to be so distressing later on."

2. Work on Affect Tolerance and Self-Soothing: Tell them we'll start with one-pound hand weights and work up to the big feeling. Teach them containerizing of emotions, mindfullness techniques, relaxation, and containing their own inner babies. (April Steele's Imaginal Nurturing is wonderful for this, as are many kinds of ego-state work.)

3. Use EMDR or Brainspotting or whatever you have that works to target the early childhood relationship with the caregivers. "Imagine looking into your mother's eyes when you were an infant. What do you notice in your body right now, as you imagine your mom?" Clear whatever comes up. Go through all the ages until there's no distress.

4. Finally, target the avoided things. I adore Jim Knipe's Level of Urge to Avoid in EMDR Solutions. Knipe would ask these clients, "How good on a scale of 1-10 would it feel to completely avoid that big project by focusing on sorting out your sock drawer?" "Where do you feel that feeling in your body?"  "Stay with it." While applying a bilateral stimulation. Often the "inappropriate positive affect" (the endorphins) go down by itself and the clients are left with the somewhat appropriate feeling of dread about what they've been avoiding. Then target the dread about the project, clear it, and have them imagine doing the damn thing, step by small step. And then imagine what having it finished would feel like. Aahhhhhh.   If the inappropriate affect doesn't go down by itself, I often two-hand it. (Also in Solutions.)  "In one hand, hold how good it will feel to continue avoiding the project. In the other, hold the consequences for not doing it." Apply bilateral stimulation, and your clients are very likely to feel their discomfort and then be directable to clear it.

I won't kid you. These people need a long therapy. They've been reinforcing avoidance in themselves since babyhood and you and they have a lot of neural networks to rewire. And it's possible, with a good alliance and good attachment and affect work to create clients who can choose avoidance (vacations, breaks, movies, Spider Solitaire) and relationships and getting their real work done, over reflexive busy work, blowups, inadequacy, and loneliness.

Resistance

I don't believe in resistance. When my consultees talk about their clients' "resistance", I immediately stop them and have them discuss what the client is doing to "resist". I believe in fear. I believe in reflexive avoidance of that which makes us uncomfortable or retraumatized. If my client "resists" my suggestion it's either because I'm pushing too hard, or she doesn't understand the request.

Structural dissociation (See the 2 "Haunted Self" posts, from June), describes how trauma or bad attachment can create an Apparently Normal Part (ANP) and an Emotional (or trauma-feeling) Part (EP). One of the functions of the ANP is to avoid any triggering of flashbacks, affect, or cognition of the traumatic event or events. That's not resistance, that's a reflex. It's my job as the therapist to help clients identify these reflexes and gain conscious (ANP) control over whether they choose to "go there" or keep "it" tucked away. I need to provide a therapeutically safe environment, a way for clients to tolerate distressing affect, "containers" for intolerable affect, and knowledge that if something is "too much" that everything stops. With some clients this takes minutes. With others it takes years. At that point the avoidance reflex shifts to a sigh and "let's do it."

Then there's non-resistance resistance. It goes like this: Client and Txist

Cl: I don't want to do anything today. I don't want to be here. I don't want to deal with my stuff!

Tx: Got it. That means you're not crazy. What sane person would want to deal with this stuff?

Cl: Right!

Tx: You willing to do it anyway?

Cl: (whining a little): Okay. . .

Long-Term Clients

I've been in practice since 1981. During that time, I've seen around 1000 clients and in the last decade consulted to other therapists about at least a thousand more. DSM diagnoses are one way to describe clients. Another way is by the length of time they stay in therapy. (Not counting analysands) Here is a list of clients, by length of time spent in therapy.

• Fly-over: never a "customer", leaves after a few sessions because it wasn't his idea to come, or the therapist isn't a fit (lost one because I wore Birkenstocks in the 80's), or she's too scared to stay.
• Questioner: Needs something normalized. "Am I crazy because. . . I'm grieving/I like to have sex the way I like it/I just moved and I don't immediately have new friends, etc." This client needs information about normal human behavior and reassurance that a trained professional finds her/him sane. (Not to be mistaken for a client with underlying issues who tests you with this kind of question.) One session.
• Three-session wonder: The famous (and extremely rare) well-attached car accident victim who clears the trauma in two sessions and comes back to praise you wildly on the third. I've treated about 20 of these in the 14 years that I've been doing EMDR. For them, therapy is penicillin: Take a good dose, and the symptoms go away.
• The Next Developmental Step Client: She's at the cusp of differentiating from her family of origin/partner/workplace and finding out how to be herself. If she's reasonably well attached and reasonably untraumatized, she'll be around from three to eight months. If more traumatized or with an abusive or alcoholic or otherly dysfunctional family and/or attachment issues, you might be seeing her from months to a few years.
• Big "T" Trauma client. She takes some time. If she was raped more than once or injured badly in the accident, or spent too many months in that war zone or horrible work environment, you have months to a few years of work. Best case, you nail the root trauma early (that molestation by the neighbor) then the rape, then work on integrating it all and dealing with her current, hopefully safe, life. Worst case: despite your thorough intake, you keep finding more and more suprise antecedents and the current life stays unsafe and in flux, and you spend three or four years getting her life in order and trauma moved through.
• Horrible attachment, relatively light trauma: Years of finding the baby parts that go into shut down or cling or fight or flight. Years of helping him own the baby and hold the baby and soothe the baby, instead of reflexively disappearing or pushing you away. He de-hunkers. He connects. He finds someone else with whom to connect. He learns self-regulation. He leaves therapy, after checking 6 times that he can return, if necessary.
• Bad chemistry clients. It depends. If she gets on the meds and "feels like myself again" and the good feeling stays, say goodbye and thank your favorite diety.    If he only gets depressed in the summer. You may see him for a year or so, the first go round, and then every time he goes down. You'll remind him to call his medicator person for a medication adjustment, and help him cope with the affects and effects of the bipolar/major-depressive dx/schizo-affective dx. In every round of therapy, you'll help him clear some more trauma and help him reset his thoughts (there's nothing wrong with Cognitive Behavior Therapy, when you need it.). When he's back on the horse, you review what you both learned, and cut him loose until the next round. If he's more chronic, fighting debilitating chemistry with little respite, or rapid cycling, you become insulin. The attachment relationship is paramount. Attachment to you may be thing that keeps this client around. Each interaction raises hope, reregulates your client, gives them an experience of being witnessed and loved. You won't fix him. You will help him cope. If attachment disruption and trauma created the depression, therapy can, finally, nail it. And it will often take years. If it's 95% "bad brain", you need to hold to your presence as the most healing tool you have. Use all your tools: CBT, EMDR, adoring your client, cheerleading ability, and connectivity. Work with them to try yet another med, keep exercising, keep eating well, get to work. Find them the best psychiatrist in town. And settle in for a long-term relationship.
• Severe dissociation with awful attachment and horrible trauma: Settle in for the long haul. You and the therapy are both penicillin and insulin. It may take months or years to make a good, trusted attachment relationship. It may take just about the same years to stabilize your client. Then you can tackle the trauma with some good penicillin (EMDR, Life Span Integration, Brainspotting, etc.) And tackle more trauma, and more trauma, and more. Then you can help her integrate all the changes. It's 10 years later. She's in a good relationship; has a better job; can have sex; and finally can say, "How do I know if I'm done?" She's making her own insulin. She may come back for another dose of penicillin. Maybe more than once. But you did your job.

As a trauma therapist,I get to see my merely traumatized clients move through material quickly. They may go from debilitated to functioning to joy in a few weeks or a few months. These people connect quickly, don't "slap" me, have appreciation, and leave grateful. If I'm working with someone with poor attachment, thus poor affect tolerance, and, often, poor relationship skills, I have to keep my whole job description in mind: The relationship is paramount, the trauma healing can go forward only when the client is ready. It will happen as it can.

I have a huge box of therapeutic tools. I can and will try every one of them. I can seek more tools. And the relationship is paramount. If I'm attached to the client (which I must be), I'll feel his hopelessness and despair. I must metabolize it, and when it's digested, find a way to hold it, without buying into it. As a consultant, I'm constantly helping consultees metabolize their clients' despair. "Yes, it's a long therapy. And you want to take the pain away. And the client is really hard on you. And that's what this kind of client is like."  I normalize. I empathize. I give examples. We work with the countertranference. And we find where the client and therapy are, developmentally, name it, and surmise what the next steps are. As the therapist holds her client, the consultation holds the therapist, offering insulin so that the therapist can metabolize another month of a long therapy. Then we talk about the client again.

Haunted Self II

I don't know where to start with this important, exhaustive description of theory, etiology, description, and treatment of dissociative phenomena. I liked this book a lot. I was frequently frustrated in my reading. Only two other people attended the book group. Neither had finished the book. They found it interesting, and slow going. They had the same issues with the language that I did. One was skimming, one plodding through. I told them both not to miss the treatment chapters, in Part 3. I hope they get that far.

The Haunted Self: Structural Dissociation & the Treatment of Chronic Traumatization by van der Hart, Nijenhuis, and Steele (Norton, 2006) explains every part of every dissociative phenomenom through the lens of Pierre Janet's theories. As I've been in practice for 26 years, and knowingly working with DID for 20, and have had great training and consultation from David Calof and others, there were few descriptions that I didn't recognize. However, van der Hart, et al., gave names to things that I'd seen and not had words for or gave good and cogent explanations for terms I already knew. For instance:

Parallel dissociation (p.66) when parts (Emotional parts/EPs) "simultaneously experience the same moment of a traumatizing event, but may contain different aspects of it."

Sequential dissociation (p.67) when different EPs experience different temporal pieces of the same event.

Emancipation (p. 76) the degree to which a part develops more separation and autonomy from other parts of the personality.

Elaboration (p. 76) "the degree to which a dissociative part develops complexity and scope of the 'ideals and function that constitute personality over time' "(Janet)

Retraction of the field of consciousness  (p.102) "The quantity of stimuli that held in conscious awareness at a given time . . . (ranging) from very wide to retracted, so the individual can be aware of a lot . . . or a little." In other words, when a "fight" EP is up, everything looks like an opponent. During a flashback, everything feels like a bad moment of the past. As an ANP (apparently normal part), there might be understanding and awareness of now and of an experience of back then, a broader field of consciousness.

Personification (p. 153) "the capacity to take personal ownership of our experiences." As in, "this happened to me, I felt it, I did it.'

Presentification  (p. 157) "that complex human endeavor of simultaneously being and acting in the momment in a higly reflective manner." "Being present." ". . . when we synthesize and personify current internal and external stimuli that are critical for our current interests and adapt our (thoughts/feelings) and actions accordingly." (I'm finding these last two words creeping into my consultation explainations when discussing many clients with Axis II, PTSD, and other dissociative symptoms.)

Haunted Self is in 3 sections: "Structural Dissociation of the Personality", "Chronic Traumatization and a Janetian Psychology of Action" and Treatment of Chronically Traumatized Patients. If you are new to the concepts and treatments of dissociation, you could read every word of this book. I did. If you have been treating dissociation and are already using good models, you may want to read the first section, skim the middle the chapter intros, summaries, and topic headings to see if you know it already. Then read every word of the brief third section and the epilogue.

The Treatment chapters are great. They are written more clearly and concretely. They leave almost nothing out. Some chapters contain wonderful lists of nearly every intervention that a therapist would do with a dissociated client or almost any client, for that matter. The authors follow Janet's simple and intelligent treatment goals. Phase 1: Stabilize the client and reduce symptoms; Phase 2: Treat the traumatic memories; Phase 3: Personality integration and rehabilitation.

Chapter 11 has a wonderful list of assessment targets, tools, and how to extract the information without blowing your client out of the water. Aside from these targets and gentle methods of doing the assessment, the authors begin their helpful discussion of the "experience of the therapist" (p 223), which continues throughout most of the treatment chapters. Their discussion goes beyond countertransference to explain what can happen with both client and therapist in dealing with dissociation.

Chapter 12 "Promoting Adaptive Action" discusses treatment in terms of Mental Economy (p.240) " 1. increase income of mental and physical energy; 2. decrease or eliminate unnecessary expenditures of mental energy; 3. reduce and eliminate debts (of) incompleted actions--old feelings, hx, traumas, etc.--that drain mental energy; 4. manage available income (energy) wisely by an increase in mental efficiency (by) investing in more adaptive actions." On pages 253-4, Table 12.1 has a wonderful list of all the skills you want your client to have or develop. These include psychophysical regulation, affect-tolerance and regulation, abilities to symbolize experience, relate to others, accurately perceive reality, manage time, organize oneself and one's environment, pay attention, and solve problems.

Chapter 13, "Overcoming the Phobia of Attachment and Attachment Loss with the Therapist" looks at how we help our clients attach to us, despite wretched attachment histories. It contains another great list, this one on "Interventions to Overcome the Phobia of Attachment" (p. 271) "Phobia" is an oft-used word in this book. It means avoidance. Of memories, emotions, attachment, loss of attachment, parts, being whole, and change.

Chapter 14, "Phase 1, Treatment and Beyond, Overcoming the Phobia of Trauma-Derived Mental Actions" discusses how to deal with fears and avoidance of "what we feel, think, wish, need, and sense." (p. 281). We need to perceive, own, and know that they're internal and may not reflect external reality. Survivors who inhibit these "mental actions", "eliminate an essential source of information that could help them integrate and live their lives more effectively and with greater meaning." Treatment techniques include psychoeducation; use of symbolism; focusing on physical sensations to build affect/body tolerance; use of medication; helping the survivor regulate affect by breathing, and connecting relational and spatially. (p.290). This chapter contains a thorough list of interventions for "Overcoming the Phobia or Trauma-Derived Mental Actions" (fear/avoidance of affect, thoughts, images, wishes, etc.)that I wish I could copy for you all.

Chapter 15 is about "the development of internal empathy and more cooperation among parts of the personality, and more realization each part belongs to a single I."  (p.301)  It contains another comprehensive table of interventions.

Chapter 16 elucidates the treatment of traumatic memory, or Phase 2. It illuminates treatment for different kinds of trauma targets and then gives explains three kinds of Guided Synthesis during which the "therapist guides dissociative parts in a series of experiences win which dissociated aspects of the traumatic memory are evoked and shared. And exposure is conducted such that its intensity and duration are adapted to the survivor's mental level." This includes "gathering all parts together, while the therapist facilitates a strong feeling of connection and empathy among them. . .Then connection with safe present and the therapist, and then a slow introduction for parts to remain together and in the present." It's a lovely step-by-step instructions for synthesis and trauma processing, while holding the "dual attention" of past and present.

Chapter 17, Phase 3 treatment, is the "Integration of Personality and Overcoming the Phobias of Normal Life." It discusses integration of parts and overcoming resistance to the new experiences in boring, normal life: routines, monotony, grieving the past, taking healthy risks, becoming intimate, becoming healthily sexual, and functioning at the highest levels. It talks about the termination of long-term therapy.

As a consultant, I'm often asked, "how long will it take?" Nowhere in this book does it warn therapists that these phases, from the initial assessment to relationship building to creating function and tolerance to clearing trauma and then integration can take several years, in some secondary, and almost every tertiary dissociative clients. I think it ought.

EMDR is mentioned a few times. It's recommended for simple PTSD and carefully in the trauma treatment stage. Joanne Twombly is cited (once from her chapter in EMDR Solutions--the first citation of my book I've actually seen) as is Denise Gelinas.

My advice. Read this book. Skim if you have to. Read every word of the treatment chapters. Swear at the language if you must. If you know it all, you'll be validated and supported. If you didn't know it, you'll be glad that you do now. Then get a great consultant before you tackle tertiary dissociation.

I like looking at the personality disorders and PTSD as dissociative disorders. It makes them much easier to treat, when you can see the rigid "parts" in clients. Even mood disorders can contain parts. In the group, we discussed that ADD, could be extra-mobilized EP states, in some people. I love this model, and the treatment that arises from it. I still wish the book was easier to read.

The Haunted Self I

Our book group selection is The Haunted Self: Structural Dissociation and Treatment of Chronic Traumatization by van der Hart, Nijenhuis and Steele. The authors are all officers in the ISSD, the International Society for Study of Dissociation. ( http://www.isst-d.org/index ) The book is the most exhaustive (and somewhat exhausting) definition and description of what dissociation is and how to treat it.

Years ago, Joanne Twombly introduced me to the writers' concept of dissociation. Here is a simple version. Start with a whole personality the PreTraumatized Personality (PTP). In Primary Dissociation or Simple PTSD, the personality splits into an Apparently Normal Personality, the part that takes care of the activities of daily living: relationships, work, caregiving, play. This ANP doesn't think about the trauma much and may even have forgotten about it. The other side of the split is the Emotional Personality (EP). The EP holds the experience of the trauma. When people are in their EP, they may be experiencing the flashbacks, emotions or cognitions of the traumatic event. They may be activated (mobilized) or shut down (immobilized). The ANP experiences the EP as "not me", an unwanted traumatic experience. So in Primary Dissociation, the PreTraumatic Personality splits into an Apparently Normal Part and an Emotional Part.

In Secondary Dissociation, complex PTSD or Borderline Personality, you have one ANP and more than one EP. The EP's are split into different mobilized or immobilized "action systems": possibly mobilized states that "freeze", "fight", "flee", "cling" or "panic" or immobilized states that "shut down", "submit", "numb", or are in the post-trauma "recuperative" state.

In Tertiary Dissociation, DID or DDNOS, there is more than one ANP (e.g. the worker, the nurturer, the organizer) and several EPs. In this configuration, there is more separation between the parts of personality, which may not be aware of each other. There may be parts that are subsets of ANPs or EPs, such as a flight part that is 2 years old, and one that is a teenager. In DID, the parts may not know that they are part of a whole. They may in fact compete with, fight, or collaborate together.

I use this way of looking at PTSD and dissociation all the time. When I meet a new client, I watch for the state changes between ANP and EP. And I get extremely alert when discussing trauma histories when the switches are dramatic and fragmented.

As an EMDR therapist, I like how the Structural Dissociation model dovetails with Francine Shapiro's Adaptive Information Processing model. The first model describes the split and the second describes how we have the innate capacity to heal that split.

What is it like to read The Haunted Self? It's readable. And it's difficult for me. The authors, two of whom are European, see dissociation and therapy through the lens of Pierre Janet (1859-1947). Janet and his successors use different psychological constructions than I know. The language is different ("action systems" for behavior). I spent a lot of time translating Janetese into American psychological language.

The authors describe every possible subset of dissociation and give names for every possible dissociative state and behavior. In every section I'd have a small "Aha!" when they named a phenomenom that I'd seen, but hadn't named.

Chapter 11, Assessment of the Traumatized Patient, has a wonderful template for intake, leaving nothing out. I'm just starting to read about the treatment of dissociative disorders, I'll get back to you next weekend with that.

I have some complaints. They go on too much. There aren't enough examples. They manage to make an interesting topic dry. As someone who has worked with dissociation for many years, and who has been familiar with the basic concepts of Structural Dissociation, I'm, so far, not learning a lot. Though I haven't found one concept with which to disagree and I have learned some new names for recognizable phenomena.

Next week, I'll tell you what I think about their ideas on the treatment of dissociation, and share with you what the group thinks about this book.