Looking Through The Eyes Bainbridge Institute for Integrative Psychology 9054 Battle Point Dr NE Bainbridge Island WA 98110 Telephone Consultation: (206) 855-1133 [email protected]www.bainbridgepsychology.com EMDR & ego state therapy across the dissociative continuum With Sandra L. Paulsen PhD
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Looking
Through
The Eyes
Bainbridge Institute for Integrative Psychology 9054 Battle Point Dr NE Bainbridge Island WA 98110
A Assessment. Assess degree of dissociation, degree of rapport, terms of treatment, accessibility of system, differential diagnosis, degree of inner conflict or red flags, readiness of mapping (to degree appropriate), degree of cooperation and consent to proceed, commitment to healing journey, presence of inner resource, psychodynamics as revealed by behavior, defense mechanisms (on-going throughout). Also assesses degree to which client can access somatic sensation and tolerate affect. CORRESPONDS TO AND EXPANDS ON SHAPIRO STEP 1 – CLIENT
HISTORY & TREATMENT PLANNING. EMDR/BLS? No Somatic: Social Resourcing and assess if ―wires hooked up‖
C Containment & Stabilization. Survival issues, inner safe place, developmental needs meeting, mediation, planning, resource building and ego strengthening, crisis management, establishing
internal conference room, putting in place imaginal resources. CORRESP0NDS TO AND EXPANDS ON SHAPIRO STEP TWO – PREPARATION. EMDR or BLS? Rare BLS for crisis intervention, not without risks. Use safer methods such as
hypnosis or somatic resourcing, somatic tracking,
T Trauma Accessing & Titration. Balancing need to know via continued mapping and interviewing of
trauma history, against need to avoid flooding and destabilization, collaboration with helper alters, fractionation planning. Establishing and practicing methods to keep arousal levels in the optimal midrange between numbing and hyperarousal. Those methods and information to be used in next phase. See ARCHITECTS. CORRESPONDS TO AND EXPANDS ON SHAPIRO STEP TWO AND THREE – PREPARATION AND ASSESSMENT EMDR or BLS? Not for DID, use hypnosis, Dissociative Table, titration/pendulation,
A Abreactive Synthesis. Dissociative protocol for EMDR, fractionated abreaction, titrating affect. Ensuring each abreactive session begins with safe place and attains complete successful closure with containment and soothing. CORRESPONDS TO SHAPIRO STEP FOUR – DESENSITIZATION THROUGH EIGHT REEVALUATION – CLASSIC EMDR BUT INVOLVES PHASE OF TREATMENT, NOT A SINGLE SESSION. See "ARCHITECTS" Phases of Trauma Processing for details of single session
EMDR for dissociative clients.
EMDR or BLS? Yes for DID when system consents and is ready, may use somatic micromovements and hypnotic interweaves, dissociative table interweaves
S Skills Building. Assessing and remediating skills deficits that haven’t already been addressed, various resource strengthening or other means, including: relationship skills building, time
management, problem solving, communications skills, assertion, project management, parenting, other. CORRESPONDS TO STEP 8 – REEVALUATION OF EMDR, BUT REFERS TO AN ENTIRE PHASE OF TREATMENT, NOT A SINGLE SESSION. EMDR or BLS? Yes, using performance enhancement model, relationship skills generalization.
I
Integration of Identity. Discussions with alters about identity of parts, negotiation for ongoing self, whicH parts will be absorbed, how they always live on, fusion ritual if needed. DOES NOT CORRESPOND TO A SHAPIRO STEP OF EMDR. EMDR or BLS? Yes, also somatic pendulation, tracing figure eight to integration
F Future Templates & Follow Up. Future templates and visioning using performance enhancement protocol, preparation for the rest of life, going forward without dissociation, generalizing skills into future, other remaining issues. NO EXPLICIT CORRELATION TO SHAPIRO STEPS BUT IS REMINISCENT OF STEP 8 – REEVALUATION OF A SINGLE EMDR SESSION. EMDR/BLS? Yes, future template, performance enhancement protocol
Fractionate abreaction Access deep levels of psychic structure
Titrate affect Enable internal negotiations and mediations Conduct ego strengthening activities and build resources Apply distancing and containing maneuvers, Implement a wide range of Ericksonian metaphors Enabling some parts to be in preconscious mind and others in conscious mind as part of learning and
preparation Seed meta-cognitions of healing and wholeness, and of slow progress over time Ameliorate attachment deficits Containing partially resolved or unresolved affect until a later time
EGO STATE THERAPY FOR DDNOS
Safety, stabilization, titration of affect, containment and closure procedures are key.
Because there is no true amnesia and dissociative barriers are less complete, it is easier to do dissociative
table with DDNOS and the ego state disorders.
To the degree that more than one part of self is simultaneously at the table (in conscious mind), and the
therapist can mediate discussion between parts of self, integration is facilitated.
No true switching occurs, though the work may pull forward different parts of the self. The therapist can
readily draw attention simultaneously to other related aspects of self.
Empathy, appreciation for the other parts of self are significant movements toward growth.
Closure and ―tucking in‖ are important though there is less likelihood of cascading affect.
EGO STATE THERAPY FOR DID
Safety, stabilization, titration of affect, containment and closure procedures are vital to outcome.
There is true amnesia and dissociative barriers are complete, more between some parts than others.
Switching may be inevitable, but most clients can learn to do dissociative table.
The client’s preference to deny that other parts of self are in the same body may cause the therapist to
work primarily with only one part, or one part at a time.
All parts work should refer to the totality of self, and that each part is a part of that self. This information
may not be well received initially, but parts that seem delusion are educable.
The use of accepting language and the inevitability of having created parts will reduce resistance.
EMDR should only be attempted after stabilization/containment is achieved, and used judiciously.
In Abreactive Synthesis Phase, Assess: THERAPIST READINESS CHECKLIST
You know your skill is approaching a level of readiness to do EMDR for a DID client when you know what
these mean and how to do them. Specific language for how to do these things is covered in ISSD
workshops, or "Looking Through the Eyes" workshop or other sources:
Enriched understanding of "dissociation"
Differential diagnosis DID, DDNOS, etc.
Screening & Assessment: DES, SCID-D, DDIS, strengths and weaknesses
Establish rapport with perpetrator or angry protective alters
Don't get rid of parts, give them better jobs
Containment Imagery including "tucking in" (Inobe)
Spontaneous integration, as well as timing on removing dissociative barriers and how to reinstate
if they come down too early, before trauma is neutralized
Educate disoriented ego states, including being in the same body
Build resources (Leeds) and expectations, including use of metaphors, imagery
The cautious use of bilateral stimulation in crisis intervention, to return to baseline, not to
uncover
Planning an EMDR session
Ego-invested or "looking through the eyes" (Inobe)
EMDR Informed Consent in language suitable for child alters
Planning an EMDR - which part will be the "star"
Which will be out of awareness (fluffy white cloud)
Which will observe or assist (ego strengthening)
Counteracting negative therapy expectations "planting a seed"
Meta-installations (Inobe) re: affect tolerance, healing and wholeness, attachment
Understanding of double-binds and their associated negative cognition pairs such as, ―It’s all my
fault‖ and ―I have no control.‖
Timing of trauma work
SARI model (Phillips & Frederick)
Handling of mute parts, headaches
Emergency procedures
In Abreactive Synthesis Phase, Assess: CLIENT READINESS CHECKLIST
Before EMDR trauma work, the client should be ready, as demonstrated answers to these:
Is the client safe?
Is the client environmentally stable?
Have cutting and other problem behaviors been explained by relevant systems parts, and
Discontinued/stabilized?
Has the client learned safe place imagery, and self soothing?
Are perpetrator introjects oriented to present time, place and person at least at times?
Is the client’s self system willing to use containment procedures between sessions?
Has the client sufficient ego strength to tolerate intense affect, abreactions?
Do older/stronger parts of the system agree to help when needed for frail child parts?
Does a sufficiency of the client’s system understand EMDR and trauma work?
Are angry/protective alters on board with the plan to process trauma?
Do you have consent of a sufficiency of the system?
Will the host leave and allow another part to help the system, if needed?
Do key parts understand they are in the same body, this is present time, and agree to work for
healing and wholeness of entire self?
Does the client know emergency procedures?
Is the client able and willing to use imagery to titrate affect? For EMDR procedure see Paulsen, S. (1995) Eye Movement Desensitization and Reprocessing: Its
cautious use in the dissociative disorders. Dissociation, 8, 32-44 at www.paulsenconsulting.com
See also appendix to Shapiro 2001 book for Task Force Report: red flags contraindicating EMDR.
In Abreactive/Synthesis Phase, to Structure an EMDR Session: ARCHITECTS
The following assumes all the preparatory phases of ACT-AS-IF were completed in prior sessions, that
therapist and client readiness has been assessed and found to be adequate for trauma processing to
begin. There will be more than one fractionated session for a given traumatic memory for a DID client.
The ARCHITECTS process is conducted in one or more EMDR sessions and corresponds to Shapiro’s EMDR
Steps 3 – Assessment through 8 –Reevaluation.
ACCESS Access self system using DT, if tolerated, or as presented. With “Refine” below, corresponds to Shapiro Step 3 – Assessment. .
REFINE. Refine pre-selected target according to what presents itself in the dynamics of the conference room.
Material may select you. Usually go with that BASK material that is most prominent. With “Access” above, corresponds to Shapiro Step 3 – Assessment.
CONSENT Obtain final consent from sufficiency of self system, reaffirming supportive roles, having previously used BLS to ego strengthen and secure adaptive roles for other alters. Remind part doing processing how closure and containment will be necessary on their part whether finished or not. Corresponds to Shapiro Step 2 – Preparation.
HYPNOSIS or IMAGERY. Use trance, imagery, e.g., dissociative table, to supply any needed resources, ego strengthening, affect titration methods. Corresponds to Shapiro Step 2 – Preparation.
TITRATE. Access traumatized neural net, keeping optimal arousal level between over-aroused (flashback) and numbed (make sure salient part is ―looking through the eyes,‖ i.e., is egotized). Use imagery, established fractionation method, distancing methods, resource teams. Corresponds to Shapiro Step 4 – Desensitization.
EMDR/BLS Initiate bilateral stimulation, with problem solving as needed, via: titrating affect, stopping and negotiating with emerging alters, mediating internal dynamics if needed, offering reframes appropriate to age of parts of self. Corresponds to Shapiro Step 4 – Desensitization.
CLOSURE. Stop appropriately, quitting while ahead, whether get to a resolution or not, with enough time to close. Close BASK by containing incompletely processed BASK elements using imagery. Close self system. Soothe and contain participating alters, providing resources they need via imagery, light stream, or other pre-established
conditioned response language, to close session. Corresponds to Step 7 – Closure. Step 6, Body Scan, is omitted.
TRANQUILITY TECHNOLOGY. Ensure that any residual processing can be soothed or contained via: telephone call, relaxation tape, butterfly hug, or other self-soothing procedures. Corresponds to Step 7 – Closure.
STABILIZE, SYNTHESIZE, SOOTHE. Based on patient’s state at next visit, synthesize or consolidate gains via talking, imagery or BLS. If patient feels raw, use soothing, slow down pace of abreactive work as much as needed. If patient not raw, continue processing next piece or BASK element if appropriate. Pace the work to maintain patients efficacy an d stabilization. Corresponds to Shapiro Step 8 – Reevaluation. Assumes may not do more EMDR immediately if patient feels “raw” to not overwhelm system.
NEGATIVE COGNITIONS & DOUBLE BINDS
DID (and to a lesser degree, any ego state disorder or other inner conflict) is all about inescapable dilemnas. Ego state therapy within EMDR enables us to give a voice to each aspect of an inner double bind, enable an integrated appreciation of the contribution of each side of the conflict. Further, ego state therapy enables the client to simultaneously view the impossibility of resolving the double bind, and permits a reframe of the dissociation of the binding elements as the only solution. This appreciation, in combination with strategically chosen cognitive
interweaves, enables parts of self to get unstuck and move on to a more adaptive resolution. DID's double-binds are
profoundly debilitating and apparently inescapable, to the severity, chronicity and inescapability of their trauma, and the developmental arrests that resulted. Example of such a paradox: "I am responsible for the abuse" vs "I am not responsible for my own behavior." "I deserve punishment" vs "Why is this happening to me?" The following cognitive
errors are nearly direct quotes from those offered by Colin Ross, MD, in his seminal contribution Dissociative Identity Disorder: Diagnosis, Clinical Features and Treatment of Multiple Personality. New York: Wiley. 2nd Edition, 1997 and
appear with permission. The core beliefs of the DID patient may be stated as erroneous syllogisms or logical propositions. The propositions, as in depression and like double binds, often begin with a moral injunction that illustrates one of the classical cognitive errors such as all-or-nothing thinking, personalization, or overgeneralization. An example (not specific to DID) is: [Good children should love their parents/ I don't love my parents/I am bad/I deserve to be punished].
EMDR IMPLICATIONS OF DOUBLE BINDS
The following examples of core assumptions can guide selection of negative cognitions for DID clients.
They can also be helpful in resolving looping in EMDR across the dissociative continuum. EMDR looping
occurs when the part of the self that would naturally come up next in the processing is disowned by the
client, or kept out of mind. In dissociative disorders, this reliably occurs when two mutually exclusive
beliefs (e.g., a double bind) would need to be processed for resolution, insight or integration. Ego state
therapy gives a voice to each side of a conflict in turn to enable resolution. Once a disowned part of self
has been given a voice, EMDR can often be resumed as with any other cognitive interweave. This devices
is useful with non-DID as well as DID clients.
CORE ASSUMPTIONS IN DID
Colin Ross MD
Different parts of the self are separate selves. We have different bodies. I could kill (or slash or burn or overdose) her and
be unaffected myself.
Her behavior is not my responsibility. The abuse never happened to me. They are not my parents. (Those are not my feelings — Paulsen)
The main personality can’t handle memories.
We have to keep the memories.
You can’t tell her about us.
If she has to remember, we will make her crazy.
If she remembers, she won’t like us.
The abuse never happened.
They must be sick to think those things happened.
My parents are not like that.
She is weak; I am strong. The victim is responsible for the abuse. I must be bad otherwise it wouldn’t have happened. If I had been perfect, it wouldn’t have happened. She deserves to be punished for it.
I’ve been abused so much I might as well be promiscuous.
She deserves to die and I might as well die too. If my parents loved me, it wouldn’t have happened. I deserved to be punished for it.
I love my parents, but she hates them. She is the bad one. You have to get rid of her. Nobody could ever be friends with her (or like her)
She wants to hurt me.
It is wrong to show anger (or frustration,
defiance, a critical attitude)
When I showed anger, I was abused.
If I never show anger, I will not be abused.
I deserve to be punished for being angry.
If I were perfect, I would not get angry.
I never feel anger–she is the angry one.
She deserves to be punished for allowing the
abuse to happen.
She deserves to be punished for showing anger.
The primary personality must be punished. It's her fault the abuse happened. She deserves all the bad things that happen to her.
Everything bad that happens to her happens because she is bad.
She has suffered enough – she would be better off dead. I can punish her and be unaffected myself.
I (the punishing alter) was never abused. Nobody would ever want to be close to me I am unlovable.
Paulsen (2006) observes that dissociative clients have states embodying and identifying with these states
(ventral vagal, sympathetic arousal and dorsal vagal). A person emerging out of dorsal vagal shutdown
can manifest high levels of sympathetic arousal. Affect tolerance and ego investedness in maintaining the
status quo can interfere with forward movement, necessitating ego state therapy interventions.
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CONSULTATION Sandra provides consultation by phone or in person and is a certified EMDRIA consultant.. To schedule, go to www.bainbridgepsychology.com and click on “schedule now” button for online scheduling. If you have trouble finding a spot, contact Sandra at 206 855-1133. Thank you.