through the eyes - the steve frankel group handout...looking through the eyes bainbridge institute...

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

mailto:[email protected]

3/29/2011

© Copyright 2010 Sandra Paulsen PhD All rights reserved. (206) 855-1133

CONTENTS

Introduction: Childhood Trauma & the Self Structure . . . . . . . . . .

.

3

Dissociative Continuum . . . . . . . . . . . . . . . . . . . . . 3

EMDR in a Nutshell . . . . . . . . . . . . . . . . . . . . . . . . 3

ACT-AS-IF Treatment in DID

4

Safety & Stabilization First . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5

Setting Limits & Keeping Boundaries . . . . . . . . . . . . . . . . . . . . .

6

Dissociative Table Technique . . . . . . . . . . . . . . . . . . . . . . . . . . .

6

Therapist Readiness Checklist . . . . . . . . . . . . . . . . . . . . . . . . . .

7

Client Readiness Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8

ARCHITECTS – To Structure an EMDR Session . . . . . . . . . . . . . .

9

Negative Cognitions & Double Binds . . . . . . . . . . . . . . . . . . . . . .

9

EMDR Implications of Double Binds . . . . . . . . . . . . . 10

Core Assumptions in DID . . . . . . . . . . . . . . . . . . . . 10

Polyvagal Theory-Fight, Flight, Freeze or Safety . . . . . . . . . . . . . .

11

Nervous Systems: Hard-Wired States . . . . . . . . . . . 11

Ego Investedness in Hard-Wired States . . . . . . . . . 11

Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16

Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17

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INTRO: CHILDHOOD TRAUMA & THE SELF STRUCTURE

Adults with complex trauma histories often began life with the nearly impossible task of surviving severe,

chronic, inescapable trauma, while at the same time attaching to their perpetrators as best they could.

This often meant going into developmental arrest at the time of traumas, and creating an internal

labyrinth of ―locked rooms‖ or ego states to hold and contain the pain and serve necessary functions for

survival and to maintain attachments. The solutions are as variable as the imagination of a child. Our

challenge is to understand that child’s solution, and unlock the doors to the house in order to strengthen

resources, achieve developmental milestones, detoxify trauma, learn new skills and reclaim tied-up

energy. This goal requires resonating with the client with empathy and appreciation, as well as a series of

steps to unlock the doors of the client’s divided house.

DISSOCIATIVE CONTINUUM Modified from J.G. Watkins

Normal roles &

state dependent

learning

Conflicted ego

states &

ambivalence

Ego state disorders

& PTSD

Complex PTSD

DDNOS & DESNOS

DID & Complex

DID

The further to the right a client is, s/he will evidence increasing inner conflict, increased disowning of

aspects of self with resulting discontinuities of identity, consciousness, memory, etc, with end point of

maximum impermeability of boundaries between aspects of self (episodes of amnesia). The DES will help

determine how dissociative a client is. See also the DDIS, SCID-D, the MID and others assessment

devices.

Ego State Therapy is useful across the dissociative continuum. At the far left, normal individuals have

conflicts, such as ―part of me wants to live in the city, and part of me wants to live in the country.‖ These

conflicts can be resolved by giving each a voice via ego state therapy. The same strategy is utilized

further to the right on the continuum. Resistance to change and impermeability of barriers is greater the

further to the right a client is on the continuum.

EMDR IN A NUTSHELL

If a client is not DID: Conduct EMDR according to the standard protocol. If processing loo9ps, use ego

state therapy as a cognitive interweave of choice.

If a client is DID: Establish trust and rapport, conduct safe place, resource development, stabilization,

containment, and engage a sufficient proportion of the client’s self-system in the work before ever doing

EMDR. When doing EMDR with DID, fractionate and use hypnotic or imagery procedures, to access,

contain, and modify aspects of self. Also use ego state therapy as a cognitive interweave when EMDR

loops.

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ACT--AS--

WHEN & WHETHER TO USE EMDR & SOMATIC

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

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In Assessment & Containment Phases:

SAFETY & STABILIZATION FIRST

A common error is to proceed with EMDR for a dissociative client without ensuring sufficient safety and

stabilization for the client. This happens either because of therapist’s falsely believing they don’t see

dissociative clients in their practice, therapists failing to screen for and appropriately stabilize a dissociative

client before initiating EMDR, or because of overrating the role of abreaction in curing dissociation. Trauma

work is a necessary, but not sufficient, part of the treatment picture. The following are some of the other steps

that should be taken and/or skills that should be in place before destabilizing a dissociative patient’s self system

with EMDR. Sometimes this progress can be created with resource installation, and sometimes it can be more

safely accomplished, for a given client, with imagery and/or hypnotic procedures.

Survival/Environmental safety: Does client have food, shelter, etc.

Family safety: Is client responsible for vulnerable others such that destabilization is risky?

Sobriety/abstinence: Is detoxification or other inpatient/outpatient treatment indicated first

Is abuse occurring now: If abuse is ongoing, client likely cannot yet give up dissociation.

Ability to name affect: Alexythymia will interfere with EMDR processing.

Ability to tolerate affect: Does patient exhibit phobic avoidance of strong emotion, loss of control,

vulnerable child affect. If so, anger protective ego state may need to be negotiated with prior to EMDR, as

well as other ego state work.

Grounding ability. One or more skills to ensure patient can ground self, e.g. golden cord.

Candor: Is patient truthful, so that therapist can rely on patient’s self report.

Rapport: Does the therapist have an established relationship with a sufficiency of the client’s self system to

count on client’s cooperation.

Trust: Are there angry protective alters that will likely sabotage treatment, are they ―on board.‖

Phobic avoidance of loss of control: Do the client’s various alters/ego states understand that EMDR will

involve a process of various emotions, some of which will be temporarily uncomfortable?

Agreed upon emergency procedures: Does therapist have an established and clearly communicated plan

with the client for between session destabilization and suicidal ideation or dyscontrol?

Contract for no harm and back up plan: Is the client willing and able to contract for safety.

Self control procedures including relaxation: Has the patient demonstrated an ability to utilize

relaxation, self hypnosis, self talk, and internal dialogue to decrease arousal, increase containment, and

stabilize between sessions.

Big picture view of course of treatment: Does the client understand that the course of treatment will be

a long road, with potholes and vistas, hills and valleys? That encountering painful emotions does not mean

that the work has failed and the perpetrator has won, but rather that the next piece of work has peeled up for

client and therapist to face together?

Support network (family, friends): Does the client have someone besides the therapist to turn to in

difficult times?

Financial: Is the client’s financial situation and commitment such that treatment can continue without

interruption at vulnerable and critical times?

Medical contraindications: Any contraindications to proceeding with trauma work?

Ability to tolerate positive expectancies, hope. Does the patient have a double bind operating internally

such that the experience of hope is unsafe or requires internal punishment?

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In Assessment & Containment Phases & Throughout: SETTING LIMITS & KEEPING BOUNDARIES

Another common error for beginning therapists working with DID clients, with or without EMDR, is to

confuse compassion and poor limit setting. It is not kind after all to fail to set limits and impose

appropriate structure on the therapeutic relationship. These are clients whose families of origins often

created personal boundary violations of the most severe magnitudes, and clients with such histories are

unable to anticipate and comport themselves with appropriate boundaries. It is up to the therapist to do

so. Failure to do so can result in harm to the therapy, the client and/or the therapist. If appropriate,

therapists should seek treatment for their own unresolved traumatic issues, attachment issues, and

boundary issues. Small mistakes in treatment are unavoidable, but serious mistakes or infractions must

be avoided. The following are examples of areas for appropriate boundaries and structure, many of them

are from Colin Ross (1997). Dissociative Identity Disorder: Diagnosis, Clinical Features and Treatment of

Multiple Personality, 2nd Edition. New York: Wiley. Unresolved issues from therapist family of origin

Over-identification with clients

Reaction formation, in which therapist’s deal with the positive pole of their ambivalent attachment to

childhood perpetrators by encouraging counter-perpetration on client’s perpetrators. (therapist is too angry

at the perpetrators)

Violations of confidentiality with colleagues

Dual relationships including being the client’s friend

Too much therapist availability

Too much therapist ownership of patient problems

Failure to give appropriate feedback if client behavior is offensive or irritating.

Acting out anger at client (though feeling angry is predictable, unavoidable)

Confusing limits with punishment

Taking a position on whether events occurred, without confirmatory evidence beyond presence of DID.

Mis-educating about the nature of memory. Memory IS subject to sources of error and distortion.

Failure to continue to get consent for EMDR verbally as new parts of client appear in treatment (Paulsen,

1995)

Overdoing abreactive work, or thinking the work is only about clearing trauma.

Failure to set limits on length of sessions

Failure to enforce financial terms of treatment agreement

Failure to clarify and require emergency procedures

Taking phone calls during sessions should be rare and for true emergencies only

Clients cannot barge in on other clients sessions

Clients should be be permitted to damage the therapist’s office or belongings.

Therapists should not assume that appropriate limits and boundaries are in themselves abandonments, even

if the client feels they are.

Boundary violations can range from mild to severe (e.g., breastfeeding a client with attachment deficits

Working in a vacuum, losing perspective.

Failing to analyze patients acting out and transference as reenactments.

Failing to analyze counter-transference and consider projective identification in therapist’s behavior as

reenactment phenomena

In Containment & Trauma Accessing Phases, and Throughout:

DISSOCIATIVE TABLE TECHNIQUE

In 1991, George Fraser originated the dissociative table technique, also called the conference room

technique, which he revised in 2001. Paulsen combined it with EMDR and an ego state approach in my

1995 article and in early EMDR Institute conference presentations (e.g., 1992). Dissociative Table

facilitates integration more than auditory accessing. This is because clients can see multiple aspects of self

that contribute to a set of mixed emotions or current conflicts. This often occurs with insight into the

childhood origins of the problems with a simple glance into the conference room. It is therefore inherently

more integrative than working with a single part at a time using an auditory method of access only. It is

a powerful means to:

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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

All memory is subject to distortions

Ego States (Watkins) and state specific learning

Parts-of-the-Self Language

Hypnosis and trance phenomena

Regulation of Affect

Dissociative Table (George Fraser) Fractionated Abreaction (Richard Kluft)

Tactical Integration (Catherine Fine) cautious, deliberate, planful, systematic

Co-consciousness

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All Points Bulletins to entire self (Paulsen)

Talking Through the host or other alters

Mapping the system

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.

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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

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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.

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The past is present.

I am 8 years old.

The abuse is till happening.

I am scared.

The doctor is going to abuse me now.

No one will protect me.

I can't trust myself or others. People have always abused me. I end up choosing abusive relationships.

In All Phases, Be Mindful of & Consider Appropriate Interventions

POLYVAGAL THEORY:

FIGHT, FLIGHT, FREEZE, SAFETY

The Polyvagal Theory (Porges, 2001) offers a neuro-biological framework through which to understand

trauma, behavior, and relationship. According to this theory, it is possible to intervene in traumatic

symptom constellations and attenuate the autonomic state by engaging the nervous system. According

to Stephen Porges it is the perception of safety is the primary requirement for our intervention.

The therapeutic relationship has long been the foundation of change, but Porges’ work helps us

understand why this is so. When experiencing a sense of safety, the lower motor neurons for the ventral

vagal system are regulated by the upper motor neurons in the frontal cortex. However, when

experiencing conditions of trauma, the instincts for fight and flight are triggered, overriding the ventral

vagal system. If fight or flight responses are thwarted, the system goes into an immobility response. In

that case, the theory proposes that cortical regulation of these lower motor neurons is displaced by more

primitive systems. These systemic elements are described below.

Nervous Systems – Hardwired States

1. Parasympathetic - Ventral Vagal. This is the system operating when the individual perceives the

environment as safe, as in a supporting and trusted therapeutic relationship. Also called the social

engagement system, this is a myelinated system, that evolved to building social relationships for safety

and for communicating distress in relationship with others. Research has found that in the state of social

engagement, oxytocin release fosters calm and rrelatedness. Developmental research has revealed that

this capacity is established and strengthed in normal infant development through the attuned relationship

with a nurturing caretaker.

2. Sympathetic System. This is the system operating when the individual perceives the environment as

dangerous, as in conditions of trauma. The state of sympathetic arousal activates mobilization of energy

and strength for a fight or flight reaction with the goal of surviving perceived present extreme danger.

Adrenalines and cortisols increase the cardiac output. If arousal is thwarted the unresolved energetic

charge, held in the body and brain in neural networks, manifest as a range of symptoms. Complex

trauma histories can result in an easily triggered state of chronic sympathetic arousal.

3. Parasympathetic – Dorsal Vagal. This is the system operating when fight or flight fails, and freeze is

the only option. The freeze state, also known as an immobilization response, involves a dorsal vagal

shutdown because the environment is perceived as life threatening but no better survival is response is

possible. This primitive, unmyelineated system feigns death and radically slows down the respiratory,

digestive and cardiac system. The pathway out of dorsal vagal shutdown is through sympathetic arousal,

so a person emerging out of dorsal vagal shutdown can by highly aroused.

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Ego Investedness in Hardwired States

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.

SELECTED REFERENCES

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ADDITIONAL RESOURCES

SIDRAN Foundation. www.sidran.org. 2328 W. Joppa Road, Suite 15 Lutherville, MD 21093 USA

American Society of Clinical Hypnosis (708) 297-3317 or (847) 480-0877 Northbrook Il 60062

Intl Soc for the Study of Trauma & Dissociation (ISST&D). www.isst-d.org 60 Revere Drive, Suite 500 Northbrook IL 60012

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Bainbridge Institute for Integrative Psychology (206) 855-1133 9054 Battle Point Dr NE Bainbridge Island WA 98110 www.bainbridgepsychology.com [email protected]

www.behavior.net is a forum originally moderated by Francine Shapiro, and moderated by Sandra Paulsen for several years.

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.

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