 Auckland PSITM Institute and Psychotherapy
tPsychotherapy for the Whole Person
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Training and Supervision for Healers
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Effective Treatment Approaches to Healing Survivors of Trauma and Childhood Abuse PLEASE NOTE: The techniques described below have been integrated into PSITM , an overall approach I use in working with trauma and abuse survivors. PSITM is described here in more detail. I mention anecdotal or scientific
in brackets next
1. Link to:
EMDR (Eye
Movement Desensitization and Reprocessing)
3.
Ego State Therapy Link to: Effective Treatment Approaches to Healing Problems Related to Poor Affect Regulation 1. EMDR http://www.emdr.com/briefdes.htm
(scientific)
What is EMDR?
....EMDR is an information processing therapy that uses an eight phase
approach.
Eight Phases of Treatment The first phase is a history taking session during which the therapist assesses the client's readiness for EMDR and develops a treatment plan. Client and therapist identify possible targets for EMDR processing. These include recent distressing events, current situations that elicit emotional disturbance, related historical incidents, and the development of specific skills and behaviors that will be needed by the client in future situations. During the second phase of treatment, the therapist ensures that the client has adequate methods of handling emotional distress and good coping skills, and that the client is in a relatively stable state. If further stabilization is required, or if additional skills are needed, therapy focuses on providing these. The client is then able to use stress reducing techniques whenever necessary, during or between sessions.... In phase three through six, a target is identified and processed using EMDR procedures. These involve the client identifying the most vivid visual image related to the memory (if available), a negative belief about self, related emotions and body sensations. The client also identifies a preferred positive belief. The validity of the positive belief is rated, as is the intensity of the negative emotions.... In phase seven, closure, the therapist asks the client to keep a journal during the week to document any related material that may arise and reminds the client of the self-calming activities that were mastered in phase two. The next session begins with phase eight, re-evaluation of the previous work, and of progress since the previous session.... (for more details go to http://www.emdr.com/briefdes.htm) 1Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures (2nd ed.). New York: Guilford Press. 2Shapiro, F. (2002). EMDR as an Integrative Psychotherapy Approach: Experts of Diverse Orientations Explore the Paradigm Prism. Washington, DC: American Psychological Association Books. Copyright 2004, EMDR Institute, Inc Also see: All About EMDR by Shirley Jean Schmidt ******************************************************************************************* 2. Sensorimotor Psychotherapy: http://www.sensorimotorpsychotherapy.org/about.html (Scientific) Founder: Pat Ogden History of Sensorimotor Psychotherapy In the 1970's, Pat Ogden became interested in the correlation between her patients' disconnection from their bodies, their physical patterns and their psychological issues. As both a psychotherapist and body therapist, she was inspired to join somatic therapy and psychotherapy into a comprehensive method for healing this disconnection. SPI offered its first course in the early 1980's under the name Hakomi Bodywork. Influenced by leaders such as Bessel van der Kolk, Emilie Conrad, Peter Levine, Peter Melchior, Allan Schore, Ken Wilber, Onno van der Hart, Ellert Nijenhuis, Kathy Steele, Stephen Porges, and Martha Stark, Sensorimotor Psychotherapy draws from somatic therapies, neuroscience, attachment theory, and cognitive approaches, as well as from the Hakomi Method, a gentle psychotherapeutic approach pioneered by Ron Kurtz. (http://www.hakomi.com/) SPI conducts trainings throughout the world, and has gained international acclaim over the past twenty years. Sensorimotor Psychotherapy integrates both cognitive and somatic methods in the treatment of trauma, attachment, and developmental issues. It is taught internationally to psychotherapists and allied professionals who want to include somatic interventions in their clinical work. ******************************************************************************************* 3. Ego State
Therapy
this is excerpted from the article Ego State Therapy: An Overview, in the
American Journal of Clinical Hypnosis by Helen H. Watkins, co-founder of Ego
State Therapy Ego-state therapy is a psychodynamic approach in which techniques of group
and family therapy are employed to resolve conflicts between various "ego
states" that constitute a "family of self" within a single individual. ...Any of
the behavioral, cognitive, analytic, or humanistic techniques may then be
employed in a kind of internal diplomacy. Some 20 years experience with this
approach has demonstrated that complex psychodynamic problems can often be
resolved in a relatively short time compared to more analytic therapies. Theoretical Concepts In approaching the theoretical concepts of ego-state therapy, it is
worthwhile to underscore two processes that are cogent in the development of the
human personality: integration and differentiation. Through integration a child
learns to put concepts together, such as dog and cat, and thus to build more
complex units called animals. By differentiation the child separates general
concepts into specific meaning, such as discriminating between Origin of Ego States The development of ego states seems to spring primarily from three sources: normal differentiation, introjection of significant others, and reactions to trauma. First, through normal differentiation the child learns to discriminate foods that taste good and those that are not. The child not only makes such simple discriminations, but also develops entire patterns of behavior that are appropriate for dealing with parents, teachers, and playmates. They are adaptive for adjusting to school, to the playground, etc. These changes are considered quite normal, yet they do represent patterns of behavior and experience that are clustered and organized under some common principle. As such, they can be considered ego states. The boundaries between these entities are very flexible and permeable. The child is quite aware of her/himself in a playground situation. Playground behaviors and feelings, however, are not as easily activated when in the classroom. There is some resistance at the boundaries. These less clearly differentiated ego states are usually adaptive and are economic in providing appropriate behavior patterns when needed. Second, through the introjection of significant others, the child erects clusters of behavior that, if accepted by the self, become roles identified as one's own, but if not, these clusters become inner objects with whom he must relate and interact. For example, if a child introjects and forms an ego state around its perception of a punitive parent, that ego state (an internalized object) may be punitive on the child, as was the original parent. The individual may then experience depression or some equivalent painful symptom. The punitive parent continues to live inside the individual, even into adulthood. However, if such an introjected ego state is infused with self-energy, the individual will not suffer internally, but she/he may abuse his/her own children. Of course, the punitive state, if it becomes overt, may inflict external punishment on the individual -- such as self-mutilation. The child may also introject the drama of the original parent/child object. For example, if a parent repeatedly nags a child to study and the child feels resistive to the nagging, it is likely that the child takes into himself or herself both the nagging parent and the feelings of the resistance. By the time the individual reaches college, the nagging and resistance may be internalized, resulting in procrastination. Finally, if the child introjects both parents who were constantly quarrelling with each other, then the conflict may have become internalized as headaches or equivalent symptoms, as the two parental ego states battle with each other. Third, when confronted with overwhelming trauma, rejection, or abuse, the child may dissociate as a survival response. For example, a lonely child may remove part of itself and produce an imaginary playmate with whom to interact. Most children with imaginary playmates discard or repress these entities when entering school. However, if such ego state is merely repressed, later conflict and environmental pressure may cause it to be reinvested with energy and re-emerge, perhaps even in a malevolent form as it did in the case of Rhonda Johnson, who, coauthored the book, We, the Divided Self, (Watkins & Johnson, 1982). It may then be manifested as an alter in a true multiple personality. Therapy Ego states that are cognitively dissociated from one another or have contradictory goals often develop conflicts with each other. When they are highly energized and have rigid, impermeable boundaries, multiple personalities develop. However, many such conflicts appear between ego states that are only covert. These may be manifested by anxiety, depression, or any number of neurotic or somatic symptoms and maladaptive behaviors. For example, we have found obesity sometimes resulting from pressures on the main executive personality by an unhappy, needy, covert ego state. Such conflicts requires a kind of internal diplomacy not unlike what we do in treating true multiple personalities. However, because the contending ego states do not appear spontaneously and overtly, they must generally be activated through hypnosis. We call this "ego-state therapy." Ego-state therapy is the utilization of family and group-therapy techniques for the resolution of conflicts between the different ego states that constitutes a "family of self" within a single individual. It is a kind of internal negotiation that may employ any of the directive, behavioral, abreactive, or analytic techniques of treatment, usually under hypnosis. As our practice in ego-state therapy has progressed, we have recorded these developments in a number of earlier reports (Watkins (H.), 1978; Watkins (J.), 1976, 1978, 1992a; Watkins & Watkins, 1979-80, 1980, 1981, 1982, 1986, 1990, 1991). It is not unusual for human being to take patterns from their childhood and carry them into adulthood. The woman whose father was abusive who marries one abuser after another is a good example. However, such replication is also true of ego states. The abuse is repeated internally by one abusive state upon another, as well as externally. No wonder it is so difficult to change the external behavior through conscious, cognitive persuasion. It is not unusual for human beings to take patterns from their childhood and carry them into adulthood. The woman whose father was abusive who marries one abuser after another is a good example. However, such replication is also true of ego states. The abuse is repeated internally by one abusive state upon another, as well as externally. No wonder it is so difficult to change the external behavior through conscious, cognitive persuasion. It is important for the therapist not to create artefacts, because a highly hypnotizable individual is capable of producing what he or she believes the therapist may want. In our workshops we teach techniques to avoid such pitfalls. In fact, it is not wise to probe for every ego state that might possibly exist inside the patient. Such probing can lead to artefacts. What is important to uncover are those ego states involved in the therapy problem to be explored and then to discover the needs of each state so that these needs can be satisfied in more constructive ways. Needs are often disguised by behavior quite contrary to the satisfaction of such needs. For example, a punitive state most often has a protective need. As one patient told me many years ago, "I have to hurt her, or the world would hurt her more." Such concrete, childlike thinking is very typical. The child who has been traumatized through abuse dissociates a part that remains as an ego state within the adult and continues to think as she/he did during the trauma. Time stands still for that ego state. This type of ego state needs to learn more constructive behaviors to protect the total personality. Dependent ego states often need nurturing, which may be provided by "someone inside" in the form of one or more internal nurturing states that are encouraged to do so and are according reinforced by the therapist. Parental states may need to learn more constructive ways of parenting in order to reach their own goals. For example, "I want her to achieve" is not best effected through nagging. Furthermore, "parental" states are usually not really mature. They are often child states that try to act like the original parents, because they were introjected when the patients was a child and hence think like a child. They are reminiscent of the little girl who dresses up in mother's clothing and mimics her. There are many ways to begin ego-state therapy. A simple method is to hypnotize the patient, either with a formal induction, progressive relaxation, or imagery. (After all, hypnosis is a focusing technique in order to reach inner resources and can be accomplished in more than one way.) Then ask, "I'd like to talk to the part that is upset by what is going on, but if there is no such separate part, that's all right." The latter admonition is to prevent an artifact. The content is determined by the information received from the waking patient. Although one should strive at all times not to suggest creation of a state by the therapist, our experience is that with normal precautions anything of significance is unlikely to be initiated. Even artifacts tend to be very transitory and disappear, because they represent no truly meaningful experience, past or present, to the patient, and with continuous, many-session therapy, fiction tends to get "weeded-out" from fact. I often use a hallucinated room in which the hypnotized patient sits on a couch while I sit on a chair and then have the patient watch the door to see if "anyone" comes in. There is an implicit suggestion that "someone" may come in, but there is no demand to do so. An even less suggestive way is to ask the hypnotized patient, "I wonder why Mary (name of the patient) has been having those headaches lately?" Or to probe further, "I wonder if anyone can tell me about the headaches (or any other symptom)." An ego state will often make itself known. Wherever we venture in hypnosis, I accompany the patient so that he or she does not feel alone or abandoned. Sometimes I use a table at which the patient and I sit together and communicate with whomever chooses to enter, thus beginning an internal dialogue. Fraser (1991) developed a systematic way of using a table in a very creative and concrete way. Sometimes an ego state will express itself only through a symptom in the body. For example, a headache may represent a communication from a particular ego state. The capability of the human brain to develop patterns to protect itself seems limitless. If available, it is useful to contact a "non-egotized" part of the personality, which acts as an observer and is not an emotional participant. It can give information as to the internal status quo, give clues as to procedure, even be able to take the patient back to significant traumas that need releasing and abreacting. It may not be possible to contact the observer except through finger signals, but then not all ego states are verbal, either. Some are mute but may express themselves through finger signals. Some are revealed through somatization. Some are figurative, such as idealized selves. For example, one patient viewed a goddess by a pool who helped the little ones who were hurt. Such visualization may seem like an artifact, but as long as the therapist does not suggest such fantasy, the experience is valid for the patient. For individuals who were severely emotionally deprived as children, the relationship with a caring therapist may be introjected and provide an idealized self. The use of such an internal self-helper (ISH) has been described further by Comstock (1991). In any event, to be most effective as an ego-state therapist, both nurturance and resonance (Watkins (J.), 1978) are necessary in order to form trust. Being able to think concretely like a child is also helpful, because ego states tend to think concretely and literally. However, the nurturance that heals comes from the inside of the patient as internal needs are satisfied and conflicts are solved. When the internal family is happy, the whole person is well adjusted. The greatest need in psychotherapy today is to find ways of constructively
changing maladaptive behavior more efficiently and in a shorter period of time.
Ego-state therapy shows great promise in moving to that goal, where we can
provide significant psychological help to more people with modest expenditures
of time and cost (Watkins (J.), 1992b). ******************************************************************************************* 4. Lifespan Integration: (Anecdotal) )This article has been adapted and reproduced by myself, with permission, from a handout originally written by Regina A Delmastro, RN., CEDA THTP, a registered psychiatric nurse in Bellevue Washington. Lifespan Integration, as currently taught by Peggy Pace, its founder, has changed and evolved since this writing in ways I have not incorporated into PSITM , as I find the approach described below to be of most benefit to my clients. For more information on LI in its current incarnation, please go here: http://www.lifespanintegration.com Description and Process of Lifespan Integration ( referred to as LI therapy) as it is used in PSITM Lifespan Integration is a psycho-neurological/bodymind therapy created by Peggy Pace, MA, LMHC, LMFT, based on early neural development research. LI is body-mind based in that memory is stored in the neurological system and comes forward in response to associated experiences as explicit verbal memory or in body sensations (implicit / before- cognition memory). The LI therapy process involves first creating a Personal Lifespan Timeline of age-specific memories which is referred to, as needed, in the LI session. Often, the client may do this at home before the actual LI session. If the client has suffered recurrent, prolonged childhood neglect or trauma, (complex trauma ), there may be little or no explicit memory of childhood. For some just the creation of the timeline may trigger traumatic anxiety or flashbacks. In this case, the Personal Timeline may be done with the therapist prior to the first LI session. In the LI Standard Protocol, the client identifies a problem, physical sensation or symptom, neurological/ body reaction (eg: nausea, anxiety) or past memory that they wish to resolve. The client then “floats back” on that body sensation, which will then locate a memory related to the current body sensation or life problem. Using bilateral stimulation of the brain via alternating tones or pulses, the therapist guides the client through the Personal Timeline of memories and corresponding “self states”. Since prolonged focus on traumatic events reinforces trauma imprinting ,(neural pathways that “fire together, wire together”), there is only brief acknowledging of any single memory or event. The focus is to imaginally travel through the Lifespan Timeline pausing only long enough to integrate the self-states that are “frozen in time”. The autobiographical narrative which was disrupted in childhood is recreated through the active imagining of the memories as sequential “past” events. In the successful LI treatment, the neuro pathways and “self states” frozen in time recognize that the upsetting experience or trauma is from the past and is no longer relevant in present time. Once accomplished, the neurological system can relax and function more properly, no longer hyper-reactive to the past experiences. The completion of the LI intervention involves repetitions through the Lifespan Timeline with bilateral stimulation (helpful, but not required) until the bodymind system is clear of neurological reaction to the upsetting memories. This may require at least 3 or more repetitions depending on the complexity of the issue or memory being targeted. The number of LI sessions needed to resolve complex trauma will vary depending on the severity of neurological and psychological disruption in the client’s system. Please Note: Lifespan Integration is a newly developed modality that is based on valid psycho-neurological research. The modality itself has not been researched or proven to be effective in any specific psychological condition. There is ample anecdotal information showing profound benefit in clients who suffer from anxiety, depression, eating disturbances and/or complex childhood neglect and abuse. In my 22 years as a psychotherapist and specialist in the treatment of post- trauma syndromes, I have been most impressed with the relief that LI has afforded my clients. I have seen the strongest effects in the healing of eating disturbances, depression, PTSD and dissociation-based difficulties. Neurobiological Basis of Lifespan Integration Therapy In the infant and young child the “self” originally exists as a series of separated emotional states. When development proceeds normally, these separated states or parts of self are integrated into a unified sense of self. “The integrating mind attempts to create a sense of coherence among multiple selves across time and across contexts.” (Siegel,1999). Though this process is not completely understood, some neurobiologists believe this integration happens as a result of the co-construction of autobiographical stories between parent and child. “The co-construction of narratives drives the integration of cognition [thought]), affect [emotion], sensation, and behavior (Cozolino, 2002). Brain development is an active process between parent and child. Siegel (1999) tells us that “the human mind emerges from patterns in the flow of energy and information within the brain and between brains” (of caregiver and infant). Schore (1994) demonstrates the importance of the caretaker-infant dyad in which the adult caregiver contains and soothes the emotional states of the infant during critical development stages until the infant has become capable of self-regulation. For optimal neural development in the infant and young child, the parent must be finely tuned to the child and receptive to his/her changing states and needs. When the parent is prevented from providing this, or if the parent is incapable of regulating his/her own emotions, neural development in the child can be impaired. Traumatic experiences which occur during development can have profound and lasting effects, ie: “neural networks that fire together, wire together”. Until recently, the prevailing view among neuroscientists was that the human brain continued to develop through childhood, but once completed, no further synaptic growth occurred. There is now ample evidence that neural networks are not static, but rather dynamic and changing, and that the cerebral cortex has the capacity to reorganize itself. This is called “neural plasticity’. “Now there is no question that the brain remodels itself throughout life, and that it retains the capacity to change itself as the result not only of passively experienced factors such as enriched environments, but also of changes in the ways we behave (taking up violin) and the ways we think” (Schwartz & Begley, 2002, pp 253-254) Research shows that learning and memory are enhanced and neural networks are more “plastic” when subjects are optimally emotionally engaged but not overwhelmed. LeDoux (2002) describes how optimal emotions contribute to neural plasticity. “[B]ecause more brain systems are typically more active during emotional than during non-emotional states, and the intensity of arousal is greater, the opportunity for coordinated learning across brain systems is greater during emotional states.” “Co-constructed narratives in an emotionally supportive environment can provide the necessary matrix for the psychological and neurobiological integration required to avoid dissociative reactions” (Cozolino, 2002). Lifespan Integration creates the opportunity to co-construct the autobiographical narrative that may have been disrupted during childhood development. Childhood trauma and neglect disrupts normal neuro-emotional development, creating a bodymind system that is hyper-reactive neurologically and lacking integration of a healthy core sense of self. Lifespan Integration allows for integration of the bodymind system, thus promoting healing from complex trauma and early relational misfortunes.
Recommendations for the Lifespan Integration Session
Because the hardest work we do is brain work; deciphering, evaluating, logging, and imprinting information from all our senses every waking moment of our lives, our brain demands an extreme amount of nutrients constantly. Hard brain work that involves emotion is very tiring. Because LI involves concentrated brain/ neurological work, the following recommendations are advised.
· Bring a healthy snack and a bottle of water with you to the session as you may need nourishment after the session. Some individuals report feeling hungry after LI due to the brain’s enormous demand for glucose during the neurological work with LI. Some diabetics have reported a 20 point drop in blood sugar level after LI.
· Sleep may be altered the night of the LI session so arrange for a quiet, relaxing evening after LI. You may experience deeper sleep than usual. Some report experiencing more disrupted sleep and/ or nightmares the night of the LI session.
· Avoid verbal mental work after the session. Give your brain 24-48 hours to process the changes.
References: Cozolino, L. (2002). The Neuroscience of Psychotherapy: Building and rebuilding the human brain. NY: W. W. Norton & Company LeDoux, J. (2002). Synaptic Self: How our brains become who we are. NY: Viking Adult Schwartz, J. & Begley, S. (2003). The Mind and the Brain: Neuroplasticity and the power of mental force. NY:Regan Books Seigel, D. (1999). The Developing Mind: How relationships and the brain interact to shape who we are. New York: The Guilford Press Shore, A. (1994). Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Development. Mahwah, N.J.: Lawrence Erlbaum Associates Also link to: Effective Treatment Approaches for Poor Affect Regulation, Imaginal Nurturing, DNMS, Best Foot Forward, Overcoming Powerlessness; Sharing Power in the Family; Fat, Thin and Power; Trauma Survivors Treatment; Self Empowerment for Women, Improving Body Image, The Diet/Binge/Purge Cycles, Techniques for Treating Eating Problems;
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