Having no way to understand the entrenched self-alienation or intense self-hatred of their traumatized clients, therapists often feel frustrated, baffled, and inadequate to the task of trying to help. Why do they seem to be at war with themselves? Or with us? Although the client has come seeking relief from a burden of trauma-related symptoms and issues, the task of exchanging self-alienation for self-compassion can feel overwhelming or distasteful. Neither client nor therapist has a language with which to explain the internal struggles being played out inside the client’s mind and body. In a mental health world that rejects the notion that personality and identity can be fragmented and compartmentalized, therapists are rarely trained to see the splits, much less the life-or-death battle for control being waged by “selves” with opposite aims and instincts.
My intention in writing this book was to share a way of conceptualizing the most complex and challenging clients who come to us, often carrying “terminal” diagnoses, such as personality disorder, bipolar II, even schizophrenia. Over three decades in the trauma treatment field, my compatriots and I have learned about trauma “the hard way,” by letting the clients teach us about their inner worlds, their intrusive, overwhelming symptoms, what it is like to live in a body organized to expect annihilation or abandonment. Lacking approaches specifically tailored to the needs of traumatized clients, all of us “winged it,” creating new techniques and interventions, seeing what “worked,” and retaining what did—either because the interventions were effective or because the clients liked how they felt.
In the 1990s, as an instructor and supervisor at Bessel van der Kolk’s Trauma Center, I was profoundly influenced by the neuroscience research that began to revolutionize our way of understanding trauma and by Bessel’s belief that “the body keeps the score” (Van der Kolk, 2014). We began then to see trauma-related disorders not as disorders of events but as disorders of the body, brain, and nervous system. The neurobiological lens also resulted in another paradigm shift: if the brain and body are inherently adaptive, then the legacy of trauma responses must also reflect an attempt at adaptation, rather than evidence of pathology.
Through that neurobiological lens, what appears clinically as stuckness and resistance, untreatable diagnoses, or character-disordered behavior simply represent how an individual’s mind and body adapted to a dangerous world in which the only “protection” was the very same caretaker who endangered him or her. Each symptom was an ingenious solution by the body to create some semblance of safety for the developing child or endangered adult. The trauma-related issues with which the client presents for help, I now believe, are in truth a “red badge of courage” that tell the story of what happened even more eloquently than the events each individual consciously remembers.
As I came to be known as an expert in treating trauma, increasing numbers of clients sought me out for consultation, asking, “Why am I not getting better? My therapist and I have a wonderful relationship, but none of my symptoms are diminishing. Am I doing the wrong kind of therapy? Or is there something wrong with me?” Time after time, as I heard from clients and therapists what had been tried and failed, I could not find a “mistake” or misguided choice of treatment. More often, what could be seen from the consultant’s perspective was something both therapist and client could not see: the client was fragmented. What it had taken to adapt was a splitting of self and identity sufficiently severe that the individual’s inner world had become a war zone. What I also noticed was the relief these clients experienced as I educated them about dissociative splitting as a normal adaptation to trauma. First describing to them the theory of Structural Dissociation (Van der Hart, Nijenhuis & Steele, 2006), I would then translate their struggles using the language of parts and the language of animal defense survival responses, the cornerstone of the Structural Dissociation theory. Often, as I spoke, I observed a look of recognition on their faces, as if I were telling them nothing new but simply giving them a language to describe at long last what they already recognized but had no words to explain. Rather than feeling stigmatized or “crazier,” the Structural Dissociation model seemed to be reassuring to them. Its central principle, that splitting had simply allowed them to adapt and survive more successfully in an unsafe world, helped even very proud, narcissistic individuals to experience the fragmentation as a validation of their survival, not further proof of their defectiveness.
As I worked in this way with a range of clients, it became increasingly clear that when they “adopted” or came to love their hurt, lost, and lonely parts, something remarkable happened. Their self-disparagement, self-hatred, and disconnection began spontaneously to yield to self-compassion. Whereas the idea of being “nice,” “taking care of” or being “compassionate” to themselves was met with disgust and avoidance, every client could be helped to “see” his or her child parts and to extend kindness and care. And as they developed internal attachment relationships to these young selves, I could see them healing.
What it means to “heal” is subjective, of course: for some clients, it implies the ability to function again, to simply reclaim their lives. But, as I observed the clients who began forming loving attachment bonds to their young selves, I could see healing at a much deeper level. Seeing them “bond” with the child they had once been and feeling their shame and self-hatred melt away convinced me that the left brain “adult” side of each one was capable of relating to the right brain “child” side, experiencing him or her as innocent and little, spontaneously evoking warmth and protectiveness. By bonding to the lost children inside, their internal states transformed, creating a warm, loving environment that felt safe at last. Best of all, it was evident that this work was not only transformative but also easy for the clients once they learned the basic skills needed to form internal attachment relationships to their parts.
The book is intended for use by a wide range of therapists and for an even wider range of clients. In writing it, I hoped particularly to address the challenges faced by chronically traumatized individuals much like those who have sought me out for consultations. These are clients young and old who battle to recover from their legacies of trauma, confused that these have not resolved despite good therapy, effective treatments, supportive relationships, or even rich full lives in the present. I also wanted to describe an effective and respectful way of working with traumatized clients who have lost their hope and ability to function or who depend upon hospitals, families, and loved ones to care for them as they struggle with self-destructive impulses driving suicidal, self-harming, addicted, or eating disordered behavior. Despite decades of research attesting to the relationship between early abuse and a later diagnosis of borderline personality disorder, it is rare for clients with borderline diagnoses to be treated as trauma patients or to be recognized as individuals whose “borderline” symptoms stem logically and tragically from the unsafe environments of their early lives. Thanks to enlightened Departments of Mental Health in the states of Massachusetts and Connecticut, I have had the invaluable opportunity to try out the treatment model described in this book with some of their most high-risk patients and to find that, with a treatment model organized around trauma-related splitting and compartmentalization, these patients could begin to stabilize, to live outside of institutional walls, and to understand their attacks on the body as a valiant attempt by one part to gain quick short-term relief from the painful implicit memories of other parts. This book is also meant for traumatized clients who have “overcome,” who have prestigious jobs and loving families of choice, whose lives are rich and full, but who still struggle to enjoy the quality of life they have fought to create. And the book is also intended to offer hope to individuals who may be stable but whose internal quality of life is still as dark and painful as the traumatic past despite the safety, support, and meaningful work in their external lives.
The treatment paradigm described in this book is not intended for the treatment of any one particular diagnosis. It is meant to be used with and on behalf of all survivors of trauma, whether the client carries a diagnosis of post-traumatic stress disorder (PTSD), has been given a common trauma-related diagnosis such as ADHD, bipolar disorder, borderline personality, or a dissociative disorder, or has never met a mental health professional. If you, the reader, have been failed, attacked, threatened, abandoned, terrorized, or abused by other human beings, and if you still carry with you the emotional and physical legacy of those experiences, or if you work to help those who do, I believe this book will speak to you.
Ten years ago, in the context of consulting with traumatized clients who came to me as an “expert,” seeking to understand why they were not making progress in treatment, I began to observe a very characteristic pattern: these clients had something unique in common. Each was superficially an integrated whole person but also manifested clear-cut signs of being internally fragmented. They experienced intense conflicts between trauma-related perceptions and impulses (for example, “the worst is going to happen,” “I will be abandoned if I don’t get out first”) versus here-and-now assessments of danger: “I know I’m safe here. I wouldn’t let my children live in this house if it were not safe.” They suffered from paradoxical symptoms: the desire to be kind and compassionate toward others or to live a spiritual life, on the one hand, and intense rage or even impulses to violence, on the other. Once their conflicts were described, the patterns became more easily observable and meaningful. Each side of the conflict spoke to a different way of surviving the unsurvivable, of reconciling the opposites that are so often part and parcel of traumatic experience. With an explanatory model that described each reaction as logical and necessary in the face of threat or abandonment and that reframed them as the survival responses of different parts of the self, to which the individual could relate, each client started to make faster, more sustainable progress. The theoretical model that best explained the phenomena they described was the Structural Dissociation model of Onno van der Hart, Ellert Nijenhuis, and Kathy Steele (2004). Rooted in a neuroscience perspective and well-accepted throughout Europe as a trauma model, it was a good fit for me as a firm believer and spokesperson for a neurobiologically informed approach to trauma and trauma treatment. The theory describes (Van der Hart, Nijenhuis & Steele, 2006) how the brain’s innate physical structure and two separate, specialized hemispheres facilitate left brain-right brain disconnection under conditions of threat. Capitalizing on the tendency of the left brain to remain positive, task-oriented, and logical under stress, these writers hypothesized that the disconnected left brain side of the personality stays focused on the tasks of daily living, while the other hemisphere fosters an implicit right brain self that remains in survival mode, braced for danger, ready to run, frozen in fear, praying for rescue, or too ashamed to do anything but submit. In each individual client, I could see that some parts were easier to identify with or “own” and some parts were easier to ignore or dismiss as “not me.” Internally, the parts were also in conflict: was it safer to freeze or fight? To cry for help? Or to be seen and not heard? What I also noticed was that the internal relationships between these fragmented aspects of self reflected the traumatic environments for which they had once been solutions. The left-brain-dominant present-oriented self avoids the right-brain-dominant survival-oriented parts or judges them as bad qualities to be modified, while the right brain implicit selves of the parts are equally alienated from what they perceive as a “weak” or absent other half. The functioning self carries on, trying desperately to be “normal”—at the cost of feeling alienated from or invaded by the intrusive communications of the parts.
Survivors of abuse, neglect, and other traumatic experiences often report functioning better as a result of their compartmentalization but then suffer from feelings of fraudulence or “pretending.” Not realizing that each side of the personality is equally “real” and necessary from an evolutionary standpoint, clients easily misinterpret the intense, palpable feeling memories of the “not me” child as more “real” than the experience of the “going on with normal life self,” doggedly “putting one foot in front of the other,” or “keeping on keeping on” even in the face of overwhelming pain. Without an explanatory paradigm that makes sense of these contradictions, there is no way for individuals to know that their intense feelings and distorted perceptions are evidence of fragmentation, not proof of internal defectiveness or fraudulence masked by the ability to function.
Over time, self-alienation can only be maintained by most individuals at the cost of increasingly greater self-loathing, disconnection from emotion, addictive or self-destructive behavior, and internal struggles between vulnerability and control, love and hate, closeness and distance, shame and pride. While longing to be loved, safe, and welcome, many traumatized clients find themselves alternating between anxious clinging and pushing others away, hating themselves or having little patience with the flaws of others, yearning to be seen and yearning to be invisible. Years later, they present in therapy with symptoms of anxiety, chronic depression, low self-esteem, stuckness in life, or diagnoses such as PTSD, bipolar disorder, borderline personality disorder, even dissociative disorders. Unaware that their symptoms are being driven not just by the traumatic events but by an internal attachment disorder mirroring the traumatic attachment of early childhood, therapist and client have no framework for understanding the chaos and/or stuckness that may soon elude their best efforts at treatment.
In the trauma treatment world in which I have practiced professionally over the past 25 years, generations of “best treatment” models have been repeatedly challenged by client vulnerability to being triggered by apparently innocuous stimuli, swept into the “trauma vortex,” and overwhelmed with painful emotions and physiological responses. For some clients, the present feels little better than the past. Since my postdoctoral fellowship in Judith Herman’s clinic in 1991 and arrival at Bessel van der Kolk’s Trauma Center in 1995 as a supervisor and instructor, my colleagues and I, led by Bessel van der Kolk, have been on a quest to find new methods or interventions that might help free our clients from the insidious impact of the traumatic past—but, even as each is an improvement on the last, we always come up somewhat short. Each new understanding or sophisticated treatment method helps some clients we haven’t before been able to reach, but it doesn’t bring resolution for all—or each brings relief in some symptoms while not alleviating others. And for some traumatized clients, the course of treatment even over the long term seems to consist of two effortful steps forward followed by a slide backward—pushing the proverbial boulder up a steep hill this week only to find by the next session that it is right back at the bottom again. Even more challenging, some clients find that their trauma-related wishes and fears of relationship are so equally intense that therapy and the therapist evoke painful yearning, mistrust, hypervigilance, and anger, or fear and shame, rather than feelings of safety and comfort. It was my hope in writing this book that the treatment approach described here would create a way for these clients and their therapists to navigate these challenges and resolve them.
Often, at this point, the client reports feeling worse instead of better, and the therapist begins to question his or her ability. Each wonders, “Am I doing something wrong?” What neither client nor therapist realizes is that stuckness in treatment reflects trauma-related internal conflicts between fragmented selves being played out on the stage of the psychotherapy. In questioning our ability as therapists or generalizing client behavior as “transference” or “resistance,” we miss the opportunity to become witnesses to the reenactment occurring inside the client’s fragmented inner world. Not understanding that fragmentation of the personality can result in simultaneous, strongly held opposing goals, such as “I want to die” and “I am determined to live,” or “I want to be connected, but I don’t want anyone to know I care.” Or “I loathe and despise myself, I look up to others above me, and then I loathe and despise them when I see that they’re not better than any other authority figure.”
Although written for the therapist committed to finding ways to better help clients for whom other methods haven’t been quite right or complete, this book is also written on behalf of the trauma survivor who comes to therapy as a client. Since the early 1990s, I have been looking for gentler, less retraumatizing ways of treating the effects of traumatic experience. It never made sense to me that a therapy for those who have been badly hurt should have to cause the same intensity of pain. I have always believed that it was bad enough for my clients to have lost their childhoods or adolescence, but it was absolutely unacceptable to allow the legacy of trauma to deprive them of their adult lives, too. And it has equally felt unacceptable that processing trauma should be as frightening and overwhelming as the early experiences themselves, that all subsequent relationships, even the therapeutic ones, should feel as threatening as those in childhood. When we are young, our caregivers have almost total control over our inner worlds and the power to evoke in us both painful and pleasurable emotions as well as lay down expectancies for how relationships work. When we have survived to adulthood with its promise of autonomy, we finally have the ability to move away from painful experiences, to choose how much or how little to trust, to negotiate boundaries and intimacy—but that’s not how survivors of trauma feel. Their bodies still remember the experience of “no control” over pleasure or pain. My purpose in developing this approach was to describe a way of coming to terms with trauma that felt healing; that spoke to survival, not victimization; that created warm and pleasurable feelings in the body rather than terrifying ones.
This book is intended to appeal to clients and therapists working with trauma, attachment disorders, and dissociation as these manifest in complex and paradoxical symptoms, alienation from self, internal conflicts, and troubled therapeutic relationships or impasses. Therapists routinely are stymied by the effects of self-alienation on the therapy: shame, punitive self-hatred, separation anxiety and fear of abandonment, self-destructive behavior, inability to self-soothe or self-care, fears of hope, happiness, and compassion for self. Psychotherapist training programs provide little information on traumatic attachment, or on how undiagnosed trauma-related fragmentation or splitting can complicate straightforward resolution of trauma, or on the treatment of dissociative disorders as one of a constellation of trauma-related disorders. Healing traumatic wounds and trauma-related fragmentation is ultimately dependent upon the individual’s relationship to self—or to his or her “selves.” Self-alienation will always impede resolution of the past by creating an internal Berlin Wall standing in the way of acceptance that “it” happened and an ability to welcome home the child who endured and survived it.
Like all books, this one reflects its author’s experience and theoretical paradigms. For me, as a practicing clinician whose professional homes have been Bessel van der Kolk’s Trauma Center (since 1996) and Pat Ogden’s Sensorimotor Psychotherapy Institute (since 2003), the theoretical models for understanding trauma to which I am committed have their origins in neuroscience and attachment research. It is important to me that we as therapists understand why we are choosing one treatment or intervention over another. Even when the interventions I choose are not immediately “successful,” I can still look to the theory to help me understand why—so that my next intervention can be informed by what was missing in the last. In the chapters that follow, I will be integrating a theoretical understanding of trauma, dissociation, neurobiology, and attachment with a practical, “hand’s on” approach to the treatment of these issues that is intended to be accessible to both client and therapist. To help clients reach below the level of “talking about,” interventions drawn from a number of therapeutic approaches were integrated into this way of working, including Sensorimotor Psychotherapy (Ogden et al., 2006), Internal Family Systems (Schwartz, 2001), mindfulness-based approaches (Pollack, Pedulla & Siegel, 2014), and clinical hypnosis.
As I set out to create a way of working clinically with the Structural Dissociation model, being a practitioner and teacher of Sensorimotor Psychotherapy (Ogden & Fisher, 2015; Ogden et al., 2006), it was only natural to start by integrating my understanding of the body and nervous system with what I knew about parts from working with clients with dissociative identity disorder (DID). Because each part in Structural Dissociation theory is driven by an animal defense response (i.e., fight, flight, etc.), the connection to the body was easy to make. How the body organizes to flee is distinctly different than how it organizes to fight or feign death. But Sensorimotor Psychotherapy speaks the language of the body, so I still needed a language of parts. Richard Schwartz’ (1995) Internal Family Systems (IFS) approach, upon which I had drawn heavily in my work with DID clients years earlier, teaches therapists to become fluent in speaking the language of parts. Not only are they asked to speak the language with their clients, but they are also expected to become mindful of their own parts. Because both IFS and Sensorimotor Psychotherapy are mindfulness-based treatment models, they also fit perfectly with my “mindfulness of parts” approach in which I help clients learn at first just to mindfully scan their bodies and feeling states for the communications from their fragmented selves.
What had drawn me originally to IFS for help in working with DID was the concept of “self” and “self”-leadership. (Schwartz, 2001) “Self” refers to innate qualities possessed by all human beings in undamaged form, no matter how much abuse and trauma they have experienced. These qualities include curiosity, clarity (the ability for meta-awareness or perspective), creativity, calm, courage, confidence, and commitment. Healing in IFS is the outcome of providing these qualities as an antidote to the painful experiences suffered by exiled child parts. With my DID clients, I had found it immensely stabilizing to help their adult selves grow these “C” qualities and to help the child parts learn to turn to a “self-led” wise adult self who could reassure their fears and loneliness. As I began to see that fragmentation was not limited just to clients with dissociative disorders, the Structural Dissociation model and IFS provided some welcome support. Structural Dissociation theory is a trauma theory, applying equally to clients with PTSD, complex PTSD, and borderline personality disorder. IFS is a parts theory, applying equally to all human beings, not just traumatized individuals with dissociative disorders. Feeling supported by these ideas, I began to use my “blend” of sensorimotor and IFS interventions and techniques with complex PTSD clients, with clients who came for consultations and were willing to try out different approaches. I also increasingly used it whenever I encountered a client who was stuck, in crisis, in turmoil or “terminal ambivalence.” Just as with borderline clients, the mindfulness approach and the attribution of each and every symptom to parts (drawn from IFS) created “breathing space” that allowed clients to be curious about these parts, less afraid, even to feel empathy for them.
Chapter 1, Alienation from Self: How We Survive Overwhelming Experience, sets the stage by describing dissociative splitting and fragmentation as an adaptive response to abnormal experience. To create distance from overwhelming events and preserve a sense of “a good me,” individuals must disown the self-states of which they are ashamed, intimidated, or experience as “not-me,” allowing them to also disown the trauma (Bromberg, 2011). The ability to encode two parallel sets of experiences in one brain and body is supported by the “split-brain research” in the 1970s and 1980s (Gazzaniga, 1985) and by the neuroscience brain scan research in the late 1990s and 2000s demonstrating how traumatic events come to be encoded as implicit emotional and physical states, rather than being encoded in the form of chronological narrative. The introduction of the Structural Dissociation model in 2000 provided the first neuroscientific understanding of dissociative splitting and compartmentalization (Van der Hart et al., 2000). Unlike earlier models of dissociative fragmentation, this theory does not emphasize the compartmentalization of memory. Instead, its central tenet is that structural dissociation is a survival-oriented adaptive response to the specific demands of traumatic environments, facilitating a left brain-right brain split that supports the disowning of “not me” or trauma-related parts and the ability to function without awareness of having been traumatized. The splitting also supports development of parts driven by animal defenses that serve the cause of survival in the face of danger. Chapter 1 provides a theoretical foundation for understanding both neurobiologically informed trauma work and the need for a parts approach to treatment. Working with a parts approach allows therapists to work more effectively with complex and personality disorder clients. In this model, these clients are not “acting out,” “manipulative,” “resistant,” or “unmotivated.” Their trauma-related parts, activated by normal life stimuli, driven by implicit trauma responses, experience the sense of threat and automatically engage instinctive responses: fight, flight, cry for help, freeze, or “feign death” (Porges, 2011).
In Chapter 2, Understanding Parts, Understanding Traumatic Responses, we explore the implications of the neuroscience research on traumatic memory as a basis for understanding and recognizing the signs of fragmented parts as they will appear in client presentations. A simplified understanding of the emergency stress response to threat is presented and how the legacy of trauma becomes encoded in the body. It is important to know how body-based trauma responses drive animal defense impulses to unsafe behavior, why the left-brain-related “normal life” self may observe helplessly but cannot hold back the impulses to action. Underlying automatic hypervigilance, reactivity, suspiciousness, and impulsive action-taking is the body’s autonomic nervous system, which governs action and inaction, strong emotions and numbing. In the wake of trauma, the nervous system adapts to a threatening world, conditioned to be “at the ready” for impending danger and therefore biased to mobilize sympathetic hyperarousal or parasympathetic hypoarousal or both, depending on the environment in which these responses were conditioned (Ogden et al., 2006). This chapter asks therapists to make a paradigm shift from a focus on traumatic events to prioritizing attention to the role of implicit memory in trauma treatment. In order to recognize, understand, and help clients work with their trauma-related parts, the therapist must help clients understand their responses to triggering so that they can accurately identify triggered, implicitly remembered feelings, beliefs, and survival responses. Lastly, this chapter addresses the question: What does it mean to “process memory”? When the memories are implicit feelings, body sensations, changes in activation, and disregulated impulsive behavior held by young parts, “what” gets processed? Modern views on memory emphasize its unstable nature: that is, the brain seems to be organized to update and rewrite past experiences, integrating them with prior and subsequent events. Rather than focusing on desensitizing the event memories, experts now advise prioritizing transformation or repair of trauma-related states through the cultivation of new experiences. Instead of focusing on developing a trauma narrative, clients are instead advised to rewrite their “self-defeating” stories and create a healing story that allows them to make meaning of what happened (Michenbaum, 2012).
Chapter 3, Working with Changing Roles for Client and Therapist, begins with a discussion of fundamental shifts in perspective and approach necessitated by a neuroscientifically informed view of traumatized clients. The treatment begins with education for the therapist on the nature of trauma and dissociation, geared to explain the symptoms with which a client struggles and to provide information to reassure him or her that these are normal, logical responses to trauma. Additionally, psychoeducation helps to equalize the inherent power differential by “making public” the knowledge base that will be used in the therapy, empowering clients to become educated consumers in their own treatments (Herman, 1992).
Most therapists have been trained in “uni-consciousness” models of personality and are less familiar with working in a “multi-consciousness” paradigm. Psychodynamically trained therapists have been trained to play a less directive, educational role than required in trauma treatment; cognitive-behavioral therapists may not have been trained in the skills of attunement and resonance. Both are critically important in the context of trauma and in a parts approach. The client’s instinctive avoidance of the trauma and trauma-related parts will continue to re-enact the behavior of non-protective bystanders if not guided to a different way of working.
Mindfulness skills must be explicitly taught, along with the language of parts necessary for identifying them. The beginning stages of the therapy involve the therapist’s attuned building of a collaboration based on what the client needs, not just on what he or she wants. To create a new story about whom he or she is in the aftermath of the painful and traumatic events requires learning new habits of observation and discovery: the “op-ed” stories clients have been writing about themselves have been biased, not in their favor. They need help in acquiring the skills of mindful observation of both positive and negative feelings and sensations without interpretation or judgment. Next, they learn to use the language of parts or “selves” to describe their often confusing or paradoxical actions and reactions as they happen moment-to-moment clients but without “identifying with them,” or interpreting them as data about the immediate present. Identification invariably intensifies any emotion or evokes shame. Learning to describe an experience without “identifying with it” allows clients to notice its “building blocks” (Ogden & Fisher, 2015): “As I talk about my father, I’m noticing a tightness in my chest and my heart beating fast” or “I’m noticing that a part of me is anxious.” Learning to dispassionately notice allows for the next steps in this approach to unfold: increased ability to hold a curious or even compassionate attitude toward whatever feelings or reactions are observed and, following that, an ability to “befriend” the emotion. In Buddhism, acceptance, welcoming, avoiding “attachment or aversion” (identifying with the feeling or fighting/judging it) are an essential part of finding equanimity, a state of calm, peacefulness, and composure. Translated into psychotherapy, this practice helps clients learn to tolerate and accept even the most painful, humiliating, or frightening emotions and sensations.
Rather than beginning with an exploration of the “old world” of painful, humiliating experiences and overwhelming feelings, the therapist is encouraged to focus on increasing the client’s curiosity and interest in feeling states, parts, thoughts, and body responses. The goal of this approach is not remembering: it is repair of the injuries suffered as a result of the traumatic events, whether remembered explicitly as narrative or implicitly as feelings and reactions.
In Chapter 4, Learning to See Our “Selves”: An Introduction to Working with Parts, therapist and client are taught the fundamental skills necessary for working in a parts paradigm. This early stage of the treatment is intended to help clients learn the basic skills necessary for working in a parts paradigm. First and foremost, clients are introduced to the Structural Dissociation model and asked to describe what resonates with their experiences and difficulties. How do they recognize themselves in the model? The Structural Dissociation model also offers a client-friendly entrée into identifying the signs of parts. Each animal defense survival response is associated with certain behaviors frequently associated with trauma. These are introduced to clients in diagram form to help them focus attention and take in this new information with greater interest and curiosity. Another approach to increasing awareness of parts activity is to ask clients to “assume” that all distressing thoughts, feelings, and body responses are communications from trauma-related parts. (This assumption is consistent with split-brain neuroscience findings on the activity and abilities associated with each of the two hemispheres.) Teaching schemas that facilitate ready identification of parts activity allows clients easier access to their internal experience, enabling them to differentiate “their feelings,” rather than identify with all emotions as “mine.” Clients are also taught to be mindful of internal conflicts, ambivalence, or confusion as manifestations of struggles between parts triggered by each other as well as by trauma-related stimuli.
Chapter 5, Befriending Our Parts: Sowing the Seeds of Compassion, focuses on interventions that begin a process of fostering the increased self-understanding and self-compassion so necessary for healing. Asked to have compassion for themselves or to better care for themselves, most traumatized clients have a strong negative reaction. But when an emotion such as fear or shame is connected to the felt sense of a young child, the same client can often feel empathy or even indignation for that child. In mindfulness-based treatment, it is not necessary that we differentiate between compassion “for ourselves” versus compassion “for the child.” The felt emotional and somatic sensations of compassion are the same, no matter who is the intended receiver, and it is those sensations of compassion that help to soothe and heal traumatic and attachment wounding. It is also not necessary to have detailed narrative memory of the client’s traumatic experience: it is only necessary for the client to have a felt sense of what the child part has been through. Having a “sense” or a synopsis of the client’s trauma history allows the therapist and client to acknowledge what younger selves have been through without overwhelming the client’s nervous system or capacity for affect tolerance. Acknowledging the parts’ traumatic experiences feels validating without triggering traumatic reactions. At this stage of the work, the emphasis is on cultivating compassion for the parts, one by one. Compassion is challenged by overwhelming emotions or disturbing body responses. The goal is to help the client feel “just enough” of the part’s suffering that empathy is evoked. It is important for the therapist to remember that, in trauma treatment, feeling too much interferes with empathy and compassion as much as feeling too little. At this stage, clients are also taught to recognize “blending” (Schwartz, 2001) or identifying with their parts, making them vulnerable to being flooded or acting out the impulse of some part, and to practice “unblending” and dis-identifying.
In Chapter 6, Complications of Treatment: Traumatic Attachment, we address the internal conflicts and struggles created by a history of traumatic attachment. If the hallmark of traumatic attachment is a reversal of roles in which the object of safety (the parent figure) becomes the object of fear and life threat, any intimate relationship thereafter, even the therapy, evokes danger signals. Growing closeness in relationship can convey threat or a promise of comfort and connection, evoking emotional memories of the longing for an attachment figure that never came alongside implicit memories of the abandonment and betrayal that did happen. Because attachment and fear have become intertwined in the client’s experience, a therapy focused on the narrative memories or on the transference is likely to ignite an internal struggle between the hunger for closeness in young attachment-seeking parts and their fear of abandonment versus the defensive responses of fight, flight, and total submission. In dissociative disorder clients with parts that are more disconnected and autonomous, this internal struggle becomes even more easily activated in personal relationships or in the therapy, harder to decode or deconstruct, and more difficult to manage behaviorally.
How therapists anticipate this phenomenon and how they help their clients accept and work with it can lead either to deeper healing or to a reopening of attachment wounds in the therapy itself. If either clinging or devaluing is interpreted as an interpersonal issue between client and therapist, they are often exacerbated. If we understand them as “intra-personal,” indicators of an internal attachment disorder still operating within the client, then the therapist can become an ally for both sides of the struggle and a facilitator of “earned secure attachment” (Siegel, 1999). In “earned” secure attachment, the insecure or disorganized attachment of childhood and/or adulthood is resolved to the point that individuals can reflect back on their early attachment relationships without becoming disregulated, without idealizing or demonizing their attachment figures, and feel a sense of acceptance. In this model, earned secure attachment is the outcome of the clients’ growing ability to bond with their own young wounded selves as innocent children who deserved the loving care of a compassionate adult but never received it. Rather than the therapeutic focus being centered on attachment to the therapist, the emphasis is consistently on building empathy and attunement to the parts.
In Chapter 7, Working with Suicidal, Self-Destructive, Eating Disordered, and Addicted Parts, unsafe and high-risk behaviors are recontextualized as manifestations of parts-related animal defense survival responses. Addictive, eating disordered, suicidal, and self-injurious behaviors are all reinterpreted through a neurobiological lens. The neurobiological premise assumes that human bodies have the same self-righting, self-healing tendencies as do the bodies of other mammalian species. If that is so, then self-destructive behavior must also have a self-righting intention. Viewed in this way, unsafe behavior historically labeled “self-destructive” can be better understood as a desperate attempt to survive, a way to tolerate shame, rage, and fear, to inhibit flashbacks and nightmares, or to use endogenous or exogenous substances to regulate a traumatized nervous system. As part of an informal, clinically oriented pilot project offering new forms of treatment to trauma patients in a Connecticut Department of Mental Health system, participating clinicians have been gathering informal data on what precedes and follows episodes of unsafe behavior. They have observed that episodes of self-harm or suicide attempts most commonly follow relational disappointments, separations or ending of relationships, preoccupation with shame and self-loathing, and intrusive memories or flashbacks. This finding implies that such events evoke the experience of threat and generate trauma-related emotional responses that feel unbearable until some impulsive behavior diminishes their intensity or creates emotional and bodily numbing. After these episodes, there is a corresponding tendency for patients to report exhaustion, loss of energy, and intense feelings of needing rest—the same indicators characteristic of parasympathetic responses following a fight or flight response. Historically, this classic post-traumatic unsafe behavior has been interpreted clinically as attention-seeking, manipulation, or avoidance. With the implementation of this neurobiologically informed approach, in which patients are helped to reframe impulsive or unsafe behavior as communications from a part driven by the animal defense of fight, the frequency of unsafe behavior has diminished. By externalizing the impulses and assigning them to a defensive part, the patients are able to keep an observing prefrontal cortex available to help them manage the impulses as “not mine—it’s the fight part.” Better yet, when these patients are taught the Structural Dissociation model, there appears to be a decrease in negative self-judgment and an increase in their curiosity, both of which are antidotes to impulsive behavior. Teaching these clients the basic skills outlined in Chapters 4 and 5 and asking them to practice their use seems to have a stabilizing effect in and of itself. In addition, clients are given psychoeducation about the biological effects of their unsafe behavior and how it “works” to regulate the nervous system, helping them to gain a perspective on the body’s role in these issues. As their ability to “unblend” from impulsive parts increases, and there is more access to an uninhibited prefrontal cortex, these clients are better able to notice the parts’ distressing emotions and unsafe impulses and regulate them, rather than react to them.
In Chapter 8, Treatment Challenges: Dissociative Systems and Disorders, we address the unique issues posed by clients who have diagnosable dissociative disorders (DID, DDNOS, depersonalization disorder). A dissociative disorder diagnosis reflects a more extreme degree of compartmentalization, affecting the ability for continuous consciousness, the ability to know moment-to-moment “who I am,” to make coherent choices and decisions and carry them through to completion, to manage impulses, to have accurate perceptions of cause-effect or time and space, and to integrate the traumatic past and normal, safe present. Clients with dissociative disorders are often underdiagnosed or misdiagnosed despite their statistically significant dissociative symptomatology (Korzekwa et al., 2009a). Most often, they present with diagnoses of borderline personality disorder, bipolar disorder II, and ADD or ADHD. This chapter reviews the diagnostic signs indicating a possible DID diagnosis, discusses assessment approaches, and suggests criteria for making a formal diagnosis. The same treatment approach outlined in Chapters 3–5 is very effective for DID and DDNOS clients, with adjustments to how the therapist works to account for the failures of memory and continuity.
Because the approach described in this book is mindfulness-based, it tends to be stabilizing for clients and to facilitate deconstructing problems encountered in normal life, as well as trauma-related issues. The language of parts allows both client and therapist to keep in mind the central challenge of working with dissociative disorders: holding in mind that the client is still one physical individual with one body and one brain, while equally appreciating that this one brain and body are fragmented and hold many parts of different ages, stages, attachment styles, and defensive responses. To feel empathy for each part’s plight, while not losing sight of the fact that the client is an adult with functional capabilities is a mental ability that often has to be practiced before it becomes second nature. With dissociative disorders, the therapist is working with clients who are not an integrated “she” or “he.” Viewing them as such is often confusing, rather than helpful, just as viewing clients as inner children without adult resources equally causes confusion.
The duality of whole and part, or a whole with parts, is always front and center in DID treatment. When the therapist asks the client to distinguish the parts responsible for a problem behavior and then becomes curious about their emotions, beliefs, motives, and defensive responses, he or she engages the left brain-driven part of the personality to “help” solve the issues and challenges raised by right brain-driven trauma-related parts. This skill is even more crucial in the treatment of clients with dissociative disorders than it is in work with fragmented individuals without DID. When right brain dominant parts can act independently outside the conscious awareness of the client, the need to have the balancing, stabilizing presence of a left brain self is especially crucial.
In Chapter 9, Repairing the Past: Embracing Our Selves, the premise is that resolution of traumatic experience is dependent upon overcoming survival-related self-alienation. By cultivating the growing attunement between child selves and grownup normal life self, each aspect of self feels an increasing comfort in the other’s presence, greater safety, and a warmth in connection. But in order to foster attachment bonds between traumatized individuals and their young selves, the therapist first must help clients acknowledge, connect, and identify with the normal life adult inside themselves—the self that has the ability to care for and express caring, that has always been instinctively driven to seek safety, normality, and stability, that can “be here now” for a small child in need of safe attachment.
Distorted cognitions associated with shame and self-loathing often interfere with clients’ ability to feel connected even to strengths they are aware they possess. Perhaps it was unsafe as a child to have strengths or a desire for mastery without traumatic consequences. The parts may be triggered by normal life activities (such as a job, a partner relationship, responsibilities, or simply having to be visible), undermining the client’s ability to handle them. Internal conflicts between parts may debilitate or destabilize the normal life self or block attempts at developing a life after trauma.
Using clinical examples to illustrate in detail how the therapist can foster the innate compassion of the normal life self on behalf of wounded child parts, the reader is given a template for how internal acceptance is built by drawing on the client’s strengths and life experiences as resources for the young child selves. While the left brain self has been learning and storing competencies, these abilities have not been available to the right brain selves. This chapter illustrates interventions that bring the two sides into contact and evoke pleasurable moments of attunement and togetherness that become the building blocks of internal secure attachment. The human brain’s complexity allows us to heal ourselves: it endows upon us the unique ability to access acquired capacities and engage them on behalf of other parts sharing the same brain and body.
In Chapter 10, Restoring What Was Lost: Deepening the Connection to Our Young Selves, the healing work takes another step forward. First, clients must earn the parts’ trust, made challenging by their implicit memories of inadequate bonding and failed trust that both increase the yearning to trust but also increase hypervigilant resistance to trusting. The therapist consistently asks the client, on behalf of the parts, to communicate, collaborate, and extend compassion to them, slowly building up a felt sense of an internal attachment figure, one who shares the same brain and body, one who might have once been the age of the parts but now is a strong, caring adult committed to creating a life different from the past: safe, nourishing, and relational.
In Chapter 11, Safety and Welcome: The Experience of Earned Secure Attachment, we address “integration” not as a goal of treatment but as a process that occurs organically when we use mindfulness-based techniques to bring awareness and compassion to the system of traumatized parts. As defined by Daniel Siegel (2010), “Integration results from differentiation coupled with linkage.” Asked to bring focused attention to a young part in distress, the client is asked to imagine a young child of the same age with the same emotions in the room, “standing right there before you.” By bringing the child part inside “alive,” the therapist facilitates the client’s access to right brain-based inherently compassionate intuitive responses. Using guided visualization, the therapist evokes images of the child’s face, body language, and plight to increase the sense of connection or empathy between child and normal life adult and the latter is asked to notice, “And how do you feel toward that part now?” Repeatedly, client and part are asked to mentalize the other’s mentalization, to notice how one impacts the other, stimulating a felt sense of connection, then enhancing the bond by sharing their responses again and again: “Ask the little girl how it feels to hear you say, ‘I’m glad I’m here—I want her to feel safe’.” While internal bonds of secure attachment are built through the dyadic interchanges between adult and part, the normal life self of the client is also asked to repair the distressed state of the child or create a new ending to the story of distress, just as secure attachment figures do. Imaginal experiences of healthy, safe attachment can generate the same feelings and sensations and evoke the same “attunement bliss” that babies and mothers enjoy, and, by simply focusing mindfully on these moments, they can be encoded as readily as a concrete, physical experience of safety and attunement (Hanson, 2014).
Chapter 11 stresses again that emotional healing of traumatic wounds has to be attachment-based. Like long-lost young relatives, the alienated disowned parts must be invited to the table and welcomed into the heart and mind and arms of the client. This process can be very moving for both client and therapist but is not without its challenges. The trauma-related fear of self-compassion is strong and unbending, leaving the therapist with the job of holding a calm, clear, courageous stance that alienation from or rejection of any part leaves us less than whole. Without welcoming each and every part “home” and offering safe, unconditional acceptance, survivors can’t fully heal the wounds left by the failed empathy of the caretakers who harmed them or allowed them to be harmed when they were too little, too alone, and too vulnerable to defend themselves. For those clients traumatized as adults, the therapist has to be absolutely clear that resolution still depends upon all parts finding safety after trauma: young parts whose needs were not reliably met in childhood or who interpreted the traumatic events in the light of insecure attachment, adolescent parts whose fight and flight responses have been reactivated, despairing submissive parts who “took the fall” in an inescapable situation, even suicidal parts who would rather turn their swords on themselves rather than be humiliated or abandoned.
Dan Siegel’s conceptualization of “earned secure attachment” reflects the belief of many in the attachment field (Main, Schore, Lyons-Ruth) that childhood attachment wounds can be modified through life experiences that “grow” states of secure attachment, even in adulthood. These experiences might include raising one’s own children, healthy friendships and intimate relationships, or creating secure attachment relationships with one’s parts. Each of these avenues for earned security capitalizes on the brain’s ability to grow new neural networks and encode new, pleasurable feeling states. By imaginally evoking new implicit memories of safety and attunement, parts feel the inner sensate experience of healthy attachment, moments that can be encoded alongside the painful memories of failed or frightening attachments, changing the ending of the story. “Earned security” is measured by the degree of “coherence” exhibited by individuals reflecting on their early attachment relationships on the Adult Attachment Inventory, that is, the degree to which they have integrated the bitter and the sweet of their lives, the pain then and the pleasure in relationships now.
Only the human brain can create a new story of safety, closeness, and compassion by evoking states of well-being connected either to imagined or remembered experiences. For neuroplastic brain change to occur, only three ingredients are needed: first, clients have to be helped to inhibit their habitual emotional, physical, and cognitive patterns. Next, they have to practice a new pattern with which they’d like to replace the old—and then practice the new pattern over and over again without losing the felt connection to the child and to their own bodies. It could be as simple as bringing the right hand over the heart to communicate calm or repeating the words, “It’s okay now” or “I’m here now.”
A client’s new “healing story” might sound a bit like this: “Once upon a time, my parts felt as unsafe and unlovable as I did as a child. Now I don’t feel anxious that I’ll be rejected and abandoned, and neither do they. I know I’m OK, and I know they’re OK—I feel connected to my parts and to myself, and I’ll always be here to keep them safe. They are special to me and always will be.”
In the appendices that follow Chapter 11, therapists and clients will find some additional tools to help them with the tasks presented throughout the book. Appendix A consists of a simple protocol for learning how to unblend from parts, especially parts with intense feelings that hijack the prefrontal cortex and destabilize the client. Appendix B consists of a meditation circle practice for parts. Appendix C presents the Internal Dialogue protocol that, practiced over and over again, builds the ability to communicate internally, calm and comfort distressed parts, and grow the bonds of compassion. Appendix D presents a treatment paradigm for internal attachment repair. Appendix E consists of a worksheet, the Dissociative Experiences Log, for helping clients increase the ability to track and differentiate the signs of parts’ activity and communication. And Appendix F provides a script for the Four Befriending Questions, a technique that builds inner communication and bonds of love and trust.
Psychotherapists have wondered and worried and philosophized for hundreds of years about the nature of healing. This book describes one theory about healing the effects of trauma and traumatic attachment that emerged from my clinical observations: healing is the outcome of reversing long-standing patterns of self-alienation and building the capacity to love and accept our “selves.” When we reclaim our lost souls and wounded children, befriend them, and allow ourselves to trust deeply felt compassionate impulses to reach out to them and build bonds of secure attachment, they feel safe and welcome at long last. And we feel whole.
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