Comprehensive Treatment of Complex Trauma and Dissociative Disorder: The Internal Family Systems Therapy Approach ISSTD

1. Comprehensive Treatment of Complex Trauma and Dissociative Disorder: The Internal Family Systems Therapy Approach ISSTD Conference, November 19th, 2009 Mark F. Schwartz, Sc.D., Richard Schwartz, Ph.D., and Lori Galperin, MSW, LCSW Castlewood Treatment Center for Eating Disorders 800 Holland Road Ballwin, MO 63021 Phone: 636-386-6611 Website: castlewoodtc.com

2. Introduction

4. Violence – Part 1 The soul needs love as vitally and urgently as the lungs need oxygen. It may not be self-evident to healthy people just how literally true this is, for healthy people have resources of love that are sufficient to tide them over periods of severe and painful rejection or loss. Similarly, one does not realize how dependent the body is on oxygen until one has nearly suffocated, or has had to resuscitate someone who is gasping for breath. But when one has worked with deeply and seriously ill human beings, the evidence of the need for both oxygen and love is overwhelming. The kind of man I am describing protects himself from the emotional suffocation of living in a loveless atmosphere by withdrawing the love he has begun to feel from everyone and everything, in an attempt to reserve for himself whatever capacity for love he may have. But his supply of self-love is also deficient. And it cannot grow to the dimensions that are necessary for health when it is not fed by love from others. If it were not deficient, he could afford to love others. But his withdrawal of love from everyone and everything around him not only protects him from emotional pain, it also condemns him to the absence of emotional pleasure or joy; for we cannot enjoy the people who make up our world, cannot enjoy being with them, except to the degree that we love them. So the person who cannot love cannot have any feelings – pain or joy. But a joyless life is a synonym for hell. A man who does not love and cannot love, is, in effect, condemned to hell. His entire environment from which – without love – he is cut off, is without enjoyment for him, and thus the world he “lives” in is a source of emptiness and emotional suffocation for him. Both the world and the self are experienced and perceived emotionally as being dead, inanimate, without a soul – without feelings. From: Gilligan, J. (1996). Violence: Our Deadly Epidemic and Its Causes. New York: G. P. Putnam’s Sons, pp. 51-52.

5. Cybersex • As of January 1999, there were 19,542,710 total unique visitors/month on the top five pay porn Websites, and there were 98,527,275 total unique visitors/month on the top five free porn Websites. • In November 1999, Nielsen Net Ratings figures showed 12.5M surfers visited porn sites in September from their homes, a 140% rise in traffic in just six months. • Nearly 17% of Internet users have problems with using sex on the Net. • Severe problems with sex on the Net exists for 1% of Internet users, and 40% of these extreme cases are women. • Most e-porn traffic, about 70%, occurs weekdays between 9 a.m. and 5 p.m. • There are 100,000 Websites dedicated to selling sex in some way; this does not include chat rooms, e-mail or other forms of sexual contact on the Web. • About 200 sex-related Websites are added each day. • Sex on the Internet constitutes the third largest economic sector on the Web (software and computers rank first and second), generating $1 billion annually. • The greatest technological innovations on the Web were developed by the sex industry (video streaming is one example).

6. Trauma Bond Why it must be addressed: • As long as the trauma bond remains strong, the internal and external safety necessary for healing/recovery work does not exist. • Overtly and covertly abusive relationships may continue with the abusive family of origin. • Re-enactment: The patient may attempt to solve the primary abusive relationship problems through re-enacting these relationships in other significant relationships. (e.g., abusive spouse)

7. Trauma Bond II Can be understood as lack of individuation or differentiation. • Victim to victimizer model including: Re-enactment for mastery. • Trauma bonded person is left with the feeling: “I am just like him/her (abuser), I am one of them ( member of abusive family), therefore unacceptable to the outside world.”

8. Control of Symptom vs… Recovery

9. Why, for instance, does an ostensibly “honorable man” do something that betrays? Why does an apparently “honest” man do something deceitful? Why does a generally “kind” man do something that wounds? Why does a reputably “caring” and decent man commit an act so steeped in contempt that it is as if someone else had done it, for he himself could not possibly? Those of us raised to be men of must ask such questions of ourselves. And all of us must ask such questions about the men whom we know most intimately…why, I have wondered, are “good” men sometimes so completely unreliably moral? Why do we sometimes act as if we have lost our values mooring, lost sight of our beacon, convictions, lost hold of our sense of self? What is going on in us? Why do we evidence such wanton behavioral swings – such unpredictable splits in who we are? Stoltenberg, 1993

10. Aleksandr I. Solzhenitsyn If only there were evil people somewhere insidiously committing evil deeds, and it were necessary only to separate them from the rest of us and destroy them. But, the line dividing good and evil cuts through the heart of every human being, and who is willing to destroy a piece of his own heart? Gulag Archipelago

11. “SELF-EMPATHY” - The internalizing (evoking) of the attentive, validating, caring relationship to oneself. This involves helping the client articulate her experience and bring it into her own internal relational context.

12. Shame Let’s take a closer look at this process. Imagine a situation in which a child awakens from a nightmare and cries out in fright. The child screams, “I’m scared, I’m scared! There’s a monster!” Mother abruptly silences the child’s screams with, “Now stop that. Don’t be silly. Big boys don’t get scared of silly things like dreams.” The effect upon the lad is that he has been shamed for being afraid. Perhaps this same boy, running away from a bully at school, is told by his Dad, “Don’t be a coward! Read boys aren’t afraid to fight.” If this boy has sufficient experiences in which his scared or frightened feelings are met with shaming, he will learn that there is something wrong with him whenever he feels afraid. Feeling afraid has become shameful, bad. Situations which trigger fear will now also trigger shame. This indirect activation of shame has now become autonomous, thereby causing the expression of fear itself to become bound by shame. Thus, a particular affect can come to spontaneously activate shame without shame itself being directly induced. Kaufman

13. Rupture in Attachment Impingement(Greenburg & Mitchell) The child’s psychological survival must not depend upon meeting the mother’s needs. The major consequence of prolonged impingement is fragmentation of the infant’s experience. Out of necessity, he/she becomes and requests of others. The child’s “true self,” – the source of spontaneous needs, images and gestures – goes into hiding, becomes detached and atrophied. The “false self” provides an illusion of personal existence whose content is fashioned out of maternal expectation. The child becomes the mother’s image of him.

14. Self-parenting: according to survivors, qualities of ideal parent • Unconditionally loving and accepting. • Affirming. • Takes responsibility. • Sets and teaches healthy boundaries. • Is protective. • Values play. • Is forgiving of mistakes. • Encourages growth. • Listens to child in open and receptive way. These are the qualities of the ideal “self-parent”

15. Reflectivity Accounts vary in the extent to which people are able to reflect on their experiences, for example, to remember how they felt, why they felt like this, how else they may have felt. Importantly, this also relates to their abilities to form ideas about other’s internal states; for example, to be able to consider what might have been going on in the mother’s or father’s minds – feelings, intentions, needs and explanations which may have guided their actions (Fonagy et al., 1991; West, 1997). This has variously been termed psychological-mindedness, sociality (Kelly, 1955, Proctor, 1981, 1984) and ‘theory of mind’ (Baron-Cohen, 1997). According to Fonagy et al.: The development of the reflexive self is, thus, intrinsically tied to the evolution of social understanding. It is through the appreciation of the reasons behind the actions of his caretakers and siblings that the child can come to acquire a representation of his own actions as motivated by mental states, desires and wishes. Fonagy et al., 1991, p. 203

16. Middle Adolescence “What am I as a person? You’re probably not going to understand. I’m complicated! With my really close friends, I am very tolerant. I mean I’m pretty understanding and caring. With a group of friends, I’m rowdier. I’m also usually friendly and cheerful but I can get pretty obnoxious and intolerant if I don’t like how they are acting. I’d like to be cheerful and tolerant all of the time, that’s the kind of person I want to be, and I’m disappointed in myself when I’m not. At school, I’m serious, even studious every now and then, but on the other hand, I’m a goof-off too, because if you are too studious, you won’t be popular. So I go back and forth, which means I don’t do well in terms of my grades. But that causes problems at home, where I’m pretty anxious around my parents. They expect me to get all A’s and get pretty annoyed with me when report cards come out. I care what they think about me, and so then I get down on myself, but it’s not fair! I mean I worry about how I should get better grades, but I’d be mortified in the eyes of my friends if I did too well. So I’m usually pretty stressed out at home, and can even get very sarcastic, especially when my parents get on my case. But I really don’t understand how I can switch so fast from being cheerful with my friends, then coming home and feeling anxious, and then getting frustrated and sarcastic with my parents. Which one is the real me? I have the same question when I am around boys. Sometimes I feel phony. Say I think some guy might be interested in asking me out. I try to act different, like Madonna. I’ll be a real extrovert, fun-loving and even flirtatious, and I think I am really good-looking. And then everybody and I mean everybody else is looking at me like they think I am totally weird! They don’t act like they think that I’m attractive so I end up thinking that I look terrible. I just hate myself when that happens! Because it gets worse! Then I get self conscious and embarrassed and become radically introverted, and I don’t know who I really am. Am I just acting like an extrovert, am I just trying to impress them, when I am really an introvert? But I don’t really care what they think, anyway. I mean, I don’t want to care, that is. I just want to know what my close friends think. I can be my true self with my close friends. I can’t be my real self with my parents. They don’t understand me. What do they know what its like to be a teenager? They treat me like I’m still a kid. At least at school, people treat you more like you’re an adult. That gets confusing, though. I mean, which am I? When you are 15, are you still a kid or an adult? I have a part-time job and the people there treat me like an adult. I want them to approve of me, so I’m very responsible at work, which makes me feel good about myself there. But then I go out with my friends and I get pretty crazy and irresponsible. So which am I, responsible or irresponsible? How can the same person be both? If my parents knew how immature I act sometimes, they would ground me forever, particularly my father. I’m real distant with him. I’m pretty close to my mother though. But it’s being distant with one parent and close to the other, especially if we are together, like talking at dinner. Even though I’m close to my mother, I’m still pretty secretive about some things, particularly the things about myself that confuse me. So I think a lot about who is the real me, and sometimes I try to figure out when I write in my diary, but I can’t resolve it. There are days when I wish I could just become immune to myself! The Construction of Self

17. Attachment and Self Fantasy Attachment becomes a highly structured vehicle through which increasingly complex information about the self becomes available. Developmentally, attachment contributes to acquired selfhood structures. Children abstract their uniqueness from the experience of being involved in a unique relationship with and then transform that relationship to identity.

18. Bowlby’s Hypothesis (Bowlby, 1990) Each person’s resilience or vulnerability to stressful life events is determined, to a very significant degree, by the pattern of attachment during early years.

19. Secure Attachment I • Because their caretakers have been routinely available to them, sensitive to their signals, and responded with some degree of reliability (though by no means is perfect care required,) these infants develop a confidence that supportive care is available to them. • They expect that when a need arises, help will be available. If they do become threatened or distressed, the caregiver will help them regain equilibrium. • Such confident expectations are precisely what is meant by attachment security. L. Alan Stroufe, 2000

20. Stroufe Securely attached individuals who have internalized the capacity for self regulation are compared to those who either down regulate (avoidant) or up regulate (resistant) affect. Felt security is no longer restricted to caregiver behavior. Appraisals of availability of security figure including threats of suicide, of leaving or sending the child away, or marital separation anticipated, all influence security.

21. Multiple Internal Working Models Reciprocally incompatible and segregated or dissociated models of self and of the attachment figure are constructed and, thereby, interfere with integrative functions of memory, consciousness and identity. This suggests that dissociative is more than a defense against trauma. The results are sequential simultaneous or trance-like contradictory behavioral systems. Disorganized infants are unable to synthesis their overall experiences of their interaction with the caretaker into cohesive mirroring structure.

22. Main Her interest was in the narrative coherence. Rather than focusing on the individual’s story, she looks at the structure of the story. What the person allows themselves to know, feel and remember in telling the story. Breaks in the story, disruptions, inconsistencies, contradictions, lapses, irrelevancies, and shifts are linguistic efforts to manage that which is not integrated or regulated in experience or memory. Fonagy calls this “mentalizing” affective experience to reflect upon the diversity and compliant of internal mental states. Specific memories used as evidence supporting general descriptions of primary relationships are important.

23. Dismissing of attachment Idealization. Dismissing derogation. Lack of memory. Response appears abstract and remote from memories or feeling. Regard self as strong, independent, normal. Little articulation of hurt, distress or needing. Endorsement of negative aspects of parents behavior. Minimizing or downplaying negative experiences. Positive wrap-up. No negative effects. Made me more independent.

25. Loving – there for child emotionally (cherish) Rejection – turning away attachment (rebuff/minimize) Involving/Preoccupying – guilt induction (spousification) Neglect – inaccessible when physically present (workaholic, narcissistic parents) Pressure to Achieve – perform or risk love

26. Metacognitional Metacognition means treatment of one’s mental contents as “objects” on which to reflect, or in other words “thinking about one’s thinking.” Distinct skills contribute to its characterization, such as the ability to reflect on one’s mental states, elaborating a theory of the other’s mind, decentralizing, and the sense of mastery and personal efficacy.

28. Self healing

29. Self Healing Therapist is no longer “healer” but more “mid-wife,” facilitating the birth of that which already exists inside the client, waiting to be born.

30. Schema of Self He emphasized the value of the alternative, psychological approach, which explains posttraumatic symptomatology as a consequence of the shattering of schemata concerning the self and the world. Trauma disrupts the meaningful organization of life experience, thereby exerting a debilitating effect on self-perception and ability to face the future. Shay, 1995

31. False Self (from Winnicott) Parents who are intensively over-involved with their infant cause the child to develop a false self based upon compliance. Care-giver doesn’t validate the child’s developing self, thus leading to alienation from the core self. Parenting practices that constitute lack of attunement to the child’s needs, empathetic failure, lack of validation, threats of harm or coercion and enforced compliance, all cause the true self to go underground.

32. reenactment

33. The Protagonist does not know that the performance is designed to master “events” that were once too exciting, to frightening, too mortifying to master in childhood. Unable to remember the events, his life is given up to reliving them in a disguised form. (Stoller, 1986)

34. Intra-Psychic Conflict Extension of intra-psychic conflict onto the stage of the outer world often manifests itself in interactions with others that cannot strictly be called interpersonal, because they are essentially extensions of the individual’s problems from the past. These problems are played out using another, not for his or her real self, but as an involuntary actor cast in a role from a scenario the patient repeats in the present in order to avoid past memories and feelings. From Masterson, J & Orcutt, C. (1989). Marital Co-Therapy of a Narcissistic Couple. In J. Masterson & R. Klein (Eds.), Psychotherapy of the Disorders of the Self. New York: Brunner/Mazel

35. dissociation

36. Putnam “Developmental Model” Multilevel developmental disturbances are produced by the segregation or compartmentalization of information, skills, and behavior into discrete dissociative states, such that this knowledge is only erratically (as opposed to reliably) available to the individual. Difficulties with the integration of dissociatively compartmentalized information impair metacognitive executive functions and iteratively disrupt the developmental consolidation of sense of self over the life course.

37. Dissociation • Early dyadic processes lead to a “primary breakdown” or lack of integration of a coherent sense of self, i.e. Unintegrated internal working models. • Disorganized attachment is the initial step in the developmental trajectory that leaves an individual vulnerable to developing dissociation in response to trauma. (Liotta, 2000)

38. Pathological Dissociation Four characteristics distinguish pathological from normative dissocation: Only in pathological dissocation do we encounter loss of executive control, change in self-representation, amnesic barriers, and loss of ownership over behavior. Kluft, 1993

39. The Self is a Conglomeration of Selves, Multiple Mental Systems • Each with the capacity to produce behavior • Each with its’ own impulses for action • One system can be cut off from other (unconscious) • Verbal self gives meaning and consistency; language becomes linked with identity and meaning making • Defense systems service the self to preserve sense of consistency

40. Pathological intensification The natural healing trajectory of the organism is impeded. The adaptation, that was originally self preserving, becomes entrenched rather than giving way naturalistically to the next phase of healing, as though it has become “snagged” on something. The “something” is prior unresolved, related “burdens.”

41. Multiplicity Internal Family Systems presumes an innate multiplicity, i.e. the unfolding of parts is natural, whether under normative, optimal or abysmal life circumstances. The degree of access and smooth interplay of parts vs. the compartmentalization and degree of polarization of parts, relates back to the kind and degree of burdening, i.e. how much has to be “exiled” and the amount of “protection” it takes to keep it so.

42. Out of control behavior as a trailhead

43. What becomes of this forbidden and therefore unexpressed anger? Unfortunately, it does not disappear, but is transformed with time into a more or less conscious hatred directed against either the self or discharge itself in various ways permissible and suitable for an adult.

44. Every deep desire, every powerful emotion, gives a trail into the unconscious. Usually there is only one-way traffic: outbound, toward the world of sensation and action. But we can follow the trail to its source by going against the current. With this desire to go against desire, to buck the demands of biological conditioning, the journey of self-realization begins in earnest. Meditation in Action Eknath Easwaran

45. Celebrating the Symptom Sincere letter of gratitude to Protective Parts for their efforts on behalf of survival or safety (relatively speaking).

46. Repetition Nevertheless, the need to repeat also has a positive side. Repetition is the language used by a child who has remained dumb, his only means of expressing himself. A dumb child needs a particularly empathic partner if he is to be understood at all. Speech, on the other hand, is often used less to express genuine feelings and thoughts that to hide, veil or deny them and, thus, to express the false self. And so, there often are long periods in our work with our patients during which we are dependent on their compulsion to repeat - for this repetition is then the only manifestation of their true self. - Alice Miller

47. Affect and Cognition I Janet believed that traumatized individuals became phobic about memory because they have failed to develop narratives about their traumata, instead experiencing posttraumatic amnesias and hyperamnesias van der Kolk, Brown & van der Hart, 1989

48. Fear of Overwhelming Affect Preach “Forgiveness” Stop! Before it intensifies Circumvent Change subject – stop abreaction or witnessing in mid-stream Keep the therapy purely Cognitive Behavioral Decide the client is not yet ready to deal with their trauma “Fix it” – whenever the client begins to feel Cite statistics to bolster your sense of rightness Project Rescue Avoidance

49. Affect and Cognition III His treatment approach involved bringing compartmentalized memories and feelings into consciousness where they could be processed therapeutically. He anticipated contemporary treatment strategies with his three-phase therapy model. van der Kolk, Brown, & van der Hart, 1989

50. Abreaction With Sexual Abuse Survivors (Hunter, 1991) Abreaction is revivification of past memory with release of bound emotion and recovery of repressed or dissociated aspects of a remembered event. Abreaction provides a psychic reworking of the trauma that identifies, releases and assimilates unresolved aspects of the abuse, allowing resolution and integration on both psychological and physiological levels.