This chapter describes two particular sessions in the course of therapy of a woman with a severe dissociative disorder. In the first of these sessions, the authors used the Constant Installation of Present Orientation and Safety (CIPOS) procedures to assist her, not only in targeting and resolving overwhelmingly difficult memory material, but also to facilitate therapeutic dialogue between separate parts of the personality. In a subsequent session, sets of bilateral stimulation (BLS) were also used to help her let go of an intense positive feeling—a psychological defense that was held by a young emotional part (EP), but was problematic for her apparently normal part (ANP). In both of these sessions, the healing effects of sets of BLS (i.e., a lessening of fear; an increase in realization of positive, reality-based information) were important in helping her resolve what previously had been a very difficult internal conflict.
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Posttraumatic stress, whether big T or little t, is a distortion of perception. Something terrible happened in the past, and today, feelings—anxiety, helplessness—erupt into the person’s consciousness, even though there is currently no present danger. The standard eight phases of eye movement desensitization and reprocessing (EMDR), with targeted sets of bilateral stimulation (BLS), have the reliable effect of moving this distorted perception to clarity and objectively accurate understanding of past and present realities. EMDR therapy targets and resolves the dysfunctionally stored memories that are the basis of an individual’s psychopathology. Typically, this means focusing EMDR procedures on specific disturbing memories. However, for some clients, at least some of the time, the only point of entry into the dysfunctional memory network will be an idealization defense—a behavior, or an image of self or others, that contains positive affect.
The method of Constant Installation of Present Orientation and Safety (CIPOS) is a procedure that can extend the healing power of eye movement desensitization and reprocessing (EMDR) to a much wider population of clients. It works on the principle that, by expanding and developing an individual’s ability to remain oriented to the safety of the present situation, that person, then, is much more able to safely access and resolve highly disturbing memory material. The CIPOS intervention utilizes short-term memory (STM), which is a particular memory phenomenon that is easily observed and which overlaps substantially with another phenomenon, working memory (WM). The CIPOS procedure is a way of helping clients learn to reduce their own catastrophic expectations regarding access of traumatic memories, while also learning an important skill—the skill of more and more easily coming out of trauma and back to the present.
An understanding of dissociation begins with the recognition that human personalities—dissociative and nondissociative—universally have parts. Sometimes, the structure of these parts involves amnesiac separation as well as significant conflicts between parts, and these conflicts, in turn, often cause significant emotional problems. This chapter provides a brief description on treating dissociation within an adaptive information processing model. It is unfortunate that there has been a kind of “sibling rivalry”, between Eye Movement Desensitization and Reprocessing (EMDR)-related methods and cognitive-behavioral methods of treatment for trauma-related conditions, including dissociative disorders. A discussion, between client and therapist, of how cognitive models apply to the individual case, are often important as a preliminary step to prepare that client for the arduous and potentially destabilizing work of trauma processing.
- Go to chapter: The Need for a Theoretical Framework and Additional “Tools” for Using EMDR With Complex PTSD
Many experienced therapists who take the standard eye movement desensitization and reprocessing (EMDR) initial training are impressed, and even surprised, by how quickly this therapy approach can transform the disturbing feelings that are held within dysfunctionally stored traumatic memories. But, even with this realization, it is often challenging to bring the full power of EMDR into therapy and work with clients who have a variety of presentations that do not line up exactly with the definitions of acute stress disorder or posttraumatic stress disorder (PTSD). There is not a specific diagnosis for complex PTSD within the Diagnostic and Statistical Manual, either the fourth edition (DSM-IV) or the fifth edition (DSM-5). The clinical picture of complex PTSD, includes, to varying degrees, not only attachment difficulties but also dissociative personality structure, dysfunctionally stored traumatic memories, and psychological defenses—particularly avoidance, idealization, addictive behavior patterns, and shame defenses.
The complex connections between issues of attachment and dissociation into parts can often be communicated to clients using a “language” of ovals. These ovals, drawn on paper during a therapy session, represent the client’s self-states or parts and complex memory networks. Drawn pictures of ovals can be used to represent the development of both positive and dysfunctional attachment patterns and the connection between dysfunctional patterns and structural dissociation within the personality. The use of this method of communication, through ovals, is especially useful for those clients who are initially frightened of the idea that they have separate parts of self, some of which may be dissociated. The use of ovals is not a rote procedure, but it is a flexible means of giving both client and therapist a communication language for how the client’s separate parts developed as a natural and normal adaptation to his or her childhood environment.
For many clients, shame is hidden beneath other aspects of a client’s presentation, such as chronic anger, depression, substance dependence, or general social withdrawal. And, for other clients, chronic shame is not at all hidden, but is a very visible part of the client’s initial presentation in therapy. When a client comes into therapy with very low self-esteem—a lack of confidence and a self-definition of inadequacy, badness, unworthiness, or deficiency—and these qualities have little or no apparent basis in that person’s abilities or behavior, the therapist should be alert to the possibility that the client’s negative self-assessment is serving a defensive purpose. A defense is any mental action or behavior that has a function within the personality of preventing full conscious awareness of disturbance connected with trauma. Shame or self-blame does not feel very good.
The Loving Eyes procedure, simply put, is asking an oriented part—typically the apparently normal part (ANP)—to form a visual image of an emotional part (EP)—a younger part that is experientially reliving a traumatic event. An ANP may be phobic of an EP because of the potentially overwhelming disturbance or information the EP contains, and because of the disruptive influence of the EP on the main function of the ANP—doing the tasks of daily living while maintaining an appearance of normality. Conversely, EPs are often frightened of encountering the judgment and rejection of an ANP and hide themselves from being accessed by ANP. These factors may be so intense as to prevent dual attention, thereby preventing the standard use of eye movement desensitization and reprocessing (EMDR). This chapter provides examples on loving eyes method as an intervention when there is “too much” disturbance, and when there is “too little” disturbance.
“Doug” was a Vietnam veteran who came to therapy in 1993, 25 years after his deployment. His initial presenting problem included chronic general anxiety as well as indecision regarding whether to continue his 20-year marriage. Doug had some very difficult times growing up. Several representative memories were targeted with eye movement desensitization and reprocessing with good results, in that Doug was able to view these events much more from an adult perspective and let go of the feelings of fear and unworthiness that had previously been connected with these particular memories. These positive results with childhood memories helped him take a second look at what could be done with the memories from Vietnam. He continued to have a strong avoidance wish with regard to thinking about his war experiences, but he was also now able to view this avoidance impulse from a place of some emotional distance and perspective.
For the dissociative client, therapy must begin and proceed with cautious vigilance regarding the client’s ability to maintain a sense of safety and orientation to the present. A client may initially have a great fear, or reluctance, to disclose, or to consciously access, personal information, memories, attitudes, emotions, physical sensations, and other mental actions. The identification of therapy goals is important, not only to structure treatment planning and therapy sessions, but also to help the client impose some increased clarity on the confusing push and pull of separate internal self-states. There are many therapeutic interventions that can help the dissociative client untangle the confusing, often contradictory, structure of internal parts. Very useful preparation procedure, especially for clients who have inadequate attachment experiences early in life and/or repeated trauma, is the Early Trauma Protocol (ETP) developed by Katie O’Shea (2009).