*Integration of IFS Interventions in the Standard

EMDR Protocol

Joanne H. Twombly, LICSW740 Main St. Room 105

Waltham, MA 02451J.Twombly@verizon.net

Learning objectives� EMDR therapists will learn to identify and

describe cases where IFS/ego state interventions will enhance and enable EMDR processing.

� Therapists will have knowledge of IFS/ego state interventions.

� Therapists will learn and be able to initiate IFS/ego state interventions in the Desensitization Phase

� EMDR therapists will be able to utilize an IFS process to clarify and utilize countertransference reactions to facilitate the client’s process through out the 8 phases of EMDR treatment.

� Basically to increase choices, options, angles of intervention and to get a taste of IFS!

Workshop Summary

Part 1:� Didactic on IFS/Ego State interventions� Phases of EMDR with IFS interventions� Case examplesPart 2:� When Countertransference Occurs� IFS strategy for dealing with

Countertransference� Demo� Practicum� Questions and Discussion

Ego States 101� We all have ego states.� They are all adaptive response to culture

and/or life, i.e. all are created to help� Are formed through introjects of parents or

other significant people, or around important events

� Can be formed in response to cumulative trauma and deprivation, attachment trauma, and neglect

� Or to manage attachment problems: Parents who accept some parts or aspects of their children, and “disconfirm” others. (Bromberg 2001)

� Parents with dissociative disorders, can model that for their children to copy.

� Parts who are organized around animal responses to trauma: fight, flight, freeze, collapse, and attachment cry

Basic IFS Concepts (Schwartz, 1995)

� Normal multiplicity of the mind. ◦ Normalizes we all have parts!

� *Everyone has a core Self with solid leadership qualities like confidence, compassion and curiosity.

� We have an inherent healing wisdom◦ This is consistent with EMDR’s concept of

Adaptive Information Processing – it’s the client’s brain that’s doing the healing…

� The intention of all parts is positive.� Dysfunction occurs when parts become

burdened with traumatic material and become blended with Self.

Basics Concepts cont.

� Process of therapy: Un-blend parts from Self, thereby releasing Self ’s resources. From Self the client can help parts get rid of burdens.

� To achieve balance and harmony within internal systems, and to

� Lead a Self-Led life

SELFExile

Bullied at School

Exileabuse

ExileAnxiety

Exileshame

ManagerCompliant

ManagerParentified child

ManagerPerfectionist

Firefighter Rager

FirefighterETOH

Blended!

ExileBullied at School

Exileabuse

ExileAnxiety

Exileshame

ManagerCompliant

ManagerCritic

ManagerPerfectionist

Firefighter Rager

FirefighterETOH

SELF

Unblended

SELF

� Self is often in the center of the “You”

� Self is not a part – it is always there� Self is competent, curious, calm,

centered, compassionate, etc.� Self energy is healing!� Parts with burdens become blended

with Self and often don’t know anything about Self

� Preview of 2d part: Therapists do their best work when they are in Self or a good enough Self like part!

3 GENERAL GROUPS OF PARTS

� Exiles

� Managers

� Firefighters

EXILES� Child parts that experiencedtrauma and became isolated fromthe rest of the system in an effort to protect the client from the impact of the burdens (pain, terror, fear, etc.) that these parts carry.

� Can become increasingly extreme and desperate in an effort to be cared for and get their story told

� ACOA concept of an inner child or inner children!

� Emotional Parts of the Personality (EPs)

MANAGERS� Parts that run the day-to-day life of the

individual – keep the status quo

� Attempt to control every situation and relationship in an effort to protect parts from getting triggered and activated

� Can do this in any number of ways or through a combination of parts e.g. parts who are controlling, critical, care takers, minimizers, parentified children, codependent, alexithymic, etc.

� Apparently Normal Parts, ANPs

FIREFIGHTERS

� Parts that react in extreme ways when Managers get overwhelmed and Exiles are activated

� Goal is to control and extinguish the Exile’s feelings in any way possible

� Can do this in any number of ways including: drug or alcohol use, Self-mutilation, binge-eating, acting out, etc.

� Have same goals as managers (keep exiles away) but have different strategies – they come out in emergency and act radically

Summary of IFS Steps to Healing� Access Self by assisting parts to -� Un-blend from Self (parts know how to

do this!)� Parts are systematically

Witnessed by Self � Retrieved i.e. brought

into the present� Un-burdened � In place of the burdens

positive qualities areinvited in, and

� The internal family becomesReconfigured

Common Concerns of Parts When Asked to Relax and Separate

� Concern: If I step back nothing will be there

Answer: Self will be there. Try it for 5 seconds

� Concern: Something bad will happen.Answer: Then you can come right back.

You have control of separating or being blended

� Concern: You’ll never work with meAnswer: Make a commitment to work

with that part when the time is right.� Concern: But, but, but…Answer: Ask: What do you think will

happen? Then address the concern

Overall Goals of IFS Therapy

� To achieve balance and harmony within our internal system by freeing parts from their burdens

� Self becomes an effective leader in our internal system.

� With Self Leadership, Parts can provide input to Self, while respecting the leadership and decision-making of Self

IFS Process with a Client1. Identify negative situation, feeling, reaction2. What thoughts, feelings and sensations come up

with it3. Focus on where you feel ____ and ask the part

that’s holding _____ to relax back4. If the part won’t or says No, ask: What concerns

does the part have?5. What are you feeling towards the part? [This is

to check for Self energy] Note: If you’re feeling something other than compassion/curiosity then you’re probably blended with another part! So, go back to step 3!

6. From Self: Ask the part: What does the part want you to know about it? [This is the Witnessing Step – this is done when the part feels fully understood by Self

7. From Self: Ask the part what is the part carrying from the past, i.e. burdens.8. From Self: Ask the part if the part is willing to unload some or all of the old feelings/belief/etc. [If Not, ask: What concerns does the part have and address them. Note: Part may need to be Retrieved from the past!]9. Check if there are any other parts with concerns.10. When the part has no concerns. Say: How does the part want to get rid of the old feelings? The part can let them go into wind, fire, earth, water, light or any other way that occurs to the part!11. Comment: “Notice what it’s like as it’s happening… How’s the part doing?” 12. Comment: “Great, the part has cleared out some space, now there’s some free space and he/she can invite in some positive qualities… just notice what’s coming in…”

And on to EMDR!� Good things about EMDR◦ It works faster than anything when processing

flows!� R-TEP/Recent Event Protocol◦ When client has good ego strengths and an

uncomplicated trauma history◦ So when you don’t have to, don’t complicate

things!� Add IFS when there’re complications� But you still need to screen for DDs

� (see: The Humanitarian Outlook Newsletter Issue 1 for article on the DES)

� Both IFS and EMDR need additions to the Standard protocols to work with DID/other DDs/extremely fragile people

When IFS can be Helpful!� EMDR Phase One: History-Taking◦ Ambivalence� Is there a part who doesn’t want to be in tx?� Is there a part with concerns about using

EMDR?◦ Secondary Gain� Is there a part that doesn’t want the symptoms

to go away? (IBS example, Smoking vs psychotic)

� Affect instability: can use IFS to identify the part(s) with e.g. anxiety and see what they need.

◦ Clarifying targets: e.g. somatic symptoms, substance abuse

Phase Two: Preparation� Resources◦ Self is a Huge Resource for people who can

get into Self!◦ RDI style: When has client had the

experience of being in Self? ◦ Install somatic/feelings/posture of being in

Self!◦ Cue it

� Use IFS to negotiate with parts to allow processing and or reduce the # of parts present during processing

Phase Three: Assessment

� Too much or too little affect� Ask for concerns (always a good

question)� Retrieving parts from the past◦ Aka orienting parts to the present◦ Make sure client has some Self energy◦ Ask client to ask the part if it’s ok to come

closer to the present or into the present.◦ Part can experiment with going back and

forth

Phase Four: Desentization� Being in Self helps maintain duality � Problems with bilateral stimulation� Are there any parts with concerns about

processing? Is there any inner objection?◦ Example: The affect disappears

� Adaptive Information Processing (AIP) blockages◦ Endless looping – Is there a part with a concern that’s

blocking processing?◦ Blocking Beliefs that don’t clear

� IF client is under-accessing affect, or over-accessing affect

� The IFS cognitive interweave◦ Ask the part who’s blocking to relax back!◦ Check for at least some Self Energy◦ What are the part’s concerns?

Examples

� Great session! Client called up day later with a massive hangover.

� Several targets successfully processed. Suddenly EMDR not working. Tgt blocked by manager. Negociated with manager so manager would allow 10% of affect/target to be processed.

Incomplete Sessions

� At the end of the session, check in with any parts (e.g. managers or firefighters) who gave their permission to allow processing and see what it was like for them.

� Check in with all parts and see if there are any questions or concerns

� Identify parts who need extra support (perhaps are holding heavy burdens) and ask if they’re willing to hold the burdens till the next session. (and/or combine with containers!)

-Phase Five: Installation: Is there a part keeping the VOC from a 7??

-Phase Six: Body ScanCheck for a Part(s) if there’s a

feeling that doesn’t clear

-Phase Seven: ClosureIs there any part that has anything

to say, or any concerns???

-Phase Eight: Reevaluation

Part 2: Using IFS to sort through Countertransference Summary

� Therapist Stance per IFS� Non-Verbal Communications◦ Enactments◦ Countertransference◦ Projective Identification

� Dealing with Countertransference IFS Style

� Demo� Praticum� Discussion

Therapist Stance from an IFS Perspective

� Therapy is best done from Self or by a Self-like Psychotherapist Part

� Countertransference happens when the therapist is blended with parts who are responding to their own burdens, and/or are triggered by the patient’s parts.

� Our parts hold valuable information about either our stuff, our clients, or both

� Self pulls for Self (alas: parts pull for parts!)

Reasons for Non-verbal Communication

� Pre-verbal trauma, neglect, and attachment trauma

� Traumatic event not encoded verbally � Dissociated material not available to

the part who’s talking and available� Client who has to keep secrets � Projective Identification, Enactments,

Countertransference Patterns� Because it’s the only way!

Enactments� (Baker, 1998): Patient and therapist become

the inevitable participants in transference enactment, each unwittingly playing a role written from the patient's past. [note: co-created!]

� …projective identification and enactment may both be viewed as a powerful type of communication, allowing the therapist to understand in a uniquely empathic way the experience of the patient. By creatively welcoming inevitable enactment, the playing out of the patient's unconscious dynamics in the therapy, the therapist and patient can work through otherwise uninterpretable clinical material.

8 Transference and Countertransference Positions

(Davies and Frawley)

� The Unseeing, Uninvolved Parent and the Unseen, Neglected Child

� The Sadistic Abuser and the Helpless, Impotently Enraged Victim

� The Seducer and the Seduced

� The Idealized, Omnipotent Rescuer and the Entitled Child

Karpman’s Drama TriangleUpdated by Turkus and Kahler, 2006

Rescuer/non-rescuerBystanders

Persecutor

Victim

Read: The Power of Ted*

EMDR Strategy for Dealing With Countertransferance (Dworkin)

1. Visualize patient and recall patient acting in ways that bring up the worst of your countertransferance reactions/feelings.

2. Target with EMDR.3. Do floatback.4. Process.5. Visualize patient acting in the way that

brought up countertransference reactions/feelings and notice how it feels now!

6. Plan for next session with patient.

Dealing with the Button Pushing IFS StyleRemember:

These clients are our “Tor-Mentors”

� Before session: think about patient and scan through body, locating areas of tension, energy, feelings

� Ask Parts that hold them to give you some space� Check for presence of Self energy - do you feel

some compassion or curiosity towards parts?) � If you don’t, check for more parts and ask them to

give you some space.� Ask each part: what do you want me to know

about the client? Then: What do you need from me to let me handle the session from Self? .

� Check for Self Energy during the session, take a moment if you need to.

I don’t want to meet with X!! I can’t wait for

this session to be over…. I feel hopeless about this patient…

#1: I’m asking all

the parts to step back!

#3: Now I can find out what they want me to know about

the patient!

#2: Check for Self – Yes I do feel curious

towards them!

Now I feel much clearer about how to

work with him!

Common Concerns of Parts When Asked to Relax and Separate

� Concern: If I step back nothing will be there

Answer: Self will be there. Try it for 5 seconds

� Concern: Something bad will happen.Answer: Then you can come right back.

You have control of separating or being blended

� Concern: You’ll never work with meAnswer: Make a commitment to work

with that part when the time is right.� Concern: But, but, but…Answer: Ask: What do you think will

happen? Then address the concern

� Demo

� Praticum◦ Get a partner◦ Choose who is the consultant ◦ Partner brings up a client who causes

countertransference responses◦ Consultant initiates IFS process or use EMDR to

process countertransference

Other Uses for IFS Process

� Teach exercise to clients to use when they get triggered in interactions with family members, bosses, etc. Can be used in combination with other coping skills.

� Use in peer groups - Colleagues can help each other out

� Use in consultation.

Critters (Possession) & Legacy Burdens

� Listen for clues� Sometimes can have a part with a %

of critter energy� Sometimes can have a part with a %

of a legacy burden� Sometimes can have a part carrying a

% of something for a parent� Sometimes its easy, sometimes not� Polarities…

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5 DSM-V Dissociative Disorders

1. Dissociative amnesia: an inability to recall important personal information, usually of a traumatic or stressful nature, too extensive to be ordinary forgetfulness, etc. Includes Dissociative fugue (Sudden, unexpected travel away from home or work, with inability to recall one’s past) is now included here.

2. Depersonalization/derealization disorder is a persistent or recurrent feeling of being detached from one’s mental processes, body, and detached from one’s world. (see Simeon in bibliography)

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DSM-5 Criteria for DID

� Symptoms of disruption of identity may now be reported, as well as observed

� Gaps in the recall of events may occur for everyday events — not just traumatic events

�

� Experiences of pathological possession in some cultures are included in the description of identity disruption

DSM 5: Incomplete Update!� PTSD� PTSD: Dissociative Subtype, i.e. PTSD with

significant dissociative symptoms� Depersonalization now includes derealization

disorder � Dissociative fugue is now a specifier of

dissociative amnesia� DID: Diagnostic criteria have been updated

and include:◦ Symptoms of disruption of identity may now be

reported, as well as observed ◦ Gaps in the recall of events may occur for everyday

events — not just traumatic events ◦ Experiences of pathological possession in some

cultures are included in the description of identity disruption

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DSM-IV DDNOS now is DSM-5 OSDD!

� Other Specified Dissociative Disorder (OSDD) (previously known as DDNOS)

◦ Ego states may or may not be less distinct and do not take over executive control.

◦ There is no amnesia criteria.

� Also: Unspecified Dissociative Disorder (UDD)

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• DSM 5 PTSD Diagnostic CriteriaHx of exposure to a traumatic event that meets symptoms from four symptom clusters:

1. intrusion, 2. avoidance, 3. negative alterations in cognitions and

mood 4. alterations in arousal and reactivity

• New to DSM-5: • Dissociative subtype of PTSD: must

meet the full diagnostic criteria for PTSD plus include dissociative symptoms

Patient to Therapist, or Therapist to Patient; or Adult part to Child part!

John Gray“What You Feel You Can Heal”