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1 Treating a Dissociative Vietnam Vet with LOUA and CIPOS Procedures with 16 Year Follow-Up EMDRIA Annual Conference Denver September 21, 2014 Jim Knipe, Ph.D EMDRIA Approved Consultant EMDR-HAP Trainer jsknipe44@earthlink.net Structure of this presentation 1. An overview, EMDR-related tools for safely targeting avoidance defenses and dissociative structure 2. An illustration of the use of these tools, from the treatment of a Vietnam veteran, seen in therapy during three separate episodes of therapy, , 1997, and 2012 Extreme trauma that is early, severe and repeated can result in a division of the into Parts Pretraumatic, or young and unintegrated self Trauma that is especially severe and/or repeated Apparently Normal Part (ANP) of the Separate Dissociated Emotional Part () of the 1

2 Dual Attention -- helping the client look from the oriented Self, to access the dysfunctional memory or Part, while still maintaining orientation to the present If the person is able to stay oriented to the present, use Phase 3 questions, with a representative memory Emotional Part with dysfunctional affect Dual attention stimulation activates the Adaptive Information Processing (AIP) System Focused Sets of Bilateral Stimulation (BLS) Increase the vividness of memory material that is at the center of consciousness expands associational networks (Christman, et al) Reduce sympathetic arousal (Wilson, et al; Elofsson, et al; Sack, et al) Reduce mental avoidance of disturbance, by taxing working memory, while decreasing emotionality of memory (Hornsveld, et al; De Jongh, et al, 2013 ) Activate parasympathetic elements of orienting response (MacColloch and Feldman; Sack, et al) Decrease interhemispheric coherence in frontal areas, possibly inhibiting PTSD memory intrusions (Propper, et al) Increase capacity for distancing/noticing (Lee) May facilitate slow thinking, which relies less on intuition and implicit memory, and results in more objective assessment (Kahneman, 2011) All of the above enhance adaptive information processing and facilitate adaptive resolution Trauma resolution with EMDR often happens off the radar often unconsciously cognition is not primary -Adult Perspective -Present Orientation -Present Safety -Positive Resources Dual Attention Bi-lateral Stimulation (BLS) Trauma memory - image, negative cognition, emotion, physical sensations --Resolution of traumatic memory --Integration of traumatic event into the individual s life story --Increased self-esteem This is how EMDR works, in the absence of significant psychological defenses and/or dissociation 2

3 We can think of three different ways that difficult life experience can negatively influence the development of structure Dysfunctionally stored (traumatic) memories, containing negative affect Psychological defenses, containing positive affect (containment, relief, idealization) Separate dissociated self states separation is primarily maintained by internal avoidance phobias Bilateral Stimulation can facilitate adaptive resolution for each of these three types of problems Target the memory with EMDR Phases 3-7 (after being sure that the client is able to maintain a sense of present orientation and emotional safety) Help the client realize that the defense is a problem, then target the positive affect of the defense Use BLS to reduce the phobias between Parts, and then proceed to safe, respectful dialogue between Parts, decreasing dissociative separation and increasing integration An AIP model of Parts Oriented, adaptive and effective ego state(s) -maintain connection with others by looking normal - engaged in tasks of daily living oriented to present reality Defenses Ego states that function to prevent intrusions from the trauma ego states into the apparently normal ego state(s) Ego states that develop from unresolved traumatic memories not really memories but relivings These different ego states may be relatively accessible to each other, and partially co-conscious 3

4 Apparently Normal Part Or widely separated and dissociated from each other Defenses to prevent intrusions of traumatic material Reliving the trauma Parts are created from the memories of specific events Being loved Being safe + Memory Being strong Being effective + Memory Denial It never happened Idealization - others Avoidance It happened, but I can t think about it Idealization - self Substance addictions behavioral addictions neglect Emotional Abandonment Memory Bullying at school beating Repeated shaming messages from parents Memory Memory The Theory of Structural Dissociation of the Personality (Van der Hart, et al, 2007) describes Parts in a way that is comparable Dysfunctional Substitute Actions -- Mental actions or behaviors that are inadequate or incomplete relative to a goal -- a substitute for more effective action -- e.g. Ineffective expression of emotion -- a subset mental or behavioral actions that function to protect ANP from intrusions of trauma material from (s) ANP(s) - Apparently Normal Part(s) (s) --Emotional Part(s) 4

5 The Effects of BLS with Different Types of Ego States Ego states that appear normal to others, manage life tasks (with effectiveness, worthiness, emotional safety, etc.), and are oriented to the present --BLS will strengthen positive affect, present orientation and safety Defenses, which function to prevent intrusions of traumatic material --BLS with positive affect (e.g. of relief, idealization, or urge intensity) will weaken the defense and reveal traumatic material, which will then be available for processing Emotional Parts or Exile Parts - Ego states that are reliving specific trauma - BLS with traumatic material (and sufficient emotional safety) will move trauma to resolution (as typically occurs with EMDR Phase 4 processing). How psychological defenses may develop Apparently Normal Part (ANP) of the It never happened It isn t real. Emotional Part () of the Psychological defense blocks access to the memories that are dysfunctionally stored. Defense may be conscious or not conscious With the defense, the ANP does n feel the full extent of disturbance about trauma memories Emotional Part with dysfunctional affect Defense 5

6 Apparently Normal Part (ANP) of the I don t want to think about it!! I won t think about it!! Emotional Part () of the Apparently Normal Part (ANP) of the I am a bad person Emotional Part () of the Avoidance Defenses: three ways of processing 1. The LOUA method: How intense, 0-10, is ( the specific urge to avoid)? 1. What s good about, or would be good about (the specific avoidance defense)? 1. Acknowledge the wish to avoid, and then ask to see if the client can put aside the avoidance and directly access the trauma. Similar to the step back one step suggestion (from Internal Family Systems Schwartz, 1995) 6

7 Level of Urge to Avoid (LOUA) procedure: Example 33 year old, professional woman, aproximately 65 pounds overweight for the past 6 years Previous successful EMDR with depression, originating in 1) stress at work and 2) a negative selfconcept of I m not good enough, learned in her dysfunctional family of origin. She now has a much stronger sense of her own worthiness. Her next goal is to lose weight. She eats in a way that is okay, that is, moderate portions, and not very many sweets. Client identifies the biggest obstacle to weight loss as, I hate exercise! Wish to have a normal weight I can t exercise because I hate it! Level of Urge to Avoid exercising = 10 Feelings of I m not worth very much, and I don t deserve good things (These feelings are less now than at the start of therapy) When avoidance is targeted, clients may respond in a variety of ways. I don t want to think of that. It s about a 9. It is hard to think of it, but I want to get through this. So, my urge to not think of it is a zero!! The good thing about not thinking about it is that I don t have to look at these pictures in my mind My gut feeling is to not think of it. But I can get past that. I can think of it. Go ahead and ask those questions. 7

8 If the person is very frightened of a traumatized Part, and there is a danger of dissociative abreaction, the BHS/CIPOS method can be used Adult Part that is very frightened of the past, or frightened (phobic) of a child Part Emotional Part with dysfunctional affect Back-of-the-Head Scale (BHS) Fully present Dissociated Dual- Attention Zone (coconsciousness; that is, simultaneous awareness of safe present and traumatic past) Back-of-the-Head Scale (BHS) - 2 The therapist says: Think of a line that goes all the way from here (therapist holds up two index fingers about 30 cm in front of the Person s face), running right from my fingers, to the back of your head. Let this point on the line (therapist moves fingers) mean that you are completely aware of being present here with me in this room, that you can easily listen to what I am saying and that you are not at all distracted by any other thoughts. 8

9 Back-of-the-Head Scale (BHS) - 3 Let the other point on the line, at the back of your head (therapist points to back of own head) mean that you are so distracted by disturbing thoughts, feelings or memory pictures that you feel like you are somewhere else your eyes may be open, but your thoughts and your awareness are completely focused on another time, or place or experience. At this very moment, show with your finger where you are on this line. Back-of-the-Head Scale (BHS) -- 4 For dissociative clients, a way of measuring and expressing a familiar aspect of their mental life. The closer to the most present end point of the line, the safer it is to do trauma work with bilateral stimulation Clients seem to be able to easily assess the full range of dissociated experiences It is necessary for the client to point to a position at least three inches in front of the face, in order for trauma-focused work to proceed (may vary from client to client listen for tone of voice). Use the BHS throughout the therapy session to insure the client is staying present while reprocessing disturbing memories. The method of Constant Installation of Present Orientation and Safety (CIPOS) Used in conjunction with the BHS Bilateral stimulation is used to strengthen the client s subjective sense of being present in the safety of the therapy office. May be used in the Preparation Phase, or during the actual Desensitization of a particular highly disturbing traumatic memory. As the person s present orientation is constantly maintained, processing of the memory can proceed with a greater sense of control on the part of the client, and much less danger of dissociated abreaction 9

10 The method of Constant Installation of Present Orientation and Safety (CIPOS) -- 2 Steps in the CIPOS method 1. Obtain full permission from the client, and other parts of the system, to work on a highly disturbing memory. Be sure there is time in the therapy session. 2. Insure the client is aware of objective reality (i.e. the present situation in the therapist s office, including the objective safety of that office. The method of Constant Installation of Present Orientation and Safety (CIPOS) Before accessing traumatic material, strengthen the client s present orientation by some or all of the following: Simple questions about the reality of the therapist s office When the client responds to these questions, the therapist says, Think of that, and initiates a short set of bilateral stimulation, to strengthen the client s present orientation. Stimulate orienting response, with a game of catch with a pillow or tissue, holding a drop of water or an ice cube in the hand, or alternately counting to 10 and humming a song. 4. The BHS can then be used to assess whether the client is truly oriented to present safety The method of Constant Installation of Present Orientation and Safety (CIPOS) When present orientation is sufficiently established, the client is asked if they are willing to go into their memory image for a very brief period of time (e.g. perhaps only two to ten seconds), with the therapist keeping track of the time. 6. This is essentially a carefully controlled dissociative process. 7. Immediately following the end of this period of seconds, the therapist instructs the client, using soothing but repetitive and emphatic words, to Come back into the room now, until the client s eyes open and they are looking out into the room again. 10

11 The method of Constant Installation of Present Orientation and Safety (CIPOS) When the client s eyes are open again, the therapist gives encouragement ( Good, or That s right. ) and then resumes the CIPOS interventions, with statements like, Where are you right now, in actual fact? with the answers followed by short sets of bilateral stimulation. The CIPOS interventions are continued until the client is able to report, using the BHS, that they are once again oriented towards the present reality of the therapist s office. At this point, Step 5 can be repeated. 9. As this procedure continues, the client develops increasing ability to stay present as well as greater confidence and a sense of emotional control in confronting the disturbing memory. This opens the door to the use of the standard EMDR Desensitization procedures, i.e. of directly pairing bi-lateral stimulation with traumatic material. CIPOS Method sequence of procedures Fully present Dissociated Use the Back of the Head Scale to check for Orientation to Present Safety Repeat as needed 2-10 seconds of deliberate dissociation into traumatic material in a way that preserves present safety No BLS Orientation to Present Safety 2-20 seconds of deliberate Paired with BLS dissociation into traumatic material while preserving safety - No BLS Continue repeating as necessary while preserving dual attention Orientation to Present Safety More than 20 seconds in trauma with BLS ---Standard EMDR Desensitization Phase Apparently Normal Part (ANP) of the Phobicly avoidant of the (s) Part of the Personality focused on Defense (e.g.avoidance, idealization, addiction and/or shame) Emotional Part () of the 11

12 Orientation to the safety of the present Apparently Normal Part (ANP) of the The affect of ANP is phobic fear of the ANP Avoidance defense Denial Defense Inappropriate self-blaming Addictions Inappropriate blaming of others Orientation to the safety of the present Apparently Normal Part (ANP) of the Part of the Personality focused on Defense (avoidance, idealization, addiction and/or shame) Emotional Part () of the Video example: using the Back-of-the-Head Scale (BHS) and the Constant Installation of Present Orientation and Safety (CIPOS) methods to help a client who is vulnerable to dissociative abreaction The client is accessing a highly disturbing memory, from age 6, of neglect and physical abuse by mother Client has intense feelings of badness, originating in times when she would ask her psychotic mother to get out of bed and feed the client and her sisters. Mother would often respond by beating the client and then sending her to her room, hungry. 12

13 Apparently Normal Part (ANP) Oriented to the present I am a good person I am safe now The client was asked to bring to mind the image that most represents her identity of shamefulness. By mother s bedside, begging mother to get up The client then bridges to many childhood traumas Adult Perspective I am a good person I am safe now Immediate bridging to many childhood traumas In response to the bridging, the defense of shame is activated Adult Perspective I am a good person I am safe now I am bad many childhood traumas 13

14 Orientation to the safety of the present Apparently Normal Part (ANP) of the Oriented to the safety of the present Shame Defense I am bad Emotional Part () of the Reliving moments of helplessness, fear and hunger Representative image: begging mother to get up Orientation to the safety of the present Apparently Normal Part (ANP) of the The affect of ANP is phobic fear of the Avoidance defense I don t have to go there I don t have to think about it Affect of defense is positive - E.g.Containment And Relief Emotional Part () of the Reliving the worst moments of the trauma terror, helplessness, abandonment The needs processing -> adaptive resolution Vietnam war veteran, with many war traumas Clearly dissociative structure (DDNOS in DSM-4, OSDD in DSM-5) Three episodes of therapy: , 1997 and 2012 Video and transcript examples of 1. Targeting avoidance defense and then combat trauma in a dissociative client (1993, 1997) 2. Back of the Head Scale/Constant Installation of Present Orientation and Safety (BHS/CIPOS method; 2012) 14

15 Doug Chronic anxiety, low self-esteem, troubled marriage -Angry outbursts with wife and children Migraines Successful Difficult resolution childhood of one memory abusive, of alcholic neglect by father Specific Memory of Vietnam ANP Avoidance I don t need him any more. I left him behind in Vietnam. LOUA = year-old in a white t-shirt You have to think about this! You have to look at this! Other memories of Vietnam Orientation to the safety of the present ANP 19-year-old in a white t-shirt You have to think about this! You have to look at this! Other memories of Vietnam 15

16 ANP Oriented to present safety No longer terrified of the specific memory -- The 19- year-old -- Get out of here. Go live your life! Personality r Parts at the start of the session, 2012 ANP Oriented to present safety Able now to have positive feelings and trust in self Continuing intrusions from unresolved trauma Continuing Avoidance I don t need him any more. LOUA = The 19- year-old -- always pointing to a path -- You have to look at this! Orientation r to the safety of the present ANP Able now to have positive feelings and trust in self Continuing intrusions from unresolved trauma -- The 19- year-old -- always pointing to a path -- You have to look at this! Avoidance put off to the side 16

17 CIPOS r procedures 2012 Session ANP Oriented to present safety -- The 19- year-old -- always pointing to a path -- You have to look at this! CIPOS r procedures ANP Still oriented to present safety I m not afraid now. I have been there. -- The 19- year-old -- We are walking together on a path Terrible images Trapped for days ANP Still oriented to present safety But now we re together -- The 19- year-old - This is what you had to see. Terrible images Trapped for days 17

18 ANP Still oriented to present safety But now we re together Terrible images Trapped for days ANP Still oriented to present safety He s not there. Considerations in using the BHS/CIPOS procedure Useful when the client is frightened of traumatic material, but is able to think of trauma for a few seconds without losing orientation to the present If the client cannot go into the trauma memory for even 2-3 seconds, without having trouble coming back, this method should not be used. At every opportunity, acknowledge the client s increasing ability to return to present orientation and safety, more and more easily Even after the client is able to reliably maintain dual attention processing, all the other tools (cognitive interweaves, conference room imagery, targeting of psychological defenses, etc.) may still be necessary 18

19 Resources Cheftez, R. (Ed.) (2006) Dissociative disorders: an expanding window into the psychobiology of the mind, Psychiatric Clinics of North America, 29(1) Christman, S.D., Garvey, K.J., Propper, R.E., & Phaneuf, K.A. (in press). Bilateral eye movements enhance the retrieval of episodic memories. Neuropsychology. Chu, J. (1998). Rebuilding shattered lives. New York: Wiley. Elofsson, U.O.E., von Scheele, B., Theorell, T., & Sondergaard, H.P. (2008). Physiological correlates of eye movement desensitization and reprocessing. Journal of Anxiety Disorders, 22, Fine, C. (1995, June). EMDR with dissociative disorders. Workshop presented at EMDR Network Annual Meeting, San Francisco, CA. Recording available through Forgash, C. and Copeley, M. (Ed.s) (2007) Healing the heart of trauma. Springer: New York. Forgash, C., & Knipe, J. (2001, June) Safety-focused EMDR/ego state treatment of dissociative disorders. Workshop presented at EMDR International Association Conference, Austin, TX. Recording available through Fraser, G. A. (2003). Fraser s dissociative table technique revisited, revised: A strategy for working with ego states in dissociative disorders and ego state therapy. Journal of Trauma & Dissociation, 4(4), Resources (continued) Hornsveld, H.K., Landwehr, F., Stein, W., Stomp, M., Smeets, M., van den Hout, M. (2010) Emotionality of Loss-Related Memories Is Reduced After Recall Plus Eye Movements But Not After Recall Plus Music or Recall Only. Journal of EMDR Practice and Research, Volume 4, Number 3 Kahneman, D. (2011) Thinking, Fast and Slow. Farrar, Straus and Giroux, New York Knipe, J. (2005). Targeting positive affect to clear the pain of unrequited love, codependence, avoidance and procrastination. In R. Shapiro (Ed.), EMDR solutions (pp ). New York: Norton. Knipe, J. (2007) Loving Eyes: Procedures to Therapeutically Reverse Dissociative Processes while Preserving Emotional Safety, in Forgash, C. and Copeley, M. (Ed.s) Healing the heart of trauma. Springer: New York. Knipe, J. (2009) The BHS and CIPOS procedures, and Targeting positive affect to resolve avoidance and idealization defenses, in Luber, M. EMDR Scripted Protocols. New York: Springer. Knipe, J. (2009) Shame is my safe place: Adaptive Information Processing methods of resolving chronic shame-based depression, in Shapiro, R. (Ed.) EMDR Solutions, Vol. II, New York: Norton. Knipe, J (2014) EMDR Toolbox: theory and treatment methods for Complex PTSD and dissociation. Springer, New York. Lee, C. (2008) More Than Imaginal Exposure Journal of EMDR Practice and Research, Volume 2, Number 4 Resources (continued) Lee, C. and Cuijpers, P. (2013) A meta-analysis of the contribution of eye movements in processing emotional memories, J. Behav. Ther. & Exp. Psychiat. 44, MacCulloch, M. J., & Feldman, P. (1996). Eye movement desensitization treatment utilizes the positive visceral element of the investigatory reflex to inhibit the memories of post-traumatic stress disorder: A theoretical analysis. British Journal of Psychiatry, 169, Paulsen, S. (1995). EMDR and its cautious use in the dissociative disorders. Dissociation, 8, Popky, A.J. (2005) The De-tur Method. In R. Shapiro (Ed.), EMDR Solutions, New York: Norton. Porges, SW (2007) The polyvagal perspective, Biological Psychology 74 (2007) Putnam, F. (1989) The Diagnosis and Treatment of Multiple Personality Disorder. New York: Guilford. Propper, R., Pierce, J.P., Geisler, M.W., Christman, S.D., & Bellorado, N. (2007). Effect of bilateral eye movements on frontal interhemispheric gamma EEG coherence: Implications for EMDR therapy. Journal of Nervous and Mental Disease, 195, Reinders, A. A. T. S., Nijenhuis, E. R. S., Quak, J., Korf, J., Haaksma, J., Paans, A. M., et al.(2006). Psychobiological characteristics of dissociative identity disorder: A symptom provocation study. Biological Psychiatry, 60,

20 Resources (continued) Sack, M., Lempa, W. and Lamprecht, F. (2007) Stress Reactions During a Traumatic Reminder in Patients Treated With EMDR. Journal of EMDR Practice and Research, Volume 1, Number 1 Sack, M., Hofmann, A., Wizelman, L., Lempa, W. (2008) Psychophysiological Changes During EMDR and Treatment Outcome. Journal of EMDR Practice and Research, Volume 2, Number 4 Schwartz, R. (1995). Internal family systems therapy. New York: Guilford Press. Suzuki, A., et al. (2004). Memory reconsolidation and extinction have distinct temporal and biochemical signatures. Journal of Neuroscience, 24, Twombly, J. (2005). EMDR Processing with dissociative identity disorder, DDNOS, and ego states. In R. Shapiro, EMDR solutions (pp ). New York: Norton. van der Hart, O., Nijenhuis, E., & Steele, K. (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. New York: Norton. Van der Kolk, B., et al (2007). A Randomized Clinical Trial of Eye Movement Desensitization and Reprocessing (EMDR), Fluoxetine, and Pill Placebo in the Treatment of Posttraumatic Stress Disorder: Treatment Effects and Long-Term Maintenance, J.Clinical Psychiatry, 68:1 Wildwind, Landry. (1994) EMDR with Depression. EMDR Network Meeting, Sunnyvale, CA. Wilson, D., Silver, S. M., Covi, W., & Foster, S. (1996). Eye movement desensitization and reprocessing: Effectiveness and autonomic correlates. Journal of Behaviour Therapy and Experimental Psychiatry, 27,