Healing-Fragmented-Selves-Trauma-Survivors_Janina-Fisher.md

Healing the Fragmented Selves of Trauma Survivors by Janina Fisher

Healing the Fragmented Selves of Trauma Survivors integrates a neurobiologically informed understanding of trauma, dissociation, and attachment with a practical approach to treatment, all communicated in straightforward language accessible to both client and therapist. Readers will be exposed to a model that emphasizes "resolution"―a transformation in the relationship to one’s self, replacing shame, self-loathing, and assumptions of guilt with compassionate acceptance. Its unique interventions have been adapted from a number of cutting-edge therapeutic approaches, including Sensorimotor Psychotherapy, Internal Family Systems, mindfulness-based therapies, and clinical hypnosis. Readers will close the pages of Healing the Fragmented Selves of Trauma Survivors with a solid grasp of therapeutic approaches to traumatic attachment, working with undiagnosed dissociative symptoms and disorders, integrating "right brain-to-right brain" treatment methods, and much more. Most of all, they will come away with tools for helping clients create an internal sense of safety and compassionate connection to even their most dis-owned selves. - Healing the Fragmented Selves of Trauma Survivors: Overcoming Internal Self-Alienation

Contents

• Contents
• Introduction
  • Fragmentation and Internal Struggles Ten years ago, in the context
  • The Price of Self-Alienation: A “False Self”
  • Stuckness: Trauma-Related Internal Conflicts
  • How This Book Is Organized
  • Working with Changing Roles for Client and Therapist
  • Understanding Parts
  • Complications of Treatment
  • Distorted cognitions
• CHAPTER 1
  • The Neurobiological Legacy of Trauma
  • The “Living Legacy” of the Past
  • Parallel Lives: The Disowning of Dissociation
  • Compartmentalization under Stress: Exploiting the Fault Lines
  • Recognizing the Signs of Structurally Dissociated Parts
  • Symptoms as Communications from Parts
  • Helping Clients and Their Parts “Be Here” Now
• CHAPTER 2
  • Understanding Parts, Understanding Traumatic Responses
  • Uninvited Remembering
  • Finding “Now,” Not “Then”
• CHAPTER 3 Changing Roles for Client and Therapist
  • Working with the Neurobiological Legacy of Trauma
  • A Multi-Consciousness Approach to Treatment
  • Pathogenic Kernels of Memory
  • Acknowledging the Past Without Exploring It
  • A Different Approach to Traumatic Memory
  • Witnessing Being Witnessed
  • The Therapist as “Auxiliary Cortex” and Educator
  • Illustration
  • A Creative Adaptation to Abnormal Experience
  • A New Role for the Therapist: Neurobiological Regulator
  • The neurobiologically astute therapist
  • The Therapist as Director, Coach, and Pace-Setter
  • The Body as a Shared Whole
  • The Changing Role of the Therapist
• CHAPTER 4
  • Learning to See Our “Selves”
  • The Cost of Adaptation
  • Years after the traumatic experiences...
  • “Getting to Know You”
  • Developing Curiosity: Who Is “I”?
  • Survival-Related Internal Struggles
• CHAPTER 5
  • Befriending Our Parts: Sowing the Seeds of Compassion
  • The Role of Mindfulness: How We Can “Befriend” Ourselves To
  • From Whose Perspective Should We Observe?
  • Differentiating Observation versus Meaning-Making
  • Blending, Shifting, and Switching of Parts
  • Facilitating Empathy
  • “Seeing” the Parts: Externalized Mindfulness
  • The visual images symbolizing each different part
  • Blending and Reality-Testing
  • Learning to Unblend
  • Less afraid to connect
  • Providing Hospitality
  • Forming a Connection to a Wise Compassionate Adult
  • Connecting to the Resources of a Competent Adult
  • Selves-Acceptance
• CHAPTER 6
  • Complications of Treatment: Traumatic Attachment
  • Trauma and Attachment: The Source of Safety Becomes the Source of Danger
  • “Controlling Attachment Strategies” and Trauma
  • Awakening the Yearning for Care
  • Not One but Many
  • Creating an Alliance with the Fight Part
  • There is No “He” or “She”
  • A Therapist for All the Parts, Not Just the “Client”
  • Speaking on Behalf of the Parts
  • Dyadic Dancing Attunement
  • Often therapists hesitate to use the language like “inner person”
• CHAPTER 7
  • Working with Suicidal, Self-Destructive, Eating Disordered
  • A Way Out or a Way to Go On?
  • Capitalizing on the Body to Gain Relief
  • Animal Defenses and Unsafe Behavior Structural dissociation
  • Treating the Causes of Self-Destructive Behavior
  • Trauma-Informed Stabilization Treatment (TIST)
  • Acknowledging Self-Destructive Parts
  • Soothing the Vulnerable, Honoring the Protectors
  • “No Part Left Behind”
• CHAPTER 8
  • Treatment Challenges: Dissociative Systems and Disorders
  • Recognizing the DID Client
  • Diagnosing Dissociative Disorders
  • Assessment Tools for Diagnosing Dissociative Disorders
  • There Is No “She”—There Is No “He”
  • Restoring Order to a Chaotic Inner World
  • Teaching the Client’s Normal Life
  • Making Meaning of Moment-To-Moment Experience
  • Creating a Present for Parts that Dwell in the Past
  • Overcoming Conditioned Learning
  • Building Trust Inside Trust
  • autonomous functioning of the parts
  • Gathering Evidence: Establishing Retrospective Consciousness
  • Building Skills to Overcome Gaps in Consciousness
  • No More “Bad Guys” and “Good Guys”
  • Increasing the Presence of a Normal Life Adult
  • Bringing Parts Up-to-Date
  • Changing Patterns and Roles Survival behavior, learned in the
  • Working with Regression and Aggression
  • Patience, Persistence, and a Good Seat Belt
  • Self-Healing, Rather than Interpersonal Healing
  • Facilitating Reunion
• CHAPTER 9
  • Repairing the Past: Embracing Our Selves
  • Accessing the Resources of a Wise Adult
  • Listening to Children Builds Attachment Bonds
  • Reaching Out to Parts from Places of Strength
  • Accessing the Resources of Normal Life
  • Taking Young Parts “Under the Wing”
  • Attachment Bonds Are Built through Body
  • Fears and Phobias of Internal Attachment
  • Rupture and Repair of Internal Attachment Relationships
• CHAPTER 10
  • Restoring What Was Lost
  • Reorganizing the Relationship to the Past
  • “Me Now” versus “That Part of Me Then”
  • Establishing Internal Communication with Dysregulated Parts
  • Rupture and Repair
  • Communicating Compassion toward Wounded Child Parts
  • Interference with Reparative Experiences
  • Building Impulses to Care
  • Creating a New Purpose and Mission for Each Part
• CHAPTER 11
  • Safety and Welcome: The Experience of Earned Secure
  • “The Symptoms Tell the Story Better than ‘the Story’”
  • Capitalizing on Dissociative Symptoms
  • Supporting a Functioning Adult Normal Life Self
  • “Earned Secure Attachment”
  • An Intergenerational Legacy of Secure Attachment
  • Secure Attachment Is a Somatic and Emotional Experience
  • Earned Secure Attachment and the Resolution of Trauma
  • Hearing the Child’s Cry
• APPENDIX A Five Steps to “Unblending”
• APPENDIX B Meditation Circle for Parts This intervention can help
• APPENDIX C Internal Dialogue Technique
• APPENDIX D Treatment Paradigm for Internal Attachment Repair

Introduction

• Therapists often feel frustrated helping traumatized clients due to their self-alienation and intense self-hatred.
• Clients seek relief from trauma symptoms but the process of exchanging self-alienation for self-compassion can be overwhelming.
• Lack of understanding about fragmented selves and dissociative splitting in mental health field.

1. Background

   • Ihe idea of this book came from witnessing the struggles faced by therapists in understanding and treating traumatized clients.
   • Author mentions experience working at Bessel van der Kolk's Trauma Center, which influenced her perspective on trauma-related disorders.

2. Neurobiological Lens

   • Trauma disorders seen as disorders of body, brain, and nervous system.
   • Symptoms are adaptations to dangerous world rather than evidence of pathology.
   • Each symptom is an ingenious solution for creating safety.

3. The Structural Dissociation Model:

   • explains how individuals with trauma-related disorders have fragmented their selves to adapt and survive
   • This model helps clients understand their struggles and provides them with a language to describe their experiences.

4. Healing through Bonding

   • Healing means reclaiming lives or transforming internal states.
   • Clients form loving attachment bonds to their young selves.
   • Shame and self-hatred melt away as left brain "adult" side relates to right brain "child" side.

5. Book's Intended Audience

   • Chronically traumatized individuals, high-risk patients, stable clients with internal pain despite external success.
   • Not limited to any particular diagnosis.
   • For anyone failed, attacked, threatened, abandoned, or terrorized by human beings and carrying emotional/physical trauma legacy.

Fragmentation and Internal Struggles Ten years ago, in the context

1. Fragmentation and Internal Struggles

   • Ten years ago, I observed a common pattern among traumatized clients: internal fragmentation.
   • Clients appeared integrated but showed signs of conflict between trauma-related perceptions and impulses versus present assessments.
   • They experienced paradoxical symptoms, such as the desire for kindness and spirituality alongside intense rage or violence.

2. Observable Patterns

   • Describing these conflicts made them more observable and meaningful.
   • Each side represented a different way of surviving traumatic experiences.

3. Theoretical Model: Structural Dissociation

   • The Structural Dissociation model by Onno van der Hart, Ellert Nijenhuis, and Kathy Steele explained these phenomena.
   • Rooted in neuroscience, it was accepted in Europe as a trauma model.

4. Brain's Innate Structure

   • The brain's innate physical structure facilitates left-right brain disconnection under threat.
   • The left brain stays focused on daily tasks, while the right brain fosters an implicit self in survival mode.

5. Identifying and Owning Parts

   • Some parts were easier to identify with or "own," while others were dismissed as "not me.
   • The internal relationships between fragmented aspects of self reflected traumatic environments.
   • The left-brain-dominant present-oriented self avoided or judged right-brain-dominant survival-oriented parts.
   • Both sides felt alienated from each other.

6. Functioning Self

   • The functioning self carried on, trying to be "normal," but at the cost of feeling alienated or invaded by intrusive communications from parts.

The Price of Self-Alienation: A “False Self”

1. Self-Alienation and its Consequences

   • Survivors of trauma report improved functioning but later suffer from feelings of fraudulence or "pretending" (compartmentalization).
   • Maintaining self-alienation leads to increased self-loathing, disconnection from emotion, addictive or self-destructive behavior, internal struggles.
   • Symptoms include anxiety, chronic depression, low self-esteem, stuckness in life, PTSD, bipolar disorder, borderline personality disorder, dissociative disorders.

2. Traumatic Attachment as a Complication in Trauma Therapy

   • Clients are vulnerable to being triggered by seemingly innocuous stimuli and overwhelmed with painful emotions.
   • Each new treatment method helps some clients but not all, or brings relief in some symptoms but not others.
   • Some clients' trauma-related wishes and fears of relationship evoke painful yearning, mistrust, hypervigilance, anger, fear, and shame rather than safety and comfort.

3. The Quest for Effective Trauma Treatment

   • Therapists have been seeking new methods to help clients free from the insidious impact of the traumatic past.
   • Each new understanding or treatment method helps some clients but not all, or brings relief in some symptoms while not alleviating others.
   • Some clients' trauma-related wishes and fears make therapy and the therapist evoke intense emotions and responses.

Stuckness: Trauma-Related Internal Conflicts

1. Stuckness in psychotherapy is a result of trauma-related internal conflicts between fragmented selves.
2. Clients and therapists may question their abilities when treatment isn't progressing as expected.
3. Fragmentation of the personality can lead to opposing goals within a single individual.
   • "I want to die" and "I am determined to live.
   • "I want to be connected, but I don’t want anyone to know I care.
   • "I loathe and despise myself, I look up to others above me, and then I loathe and despise them.
4. The author's goal is to find gentler ways of treating trauma without causing additional pain.
5. Trauma survivors should not be deprived of their adult lives due to the legacy of trauma.
6. Processing trauma should not be as frightening or overwhelming as the original experiences.
7. The author's approach aims to describe a healing way of coming to terms with trauma.
8. This book is for clients and therapists dealing with trauma, attachment disorders, and dissociation.
9. Therapists often face challenges due to the effects of self-alienation on 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

How This Book Is Organized

1. Theoretical Background

   • The author's clinical experience is rooted in neuroscience and attachment research.
   • The book integrates a theoretical understanding of trauma, dissociation, neurobiology, and attachment with practical interventions.
   • Interventions drawn from Sensorimotor Psychotherapy, Internal Family Systems, mindfulness-based approaches, and clinical hypnosis are used.

2. Integrating Sensorimotor Psychotherapy and Internal Family Systems

   • The author's understanding of the body and nervous system is integrated with parts theory from IFS.
   • Both models are mindfulness-based and help in speaking the language of parts and becoming mindful of one's own parts.
   • They provide a foundation for working with complex PTSD clients and those who are stuck, in crisis, or ambivalent.

3. Understanding Dissociative Splitting and Fragmentation

   • Dissociative splitting and fragmentation is an adaptive response to overwhelming experience.
   • Individuals disown self-states that are intimidated, ashamed, or not-me, allowing them to function without awareness of having been traumatized.
   • The Structural Dissociation model (2000) provides a neuroscientific understanding of dissociative splitting and compartmentalization.

4. Understanding Parts and Traumatic Responses

   • Neuroscience research on traumatic memory is explored to understand and recognize signs of fragmented parts.
   • The emergency stress response to threat is presented, including how the legacy of trauma becomes encoded in the body.
   • The role of implicit memory in trauma treatment is emphasized, requiring therapists to make a paradigm shift from focusing on traumatic events to understanding and helping clients work with their trauma-related parts.

Working with Changing Roles for Client and Therapist

1. Neuroscientific Perspective on Trauma: Therapy begins with educating therapists about trauma and dissociation, empowering clients as informed consumers in their treatments.
   • Most therapists lack experience in multi-consciousness paradigm.
   • Psychoeducation equalizes power differential and provides reassurance.
2. Role of Therapist: Therapist's role shifts from less directive to more attuned, resonant, and mindfulness-focused.
   • Attunement and resonance are crucial in trauma treatment.
   • Mindfulness skills must be explicitly taught for observing feelings and reactions without judgment or identification.
3. Building a Collaboration: Therapist's role is to create a new story about the client based on their needs, not just wants.
   • Clients need help in acquiring skills of mindful observation and discovery.

Understanding Parts

Clients are introduced to Structural Dissociation model

• Each animal defense survival response is associated with certain behaviors.
• Mindfulness-based interventions help clients differentiate their feelings from parts' communications.

Befriending Parts (Chapter 5)

Interventions foster increased self-understanding and self-compassion.

• Clients are taught to have compassion for themselves or younger selves.
• Acknowledging parts' traumatic experiences validates without overwhelming the client.

Recognizing Blending and Unblending: Clients learn to recognize identifying with their parts (blending) and practice dis-identifying (unblending).

Complications of Treatment

1. Traumatic Attachment

   • Reversal of roles: parent figure becomes object of fear and life threat
   • Intimate relationships or therapy evoke danger signals
   • Growing closeness can convey threat or promise of comfort, triggering emotional memories
   • Internal struggle between hunger for closeness and fear of abandonment versus defensive responses
   • Therapist's role: ally for both sides, facilitator of "earned secure attachment

2. Earned Secure Attachment

   • Outcome of resolving insecure or disorganized childhood attachment
   • Individuals can reflect on early attachment relationships without becoming disregulated
   • Emphasis on building empathy and attunement to parts, not attachment to therapist

3. Unsafe Behaviors

   • Manifestations of parts-related animal defense survival responses
   • Addictive, eating disordered, suicidal, self-injurious behaviors reinterpreted through neurobiological lens
   • Episodes follow relational disappointments, shame, and intrusive memories or flashbacks
   • Post-traumatic unsafe behavior: exhaustion, loss of energy, intense feelings of needing rest
   • Neurobiologically informed approach: help patients reframe impulses as communications from a part

4. Dissociative Disorders

   • More extreme degree of compartmentalization affecting consciousness, choices, decisions, and memory
   • Underdiagnosed or misdiagnosed despite dissociative symptomatology
   • Treatment approach: mindfulness-based, effective for DID and DDNOS clients with adjustments
   • Therapist's role: hold in mind that client is one physical individual while appreciating fragmented parts
   • Engage left brain-driven part to help solve issues raised by right brain-trauma related parts

Distorted cognitions

1. Shame and self-loathing interfere with clients' ability to connect with their strengths due to potential unsafe conditions in childhood.

   • Distorted cognitions hinder the normal life self from handling normal activities.
   • Internal conflicts between parts debilitate or destabilize the normal life self.

2. Therapist's role: Foster compassion of the normal life self towards wounded child parts.

   • Use clinical examples to illustrate the process of building internal acceptance.
   • Draw on clients' strengths and life experiences as resources for young child selves.

3. Left brain vs. right brain selves: Competencies learned by left brain self not available to right brain selves.

   • Interventions bring the two sides into contact, evoking moments of attunement and togetherness.

4. Healing process: Clients must earn parts' trust before deepening connection to young selves.

   • Consistently ask clients to communicate, collaborate, and extend compassion to parts.
   • Build up a felt sense of an internal attachment figure.

5. Emotional healing: Healing traumatic wounds requires attachment-based approach.

   • Invite disowned parts into the heart and mind and arms of the client.
   • Overcome fear of self-compassion to welcome all parts "home".

6. Earned secure attachment: Childhood attachment wounds can be modified through life experiences.

   • Raising children, healthy friendships, intimate relationships, or creating secure attachment relationships with parts.
   • Brain's ability to grow new neural networks and encode new feeling states.

7. Healing story: Clients create a new story of safety, closeness, and compassion by evoking states of well-being.

   • Neuroplastic brain change requires clients to inhibit old patterns, practice new patterns, and maintain the felt connection to their bodies and child selves.

CHAPTER 1

The Neurobiological Legacy of Trauma

1. Neurobiological Legacy of Trauma

   • Trauma memories are deeply engraved due to stress hormones (Van der Kolk, 2014).
   • Ordinary life becomes less compelling and harder to concentrate on (Van der Kolk, 2014).
   • Splitting or Fragmenting as a survival strategy:
     • Children disconnect from traumatic experiences to survive psychologically.
     • They create a "good child" persona for acceptance and safety.
     • Rejected "not me" child is kept out of consciousness through dissociation, denial, or self-hatred.
   • Surviving trauma involves mastering normal developmental tasks:
     • "Good" part of the child develops normally while "not me" part bears emotional and physical imprint of past.
   • Complications:
     • Neither self has well-developed chronological memories of traumatic events.
     • Traumatic memory appears as intrusive images, emotions, and physical reactions (Van der Kolk, 2006; 2014).

2. Impact of Childhood Abuse

   • Children need psychological distance to survive traumatic experiences.
   • Splitting or fragmenting self is an adaptive strategy but comes with a cost.
   • Individuals continue to rely on dissociation, denial, and/or self-hatred for enforcing disconnection.
   • Struggling with feelings of fraudulence, resentment, shame, or self-doubt.
   • Trauma remains alive rather than resolved.
   • Mastering normal developmental tasks supports survival: learning, peer relationships, interests.
   • "Good" part develops normally while "not me" part bears emotional and physical imprint of past.
   • Neither self has clear-cut narrative memories of traumatic events.
   • Traumatic memory appears as intrusive images, emotions, and physical reactions.

The “Living Legacy” of the Past

1. Trauma Legacy: Individuals carry symptoms and reactions without clear context from past traumatic experiences.

   • Anxiety, depression, shame, low self-esteem, loneliness, alienation, problems with anger, impulsivity or acting out.
   • Chronic expectations of danger: intrusive fear and dread, hypervigilance, chronic shame and self-hatred, conviction that the worst is about to happen, hopelessness and helplessness, fear of abandonment, numbing and disconnection from emotions.
   • Self-destructive impulses: addiction, self-harming impulses, eating disorders, or a longing or determination to die.

2. Early Trauma Treatment Approaches:

   • "Talking cure": therapists encouraged clients to retrieve memories of traumatic events until they had a detailed narrative.
   • Resulted in overwhelming implicit memories and traumatic reactions, increasing symptoms rather than resolving past trauma.

3. Addressing the Effects of Trauma:

   • Focus on feeling safe and reassuring oneself instead of remembering horrific experiences.
   • Reclaim lost children and disowned parts of self, creating safety for them and making them feel wanted, needed, and valued.

4. Acceptance of Child Abuse and Dissociation:

   • Scientific research has shown that child abuse is an epidemic, not a rare occurrence.
   • Untreated post-traumatic stress results in significant social costs, not just individual suffering.
   • Concepts of implicit memory and bodily-driven responses to trauma have become more widespread but still controversial.

5. Disowning Parts of the Self:

   • Disowning parts of one's self and over-identifying with other parts does not facilitate integration and a sense of being whole.
   • Mental health world has had a history of disowning prevalence of child abuse, dissociation, and fragmentation of personality.
   • Pressure on therapists to "un-see" signs of dissociation and treat fragmented clients as if they were whole integrated human beings.

Parallel Lives: The Disowning of Dissociation

1. Dissociation and splitting have been observed in trauma cases but rejected due to lack of scientific validation.
   • Difficulty gaining acceptance for dissociative disorders due to absence of brain-based studies.
   • Theories are metaphorical, not biologically or brain-based.
2. Dissociative Disorders:
   • Historically explained as stress-related, exceeding brain's capacity to process traumatic events.
   • Memories are compartmentalized among dissociated parts.
   • Parts viewed as repositories of memory, representing client's history at a specific time.
3. Alternative Theory: Multiplicity is normal, all human beings have multi-consciousness.
   • Mindfulness-based approach: Internal Family Systems (IFS).
4. IFS Model:
   • Depends on metaphorical theory based on intrapsychic defenses.
   • "Exiles" are hidden from conscious awareness by "managers".
   • "Firefighters" create distraction and crisis when exiles are not protected.
5. Healing in IFS Model:
   • Exiled parts are reclaimed and share memories with "self", the higher self of the client.
6. Lack of Scientific Validity for Dissociation:
   • Good clinical models without a theoretical basis are insufficient to overcome skepticism.
7. Neuroscience Revolution:
   • Provided scientific explanation for concept of "splitting" and "parts of the self".
8. Challenging Fixed Negative Beliefs about Dissociation:
   • Took years of research to challenge prevalent negative beliefs in the field.

Compartmentalization under Stress: Exploiting the Fault Lines

1. Compartmentalization under Stress
   • Biological basis in brain's "fault lines
2. Right Hemisphere-Left Hemisphere Split
   • Children are right brain dominant in early childhood
   • Left brain development is gradual and dependent on corpus callosum development
   • Trauma can lead to independent development of right and left hemispheres
     • Deficits in communication between the two brains may hinder integration
3. Split-Brain Research
   • Shows independence and differences between left and right hemispheres
   • Left hemisphere uses language, right hemisphere is more visual and better at recognizing differences
   • Right hemisphere remembers episodically and implicitly, left specialized for autobiographical memory and acquired knowledge
   • Emotions experienced on both sides but only verbalized by left hemisphere
4. Attachment Research
   • Children with disorganized attachment status at age one are more likely to exhibit dissociative symptoms or borderline personality disorder in adulthood
   • Abusive attachment figures can leave children caught between attachment and defense instincts, necessitating dissociative splitting
5. Action Systems or Drives
   • Children have innate propensity for attachment, exploration, play, and social engagement
   • Equally, they depend on animal defenses to ensure self-protection
   • For children raised in unsafe environments, both types of action system are necessary
     • Ability to shift from state to state as needed to deal with different threats is essential
6. Trauma-Related Procedural Learning
   • Safer to adapt using a system of selves rather than becoming fully integrated "self"
   • Parts of the Personality
   • Controversial term in mental health world
   • Advantages: suggests whole person, easily adopted by clients, and neural networks hold related neural pathways that encode complex systems of traits or systems representing aspects of personalities.

Recognizing the Signs of Structurally Dissociated Parts

1. Structurally Dissociated Personality Systems

   • Unique to each individual
   • Clients with complex trauma histories may have a well-developed normal self and several parts driven by survival responses
   • Fragmentation can be subtle or dramatic
   • Clients with PTSD, bipolar II, or borderline personality disorder might exhibit clear-cut states or compartmentalization
   • Mild to moderate dissociative disorder not otherwise specified (DDNOS) clients might have compartmentalization and difficulty with memory.

2. Dissociative Identity Disorder (DID)

   • More complex structural dissociation
   • Greater number of trauma-related parts
   • Subparts serving priorities associated with the normal self
   • Neural systems governing each part become more autonomous, leading to switching and time loss

3. Signs of Dissociative Disorders

   • Difficulties carrying on with normal life while other parts are activated
   • Hypervigilance and mistrust
   • Overwhelming emotions
   • Incapacitating depression or anxiety
   • Self-destructive behavior
   • Fear or hopelessness about the future

4. Evidence of Dissociative Hijacking

   • Celia: Surprised by a memory loss related to an award she won in 1990
   • Annie: Received a letter from her oldest friend asking her never to contact him again due to something she said, but couldn't recall the incident.

Symptoms as Communications from Parts

1. Structural Dissociation

   • Clients may present with seemingly straightforward symptoms like PTSD, anxiety, mood disorders, or personality disorders, but underlying structural dissociation can be present.

2. Signs of Internal Splitting

   • Client functions highly at work due to positive triggers but regresses in personal relationships due to trauma triggers.
   • Alternating fears of abandonment and pushing away others.
   • Paradoxical behavior: intense fears but lack of appropriate fears for real threats, planning a vacation while ruminating on suicide.

3. Treatment History

   • Previous treatments have resulted in little progress or clarity.
   • Therapists report feeling overwhelmed or inadequate.
   • Client reports fearing therapist abandonment more than therapeutic inadequacy.

4. Somatic Symptoms

   • Unusual pain sensitivity or high pain tolerance.
   • Stress-related headaches, eye blinking or drooping, narcoleptic symptoms, physical symptoms with no diagnosable medical cause.
   • Non-responsiveness to psychopharmacological medications.

5. Regressive Behavior or Thinking

   • Client's body language and verbal style reveal presence of younger parts.
   • Inability to make small everyday decisions, patterns of indecision or self-sabotage.

6. Memory Symptoms

   • Difficulty remembering how time was spent in a day, conversations, focus of therapy sessions, "black outs," forgetting well-learned skills.

7. Patterns of Self-Destructive and Addictive Behavior

   • Activation of fight and flight-driven parts by trauma triggers.
   • Fight parts engage in high-risk behavior or attempt to harm the body or end life.
   • Flight parts engage in eating disorders, self-harm, suicidal behavior.

8. Neurobiological and Psychological Effects

   • Unconsciously driven by post-traumatic implicit procedural learning activated by trauma-related triggers.
   • Symptoms feel familiar and automatic, a history held by different parts of the personality with different perspectives, triggers, and survival responses.

Helping Clients and Their Parts “Be Here” Now

1. Symptoms as communications from trauma-related parts:

   • Trauma responses are misinterpreted as current danger or proof of defectiveness.
   • Therapists need to counteract the triggered danger signals by calling attention to reactions as communications from parts.
   • Clients can build capacity for self-regulation and "being here now" through psychoeducation, mindfulness, and new responses to triggers.

2. Post-traumatic implicit memory and structural dissociation:

   • Clients interpret fear, shame, and anger as signs of imminent danger or deep-seated inadequacy without this understanding.
   • Discovering that stuckness, resistance, chronic depression, etc., are communications from parts who fear for their lives can be a relief.
   • Trauma-related implicit memories evoke parts that hold them, even when the dangers are now in the past.

3. Become curious and interested in their symptoms:

   • Learning to identify the voices that speak through reactions can change their relationship from shame and dread to compassion.
   • Understanding how each part participated in survival increases the sense of "we, together" and challenges the sense of being abandoned and alone.
   • Feeling warmth and empathy for young wounded selves feels healing and comforting."

CHAPTER 2

Understanding Parts, Understanding Traumatic Responses

1. Implicit-only memories: Memories that remain in unassembled neural disarray and continue to shape our perception of reality without being accessible to awareness (Siegel, 2010).

   • Trauma survivors may not be able to remember or generalize new learning outside of therapy.
   • They may feel ashamed, mistrustful, or exposed instead of relieved after disclosing secrets.
   • Their experiences may shift from week to week, making it difficult for therapists to understand their clients' states of mind.

2. Trauma and survival responses:

   • The brain instinctively mobilizes the emergency stress response when faced with potential threat.
     • Activation of the amygdala triggers a chain reaction leading to an adrenaline release and sympathetic nervous system activation.
     • This results in feelings of braced strength, slow motion perception, and icy calm.
   • The parasympathetic nervous system also plays a role in preparing the body for potential danger by activating the freeze response or facilitating recovery from the energy expended during fight-flight responses.

3. Impact of traumatic environments:

   • Children and adults living in traumatogenic environments may develop automatic patterns of response, which can be sympathetically activated (hypervigilance, high arousal) or parasympathetically dominant (passivity, slowed thinking, depression).
   • The lack of opportunity to develop a "window of tolerance" in such environments makes it difficult for individuals to tolerate intense emotions or recover from stress.

4. Characteristics of traumatic memory:

   • Traumatic memories are not easily retrievable through deliberate recall and can be activated by triggers, even decades after the event.
   • The hippocampus, responsible for putting experiences into chronological order and perspective, is often suppressed in traumatic memory, leaving individuals with unintegrated sensory elements of the experience.

5. Brain scan research on traumatic memory:

   • Research using brain scans has revealed that when subjects recall a traumatic event, the language and narrative areas of the prefrontal cortex become inactive while emotional memory centers in the right hemisphere limbic system, especially the amygdala, become highly activated.
   • This inhibition of the left hemisphere language centers allows the amygdala to "fire" unchecked, potentially leading to re-enactment behavior and other symptoms associated with PTSD.

Uninvited Remembering

1. Negativity Bias and Long-Term Sensitivity

   • Brain's tendency to perceive negative stimuli more quickly than positive ones
   • Subtle cues can trigger implicit memories, leading to body responses as if in immediate danger

2. Uninvited "Remembering"

   • Trauma survivors have unique and fragmented memories
   • Explicit, implicit, procedural, and conditioned learning memories
   • Triggers can reactivate memory and defense responses

3. Impact of Triggers

   • Many traumatized individuals isolate or withdraw due to fear of triggers
   • Some function but avoid living life fully to reduce exposure
   • Others engage in self-destructive behavior to manage feelings

4. Understanding Traumatic Memory

   • Fragmented and unintegrated memories
   • Unique encoding of traumatic past for each individual
   • Procedural memory system encodes function, action, and habit

5. Survival "Habits" Encoded as Procedural Learning

   • Tendencies to disconnect from strong emotion or feel overwhelmed by it
   • Difficulty making eye contact, need for physical proximity or distance
   • Withdrawal or isolation, difficulty asking for help or disclosing feelings
   • Phobias of emotions or emotional expression, avoidance of having one's back to others

6. Reality-Testing and Self-Triggering

   • Difficulty identifying implicit memories as "memory" can compromise reality-testing
   • Particular people or situations can become "demonized" and experienced as dangerous

7. Fear of Helping Professionals

   • Innocuous stimuli can become associated with a sense of threat
   • Difficulty connecting implicit memory states to young parts of the self

8. Integrating Past and Present for Effective Trauma Treatment

   • Education about traumatic memory, triggers, and labeling triggered states
   • Connecting implicit memory states to young parts of the self
   • Reframing triggered sensations as "the child part's feelings
     • Feeling compassion or protectiveness for younger selves to appreciate one's "big-ness" and safety.

Finding “Now,” Not “Then”

1. Traumatized individuals can find it difficult to stay connected to the present due to past experiences.
2. Acknowledging the past is important, but staying connected to the present is crucial for traumatized individuals.
   • Acknowledgment of the past without exploring it can be validating.
3. Implicit aspects of memory can make clients feel danger in the present instead of acknowledging past dangers.
   • This prevents them from looking back on the past and finding resolution.
4. The goal of trauma treatment is not just to remember what happened, but to transform or reconstruct traumatic memories.
   • This involves changing the individual's relationship to both implicit and explicit memories.
5. Transformation of traumatic memory occurs as tolerance for triggered states expands and individuals can live more fully in the present.
6. Healing story is slowly reorganized from unprocessed implicit elements into a new narrative.

CHAPTER 3 Changing Roles for Client and Therapist

1. Adaptive Strategies as Survival Resources

   • Trauma survivors' symptoms are adaptive strategies to cope with dangerous circumstances (Ogden et al., 2006).
   • These strategies include numbing, depression, hypervigilance, and anger.
   • They served a purpose in the past but become liabilities during recovery.

2. Impact of Trauma on Individuals

   • Trauma survivors may disown aspects of themselves to cope with their experiences (shame, hopelessness, fear).
   • Over-identification with these feelings can constrict their lives and make them smaller than they need to be.

3. Misunderstanding Trauma Reactions

   • Clients may assume the worst about themselves due to lack of understanding about trauma reactions.
   • Therapists, without specialized training, might not recognize these reactions as adaptive strategies or survival resources.

4. Interpreting Client Behavior

   • Misinterpretations of client behavior can hinder effective therapy for trauma.
   • Labeling clients as "help-rejecting complainers," "passive-aggressive," "borderline," "attention-seeking," or "manipulative" is not helpful.

5. Understanding Depression and Low Self-Esteem

   • Depression and low self-esteem can be adaptive responses to trauma, not just mental disorders.
   • Understanding their origins in the past can provide insight into their role and purpose.

Working with the Neurobiological Legacy of Trauma

1. Neurobiologically Informed Treatment focuses on present-time reactions to trauma-related stimuli instead of creating a verbal narrative of past experiences.
2. Implicit Memories, encoded in nonverbal areas of the brain, are subjectively experienced as emotional and physical reactions.
3. Trauma-informed Therapy: Helping clients recognize and "befriend" their triggered reactions instead of reacting negatively.
4. Complex Trauma Histories often involve severe childhood abuse, neglect, abandonment, multiple perpetrators, or sadistic abuse with mind control practices, child pornography, or forced witnessing of violence.
5. Borderline Presentations, dissociative disorders, self-destructive behavior, suicidal tendencies, and addictive behavior are common in clients with complex trauma histories.
6. Phase-Oriented Treatment Model is the "gold standard" of trauma therapy, treating consequences of autonomic dysregulation first before addressing traumatic memories.
7. The goal of stabilization can be elusive for clients with chronic, multi-layered trauma histories and severe dissociative symptoms, dysregulated unsafe behavior, or chronic stuckness
8. Years of treatment focused on self-regulation and avoidance of traumatic content may lead to small steps forward followed by setbacks.
9. Therapists might collude with clients' tendencies to ignore trauma or allow them to say too much, leading to overwhelming feelings.
10. The therapist's role is to help the client stabilize while also feeling heard and validated and to resolve past traumas.

A Multi-Consciousness Approach to Treatment

1. Parts Approach: A new way to address challenges in therapy.
2. Mindfulness-based Practices: Instead of "getting in touch with feelings," clients are taught to "notice" them.
   • Allows for dual awareness: staying connected while observing from a slight distance.
3. Titrating Emotions or Memories: Overwhelmed parts can be balanced by calm, curious, or empathic parts.
4. Multiple States of Consciousness: Human brain capable of holding multiple states at once.
   • Left hemisphere: positive moods.
   • Right hemisphere: negative states.
   • Medial prefrontal cortex: observing consciousness, enables detachment from feelings.
5. Dual Awareness: Ability to fully inhabit the present moment while accessing past memories.
6. Language of Parts vs Brain: Describing experiences using parts language is more engaging and compassionate.
7. Curiosity and Compassion: Teaching clients to observe their emotions fosters curiosity, connection, and self-compassion.
8. Medial Prefrontal Cortex and Amygdala: Activation of medial prefrontal cortex decreases amygdala activity.
   • Reduces flashbacks, intrusive memories, automatic responses, or disconnection.

Pathogenic Kernels of Memory

1. Pathogenic Kernels of Memory

   • Concept: Focus of modern trauma therapy should be on effects or "pathogenic kernels" of trauma, not the traumatic events themselves.
   • Example: Annie's fear to leave her house despite hating isolation.

2. Implicit Memory vs Factual Reality

   • Issue: Implicit memory held by a dissociated part of Annie preventing her from leaving the house.
   • Solution: Identifying and addressing the fear causing the issue.

3. Pathogenic Kernel: Fear of Being Away from Home Alone

   • Origin: Experience leading up to kidnapping.
   • Impact: Continued effect on Annie's life, distorting her reality.

4. Another Pathogenic Kernel: Absence of a Protective Adult

   • Issue: Lack of feeling cared for and safe.
   • Solution: Addressing the need for someone to care for and watch over her parts.

5. Quandary for Therapists

   • Dilemma: Balancing between asking clients to avoid telling their stories (risk of empathic failure) and meeting their "need to 'get it out'" (risk of destabilization).

Acknowledging the Past Without Exploring It

1. Neurobiological Perspective of Traumatic Memory
   • Client memories don't need to be avoided or discharged.
   • Develop a different relationship with explicit and implicit memories.
2. Impact of Memory Details
   • Detailed retelling activates implicit memories, dysregulates nervous system.
   • Acknowledgment in a general way validates clients.
3. Choices of Focus during Trauma Discussion
   • Experience of horror likely to trigger implicit memories.
   • Victimization and objectification likely to trigger shame.
   • Survival techniques and adaptations can be focused on instead.
4. Annie's Fear and Survival
   • Fear of leaving house, need for proximity to protective figure.
   • Defensive avoidance dictated by frightened 7-year-old.
5. Working with "Agoraphobia"
   • Interpreting fear as communication from a frightened child.
   • Praising the child part for survival techniques.
   • Reassuring the child that they are safe in the present.

A Different Approach to Traumatic Memory

1. Traumatic Memory Approaches: These include implicit or explicit memories, memories of dehumanizing events versus ingenious survival, memories held by parts, cognitive schemas, incomplete actions, and procedural memories.
2. Acknowledging Trauma Memories: Therapists can acknowledge the existence of traumatic memories without requiring clients to narrate them extensively. They can help clients observe how these memories continue to impact their lives through pathogenic kernels.
3. Role of the Therapist: The therapist's role is no longer solely focused on becoming a witness to the client's narrative. Instead, they create a neurobiologically regulating environment that enhances safety and expands the client's capacity for tolerating past and present experiences.
4. The Need to Tell: Some clients express a strong desire or need to tell their story. In a neurobiologically informed approach, therapists can bear witness but in a different way than in traditional models to avoid triggering trauma-related autonomic responses and implicit memories.
5. Differentiating Past from Present: Clients must be able to distinguish between being triggered and being threatened for effective trauma treatment. The therapist should help clients understand the concept of implicit memory and ensure they can differentiate objectively between a trauma and a trigger.
6. Interrupting the Process: In some cases, therapists may need to interrupt the client's narrative to check on their nervous system's coping ability or slow things down for the client to settle. This approach is crucial in maintaining safety during therapy sessions.

Witnessing Being Witnessed

1. Witnessing and Being Heard:
   • Crucial for witnessing that longing to be heard is an implicit memory for those who didn't tell their secrets during abuse.
   • Clients desperate to tell may not fully remain present due to intrusive traumatic reactions.
2. Post-Traumatic Stress Disorder (PTSD):
   • Trauma-related stimuli, including narratives, can trigger alarm responses, animal defense reactions, and inhibition of prefrontal activity.
3. Sensorimotor Psychotherapy:
   • Therapist directs client's attention back to the present moment during narrative sharing.
   • Asks clients about their experience in the present while listening to their story.
4. Recognition and Change:
   • Moments of recognition allow clients to feel the difference between past and present, leading to a changed ending for the story.
   • Being heard without shock or horror can significantly alter feelings inside.

The Therapist as “Auxiliary Cortex” and Educator

1. Neurobiologically Informed Treatment Approach

   • Trauma issues stem from dysregulated autonomic arousal, implicit memories, disorganized attachment, and structural dissociation.
   • Traditional models assume individuals have words to describe traumatic experiences but this is being re-examined.

2. Impact of Trauma on Memory

   • Traumatic memory evokes "speechless terror" and experiences "beyond words.
     • Brain scan studies show inhibited cortical activity, especially expressive language centers, leaving subjects "speechless".
     • Prefrontal cortex inhibition cuts off clients from language areas of the brain.

3. Role of Therapist

   • Therapist acts as an educator and temporary "auxiliary cortex".
     • Provides a template for understanding trauma-related symptoms and the phenomenon of triggering.
   • Reinterprets client's "self-defeating story" with psychoeducationally informed meaning.

Illustration

1. Lillian's Story:

   • Lillian, a recently retired pediatrician, experiences intense fear and becomes unable to leave her house alone.
   • Fear emerges after retirement when she no longer has goals or people to help.
   • Therapist explains that the fear is a memory of feeling hopeless, unlovable, alone, and scared as a child.
   • Therapist uses motherly reassurance to help Lillian understand and cope with her fear.

2. Lillian's Africa Experience

   • Triggered implicit memories of terror, loneliness, shame, fears of abandonment.
   • Transformed from confident globe-trotter to quivering child.
   • Couldn't explain her transformation with words.

3. Therapist/Educator's Role

   • Made psychoeducational meaning of symptoms and story.
   • Introduced terms like "trigger," "part," "feeling memory," "dysregulation.
     • Provided concrete information and experimentation opportunities.

4. Lillian's Symptoms

   • Frightened part had "hijacked the body," inhibiting prefrontal cortex.
   • Question "What do I do?" opened discussion of autonomic dysregulation, implicit memory, structural dissociation.

5. Client Narratives and Psychoeducation

   • Clients might describe symptoms as body running amuck or falling apart.
   • Shame-related cognitive schemas require education about symptoms and self-defeating stories.
   • Clients may feel disconnected from "person I used to be" due to limbic hijacking.

6. Connecting to Vulnerability and Strengths

   • Trauma treatment often focuses on vulnerable emotions like fear, grief, shame, and rage.
   • Clients can get stymied when these emotions are overwhelming or exacerbate shame.
   • Important to acknowledge child's survival resources and animal defenses that enabled them to remain intact.

A Creative Adaptation to Abnormal Experience

1. Defensive Responses: The body instinctively chooses defensive responses during abnormal experiences to limit injury, shock, or pain. These responses include feigning death or submission when fighting back might not be safe.
2. Freezing: Freezing is an adaptive response when communication could provoke the aggressor. This state inhibits active defenses and may result in temporary loss of access to verbal information or conceptual thinking.
3. Childhood Fighting Back: Children's instinctive assessment determines whether fighting back or submitting is safer during a conflict, even if it results in punishment.
4. Reassuring the Client: Emphasizing the strengths and normal life self that remain intact despite dissociation is crucial for reassurance and reconnection.
5. Role of Therapist: The therapist acts as an auxiliary cortex, providing psychoeducation, testing interventions, and mapping out steps to stop flooding and access the normal life self.
6. Risks: The biggest risks for the client are regression and avoidance, which could lead to blending with parts or ignoring trauma-related experiences.
7. Healing Relationship: Building a protective, caring relationship with young parts is essential for healing and going on with life. This can be achieved by utilizing determination and motivation from the normal life self.

A New Role for the Therapist: Neurobiological Regulator

1. Early Attachment Relationships: Parent figures provide neurobiological regulation for infants, contributing to their sense of attunement and well-being. This regulation is crucial for developing affect tolerance and expanding the "window of tolerance".
2. Impact of Childhood Trauma: Neglect, trauma, loss, or violent caregiving interfere with attachment formation and the development of a spacious window of tolerance, affecting resilience.
3. Adult Trauma: Disrupts previously established autonomic patterns, priming the nervous system to respond to stressors with over-or under-activity.
4. Dysregulated Clients in Therapy: Enter therapy with a dysregulated nervous system and a truncated window of tolerance, making it difficult to engage in traditional psychotherapy.
5. Role of the Therapist: Offers interactive neurobiological regulation to help clients regulate their nervous systems and expand their windows of tolerance.
6. Meeting Carla: A 45-year-old attorney who is visibly shaken, struggling with eating and sleeping, and overwhelmed by therapy.
7. Interactive Neurobiological Regulation: Slowing down the conversation, smiling, and using a confident energy to help Carla regain control of her nervous system and focus on her strengths.
8. Psychoeducation: Reinterpreting Carla's difficulties as dysregulation and focusing on getting her prefrontal cortex back online.
9. Focusing on Strengths: Eliciting recognition and reconnection to resources by focusing on clients' strengths.
10. Curiosity and Determination: Encouraging clients to be curious about their body memories and using determination to regain control of their nervous systems.

The neurobiologically astute therapist

1. Neurobiologically astute therapy: Therapist's goal is to ensure interventions regulate client's nervous system, acknowledging potential triggers.
   • Trauma-related material is dysregulating.
   • Trusting therapist, being the center of attention, revealing emotions, feeling too close or not close enough are all triggering.
   • Proximity to another human being in a small space may be activating for some clients.
2. Triggers in therapy: Once committed to therapy, potential triggers multiply.
   • Changes in schedule.
   • Not feeling "gotten".
   • Inadequate time or words to express feelings.
   • Disappointed hopes for specific responses.
   • Separation between sessions.
   • Distorted beliefs and projections.
3. Assumptions in neurobiologically informed trauma treatment: Clients are likely to be dysregulated by therapy as well as feeling safe.
4. Tessa's story: Tessa struggles with structural dissociation in her personal relationships.
   • Conflicts between parts: one that likes him, one that pulls away and questions, one that wants sex, and one disgusted and frightened.
5. Effects of relational trauma: Tessa experiences terrible longing when not together and a 'yuck' feeling in his presence.
6. Communication with her dates: She tries to be honest about her ambivalence but keeps texting to explain herself, leading to confusion for the guy.
7. Understanding structural dissociation: If clients like Tessa accept the model, they can learn to voluntarily "split off" intense affects and assign them to younger parts for relief.
8. Healing wounds: Clients need help and direction from therapists to learn abilities needed for healing.

The Therapist as Director, Coach, and Pace-Setter

1. Therapist's Role: Therapists need to gently direct and pace treatment due to dissociative fragmentation, confusion, and risk of retraumatization or avoidance.
2. Roadmap Concept: The therapist provides a roadmap for clients with traumatic reactions that inhibit consistent access to the prefrontal cortex.
3. Family Therapist Model: The therapist's active role is similar to a family therapist, guiding sessions to prevent chaos and help clients develop compassion.
4. Mindful Noticing of Child Parts: Clients are taught to notice and empathize with child parts, which can be challenging due to past loathing or despising of feelings.
5. Acknowledging the Child's Experience: The therapist asks clients to pause and be curious about the child part's feelings, age, appearance, and expressions to evoke compassion.
6. Using Resources for Child Parts: Clients are taught to use resources from their normal life self to help distressed child parts.
7. Noticing Upset as Communication from a Part: The therapist assumes that upset is a communication from a part, encouraging clients to notice and help the part instead of pathologizing it.
8. Mindfulness-Related Bias: Noticing thoughts, feelings, and body experiences with curiosity and compassion can lead to positive change.
9. Encouraging Normal Life Self: The therapist encourages the normal life self to take a mental step back, increase curiosity about younger parts, notice bodily and emotional signs, and experiment with what might help the parts feel safer.

The Body as a Shared Whole

1. Empathy and Body Response

   • Empathy extends beyond verbal communication to nonverbal somatic experiences.
   • These experiences include warmth, relaxation, deeper breathing, and emotional connection.
   • Despite multiple parts, there is only one shared whole of a body.

2. Understanding the Client's Experience

   • Ted, a bright and talented man, had been taken over by a depressed, ashamed submit part due to unexpected professional success and post-traumatic implicit memory.
   • He felt misunderstood and helpless, questioning his adequacy as a person.

3. Shared Empathy and Body Language

   • During therapy, I unintentionally mirrored Ted's body language and feelings of hopelessness and inadequacy.
   • When he recognized this, he felt understood and validated.

4. Transforming Internal Experience with Movement Interventions

   • Using Sensorimotor Psychotherapy techniques, we focused on Ted's physical posture and body language to communicate a new message to the depressed part.
   • This change in body language conveyed that he was not alone or less than, allowing the depressed part to hold its head high with Ted.

5. Working with Parts and the Whole

   • By combining a parts perspective with somatic interventions, we could address both individual parts and the overall shared whole of Ted's body and experiences.

The Changing Role of the Therapist

1. Role Changes for Therapists

   • Parts approach requires therapist to shift roles from listener to educator, individualistically oriented to systems-oriented, facilitator to role model.
   • Neurobiologically informed trauma treatment demands greater differentiation between parts for self-observation.
   • Traditional talking therapy focuses on treating client as one person in one integrated body, but it may not work with fragmented or traumatized clients.

2. Focus on Legacy of Trauma

   • Emphasis is on transforming how parts have encoded the effects of traumatic events rather than accessing event memories.
   • Goal is to change client's relationship to parts from alienation to unconditional acceptance and earned secure attachment.

3. Event-Focused Therapy vs. Repair Perspective

   • Traditional trauma therapy focuses on processing traumatic events, but the model described here emphasizes the legacy of trauma carried by parts.
   • Therapists may encounter resistance from parts that want to keep past secrets or avoid "going there".
   • The goal is not remembering what happened but the ability to be present in the here-and-now and heal injuries caused by the trauma.

CHAPTER 4

Learning to See Our “Selves”

1. Trauma is overwhelming, unbearable, and demands acceptance of a dual reality: the present and the past.
   • Patients require us to suspend our sense of normalcy.
   • The self from traumatic experiences isn't the current self.
2. Brain and Body Adaptation
   • Prioritizes survival over other drives.
   • Attachment drive is powerful in infancy and early childhood.
   • Balance shifts towards fight/flight responses in adolescence.
3. Defensive Responses
   • Freezing and submission are automatic at all developmental stages.
   • Instinctively seek psychological distance from traumatic events or "deep memory".
4. Survival Response: Disowning Traumatized Parts
   • Preserves hearts and souls from growing bitter.
   • Allows focus on mastering age-appropriate developmental tasks.
5. Disowning Needs and Feelings
   • Protects from unbearable disappointment or punishment.
6. Alienation from Self
   • Necessary for maintaining attachment to neglectful and abusive caretakers.
7. Identifying with Adaptive Parts
   • Depending on the environment, children might have to identify with their angry, aggressive, hypervigilant parts and disown their innocent, trusting, attachment-seeking parts or vice versa.

The Cost of Adaptation

1. Selective Attention and Disowning: In traumatic environments, we focus away from feelings that aren't "us" (anger, dependence, fear). Senses fail to register events, emotional responses are muted, and we can't "own" unobserved traumas or whole selves.
2. Affect Intolerance: Escaping emotions by shifting into different parts of self prevents emotional muscle development, leading to intolerance for all feelings.
3. Inner Conflicts and Coping Mechanisms: Unresolved inner conflicts result in acting out (self-destructively or addictively) or "acting in" (through self-hatred, self-judgment).
4. Complexity of Splitting/Fragmentation: As traumatic events prolong and severity increases, the risk for more complex trauma-related disorders like borderline personality disorder, dissociative disorder not otherwise specified, and dissociative identity disorder rises.
5. Normalizing Compartmentalization: The Structural Dissociation model simplifies understanding of brain's ability to split during overwhelming situations.
6. Left Brain Aspect (Going on with Normal Life Part): Verbal, linguistic self that keeps functioning in daily life.
7. Right Brain Aspect (Trauma-Related Part): Corporeal and emotional self with survival resources to prepare for threats.
8. Additional Subparts: Each subpart contributes a different survival strategy; clients can identify their own parts based on their behaviors, defense mechanisms, and relationships to others.

Years after the traumatic experiences...

1. Traumatized clients describe symptoms without knowing they're from traumatized parts or implicit memories.
2. Animal defense strategies have become maladaptive automatic responses, activated by trauma-related stimuli.
   • Once reduced harm or enhanced survival.
   • Now outdated and extreme in normal life.
3. Symptoms include:
   • Major depression (submit)
   • Anxiety disorders (freeze)
   • Substance abuse, eating disorders (flight)
   • Anger management, self-harm issues (fight)
   • Disorganized or traumatic attachment
4. Co-occurring issues: suicidality, chronic pain, obsessive-compulsive disorder, inability to function, loss of previous functioning.
5. Often misdiagnosed with borderline personality disorder, bipolar II, or other disorders.
6. Standard treatments have little impact on dissociative clients.
7. Dissociative disorders (dissociative amnesia, fugue, not otherwise specified [DDNOS], and DID) are under-diagnosed.
8. Severity of symptoms correlates with undiagnosed dissociative disorder.
   • Increased risk behavior.
   • More frequent relapses.
   • Instances of suicidal behavior.
9. Borderline personality and dissociative symptoms are correlated.
   • Approximately two-thirds of borderline patients have significant dissociative symptoms.
   • One-third may meet criteria for DID.

“Getting to Know You”

1. Aaron's Internal Struggle

   • Attachment-seeking part: Quickly connects to women, sees them as "the one".
   • Hypervigilant, hypercritical fight part: Reacts to less-than-optimal qualities as signs of trouble.
   • Flight part: Feels trapped, generates impulses to leave when feeling guilty or afraid.
   • Submit and cry for help parts: Prevent Aaron from leaving relationships due to guilt and fear.

2. Aaron's Dilemma

   • Suicidal part: Threatens to end it all due to painful dilemma.
   • Wandering eye part: Trolls for prospective partners, at odds with desired family life.

3. Nelly's Struggle

   • Underachieving, self-denigrating child part: Protected Nelly from her father's wrath, won him over.
   • Critical part: Mirrors her father's harsh judgments, convinces Nelly of being a waste of human life.
   • Going on with normal life self: Professionally focused, witty, charming, and self-compassionate.

4. Nelly's Internal Confusion

   • Submit part: Afraid to let Nelly actualize as a talented professional.
   • Critical part: Hypervigilantly worries about failure.
   • Freeze part: Afraid to leave the house due to fear of encountering scary people like her father.

5. Misunderstanding of Self

   • Aaron and Nelly both assumed their feelings were entirely their own, not realizing the internal conflict among parts.

Developing Curiosity: Who Is “I”?

1. Parts Model vs. Psychotherapy Models

   • In psychotherapy models, all emotions are treated as expressions of an individual's whole self.
   • In parts model, each emotion is treated as a part.
   • Therapist uses the language of "parts" to help client observe each feeling or reaction with curiosity and distance.

2. Aaron and Nelly's Case

   • They had lost curiosity about their symptoms.
   • Identified too much with parts' struggles and conflicts, missing paradoxical responses.

3. First Task in Therapy

   • Challenge assumptions.
   • Ignite curiosity using "language of parts" and mindful observation.

4. Mindful Noticing of the Inner Landscape

   • Continued rumination on trauma-related emotions and cognitive schemas triggers more dysregulation.
   • Learning to observe rather than react is foundation of a parts approach.
   • Mindful observation evokes activity in prefrontal cortex, counteracting trauma-related cortical inhibition.

5. Benefits of Mindful Observation

   • Clients can have a relationship to the feeling rather than be consumed by it.
   • Decreased amygdala activation and increased medial prefrontal cortex activity.
   • Slower pace, increased concentration, and greater observational capacity.

6. Advantages of Increased Prefrontal Cortex Activity

   • Clients can use mindful noticing to separate from intense reactions of a part.
   • Can have curiosity or compassion towards the part's feelings or perspective.
   • Can create ways of soothing or managing emotions.
   • Can choose to react differently to foreseeable events or triggers.

7. Parts Under Influence of Implicit Memory

   • Have same reactions over and over again.
   • Coping skills and problem solving less effective when parts are triggered.
   • "Problem" is most often an implicit memory, not a current stress or challenge.

Survival-Related Internal Struggles

1. Internal Struggles

   • Predictable responses: help/attach (submit part) evokes flight-related distancing or fight-related protective reactions (flight and fight parts).
   • Critical thoughts from fight part trigger shame, hopelessness, inadequacy (submit part).
   • Interpersonal closeness triggers yearning for more proximity (attach part), fear of harm (freeze part), and alarms (fight and flight parts).
   • Professional or family responsibilities can feel like old burdens to submit part.
   • Steps forward in life taken by normal life part can alarm trauma-related parts and trigger conflicts and crises.

2. Self-Defeating Stories

   • Submit part: shame-based, hopeless story of victimization.
   • Cry for help part: story of no one coming or caring.
   • Fight part: better to die than continue being used and abused.

3. Beliefs and Meaning-Making

   • Trauma is an experience beyond words.
   • Beliefs bias meaning-making, leading to self-defeating stories.

4. Impact of Attention or Achievements

   • Fear of visibility in freeze part.
   • Expectation of being used or abused in fight part.

5. Unblending and Compassion

   • Understanding belief-emotion connection.
   • Compassion for younger selves.
   • Protecting young boy from hurt.

6. Self-Acceptance and Befriending

   • Not simply a therapeutic endeavor.
   • Slowing down reactions, settling autonomic arousal.
   • Living amicably and collaboratively with parts.
   • Rejecting parts diminishes self-esteem.
   • Radical acceptance of sharing bodies and lives with parts.

CHAPTER 5

Befriending Our Parts: Sowing the Seeds of Compassion

1. Mindfulness as an Act of Hospitality

   • Mindfulness is a way of treating ourselves with kindness and care.
   • It asks us to offer hospitality to ourselves, regardless of feelings or thoughts.
   • This isn't about denial or self-justification, but self-compassion towards difficult aspects of life.

2. Alienation from Self

   • Disowning traumatic experiences leads to profound alienation: "I don’t know myself, but one thing is clear: I don’t like myself.
     • Survival mechanisms created a bind: self-compassion was adaptive "then," but now it feels unbelievable.
   • Others are seen as deserving and trustworthy, while we are not.

3. Importance of Internal Attachment Bonds

   • Compassion for ourselves is crucial for emotional resilience.
   • Healing from wounds requires relational safety within ourselves.
   • Our attachment to ourselves may be more influential on our sense of well-being than interpersonal attachments.

4. Focus on Cultivating Compassion for Disowned Selves

   • Trauma treatment should focus less on traumatic events and more on compassion for disowned selves and their experiences.
   • When all parts of us feel internally connected and held lovingly, each can experience safety, welcome, and worthiness.

5. Becoming Curious about the "Other" Inside

   • The first step is to become curious about the parts of ourselves we don’t truly know.

The Role of Mindfulness: How We Can “Befriend” Ourselves To

1. Mindfulness is crucial in treating trauma due to its impact on the brain and body.
   • Requires a witnessing mind for focused concentration or "directed mindfulness".
2. Effects of Mindfulness on the Brain:
   • Increased activity in the medial prefrontal cortex.
   • Decreased activity in the amygdala.
3. Role of Mindfulness in Trauma Treatment:
   • Counteracts trauma-related cortical inhibition.
   • Regulates autonomic activation.
4. Facilitates "dual awareness" or "parallel processing":
   • Allows exploration of past without retraumatization.
   • Present and past experiences coexist in the mind.
5. Mindfulness-based methods for trauma treatment:
   • Sensorimotor Psychotherapy.
   • Internal Family Systems.
   • Hypnotic ego state therapy.
   • Eye Movement Desensitization and Reprocessing (EMDR).
   • Somatic Experiencing.

From Whose Perspective Should We Observe?

1. Internal Family Systems (IFS) Approach
   • Distorted perspectives from telescopic lenses of each part
   • Particular biases limit data picked up by each part
2. Part Responses
   • Fight part: hypervigilant towards threat stimuli, never sees danger signals
   • Freeze (submit) part: hypersensitive to data confirming unworthiness or not belonging
   • The attach part only sees warm smiles, reassuring words, and polite manners, and never sees danger signals.
   • The submit part doesn't see respect from colleagues or approval from family members, but is hypersensitive to data confirming beliefs in unworthiness or not belonging.
3. Meta-awareness Perspective
   • Clients learn to identify lens through which they are looking
   • Separate from intense reactions of a part, acknowledge feelings as "his" or "her distress
   • Bear witness to child part's painful experience
4. Mindful Observation
   • Mindful interest instead of attachment or aversion
   • Tolerate emotions and sensations that may have previously felt frightening
   • Supported by curiosity, compassion, calm, clarity, creativity, courage, confidence, and connectedness (C qualities)
5. Accessing C Qualities
   • Observer is ascribed to "self," an internal state that draws upon eight "C" qualities:
   • curiosity
   • compassion
   • calm
   • clarity
   • creativity
   • courage
   • confidence
   • connectedness
   • Some individuals may need to practice to access these states consistently
   • Clients may be triggered by certain qualities
   • Observing body responses can help clients mindfully notice their reactions without interpreting or describing them in a narrative
6. Therapist's Role
   • Support clients by prompting them to observe thoughts, feelings, and physical reactions as separate communications
   • Observe each thought or feeling as a separate communication
   • Notice perspectives of different parts in internal conflicts

Differentiating Observation versus Meaning-Making

1. Trauma is an experience beyond words (Meichenbaum, 2012).
   • Individuals attach beliefs or stories to traumatic events, influencing meaning-making.
   • Self-defeating stories can be created based on different parts of the trauma experience:
     • Submit part: Shame-based, hopeless story of victimization.
     • Cry for help part: Story of neglect or indifference.
     • Fight part: Belief that it's better to die than to continue being abused.
2. Only going on with normal life allows for higher level meaning-making and conceptualization (Meichenbaum, 2012).
   • Requires higher order cognitive processing.
   • Comprehending adaptive vs maladaptive beliefs.
3. Beliefs should be differentiated from:
   • Feelings.
   • Visceral reactions.
   • Perceptions.
4. Tension and relaxation should also be distinguished.
5. Connecting all inputs to the contributing parts helps clients understand their whole self and trauma logic.

Blending, Shifting, and Switching of Parts

1. Blending, Shifting, and Switching of Parts

   • Parts do not come with labels or manuals.
   • Every part shares the same body, brain, and environment.
   • Feeling or thought could be from any part.
   • Blending refers to identifying with parts and losing self-awareness.

2. Blending: Example of Catherine

   • Woke up feeling lonely on vacation, believing it was her feeling.
   • Accused husband of not caring, lost connection to present life.
   • Later realized the feeling came from a disconnected young part.
   • Needed reassurance, not alone.

3. Shifting: Example of Rachel

   • Experienced depression and irritability, sometimes blended with parts.
   • Depression triggered by loss of partner's attention.
   • Irritability triggered by partner's tendency to help others.
   • Recalled childhood experiences associated with each part.

4. Unblending: Mindful Separation

   • Practicing noticing and separating from parts rather than identifying with them.
   • Gaining perspective, compassion, and relief.
   • Facilitating creative solutions to internal conflicts.

Facilitating Empathy

1. Facilitating Empathy

   • Therapist models empathy for each part.
   • Uses language of parts, noticing voices, feelings, and points of view.
   • Adds warmth and appreciation to communication.
   • Describes plight of parts when clients struggle with compassion.
   • Verbalizes appreciation for parts' contributions to client's survival.
   • Shares personal experience to bring parts alive.
   • Uses language that evokes positive feelings and associations.
   • Admires ingenuity or courage of parts.
   • Defends or sticks up for parts.

2. Modeling Empathy

   • Therapist models bearing witness to each part's qualities, emotions, and trauma-related perspective.
   • Uses mindful language to describe parts.
   • Communicates warmth and appreciation.

3. Understanding Parts' Plight

   • Describes the difficulties faced by parts when clients struggle with compassion.
   • Verbalizes appreciation for parts' contributions to client's survival.

4. Bringing Parts Alive

   • Uses language that evokes positive feelings and associations.
   • Admires parts' ingenuity or courage.

5. Defending Parts

   • Challenges clients' judgment of parts.
   • Encourages curiosity about the origins of parts' behaviors.

“Seeing” the Parts: Externalized Mindfulness

1. Dual Awareness: When individuals are too identified with their parts' feelings and beliefs, therapists need alternative methods to facilitate observation.
2. Visual Focusing: Trauma therapists can use visual aids like an easel or large clipboard to increase curiosity and activate the medial prefrontal cortex.
3. Drawing Parts: Clients are asked to draw pictures of parts they're struggling with, then observe and learn from the drawing.
4. Flow Charting: Creating a flow chart helps clients track internal relationships between parts in conflict, starting with an initial trigger.
   • Identifying Parts: Each part is represented by a circle with its age or descriptor, followed by its feelings and beliefs.
   • Internal Struggles: Typically, internal struggles involve 3 to 6 different parts.
5. Diagramming: Clients rarely refuse to diagram as it feels less threatening than talking about emotions.
6. Triggering Parts: The first part triggered is described, followed by the part that gets triggered by the initial part.
7. Shame Part: In the example given, the client felt lonely and unwanted, then intense shame, blaming herself for everything.

The visual images symbolizing each different part

1. Unblending: Clients' body language or tone shifts when studying diagrams, indicating they are noticing separate parts instead of blending with them. If unblending doesn't occur spontaneously, ask clients to focus on each part and increase curiosity.

2. Understanding the System of Parts: The system of parts gets activated and polarized due to triggers. The normal life self can provide healing and care for child parts, making suicidal or destructive parts' attempts unnecessary.

3. Importance of Compassion: A compassionate normal life self is crucial in taking care of vulnerable child parts. This approach evokes positive sensations and fosters a sense of care and protection.

4. Externalizing the Parts' Struggles: Using diagrams, gestures, or objects like rubber ducks helps externalize the parts' struggles and conflicts for witnessing and understanding.

5. Client's Experience - Cath's Story: Cath, a client with internal conversations among voices, used rubber ducks to represent her parts due to their appeal to a child's mind. This approach helped her describe her internal problems and conflicts more effectively.

6. Benefits of Externalization: Externalizing the parts in interaction facilitates a wider field of awareness, greater curiosity and interest, a sense of perspective, and increasing capacity to access the better judgment of the wise mind.

Blending and Reality-Testing

1. Blending and Reality-Testing

   • Annie's survival strategy was to automatically blend with activated parts.
   • She never questioned information from body, thoughts, or emotions.
   • Small events could trigger multiple parts and their implicit memories.
   • Blended state assumed world as humiliating, dangerous, and herself as defective.

2. Blending Keeps the Trauma "Alive"

   • Resolving traumatic experiences in an unsafe environment is challenging.
   • Both client and therapist may believe trauma can be resolved by processing events.
   • Safety equated to freedom from self-harm or non-abusive home environment.
   • Unblended perspective allows for appreciation of both realities.
   • Normal life self can orient to immediate environment, evaluate safety, and feel parts' fear.

3. Unblending is Essential for Trauma Resolution

   • Clients blended with implicit memories and parts may not feel safe.
   • Unblending allows the normal life self to bear witness to parts' past reality and feel empathy.
   • From an unblended perspective, trauma can be addressed effectively.

Learning to Unblend

1. Insta-blending is a habitual response where one automatically merges with the strongest feelings of inner parts, often without mindful noticing.
2. Unblending is the process of separating from these inner parts to gain perspective and maintain dual awareness.

Suzanne struggled with unblending due to her hypervigilant "bodyguard" part's fear of disappointment or betrayal

1. Therapist used various techniques to help Suzanne unblend:
   • Encouraging the use of non-interpretive, non-pathologizing language.
   • Teaching "unblending protocols".
2. Suzanne found it difficult to feel parts without merging with them completely.
3. Therapist validated her concerns and introduced a structured approach to unblending:
   • Noticing feelings and repeating "She's afraid/upset.
     • Engaging the core muscles to feel presence.
   • Lengthening the spine for heightened awareness.
   • Connecting to a department supervisor role.
   • Asking parts if they need something else.

Less afraid to connect

1. Suzanne's ability to connect with her young self: Provided with structured steps, Suzanne was able to unblend and initiate a dialogue with the upset part of herself.

2. Client's compassion for their parts: Clients often feel compassion towards their parts once they are no longer blended.

3. Therapist's role in parts focus: The therapist should keep the client mindful and focused on the child, asking questions that deepen the connection.

4. Positive internal states: Clients usually experience warmth, relaxation, and calmness when they reach out to their younger selves.

5. Deepening the felt connection: To ensure these positive feelings are not momentary, therapists should continue focusing on the child's internal experiences.

6. Embodied connection: Clients may say all the right words but lack an embodied connection; therapists should ask clients to focus on changes in emotion or sensation when they offer comfort.

7. Repetition of new patterns: Change will come only through repetition of new patterns, which the therapist may need to emphasize.

8. Child's predicament translation: The therapist may need to translate the child's situation to help the normal life self understand and respond effectively.

9. Showing up consistently: The child needs to feel that the therapist is there for them consistently, which requires daily communication and care.

Providing Hospitality

1. Host/Normal Life Self

   • Empty vessel for traumatized parts in Early Dissociation theory
   • Homeowner and provider of hospitality
   • In charge of body's health and well-being
   • Access to medial prefrontal cortex for wider perspective, conceptualization, reconciliation
   • Capable of holding dual awareness: past and present, part and whole, animal brain and thinking brain
   • Demoralized or depleted when clients come for treatment
   • Needs education to recognize parts as young child selves

2. Welcoming Trauma-Related Parts

   • Normal life self becomes a "warm and welcoming host
     • Link between client's hopes and dreams and ability to befriend parts
   • Focus on relationship between parts and normal life self in present moment
   • No emphasis on discovering past events or connecting parts' reactions to specific events
   • Therapist communicates support for young, vulnerable, traumatized parts

3. Practicing New Habits

   • Practice noticing, naming, and unblending parts
   • Relinquish automatic assumption that all thoughts, feelings, and physical reactions are "mine
     • Use language of parts in therapy and ask clients to do the same
   • Develop capacities of "wise mind" or "self energy" in the normal life self
   • Encourage development of functional ability to take action for the sake of the whole system.

Forming a Connection to a Wise Compassionate Adult

1. Trauma Survivors and Identified Parts

   • Survivors of trauma may identify with certain parts, disowning others.
   • Some identify with normal life selves (Carla).
   • Others identify with suicidal or angry parts.
   • Some identify with the attach part seeking proximity.
   • Some identify with the submit part becoming caretakers.

2. Loss of Connection to Normal Life Self

   • When clients identify with trauma-related parts, they can lose access to prefrontal cortex and normal life self.
   • Intensity of parts' responses "drowns out" connection to left brain self.
   • Normal life self's persistence is often seen as fraudulent or pretending.

3. Rejecting the Concept of a Normal Life Self

   • Some clients reject the concept, believing there's no adult part.
   • Depressed parts can make it harder to function.

4. Accessing the Normal Life Self

   • Remembering functional days can help reconnect with normal life self.
   • Challenging over-identification with depressed parts by accessing career experience and compassion.

5. The Brain and Information Retention

   • The brain doesn't lose information, even if access is lost.
   • Abilities like curiosity or clarity of mind are still within the person.

Connecting to the Resources of a Competent Adult

1. Normal Life Self
   • Essential part of an individual's identity
   • Associated with roles, activities, or experiences where they functioned effectively
   • Can be identified through past or future visions of a normal life
2. Identifying the Normal Life Self
   • Ask about past roles, hobbies, causes, or dreams
   • Recognize parts that seek normalcy despite symptoms
3. Connecting with the Normal Life Self
   • Understand it as the part that wants to be functional and live a normal life
   • Encourage association with activities or roles related to this self
   • Challenge beliefs of it being a 'false self'
4. Importance of the Normal Life Self
   • Helps develop a stronger sense of having an adult body and mind
   • Can be found in various activities, hobbies, or roles
   • Instinctively drives individuals to seek normalcy even in abnormal environments

Selves-Acceptance

1. Selves-Acceptance and befriending parts contribute to self-acceptance:

   • Pausing emotional reactivity leads to calmness and peace.
   • Autonomic arousal settles, reducing sense of urgency.
   • In a calmer state, parts feel more at peace.

2. Self-alienation does not promote peace:

   • Disowning parts creates tension and pits them against each other.
   • Communicates a hostile environment, similar to traumatic environments.
   • Diminishes self-esteem of every part.

3. Meditation Circle for Parts:

   • A daily practice where all parts are invited to join.
   • Provides a safe space for parts to express concerns.
   • Encourages communication between parts and therapist.

4. Befriending our parts:

   • Acceptance that we live with multiple selves.
   • Living amicably and collaboratively with all selves, not just comfortable ones.
   • Welcoming owned and disowned selves makes internal worlds safer.

CHAPTER 6

Complications of Treatment: Traumatic Attachment

1. Attachment is a reflection of an infant's need for safety. It's not innately secure.
   • Infants perceive threats based on caregiver signals and availability, not actual danger.
2. Secure Attachment: Essential early experiences include heart-to-heart contact, coos, smiles, and warm gazes.
   • These experiences are remembered as "implicit" or "emotional memories.
3. Impact of Early Attachment: Secure attachment promotes tolerance for distress and self-soothing abilities.
   • Affect tolerance in adulthood is linked to the autonomic nervous system's development.
4. Attachment Styles and Strategies: Represent adaptations to caregiving environments.
   • Procedurally learned habits of action and reaction are stored in nonverbal memory.
5. Memory Systems in Attachment Relationships:
   • Procedural memory: "what we do with one another.
     • Autobiographical memory: "what we know about one another.
     • Emotional memory: determines emotional state alterations.
6. Attachment Habits and Implicit Memories: Reflect early attachment experiences.
   • Some individuals may tense up, avoid, prefer family, or have eye contact issues based on their history.

Trauma and Attachment: The Source of Safety Becomes the Source of Danger

1. Trauma and Attachment
   • Infants' defense systems motivate them to flee from frightening caregivers
   • At the same time, their attachment system motivates them to seek comforting proximity
   • Result: Disorganized or Type D attachment (Main & Hesse, 1990)
2. Impact of Neglectful and Abusive Caregivers
   • Frightening behavior evokes fear/flight/fight responses
   • Intensifies yearning for proximity
3. Infants' Expectancies
   • Develop patterns of behavior based on interactions with caregivers
   • Disorganized attachment infants: shutting down, matching mother's dysregulated states
4. Survival Responses in Infants and Young Children
   • Limited repertoire for survival: proximity-seeking, fight, flight, or parasympathetic dorsal vagal system response (freezing)
5. Power of Early Nonverbal Attachment Learning
   • Karin's story: body remembered that closeness is dangerous
6. Impact on Relationships and Mental Health
   • Children like Karin develop strong association between soothing/proximity and fear
   • Result in crisis after crisis in relationships, oppositional-defiant disorder, borderline personality disorder, or parasympathetic dominance (mistaken for depression)
7. Evolutionary Instincts
   • Attachment drive: seeking and maintaining proximity
   • Animal defense survival responses: polar opposite of attachment drive
8. Observable Signs in Orphanage-Raised Adoptees
   • Initially arch away from adoptive mother's body or stiffen on contact
   • Look away rather than toward caregiver
9. Secure Attachment Relationships
   • Infants actively search for gaze-to-gaze contact and socially engage with adults

“Controlling Attachment Strategies” and Trauma

1. Disorganized Attachment in preschool children is characterized by two types of controlling behaviors:
   • Controlling-caretaking: Children exhibit a parentified style, soothing, reassuring, and helping their mothers. More common in girls and when mothers exhibit role-reversal or guilt-inducing behavior.
   • Controlling-punitive: Children attack the mother verbally and/or physically, humiliating and devaluing her. More common in boys, especially in response to maternal hostility.
2. These controlling strategies stem from a need to defend and attach simultaneously, maintaining proximity while inhibiting dependency needs.
3. The legacy of disorganized attachment affects all later relationships, including therapeutic ones. This phenomenon is referred to as the "phobia of therapy and the therapist".
4. Traumatized clients may crave relief, understanding, and care from therapists but experience fear and distrust due to past experiences.
5. Closeness and dependency are paradoxical for traumatized individuals: they cannot be fully trusted, yet distance or aloneness is also not safe.
6. Clients' internal conflicts can complicate the therapeutic relationship, with different parts having biased perspectives on attachment versus safety.
7. Attach parts often idealize the therapist and seek a close relationship, believing that only safety lies in closeness and care. However, they may become increasingly childlike or needy over time, developing separation anxiety or crises.

Awakening the Yearning for Care

1. Structural Dissociation in psychotherapy:

   • The attach parts may react adversely to therapeutic relationship or growing closeness, intensifying fears of abandonment and sensitivity to empathic failure.
   • These reactions can lead to increased demands on the therapist's time and energy, evoking implicit memories of yearning for care.
   • The hunger for contact can become obsessive and pathologized as psychotic or erotic transference.
   • Therapists may misinterpret these behaviors as signs of borderline personality disorder if not familiar with Structural Dissociation model.

2. Behavior of Attach Parts:

   • Trust therapist immediately and unconditionally, but their yearning for closeness is easily triggered by kindness, warmth, and care.
   • Desperate for contact, they often have difficulty leaving therapy sessions and seek proximity between visits through various means.
   • Their messages may appear as signs of crisis to which therapists feel a responsibility to respond.
   • Over time, the therapist may notice a pattern of increasing urgency, less successful therapeutic reassurance, heightened sensitivity to empathic failure, and more frequent crisis calls.

3. Misunderstanding Disorganized Attachment:

   • Interpreting disorganized attachment as expression of whole integrated client can lead to frustration and confusion for therapists.
   • The symptoms are not signs of a personality disorder but represent disorganized attachment associated with structurally dissociated parts.

4. Alternating Appearances of Attach and Flight Parts:

   • Attach parts express needs for more proximity, while flight parts distance, control, or devalue the treatment.
   • Early on or as attach part becomes more vulnerable, flight part may manifest in therapy as client expressing ambivalence about the treatment.
   • Flight parts' instinctual avoidance is likely to be triggered by therapy sessions.
   • Attempts to process these patterns as if they were those of a whole integrated individual are usually frustrating.

5. Distinguishing Normal Life Self and Flight Part:

   • In dealing with two different subparts with conflicting wishes and fears, it is important for therapists not to become confused or frustrated.
   • Therapist should make a clear distinction between the normal life self and the flight part in understanding their intentions and desired outcomes.

Not One but Many

1. Attachment Issues and Multiple Transferences

   • Each part in a client may develop different transferential relationships with the therapist.
   • Attach needs warmth, connection, and attunement.
   • Flight requires space and acceptance of distance.
   • Fight seeks proof of trust and no hidden agendas.
   • Submit wants to please and comply.
   • Freeze doesn't want to be hurt.

2. Understanding the Transference of Parts

   • Disorganized attachment reflects the relationship between a proximity-seeking attach part and a hypervigilant, protective fight part.
   • Submit part may appear as the identified patient but serves the needs of the attach part.
   • Submit part might strive to be the best client to increase positive feelings for the attach part.
   • Progress may not be visible when dealing with a submit part.

3. Identifying Parts through Rigidity

   • Parts expressing themes are rigid in their beliefs and understanding.
   • Struggles or resistance from clients often indicate dialogue with one part, not the larger consciousness.
   • Therapist responses should acknowledge and validate the part's perspective to encourage further exploration.

Creating an Alliance with the Fight Part

1. Disorganized Attachment and the Fight Part

   • Reflects internal conflict between proximity-seeking drives and fight/flight responses.
   • Focus of therapy due to hypervigilance, wariness, and mistrust towards therapists and process.

2. Identifying the Fight Part

   • Subtle indicators: client's comfort with sharing personal information, questions about office policies.
   • Indicators in history: previous therapy ending badly, dropped friendships, difficulties at work.
   • Active role in treatment: defending child part from perceived empathic failures.

3. Empathic Failures and the Fight Part

   • Hurt feelings of child part communicated through an angry, indignant fight part.
   • Misunderstood intentions: words or actions perceived as cold or cruel to the child part.
   • Defensive responses from therapists: feeling criticized, devalued, and found wanting.

4. Consequences of Empathic Failures

   • Disorganized attachment "system": therapist feels badly for hurting client but also defensive.
   • Misattuned repair efforts due to lack of understanding of the child part's vulnerability.

5. Fight Part and Self-Destructive Behavior

   • Suicidality, self-harm, and unsafe sexual behavior as manifestations of the fight part's aggression.
   • Triggers: empathic failures, losses, painful loneliness, intrusive memories or flashbacks.

6. Threatening Therapy for the Fight Part

   • Any therapy that appears to emphasize dependency or encourage vulnerability is threatening.
   • Normal stimuli, like a box of tissues, can be perceived as danger signals by the fight part.

There is No “He” or “She”

1. Disorganized Attachment

   • Therapists may encounter a closed, counterdependent client at the start of therapy.
   • This is not an integrated whole but a part named "fight".
   • Beneath the militant counterdependence lies an "attach" part with longing and hurt.

2. Interaction between Fight and Attach Parts

   • Therapist's reaching out to help client "open up" activates attach part.
   • Activation of attach part results in increased dependence and vulnerability.
   • Fight part, distrusting connection, defends the attach part from dependence.

3. Impact on Therapy

   • Intensified separation anxiety in attach part triggers fight part's defense.
   • More frequent contact increases fight part's sense of threat.
   • Accusations of empathic failure from client due to perceived insufficient contact.

4. Implications for Diagnosis and Treatment

   • Client with disorganized attachment may fulfill criteria for Borderline Personality Disorder.
   • Manifestations of disorganized attachment may be confused with personality disorder symptoms.
   • Role of trauma and traumatized parts often goes unrecognized and untreated.

5. Consequences for Client

   • Client's normal life self realizes worst fears: getting worse in therapy instead of better.
   • Therapist may become engaged in a struggle with self-destructive or suicidal fight parts, losing opportunity to help client work with these parts.

A Therapist for All the Parts, Not Just the “Client”

1. Trauma-Related Themes: Therapists should be attuned to trauma-related themes when working with traumatized clients, as they may be dealing with multiple parts. These themes include painful loneliness, despair, fear, addictions, eating disorders, and impact on relationships.

2. Listening for Parts' Voices: Encourage curiosity, provide psychoeducation, and listen intently for the "voices" of different parts. Be alert for signs of a normal life self and dysregulation.

3. Understanding Client's Regulation: Awareness of how clients regulate emotions provides insight into their windows of tolerance and observing selves.

4. Language of Triggering and Parts: Introduce the language of triggering and parts early in treatment to help clients understand their experiences.

5. Patterns and Indicators of Trauma: Listen for subtle indicators of losses of functioning, internal conflicts, self-sabotage, and paradoxical behavior. These can be triggered by normal life events or trauma-related triggers.

6. Client's Perspective: Clients often come to therapy feeling confused, desperate, and fearful. Reassuring them with a new perspective that makes sense of their experiences can provide relief.

7. Parts Protection Mechanisms: Some parts may have formed to protect the client from further harm or exposure. Understanding these protective mechanisms is crucial in therapy.

8. Normal Life Self and Trauma-Related Parts: Be curious about both the normal life self and trauma-related parts, as they often coexist in clients with a history of trauma.

Speaking on Behalf of the Parts

1. Difficulties in Implementing Parts Language

   • Clients have trouble maintaining access to their parts.
   • Difficulty empathizing with parts.
   • Struggle to retain initial curiosity about this new way of thinking.
   • Therapist may feel discouraged by slow progress.

2. Changing Procedural Learning

   • Human beings never forget procedural learning.
   • Learning to use the word "part" instead of "I.
     • Practice involves repetition and patience.

3. Using Parts Language in Therapy

   • Using parts language in opening greeting.
   • Interrupting automatic assumption of "I.
     • Reiterating psychoeducation on structural dissociation.
   • Mirroring client's words into parts language.

4. Connecting with Parts

   • Client connects emotionally to parts and reports fears.
   • Therapist speaks "on behalf" of parts to generate compassion.
   • Using mindful contact statements to ensure parts are heard.

5. Avoiding the Tendency to "Pick Sides"

   • Therapists and clients have a tendency to side with some parts over others.
   • Challenges in working with difficult parts.
   • Remembering that internal struggles are between parts, not the client.
   • Maintaining a neutral perspective to resolve internal conflicts.

Dyadic Dancing Attunement

1. Dyadic Dancing (co-regulation): therapist's body expresses attunement through facial expressions, tone, and posture.
   • Soft or firm face, communicating warmth or calm.
   • Leans forward/back in rhythm with client.
   • Uses right brain perception to monitor client's body and nervous system.
2. Client's Agitation: therapist responds by slowing respiration, pace of speech, and softening tone.
   • Asks client to "notice" agitation or belief behind it.
   • Engages in dialogue instead of listening to entire statement before replying.
3. Dialogue as a Dyadic Dance: therapist echoes client's words, translates them into parts language, and makes comments from a bird's eye perspective.
4. Interruptions and Reinterpretations: sensitive attunement ensures clients feel met rather than cut off.
5. Infant Dialoguing Parallels: mother responds to baby with soothing or exciting statements, tracks signals to ensure enjoyment and proper stimulation.
6. Attending to Multiple Parts: therapist must consider how responses will affect all parts, not just the normal life self.
7. Logistical Issues: discussing logistics can trigger anxiety in child parts; reassurance is necessary.
8. Billing and Shame: acknowledging all parts' views is important when discussing billing and feelings of shame connected to money.
9. Safety Discussions: respecting different conceptions of safety is crucial to avoid triggering survival responses.
10. Higher-Level Goal: developing close emotional bonds between the normal life survivor and young parts.
11. Collaboration and Consensus: trusting therapist and collaboration between parts support internal bonds.
12. Speaking from a Place of Respect: therapist empathizes with each part's point of view, allowing the normal life self to accept them as resources rather than liabilities.

Often therapists hesitate to use the language like “inner person”

1. Inner person or parts: Therapists may avoid using this term due to potential fragmentation, but if visualized and treated like children or teens, interaction becomes easier for the normal life self.
2. Going on with normal life part: Benefits from warm, open interest in other parts.
3. Survival contributions of fight and flight parts: Must be acknowledged and honored as war veterans for their role in client's survival.
4. Submit and freeze parts: Despite avoidance strategies, they were essential to client's survival and adaptation.
5. Childhood survivors: Without these parts, reactions might have been more harmful to the abuser(s).
6. Attach part: Benefited from moments of support, providing hope and role models.
7. Triggered parts: Continue to drive trauma-related symptoms, but therapist should ask "How is this part still trying to help?" and "What is this part worried about? How is this an attempt at a solution?
8. Client's parts: Still attempting to fix what was wrong in their past.

CHAPTER 7

Working with Suicidal, Self-Destructive, Eating Disordered

1. Trauma Overload

   • Human defense system becomes overwhelmed when resistance or escape is impossible (Herman, 1992)
   • Survival responses (flight-fight) markedly augment individual's capacity to shift into aggressive state (Teicher et al., 2002)

2. Impact of Trauma

   • Daily life challenges and traumatogenic environments tax belief in safety, determination to live
   • Feeling helpless, overwhelmed, vulnerable, terrified, alone with no resources or support

3. Body's Response to Trauma

   • Disconnection, numbing, dissociation as coping mechanisms
   • Neurochemicals (adrenaline, endorphins) for survival
   • Animal defense survival responses: fight, flight, freeze, submit, attach

4. Trauma and Self-Destructive Behavior

   • Road rage, sexual compulsivity, inability to leave dangerous situations or relationships
   • Suicidal ideation, threats, attempts correlated with PTSD (Khoury et al., 2007; Krysinska & Lester, 2010; Min et al., 2007)
   • High relapse rates among those with trauma histories (Najavits, 2002)

5. Understanding Coexistence of Will to Live and Death Wish

   • Complex inter-relationship between strong will to live and intense longing to die in individuals with trauma histories

A Way Out or a Way to Go On?

1. Surviving Trauma requires immense determination and belief in safety while dealing with normal and abnormal challenges.
   • Young children rely on body's resources for survival (disconnection, numbing, dissociation).
   • Adolescents have more options due to a stronger body and developing brain.
2. Desperate Measures are taken in response to feelings of terror, helplessness, and despair.
   • The sympathetic nervous system mobilizes the body for defense but can lead to self-destructive behavior when fighting or fleeing are not options.
3. Self-Destructive Behavior originates from feelings of annihilation, isolation, and vulnerability.
   • Emotions and emotional expression can feel dangerous due to past experiences of danger.
4. Lack of Soothing Abilities contributes to self-destructive behavior.
   • Consistent early experiences of soothing condition the nervous system to settle and recalibrate.
5. High-Risk Behavior is a relief-seeking, not destruction-seeking, response to unbearable feelings or sensations.
6. Understanding High-Risk Behavior requires acknowledging its role in providing relief and developing a collaborative relationship with the client.
   • Clients have no better way of self-soothing and need validation and understanding.
7. Treatment Approach should focus on attending to the internal struggle rather than reacting to behavior as a safety concern.
8. Sharing the Intra-personal Dilemma is crucial for effective treatment of unsafe and addictive behavior.
9. Encouraging Healthier Options requires understanding the client's perspective and providing alternative, healthier ways to manage emotional arousal.

Capitalizing on the Body to Gain Relief

1. Child abuse and neglect, torture, domestic violence

   • the victim's body, mind, and emotions have been exploited by others

2. Self-Destructive Behaviors as Relief Mechanisms

   • Instant relief from hyperarousal and overwhelming emotions.
   • Adrenaline production followed by endorphin release.
   • Effects specific to each behavior: numbing, relaxation, disconnection.

3. Eating Disorders as Self-Destructive Behaviors

   • Anorexia: numbing through food restriction and ketosis effects.
   • Bulimia: relief via activation of the dorsal vagal system.

4. Substance Abuse:

   • Consistent with the tendency of the left brain to create rational arguments for right brain-driven irrational behavior
   • clients with eating and/or substance abuse disorders will have "stories" or rationales for their symptoms.

5. Attachment Drive and Self-Destructive Behaviors

   • Minimizing danger and maximizing relational resources.
   • Avoiding vulnerability to those who might do harm.
   • Controlling strategies: appeasement, parentification, hostility, distancing.
   • Safety equated with choice between appeasement/parentification and hostility/distancing.
   • Patterns of attachment behavior persist into adulthood.

Animal Defenses and Unsafe Behavior Structural dissociation

1. Structural dissociation facilitates managing unsafe attachment relationships:

   • Attach part: desires closeness
   • Submit part: appeases
   • Flight part: needs distance
   • Freeze part: fears attack
   • Fight part: instinctively controls situations
   1. Each part can operate independently, creating defensive flexibility
   2. Quick transitions from hypervigilant to needy to distancing to robotic compliance
   3. Avoiding danger increases safety

2. Defensive patterns are adaptive when dependent on abusive individuals but not useful once safe:

   • Parts scan environment for traumatic triggers
   • Activation increases susceptibility to internal conflicts
   • Most threatening triggers are other human beings
   1. Angry, violent individuals evoke strong defensive responses
   2. Authority figures, partners, therapists, family members, close friends, and love objects can be as triggering
   3. Healing process can lead to increasing polarization and internal conflicts

3. Young traumatized parts have unique needs:

   • Attach part longs for gaze-to-gaze contact, hugs, and someone who hangs on every word
   • Fight part is hypervigilant and reacts to minor offenses with hostility and vigilance
   1. Isolation does not solve underlying attachment wound
   2. Particularly challenging during adolescence when separation-individuation instincts require inhibition of the attachment drive but also at a time when the child’s physical strength and greater independence increase opportunities for disordered eating, self-harm, and access to substances

4. Trauma-related triggers interfere with differentiating what is safe now from what was dangerous then:

   • Even after individuals are safe, trauma-related triggers can cause feelings of hurt, desperation, and panic
   • Alcohol use can be a way to regulate trauma-related implicit memories and their accompanying autonomic arousal but can lead to blackouts and unwanted consequences.

Treating the Causes of Self-Destructive Behavior

1. Self-destructive behavior originates from a combination of factors:
   • A trigger evokes trauma-related implicit memory.
   • The implicit memory's association with danger activates the emergency stress response.
   • The sympathetic nervous system reaction shuts down the prefrontal cortex, impairing judgment.
   • Conflicting defensive responses act on their survival instincts, leading to relief-seeking behaviors.
2. Clients report temporary feelings of control or well-being after these actions.
3. Traditional treatments like Dialectical Behavior Therapy (DBT) and Internal Family Systems (IFS) have limitations:
   • DBT focuses on skills for the normal life part but doesn't address fragmentation or differentiating the self from parts.
   • IFS addresses parts but conceptualizes self-destructive behavior as firefighter parts suppressing vulnerable exiles.
   • The normal life self is seen as a manager in IFS, emphasizing functioning and top-down behavior management.
4. In IFS, the wise mind or wise self possesses qualities like curiosity, compassion, wisdom, courage, calm, clarity, confidence, and commitment.
5. Sensorimotor Psychotherapy focuses on autonomic dysregulation and animal defenses in posttraumatic stress disorders but lacks specific interventions for unsafe behavior.
6. Both IFS and Sensorimotor Psychotherapy encourage mindful interest and curiosity in habitual patterns rather than a solution-oriented approach to safety issues.
7. In IFS, firefighters are seen as protective of exiles.
8. In Sensorimotor Psychotherapy, unsafe behavior is framed as a survival response to autonomic dysregulation.

Trauma-Informed Stabilization Treatment (TIST)

1. Trauma-Informed Stabilization Treatment (TIST)

   • Developed for severe self-destructive behavior unresponsive to conventional treatments (Fisher, 2015)
   • Initially developed in Connecticut's Young Adult Services due to high trauma history among chronically suicidal clients
   • Clients had histories of trauma, self-injury, substance abuse, eating disorders, and aggression towards others
   • Lacked treatment models addressing origins of behavior, trauma triggers, cortical inhibition, and relief experienced from behavior

2. Background of TIST

   • Developed due to high percentage of severely traumatized clients in age range 18-25
   • Clients had been hospitalized for over 6 months to 10 years
   • Lack of effective treatment models due to inability to address multiple components of self-destructive behavior

3. Theoretical Foundation: Structural Dissociation Model

   • Each separate variable contributing to unsafe actions identified
   • Self-destructive impulses externalized and assigned to appropriate part
   • All aspects of self described in positive terms for non-shaming approach

4. Acknowledgment of All Parts Involved

   • Treatment models should acknowledge all sides or parties involved, not just those towards whom we are biased
   • Successful treatment requires acknowledgment of conflicting drives and their contribution to survival

5. Struggle for Traumatized Clients

   • Difficulty believing that "keeping on keeping on" has a chance of success
   • Intensified emotional vulnerability and fight-flight impulses wanting discharge
   • Clients have to learn to trust all parts are committed to survival in different ways
   • Even most intensely suicidal parts "want to die in order to live."

Acknowledging Self-Destructive Parts

1. TIST Model: This model assumes that suicidal thoughts reflect the perspective of one part, not all. The question is which "I" feels suicidal?
2. Understanding Parts: Each answer would require a different solution based on the triggered parts and the missing normal life self.
3. Ineffective Treatment Approaches: Criticism and suppression are not motivating for clients with suicidal, self-destructive, eating disorder, or addicted behaviors. These approaches can alienate and polarize the parts we want to understand.
4. Intentions vs Actions: The TIST model differentiates the intentions of a part from its actions. What is the suicidal fight hoping to accomplish? How is it trying to protect the client?
5. Example of Katya's Treatment: Katya, a long-term hospitalized patient, recognized her fight part but sometimes couldn't control it. The suicidal part wanted to push people away because it believed they couldn't hurt her if they couldn't get close.
6. Dialogue with Parts: By learning to "ask inside," Katya learned how to dialogue with her parts, rather than interpreting their behavior. This helped her discover why the fight part was so determined to lead her down a self-destructive path.
7. Understanding Trauma: Katya felt pride when she was assigned to a trauma program because she saw herself as someone who deserved special services and wasn't sick. She could begin to differentiate her willingness to work therapeutically as evidence of an intelligent, motivated normal life self.
8. Separating Self from Parts: This process took several years and required the help of staff who embraced the TIST model. It allowed Katya to avoid acting on the fight part's impulses and tolerate the risk that she might die before her team could help her learn how to help the parts.
9. Outcome for Katya: Today, Katya lives on her own, takes no psychiatric medications, has been discharged from the Department of Mental Health system, and has a Facebook page to share her story of survival and redemption.

Soothing the Vulnerable, Honoring the Protectors

1. TIST Model: Focus on soothing vulnerable parts before inhibiting fight or flight responses.

   • Recognize signs and symptoms of distressed child parts.
   • Anticipate unsafe situations based on their appearance.
   • Model mindful observation of "domino effects" (triggered parts triggering others).

2. Understanding Client's Patterns: Identify relationship between suicidal part and distressed child part.

   • Wait for right moment when client expresses anxiety about future crises.
   • Observe pattern: suicidal part only gets activated when a specific child part is having a hard time.

3. Depressed Parts as Triggers: Depressed parts can indicate imminent activation of suicidal part.

   • Intervene to help the depressed part before a crisis ensues.
   • Acknowledge distress of depressed part to prevent suicide attempts.

4. Parts who Communicate via Flashbacks and Memories: Somatic messages from young parts can trigger fight or flight responses.

   • Help client's normal life self provide soothing to vulnerable parts.
   • Reduce risk of impulsive behavior by anticipating its poetential.

5. Ashamed Parts: Ashamed parts can also trigger fight response due to intolerable vulnerability.

   • Predict risk and help client's normal life self provide soothing to ashamed parts.

6. Internal Dialogue Technique: Clients are taught this technique to regulate parts' unbearable feelings independently.

“No Part Left Behind”

1. No Part Left Behind

   • Clients are taught this standard in therapy.
   • Challenges survival strategy of self-alienation.
   • All parts responsible for survival deserve respect and compassion.
   • Includes ashamed, frightened, addicted or eating disordered, suicidal, angry, self-injurious, and justice-seeking parts.

2. Impact of "No Part Left Behind"

   • Lifts threat of abandonment.
   • Reparative experience for parts as someone has heard them.
   • Normal life self feels grateful as parts' attachment grows.
   • New, safer internal environment can be established.

3. Specialized Roles of Parts

   • Fight response: increased energy, determination, refusal to give way, ability to guard rights and privileges.
   • Normal life self learns to ask fight part for courage and strength.
   • Freeze part feels protected.
   • Submit part is not freely used by others.
   • Flight part doesn't have to run for cover because parts are safe.

4. Robert's Story

   • Tormented by voices warning him of death since early 20s.
   • Fear of being killed familiar from witnessing mother's abuse.
   • Devout Catholic faith prevented suicide.
   • Terrified of dying despite longing for it.
   • "Wanting to die is about taking control, not wanting death."

CHAPTER 8

Treatment Challenges: Dissociative Systems and Disorders

1. Dissociation is a result of traumatic experiences, leading to fragmented memories intruding into the present (Van der Kolk, 2014). 2. The concept of a single self is misleading; there are conscious and unconscious self systems (Schore, A., 2011). 3. Dissociative Disorders, including DID, were controversial in the 1950s and still face skepticism among mental health professionals. 4. The field has overlooked research validating the reliability of DID diagnosis and its prevalence in the population (Brand et al., 2012; 2016). 5. Borderline Personality Disorder (BPD) is associated with dissociative symptoms, but these are often overlooked or untreated. 6. The Structural Dissociation model, while not specifically a dissociative disorders model, can be helpful in treating clients with borderline personality and their dissociative symptoms. 7. Using parts language allows clients to externalize the problem, improving their relationship to it (Edwards & Grisham, 2017).

Recognizing the DID Client

1. Dissociative Disorders (DD) and Dissociative Identity Disorder (DID) are common in therapists' practice, especially those dealing with trauma, borderline, or suicidal clients.
2. DSM-5 and ICD-9 diagnoses of DID require "evidence of losses of consciousness: two or more parts of the personality take control of the body and operate outside of conscious awareness.
3. Therapists may encounter challenges in recognizing DID due to its similarities with other disorders, such as psychosis.
4. Caitlyn, a patient during an internship, was initially diagnosed as acutely psychotic but later revealed to have DID.
5. Caitlyn's parts operated autonomously and outside of conscious awareness, leading to confusion and disorientation.
6. The therapist's suggestion to confront Caitlyn's voices led to her discharge from the hospital.
7. Upon meeting Caitlyn again, she presented as a child wearing inappropriate clothing and behaving confusedly.
8. The therapist's maternal instincts helped calm Caitlyn down by speaking to her as if she were a child.
9. Caitlyn revealed that she was 6 years old when she was raped, bullied, and emotionally abandoned, leading the therapist to understand her past trauma.
10. The therapist learned important lessons from working with Caitlyn, including the existence of DID and the usefulness of previous child-rearing experience.
11. Working with dissociative disorders can be challenging as therapists cannot please all parts of a client all of the time.

Diagnosing Dissociative Disorders

1. Dissociative Disorders
   • Five symptom clusters for diagnosis:
     1. Dissociative Amnesia: missing time or gaps in daily memory unexplainable by ordinary forgetfulness after age nine.
     2. Dissociative Fugue: finding oneself in an unfamiliar location with no memory of planning to go there, sometimes accompanied by dissociative amnesia for personal information.
     3. Depersonalization: feeling disconnected from one's self or experience.
     4. Derealization: experiencing others or surroundings as unreal.
     5. Identity Confusion and Identity Alteration.
   • Psychotic-like symptoms, such as voices, can also indicate a dissociative disorder.
2. Comparing DID and Schizophrenia
   • DID subjects reported hearing voices at a more frequent rate than schizophrenic subjects.
   • DID voices had different genders and ages, and content was negative and personally directed.
   • Schizophrenic voices were fewer in number, did not have different ages or genders, and spoke from a more abstract perspective.
3. Making a Diagnosis
   • Not clinically essential if clients are using trauma-informed treatment models.
   • Advantages: reassuring for clients feeling crazy or afraid of being "locked up.
     • Disadvantages: can trigger fear or reinforce negative beliefs in some clients.
4. Annie's Situation
   • Diagnosis was supportive and helpful for Annie, who was struggling with dissociative amnesia.
5. Dustin's Situation
   • Diagnosis would have been detrimental for Dustin due to his fear of being diagnosed psychotic and deeply ingrained beliefs about his inadequacy.

Assessment Tools for Diagnosing Dissociative Disorders

• Most common tool is the Dissociative Experiences Scale (DES), but it's least reliable with high false negatives.
• Trauma Symptom Inventory (TSI) is more reliable, providing an objective statistic for dissociation symptoms.
• Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) is the best tool for formal diagnoses but challenging due to its long format.

1. Importance of Formal Assessment:

   • Helps clients accept diagnosis as true and useful information.
   • Provides reassurance of objectivity, reducing suspicion and defensiveness.
   • Encourages detailed, non-pathologizing discussion of dissociative symptoms.

2. Challenges with Dissociative Experiences Scale (DES):

   • Easiest to administer but least reliable tool.
   • High rate of false negatives, potentially dangerous for therapeutic work.

3. Trauma Symptom Inventory (TSI):

   • Self-report instrument that elicits information about a range of symptoms.
   • Provides an objective statistic for dissociation severity, useful for discussing dissociation.

4. Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D):

   • Most reliable assessment instrument for formal diagnoses of Dissociative Identity Disorder (DID).
   • Long and complex interview format, valuable for detailed discussion of dissociative symptoms.
   • Questions can be introduced separately during therapy to elicit information about dissociation.

5. SCID-D Questions:

   • Useful for therapists curious about a client's dissociative symptoms, even without immediate need for formal assessment and diagnosis.
   • Many questions can be incorporated into therapeutic dialogue to gather information about dissociation.
   • Examples: memory problems, transient time loss, depersonalization, derealization, internal struggles, identity alterations.

There Is No “She”—There Is No “He”

1. DID Clients and Challenges for Therapists

   • Many therapists find it intimidating to treat their first DID clients due to lack of exposure and training.
   • DID clients present complex symptoms including regressive behavior, functional losses, suicidal or self-harming behavior, and dissociative fugue states.
   • The biggest challenge is the absence of a single integrated psychological being in the client.

2. Information Gap

   • Clinicians rely on clients as experts on their internal states.
   • With DID clients, even basic information can be inaccessible or censored by protector parts.
   • Unrequested information from trauma-related parts can also confuse therapists.

3. Communication and Secrets

   • Child parts often use text and email for communication without the client's knowledge.
   • Loss of reality-testing, continuous consciousness, and behavioral control when parts act autonomously.
   • Therapists may unintentionally take sides with certain parts, exacerbating the situation.

4. Risks of Memory Disclosure Approach

   • Encouraging disclosure of memory can increase instability for DID clients.
   • Normal life self may not want to hear disclosures, triggering child parts.
   • Fight and flight parts can become agitated, leading to increased addictive or self-injuring behavior.

5. New Paradigm in DID Treatment

   • Shift from memory retrieval and disclosure to focus on implicit memory and mindful witnessing.
   • Mindful self-witnessing helps maintain continuity of consciousness.
   • Understanding parts as disconnected "containers" reduces feeling weird or crazy.

6. Sheila's Experience

   • Encouraging disclosure of memory dysregulated Sheila's system and triggered attach part's need for contact between sessions.
   • Therapist assumed more sessions would help, but it created a vicious circle.
   • DID clients require even more sensitivity to attachment issues and countertransference.

Restoring Order to a Chaotic Inner World

1. Inner Worlds of DID Clients

   • Reflect environments of upbringing: harsh, secretive, critical, punitive, neglectful, intimidating, terrorizing.
   • Parts survived by creating secrecy or suppressing vulnerability/fighting for control.
   • Each step forward reveals another layer of secrecy maintained by saboteur parts.

2. Characteristics of Inner World

   • Reflects harsh, punitive, neglectful early environments.
   • Parts fight to prevent vulnerability, associated with self-care and safety concerns.
   • Flight parts driven by the need for meaningful activities.

3. Annie's Inner World

   • Survived neglect and learned to care for others but not herself.
   • Morning routines disrupted by depressed or caretaking parts.
   • Flight parts drive frantic activity, followed by anesthetization with alcohol.

4. The Role of the Normal Life Self

   • Associated with prefrontal cortex and ability to observe system's operations.
   • Cultivates dual awareness and learns new skills for managing trauma-related parts.
   • Engages prefrontal cortex for access to past and present information, connecting parts, and visualizing them.

Teaching the Client’s Normal Life

1. Dissociation-related amnesia prevents the client's normal life self from remembering some events.
2. The client is asked to assume that all feelings, reactions, and thoughts come from parts.
3. The normal life self is taught to observe these signs, name each feeling state or belief as that of a part, and validate the part's experience.
4. Events with no memory must be "decoded": identify triggers and clues to fill in gaps.
5. Use structural dissociation model and creative thinking to make educated guesses about parts and their behaviors.
6. Naming overwhelming emotions as feelings of a part decreases emotional intensity.
7. Developing ability to observe comings and goings of different parts helps clients make conscious decisions.
8. Internal communication skills and observing intrusive feelings are crucial in DID treatment.
9. Reframe fear or anxiety as feelings of a part and encourage information gathering.
10. Blending also takes place in DID clients, where normal life self interprets parts' feelings as "my feelings".
11. Practice noticing moments of being blended and then unblended is crucial for DID clients.
12. Feelings of depression, critical thoughts, or ruminations should be attributed to parts.
13. Identify feelings of anger as indicators of a fight response.

Making Meaning of Moment-To-Moment Experience

1. DID clients experience intrusions from parts through thoughts, feelings, images, body sensations, and actions outside their awareness.
2. Curiosity is essential for understanding these experiences. Therapist should ask questions to decode the meaning behind these patterns.
3. Parts' actions can be unsettling but should not hinder therapeutic work. Evidence of these actions should be explored with empathy and creativity.
4. Unblending from parts is crucial for DID clients, especially when parts take over the body independently.
5. Depressed part may sacrifice itself for others, disregarding healthy boundaries.
6. Anxious part might sabotage the client's progress with self-doubting questions.
7. Parts should not be identified with but differentiated as child selves worried about coping with adult life or triggered memories.
8. In therapy, clients learn to understand parts' phenomena and respond with reassurance and validation.
9. Clients resist acknowledging past traumatic experiences due to fear and resistance.
10. The therapist helps the client differentiate their current world (Maine) from their past (New Jersey).

Creating a Present for Parts that Dwell in the Past

1. Loss of Time Orientation in DID clients:

   • Traumatized parts disconnected from one another.
   • Survival responses lead to distorted time orientation.
   • Past experiences trigger present reactions.

2. Triggering Activities:

   • Simple tasks can become triggering.
   • Triggers activate implicit memories and emotions.
   • Clients assume danger in the present based on past experiences.

3. Annie's Experience:

   • Dread and anxiety in morning routine.
   • Fear intensifies during school lunch preparation.
   • Automatic assumption of failure and danger.

4. Understanding Triggers:

   • Questions to acknowledge links between past and present.
   • Validating feelings and body memories as normal responses to trauma.

5. Dense Dissociative Barriers:

   • Challenging for DID clients to recognize shifts in mood, belief, and behavior.
   • Importance of curiosity and care for inner worlds.

6. Hijacking:

   • Term for what happens when traumatized clients are exposed to triggers.
   • Body mobilizes emergency stress response, inhibiting prefrontal cortex.
   • Parts can stimulate the emergency stress response and animal defense responses.
   • Normal life self loses conscious awareness and control.

7. Reclaiming Life:

   • Reframing crisis as parts' coup d'etat.
   • Empowering normal life self to take back control.
   • Importance of wanting a life after trauma, not determined by it.

Overcoming Conditioned Learning

1. Conditioned Learning and implicit reactions are linked to traumatic experiences that feel life-threatening. These responses are challenging to alter due to the body's reluctance to give up automatic safety responses.
2. Trauma Clients often have difficulty retaining new information due to chronic dysregulation and repeated inhibition of left brain activity. They may also have parts that interfere with encoding of new information.
3. The goal for DID clients is to develop continuous consciousness, which requires repetitive practices like focused concentration, awareness of being present in the body, and inner communication with parts.
4. With greater access to continuous consciousness, DID clients can stabilize and learn to know "who they are" moment to moment, making sound life decisions that consider their parts' feelings and needs.
5. Involuntary dissociation can be managed by developing dual awareness and inner communication, allowing for the normal life self to negotiate with parts and inhibit unwanted switching.
6. Dissociation can also be a resource when clients learn to summon the right part for specific tasks, leading to feelings of triumph and increased confidence.
7. The therapist's role is crucial in helping clients remember new practices and encouraging them to show parts what they have learned. Opaque dissociative boundaries between parts must be addressed to ensure effective learning.

Building Trust Inside Trust

1. Trust begins to build with improved internal communication and experiences of mastery and competence.
   • Young parts long for someone strong enough to protect them from harm.
   • Teenage parts seek protection for younger and adolescent parts as well.
   • Confidence in the normal life self allows younger parts to relax their hypervigilance.
   • Increased trust in an older, wiser grownup self enables belief in reassurances and perspective.
2. Healing attachment wounds requires "basic trust" in a normal life self who is reliable and present.
   • Trust is necessary for offering reparative experiences to young parts.
   • Child parts need to feel emotionally and physically welcomed by this "other.
3. Annie's parts associated her new environment with their old, dangerous one due to hypervigilance.
4. Annie struggled with feeling safe in her own life despite creating a refuge for others.
   • She often blended with their emotions and fears.
   • Some parts operated in secrecy.
5. The presence of an "eraser part" erased positive or empowering experiences from memory to protect the system.
6. Techniques were developed to help Annie remember important information:
   • Writing down key points on index cards.
   • Sending emails summarizing sessions.
   • Journaling about sessions or parts.
7. The eraser part was asked to perform two jobs: erase harmful information and help save important information.

autonomous functioning of the parts

1. Dissociative Identity Disorder (DID): Clients experience problems with reality-testing, relationships, safety, and judgment due to autonomous parts.
   • Lack of conscious awareness interferes with getting to know parts.
2. Less Severe Compartmentalization: Parts can be "known" through feelings, wishes, beliefs, body language.
3. DID Client Behavior: Trouble leaving office, repeated texts/calls between sessions.
4. Normal Life Self vs. Parts: Differences in perspective, safe reality felt in body (heart rate slows, breathing easier).
5. Part Manifestations: Urged not to trust normal life self, held beliefs about past environment.
6. Therapy Approach - Orienting the Parts:
   • Asking parts to show images of traumatic past.
   • Showing parts images of present environment.
7. Effects of Orientation: Decreased blending, increased objectivity, appreciation for present.
8. Annie's Transformation:
   • Recognized her home as "quaint" instead of a "slum".
   • Saw personal touches reflecting who she is.
9. Impact on Perception: Parts could not perceive new environment until consciously drawn to details.

Gathering Evidence: Establishing Retrospective Consciousness

1. Establishing retrospective consciousness in DID clients:

   • Clients must learn to "fill in the blanks" about their autonomous activity.
   • Gazzaniga's research on split-brain patients shows that the left brain constructs a narrative even when disconnected from right hemisphere actions.
   • Therapists should ask clients if they remember details or just outcomes of events.

2. Challenges for DID clients:

   • Problem of self-destructive or sabotaging behavior outside the left brain's awareness.
   • Gazzaniga emphasizes that language rationalization increases chances of behavior happening again, potentially risking life in DID clients.

3. Therapist's role in treatment:

   • Distinguish between blending with a part and hijacking by an acting out part.
   • Work on recognizing when the client is blended and practicing unblending strategies.
   • If the part acts outside of left brain consciousness, focus on internal communication and negotiation.
   • Therapists can help clients reconstruct events through diagramming or "back in time" imagining."

Building Skills to Overcome Gaps in Consciousness

1. Building Skills for Continuous Consciousness

   • Importance of independent actions and shared consciousness in client's life stability.
   • Lack of meta-awareness can lead to unconscious sabotage.
   • Early treatment focus on present consciousness, not past traumatic memory.

2. Example of Gaby's Experience

   • Initial stabilization: proud and energized after years of addiction and high-risk behavior.
   • Depression sets in: missed classes, fell behind on schoolwork, skipped work.
   • Partner became frustrated and critical.
   • Memories resurfaced: losses, abuse, loneliness, pain.
   • Suicidal part acted to end suffering of depressed part without conscious thought.

3. Importance of Building Conscious Awareness Skills

   • Daily activities recording: hourly time schedule.
   • Filling in gaps: looking for clues.
   • Decreases likelihood of switching or spacing out.

4. Noticing "Who You Are" Moment by Moment

   • Observing signs of blending with different parts.
   • Noticing words, themes, emotions, and beliefs.
   • Recognizing different parts requires curiosity and structural dissociation model understanding.

5. Additional Skills for DID Clients

   • Using an inexpensive watch with an alarm function to notice "who I am" or "who's here?" every hour.
   • Keeping a Dissociative Experiences Log to record observations.
   • Setting car's trip odometers at the end of each day and checking in the morning for evidence of dissociative fugues.
   • Recruiting a scheduling part to keep track of activities.
   • Asking inside, "Does anyone know why ______ happened? Who is responsible?" and "How was that part trying to help?"

No More “Bad Guys” and “Good Guys”

1. Protective Communication: In this therapeutic approach, no one is labeled as a "bad guy" or "internalized perpetrator". Instead, all parts are encouraged to communicate and develop trusting relationships. This language creates a safe environment where parts can share without fear of judgment or suppression.

2. Collaborative Nature: The goal is to increase communication and collaboration among the parts. Parts with harmful behaviors are reframed as having good intentions, which increases their likelihood of sharing more and allowing others to do the same.

3. Coaching a Team of Parts: In DID clients, the therapist acts as a coach for a team of individual parts, each reacting to past experiences rather than present threats. The normal life self may not be present during all sessions, so the therapist must create an alliance with this part and teach it self-regulation skills.

4. Balancing Parts' Needs: The therapist needs to balance welcoming all parts while empowering the normal life self. This involves creating a structure for each session that addresses the needs of both the parts and the normal life self.

5. Addressing Dissociative Barriers: In DID clients, dissociative barriers are more impermeable, making it easier for clients to disown some parts and over-identify with others. The therapist must acknowledge each part while emphasizing the importance of the normal life self in the therapeutic process.

6. Normal Life Self's Role: The normal life self is more autonomous in DID clients and has greater access to prefrontal processing and learning. Therapeutic work can be most effectively done when this part is present in sessions.

7. Understanding Parts' Agendas: Different parts may have different agendas: attachment, submission, fight, flight, or freeze. The therapist must understand these agendas to prevent chaos in the therapy session and help the parts become a team.

Increasing the Presence of a Normal Life Adult

1. finding connection to their normal life self can be difficult: due to past experiences and feelings of powerlessness or foreignness.
2. Clients may feel disconnected from their normal life self if they've identified more with younger, traumatized parts.
3. Clients often doubt their positive qualities or skills due to feelings of overwhelm, shame, despair, and impulses.
4. Therapists play a crucial role in reminding clients that everyone has a normal life part, even if it's not easily accessible.
5. Cecilia's story: illustrates the importance of recognizing and connecting with the normal life self, despite a challenging past.
6. Clients should begin identifying their parts and naming them based on what they do or feel to strengthen their connection to their normal life self.
7. Therapists must maintain belief in the client's ability to live a normal life, even when faced with challenges like eating disorders, self-injury, and substance abuse.
8. Evidence of belonging can be found in various aspects of adult life, such as having friends, family, and being asked to take important roles.
9. Clients should share evidence of belonging with their parts to help them feel included and valued.

Bringing Parts Up-to-Date

1. Trickle-Down Effect: When amnestic barriers prevent communication between dissociated self-states, current life experiences cannot be integrated.
   • The attach part longs for importance in relationships but doesn't receive news about caring people due to the barrier.
   • The normal life part plans a vacation unaware of suicidal impulses from other parts.
2. Parts Feeling Isolated: Parts feel scared, vulnerable, and abandoned, believing they are still in the traumatic past.
   • They fear danger without the presence of the therapist or protector figure.
3. Bringing Parts Up-to-Date: Therapist helps clients provide information about present time to parts lost in the past.
4. Annie's Experience: Annie feels anxiety and dread when her therapist goes on vacation, fearing abandonment and danger.
   • The parts believe she is their protector and fear the bad people will hurt them if she's not around.
5. Communicating the News: Therapist explains to Annie that she left the scary house in New Jersey long ago and is now safe.
   • The parts are stunned but want to believe the news.
6. Recognizing the Present: Therapist asks Annie to show her parts their current home, helping them understand they are no longer in New Jersey.
7. Strength in Numbers: The parts feel reassured by the presence of strong males (husband, sons, nephew) who want to protect Annie.
8. Calming the Parts: Therapist encourages Annie to ask her parts to focus on their current surroundings and recognize they are no longer in New Jersey.

Changing Patterns and Roles Survival behavior, learned in the

1. Survival Behavior and Body Resistance:

   • Changing patterns of clenching, bracing, increased heart rate and respiration are difficult for trauma survivors due to implicit memories connected to past threats (Ogden et al., 2006).
   • Lowering guard, softening tension, opening heart can feel threatening.
   • Anxiety escalates as soon as body relaxes without ability to modify automatic threat responses.

2. Dissociative Disorders and Challenges:

   • Difficult for clients with dissociative disorders to remember or utilize basic skills of trauma recovery due to compartmentalization and internal struggles.
   • Amnesia, internal conflicts, self-regulation problems, and attachment issues need addressing but require certain prerequisites.

3. Approach to Helping Clients with Dissociative Disorders:

   • Increase conscious mindful awareness of parts and signs of triggering, switching, and blending.
   • Psychoeducation.
   • Help clients learn "language of parts.
   • Piece together a continuous sense of consciousness.
   • Emphasize practice and repetition of new patterns or actions.
   • Renegotiate internal relationships using inner communication.

4. Addressing Complex Challenges:

   • Address amnesia, internal conflicts, problems with self-regulation, and attachment issues in a systematic order.
   • Develop dual awareness, unblending skills, and capacity to convey empathy to parts.

5. Renegotiating Internal Relationships:

   • Differentiate suicidal part from normal life self.
   • Unblend from suicidal part's impulses and emotions.
   • Communicate respect and build relationships with both angry or suicidal part and wounded child selves it protects.
   • Comfort and bond with attach parts to reduce vulnerability to painful emotion.
   • Build up somatic sense of protection connected to fight response.

6. Building Blocks of DID Treatment:

   • Awareness of shifts in emotion and sensation connected to parts.
   • Mindful naming of each part’s function or attributes.
   • Unblending from parts' impulses and emotions.
   • Befriend each part.
   • Develop interest in and compassion for them.
   • Learn through inner dialogue to decipher their intentions and motivations.
   • Ally with the “best self” of each part.
   • Negotiate new resolutions to old issues.

7. Patience and Repetition:

   • Annie's example shows the necessity of patience and repetition for DID clients to become proficient in these skills.
   • Layers of parts defending other parts result in patterns of stuckness.

8. Amnestic Barriers between Parts:

   • Interfere with client’s ability to know inner world and parts, creating opportunities for sabotage by parts.
   • Ensure trauma-related parts are unaware of safety, stability, and comfort of normal life part's consciously constructed adult life.

Working with Regression and Aggression

1. Attachment Drive and Fight Response: Two fundamental human drives crucial for survival. Intensified in DID clients due to disorganized or traumatic childhood attachments.

   • Attachment Drive (Proximity-seeking): Necessary for protection of young, triggers fear of rejection and abandonment when threatened.
   • Fight Response: Animal defense, intensified in DID clients, can lead to anger, hypervigilance, mistrust, even paranoia.

2. DID Clients and Disorganized Attachment:

   • DID clients have dissociatively encapsulated attach and fight parts.
   • Fear of rejection and abandonment are easily activated in the attachment part.
   • Fight part comes to defense, assuming therapist is cause of feelings of hurt and anger (traumatic transference).

3. Therapist's Role:

   • Therapist may feel pulled or yearned towards the needy attach part or pushed back by the accusatory fight part.
   • Setting clear boundaries can inflame the fight part, triggering feelings of rejection in the attach part.
   • Giving and doing more can also be threatening to the attach parts' fear of loss.

4. Working with Disorganized Attachment:

   • Holding in mind the paradox: each part is separate but part of a whole.
   • Resonating with the young part and communicating at their developmental level.
   • Acknowledging the angry part's positive intentions to protect the child.

5. Therapist's Restraint:

   • Avoiding over-reacting to either regression or aggression.
   • Teaching the client how to manage internal forces triggered by relationships.
   • Preventing dependency on the therapist and fuelling disorganized attachment.

Patience, Persistence, and a Good Seat Belt

1. Patience and Persistence

   • Therapist should exercise restraint, not becoming responsible for parts that want attachment or special treatment.
   • Avoid taking on roles of rescuer, victimizer, or victim.
   • Maintain commitment, care, and compassion without induction into the system.

2. Importance of the Normal Life Self

   • Shoulder responsibility of caring for young parts.
   • Therapist not competing for job.
   • Warmth, respect, and admiration for all parts.

3. Role of the Therapist

   • Coach for client's team.
   • Parent educator.
   • Ensure clients can manage bad feelings and evoke good feelings internally.

4. Impact of Trauma

   • Child parts believe their feelings are not their own.
   • Dependency on others for regulation and transformation of negative feelings into positive.

5. Building Internal Relationships

   • Developing warm attachment bonds internally.
   • Control rests with the client.
   • Client becomes source of warm, pleasurable safe feelings.

6. Dependency and Abandonment Fears

   • Dependency is safe when child parts depend on a caring adult self available in the same body.
   • Unrelenting fears of abandonment of attach parts are heightened without therapist's presence.

Self-Healing, Rather than Interpersonal Healing

1. Self-Healing vs. Interpersonal Healing
   • In family therapy, therapists take a more "backseat" role compared to individual therapy.
   • Dealing with multiple "clients" in fragmented or DID clients.
   • Family system must heal itself for freedom from the past.
2. Organicity/Self-Leadership
   • Principle of body's innate drive toward healing and growth.
   • Heal ourselves through access to innate capacities.
     • Compassion, curiosity, clarity, creativity, courage, calm, confidence, commitment.
3. Therapist's Role
   • Provide a "container" or "growth-facilitating" environment.
   • Evoke natural tendencies for healing.
     • Use of therapist's qualities (compassion, curiosity, etc.) to stimulate client's access.
4. Social Engagement System
   • Neural system connected to the vagus nerve.
   • Channels of communication between babies and parents.
   • Creates a felt sense of safety for clients.
     • Use of tone, facial expression, and gaze to communicate welcome, warmth, understanding.
5. Therapist's Communication with Clients
   • Speak with warmth, sadness, respect, or delight to parts.
   • Reassure, educate, model attunement to child parts.
   • Urge clients to make a place for vulnerable parts.
   • Use facial expression, tone of voice, and softening of gaze to communicate empathy.

Facilitating Reunion

1. Prefrontal Cortex associated with neutrality, observing presence, and access to compassion.
2. Distancing or gatekeeper part appears when vulnerability is triggered.
3. Wise, compassionate "best self" not speaking during hostile remarks.
4. Belief in client's best self used to challenge unrepresentative "I".
5. Tom's desire for traumatized parts to be dead.
   • Embarrassment and fear of vulnerability.
6. Interaction with a little boy metaphor for Tom's inner child.
   • Child represents traumatized part.
7. Tom's impulse to help the child instead of dismissing him.
8. Tom's feelings towards the child mirror his true nature.
9. Tom's need for someone to hold him as a child.
10. Tom's experience of being unnoticed and uncared for.
11. Tom's relief and joy in feeling held and noticed.
12. Tom's inner child's fear of crying and seeking validation.
13. Tom's realization that it's okay to cry and feel emotions.
14. Tom's experience of grief and relief.
15. Tom's inner child finally getting what he always wanted: attention and care.

CHAPTER 9

Repairing the Past: Embracing Our Selves

1. Trauma Experience: At the moment of trauma, the child feels helpless and abandoned, leading to a deep-rooted need for an omnipotent rescuer. (Herman, 1992)

   • Child's emotional conviction of helplessness and abandonment increases the need for a rescuer.
   • The rescuer is seen as essential for survival due to the child's belief that their life depends on them.
   • No tolerance for human error due to the importance of the rescuer.

2. Innate Capacities: Human beings are born with innate drives and capacities, enabling them to keep going despite adversity.

   • Capacity to attach, explore, laugh and play, bond with social group, and nurture young.
   • Developing brain offers resources like curiosity, compassion, creativity, and wonder.
   • Ability to imagine a life we've never known.

3. Impact of Neglect or Trauma: Under chronic conditions of neglect, trauma, or frightened and frightening parenting, our bodies prioritize survival responses and anticipation of danger.

   • Normal attachment, exploration, learning, play, even sleeping and eating take a back seat to hypervigilance and defensive reactions.

4. Importance of Balanced Parts: It's essential to have parts that support survival under threat as well as a part able to "make do" in the worst circumstances.

   • The normal life child self, who smiles for family photographs, cares for siblings, goes to school, and finds pleasure or mastery in developmental tasks.

5. Neglecting the Normal Life Self: Therapists often focus on wounds and wounded parts, neglecting the side of the child who "kept on keeping on.

   • Failure to listen for indicators of the child's drive for normality can result in a shared portrait of the client as a wounded victim instead of an ingenious survivor.

6. Example of Annie: Despite severe neglect and trauma, Annie's normal life self was driven to make the most out of whatever "normal" she could create or emulate.

   • Eager, bright, sociable little girl who naturally evoked support and attention from teachers and peers.
   • Managed to compensate for stigmata of neglect and poverty with an exuberant personality and sports equipment.
   • Cared for younger siblings, providing important normal developmental experience and later ability to raise securely attached children.

7. Dominance of Traumatized Child Parts: Despite the strengths and resources of her normal life self, Annie found her day-to-day experience dominated by traumatized child parts.

   • Compelled to isolate, avoid going outside, cancel dates with potential friends, and never answer the door or telephone.
   • Caretaking had been the safest role she knew in childhood, and many parts did not want to give it up despite criticism from judgmental protector parts.

8. Lack of Perspective: Individuals like Josh, who have a competent, successful, well-liked adult self but are dominated by traumatized child parts, struggle to see their life or themselves in perspective.

   • Child parts hold anxiety and self-doubt, making it hard for them to believe positive qualities about themselves.
   • Cynical part convinces them there is no data to support any positive qualities, preventing them from accepting compliments or practicing self-care.

9. Impact of Trauma on Functioning: Traumatized child parts' intense emotions and reactivity can hijack an individual's body and drive impulsive behavior, making it difficult for the normal life self to function effectively.

Each of these clients had normal life selves

1. Normal Life Selves: Each client had a normal life self with inherent strengths and resources, driven to be their best selves despite their past traumas. These selves were strong-willed, creative, and knew what "normal life" meant for them.

2. Left-Brained Normal Life Selves: When in control, these selves defined personalities, identities, and values. However, they blended easily with the traumatized parts, leading to little communication or collaboration.

3. Inner Worlds as Battlegrounds: Annie's normal life self wrestled with parts terrified of the world outside her home; Josh's intelligent part lost conflicts to critical and ashamed parts; Dawn's normal life self was on "lockdown" due to violent parts.

4. Intense Internal Conflicts: Traumatic attachment experiences created intense conflicts between fearful attach parts and determined fight parts, leading to an endless cycle of fear and defense.

5. Belief Systems and Emotions: Each part's belief system, reactivity, defensive responses, and emotions implicitly described its place in their histories and embodied the defensive responses needed at the time.

6. Missing Conscious Memories: Normal life parts were missing from daily consciousness and childhood memories, identified with traumatic lives instead of consciously created "life after trauma".

7. Vulnerability to Depending on Others: Disordered attachment led to a vulnerability to depending on others, causing fight parts to perceive continued abuse or potential for it.

8. Fight Parts' Attacks: Fight parts attacked bodies, credibility, and those closest to them, demoralizing normal life selves and affecting their ability to be effective or feel effective.

9. Gaining Perspective: None of the three could gain perspective without a trusting relationship between the parts and the self who could create safety, stability, and a life after trauma.

10. Connection with Traumatized Parts: Dawn identified with the little girl inside who had been left alone and unprotected, but failed to win her trust and reassure her effectively.

When Josh’s fight part was triggered...

1. Josh's prefrontal cortex couldn't compete with emotional intensity, leading to blending with his child selves (ashamed little boy, depressed 12-year-old) who had no relationship with his normal life self.
   • The ashamed and depressed parts had a long, troubled relationship with the fight part.
   • Josh was too blended with them to reassure or support his child selves.
   • The parts did not seek him out when they needed help.
2. Annie had no emotional connection to her words spoken to her parts due to past overwhelming emotions.
   • Historically, she took on surrogate children and helped them develop skills for independence.
   • She was exceptionally gifted in helping others but couldn't access these abilities for her own parts.
3. Annie's normal life self kept a safe distance from her parts due to fear of being overwhelmed by their emotions.
   • The parts felt abandoned when Annie blended with them and couldn't stay present.
4. Annie's protector parts were holding her on "house arrest" due to fear of the dangerous people outside her house like those who had harmed her in the past.
   • She didn't realize she needed to tell her parts about her safety and new life.
5. Josh identified with his ashamed part early in adulthood, facilitating survival but minimizing abuse.
   • He couldn't recognize or integrate healthy normality he had created as an adult.
6. Annie and Josh both needed to be encouraged to thank their ashamed parts for helping them survive without losing their hearts or souls.
7. Dawn, unlike Annie and Josh, could unblend from her parts and have warm feelings towards them.
   • Her treatment team helped her recognize the normal life part despite its ups and downs caused by triggered reactions.

Accessing the Resources of a Wise Adult

1. Trauma survivors may find their past, as recalled by implicit memories of dissociated parts, more real than the present, leading to continuous reliving of traumatic experiences.
2. Carla's story: Her normal life self was supported by two trauma-related parts - one afraid of failure and one determined to succeed. However, when her partner had an affair and other significant losses occurred, these parts were activated, incapacitating the normal life part.
3. Identifying parts: The therapist helped Carla identify the young distressed parts responsible for her overwhelming reactions.
4. Deconstructing situations: By dividing overwhelming situations into smaller components, each part could experience the situation as more manageable.
5. Understanding parts' roles: The therapist validated and explained the different reactions of Carla's parts to various stressors.
6. Connecting with parts: Carla began to connect with her younger parts, especially the little girl, through compassion and care.
7. Mindful noticing: Shifting from narrating experiences to mindfully noticing thoughts, feelings, and bodily reactions is crucial for healing and secure attachment.
8. Different responses to therapy: Clients may respond differently to therapy; some may intuitively understand their parts and connect with them easily, while others may take more time.
9. Mindful dual awareness stance: This shift from narrating experiences to mindfully noticing thoughts, feelings, and bodily reactions is essential for the success of the work.
10. Different part attachments: Different parts have different attachments to therapy; some may be attached to talking or problem-solving, while others may yearn for connection or focus on avoiding trauma.

Listening to Children Builds Attachment Bonds

1. Attachment Bonds

   • Children need someone to respond to them for a trusting relationship.
   • Asking clients to use the language of parts can ease distress.
   • Normal life self should respond with concern and genuine interest.

2. Identifying Parts' Feelings

   • Dissociated child parts need a caring adult response.
   • Clients often have difficulty distinguishing their feelings from parts'.
   • Disidentifying from cognitive schemas held by different parts can be challenging.

3. Helping Clients Embrace Parts

   • Clients must learn to observe signs of being blended and unblend.
   • They must access innate compassion for young parts.
   • Therapist's role is to ensure dual awareness before helping parts.

4. Trust Issues

   • Jenny had trouble trusting the therapist due to past experiences.
   • Clients may entertain thoughts about therapists' intentions.
   • It's natural for clients and their parts to have mixed feelings about therapy.

I utilize an “equal opportunity” approach

1. Equal Opportunity Approach: I support all parts equally in therapy, regardless of trust levels. This ensures a welcoming environment for all.
2. Empathy and Curiosity: Model empathy and curiosity to earn the trust of distrusting parts.
3. Understanding Parts' Behavior: Instead of reacting negatively, understand why parts withhold trust or collaborate.
4. Secure Attachment: Built through co-regulation, where parent mirrors child's feelings and communicates understanding back.
5. Co-regulation: Parent responds to child's feelings, leading to repair attempts until attunement is achieved.
6. Attunement: Deeply relaxed calm state where both parties feel safe and connected.
7. Social Engagement System: Neurobiologically connected to the sense of safety in the body.
8. Neuroception: Physiological response that determines whether a person feels safe or not based on past experiences.
9. Trauma and Safety: Traumatized individuals need attachment bonds with their traumatized parts to feel safe.
10. Soul Retrieval: Therapy helps retrieve lost, frightened child parts inside oneself and bring them to safety.
11. Sarah's Story: Despite functioning well in life, Sarah felt a terror or anxiety due to unmet attachment needs and fragmented parts.
12. Soul Retrieval Concept: Sarah was drawn to this concept unconsciously, indicating hidden child parts.
13. Parts' Understanding: Only when these parts were known, thanked, welcomed, and made safe did Sarah value her relationship with them.

Reaching Out to Parts from Places of Strength

1. Sarah and Josh had strengths in nurturing younger colleagues and vulnerable beings.
2. Dawn was known for helping friends with problems they couldn't tell others.
3. Annie provided support to struggling friends, injured animals, and surrogate children.
4. Sarah, Annie, and Josh were educators, teachers, and hospital administrators who mentored younger people.
5. They learned to unblend, notice, empathize with their parts, and engage in internal conversations.
6. Each client has the qualities needed for taking care of their child or adolescent parts.
7. Josh engaged in roles where he used his capacity for empathy, attunement, interpersonal connection, and courage of convictions.
8. Annie was a mother, teacher, and surrogate mother who could use her creativity and structure to manage her inner family of parts.

Accessing the Resources of Normal Life

1. Normal Life Role Connection

   • Therapist connects client's experiences as a parent or caretaker to their inner child parts.
   • Ignoring upset or scared child parts leads to increased distress.
   • Suggestion: Treat inner child parts the same way you would treat your biological children.

2. Impact of Trauma on Normal Life

   • Rachel, despite childhood trauma and early adult crises, managed to finish university education and start graduate school.
   • Her parts hijacked her ability to function again due to fear of success or visibility.
   • Strong normal life self vs. helpless, needy, frightened parts.

3. The Four Befriending Questions

   • Rachel used the Four Befriending Questions to understand a young, anxious, helpless part.
   • This part had once provided protection against her father's rage.
   • Resulted in a split inside Rachel between strong and proud parts vs. needy, scared parts.

4. Building Resources of a Normal Life Self

   • Rachel committed to activities that provided a feeling of a steady inner presence: yoga, running, caring for her dog, socializing with friends.
   • Consistent commitment helped all parts feel less vulnerable.

5. Compassion and Connection

   • Rachel struggled when the parts' strong emotions required compassion.
   • Curiosity provides mindful distance but can diminish mental space, leading to intrusion of other parts or flooding by distressing feelings.

6. Somatic Interventions

   • Simple somatic interventions help regulate the nervous system and communicate commitment and compassion to the parts.
   • Placing a hand over the heart or chest calms young parts and communicates caring.
   • Making a big circle gesture opens a container for all parts, sending a message of welcome.

Taking Young Parts “Under the Wing”

1. Emotional Connection with Child Parts

   • Annie, Rachel, and Sarah struggled to emotionally connect with their traumatized child parts due to intense emotions and fear of harm.

2. Identifying Parts by feelings of distress, negative thoughts, and physical ailments but couldn't emotionally engage with them.

3. Each needed an intermediate step between recognizing and appreciating their parts' dilemmas and emotionally meeting them.

4. Attachment-Oriented Intervention

   • The therapist suggested "taking the parts under your wing," emphasizing attachment and protection.

5. Understanding Child Parts

   • Sarah had a clear sense of her child parts but struggled with proximity to some, feeling connected yet distant.

6. Offering a Wing

   • The therapist suggested offering a "wing" to the scared parts, creating a non-threatening sense of safety and protection.

7. Healing through Connection

   • Offering a wing allowed clients to feel emotionally close while staying centered in their normal life selves.

8. Non-Judgmental Communication

   • The language of "offering a wing" was non-threatening and didn't trigger judgmental parts, making it an effective communication tool.

Attachment Bonds Are Built through Body

1. Attachment Bonds: Develop through body experiences in infancy, starting with how parents hold, reach for, rock, feed, soothe babies.
   • Somatic transactions repeated over time form secure attachment.
   • Parents' arms convey safety, insecurity, or threat.
2. Focus on Present: In contrast to early models of trauma treatment, focus is on being "here" rather than revisiting past traumas.
3. Missing Experiences: Normal life self can provide crucial missing experiences for parts that developed at a distance from traumatic events.
4. Under the Wing: Providing emotional and relational connection to childhood self, offering feelings of safety, pride, protection, and admiration.
5. Holding Present Moment Perspective: Elizabeth realizes she was a right child born into the wrong family.
6. Connecting with Parts: Therapist helps Elizabeth connect with parts, inviting them to see new images and experiences.
7. Amplifying Positive Feelings: Directing attention to positive feelings shared between adult and child to amplify each other's pleasurable experience.
8. Multisensory Experience: Key to emotional connection between Elizabeth and the child part, involving seeing, hearing, re-experiencing, feeling, sensing impulses, and exchanging images.

Fears and Phobias of Internal Attachment

1. Fears and Phobias of Internal Attachment
   • Carl's intrusive thoughts disrupt his empathy towards his younger self.
   • An analytical part emerges, questioning the work and suggesting other treatment options.
   • This pattern repeats, with Carl feeling curiosity followed by irritability.
2. Origin of the Gatekeeper Part
   • Carl's parents' expectations shaped his behavior: only rational, goal-oriented actions were acceptable.
   • As a sensitive, anxious child, Carl struggled with separation anxiety and fear of rejection.
3. The Gatekeeper's Role
   • The gatekeeper part evolved to protect the little boy from rejection and abandonment.
   • It was successful in keeping Carl focused on "important things," but failed when Carl experienced intense feelings of neediness and fear of abandonment.
4. Encountering Another Gatekeeper
   • A new gatekeeper emerges, blocking Carl's attachment to the child part.
   • The child expresses a deep fear of being alone and unloved.
5. Befriending the Child Part
   • Through Befriending Questions, Carl begins to understand the child's fears and needs.
   • He acknowledges the difficulty of the situation and promises to stay present with the child.
6. Healing the Wounds
   • Carl realizes that his mother was not always reliable, contributing to the child's lack of trust.
   • He apologizes for past neglect and assures the child that he will be there for him.
7. The Power of Attachment
   • The child feels relief and trust as Carl stays present with him.
   • They both experience the importance of attachment and being together.

discussion of “parenting tips”

1. Parenting tips for Carl to help him connect with a fragmented child.
   • Child needs recognition, feeling seen.
   • Importance of daily "good morning" and face-to-face interaction.
   • Finding a toy based on child's interest.
   • Carrying a symbolic object as a reminder.
   • Imaginatively tucking the child in at night for safety.
2. Outside session importance: Therapist's role in facilitating work past the hour.
   • Attentiveness to individuals with trauma histories.
   • Heart-to-heart connection between small child part and compassionate adult self.
3. Shift from internal alienation: 10% inspiration, 90% perspiration.
   • Repetition of steps: connecting to a part, creating moments of repair, deepening bond.
4. Lasting change: Intensive repetition and neuralplasticity.
   • Neural change best facilitated by new patterns of action and reaction (Schwartz & Begley, 2002).
5. Previous beliefs: Intensity of emotional experience leads to transformative shift.
6. Importance of therapist's role:
   • Attentiveness outside session hours.
   • Facilitating shift from internal alienation.
   • Repetition and integration for lasting change.

Rupture and Repair of Internal Attachment Relationships

1. Emotional Ruptures and Repair

   • Healing cannot be achieved through re-experiencing old emotional pain; focus on repairing emotional ruptures instead.
   • Traumatized clients cannot feel whole without efforts to bring solace to distressed parts and combat self-alienation and self-loathing.

2. Role of the Therapist

   • The therapist should keep in mind the ultimate purpose: repairing implicit memories of early attachment rupture.
   • Each client and part is unique, but building blocks of internal attachment repair remain the same.

3. Identifying Traumatized Parts

   • Ask clients to recognize symptoms as a part and help them differentiate traumatized part versus adult observer.
   • Elicit a felt sense of each part, not an intellectual interpretation.

4. Communication with Parts

   • Place greater emphasis on togetherness of adult client and child than on content of their conversation.
   • Encourage inner reciprocal communication between parts.
   • Cultivate trust by understanding the reasons for fear of trusting.

5. Repair Moments

   • Use what doesn't work as an attachment-building moment.
   • Use the Four Befriending Questions to explore fears, conflicts, mistrust, etc.
   • Insist on responsibility and accountability within the internal community of parts.

6. Maximizing Moments of Attunement

   • Maximize moments of attunement physically and emotionally.
   • Avoid shifting away from mindful connection to insight-oriented discussion.

7. Earned Secure Attachment

   • Repeated steps lead to normal life self feeling differentiated from trauma-driven emotions.
   • Each part feels "held" by someone older and wiser, leading to earned secure attachment.

CHAPTER 10

Restoring What Was Lost

1. When those aspects of ourselves that have been unconsciously refused are returned, the need to maintain the self-conscious edifice disappears, and the force of compassion is automatically unleashed.
2. As clients learn to speak the language of parts, increase their ability to unblend, there is often a spontaneous settling of the nervous system, calming trauma-related parts.
3. The habit of mindful noticing creates a little space between the young child and a wise adult who finds it much easier to be curious now that he or she is less overwhelmed.
4. The client feels less "crazy" when "over-reactions" are reframed as normal reactions of traumatized children. Now, the client can observe the influence of the parts on their actions and reactions and practice being aware of impulses to blend and make a conscious choice.
5. With a conscious, voluntary separation from trauma-related parts and a more regulated nervous system, clients begin to develop less aversion and more compassion for them—or at least perspective toward them.
6. Traditional treatments for these issues typically focus on cessation of unsafe behavior, thereby alienating and polarizing the fight and flight parts and often jeopardizing stabilization.
7. Shame, exhaustion, and self-doubt are most often treated as indications of chronic depression or low self-esteem, rather than understood as communications from parts who bear the burden of submission and humiliation.
8. Stabilization of even the most dysregulated, dissociated clients can gradually be achieved with repeated practice of the following simple steps: learning to recognize triggered emotional and somatic reactions as "triggering" and avoid interpreting them as here-and-now responses to the environment; evoking curiosity by reframing these responses as "communications from parts"; cultivating not only the ability to name the parts but growing compassion for their youth and ability to survive in the face of "what happened"; learning to communicate internally, building trust, and making felt connections to the parts.
9. These simple initial tasks are the foundation upon which any deeper work must be built, and it is well worth the therapist taking the extra time to stabilize these abilities until the client can use them independently outside of therapy, not just with the therapist present.
10. In trauma work, the therapist's motto should be, "Slower is faster." Taking the time to build a foundation for each piece of work allows a steady progression toward resolution, rather than a great leap forward followed by two steps back—a pattern to which traumatized clients are all too prone.
11. "Trauma processing" must therefore include the body and the parts, and it must focus on reorganizing the individual's implicit memories and relationship to the traumatic past. For clients to transform their relationship to frightening, overwhelming, humiliating events necessitates acquiring the ability to be "on speaking terms" with the traumatic past without fear of being overwhelmed or humiliated."

Reorganizing the Relationship to the Past

1. Reorganizing the Relationship to the Past
   • Developing compassionate relationships with hurt, lonely, etc. parts is challenging due to raw emotions.
   • Therapist must help clients maintain curiosity and cultivate compassion.
   • Importance of therapist's "loving presence" - warm, compassionate, curious, looking for what is right.
2. Role of Memory
   • Traumatic memory processing not the objective, but memories may come up.
   • Memories provide context for evoking compassion for young child.
   • Deepening bond between normal life self and child through empathy and connection.
   • New experiences are encoded as memory when focused on for 30 seconds or more.
3. Annie's Experience
   • Afraid of leaving house, unable to unblend from parts.
   • Parts afraid of making mistakes, not knowing enough, having people in the house.
   • Validating parts' fears without exploring events to keep emphasis on feelings.
   • Modeling intervention for Annie: emphatically assure parts of safety.
   • Repeating announcement calms parts and allows Annie to do her job without interruption.

“Me Now” versus “That Part of Me Then”

1. Traumatized parts and normal life share the same mind and body, leading to blended identities for many clients.
2. Annie's experience: As an adult, Annie lived a different life from her traumatic past. She had been so focused on repairing her past that she hadn't questioned why she avoided revisiting those memories. Her normal life reflected her values and priorities, which were deeply connected to her experiences of care, safety, and creativity.
3. Sam's experience: Sam identified more with his younger, depressed parts than his normal life self. He minimized his adult achievements and commitments, allowing his younger parts to influence his decisions. This further weakened his connection to his normal life self.
4. False self assumptions: Clients may believe they have created a false self due to the disconnect between their traumatic past and their current functioning self. However, this is not the case as both sides of the brain and both priorities are necessary for a full life.
5. Importance of acknowledging normal life selves: Therapists should help clients appreciate their normal life selves and be more aware of their capacity for positive emotions and abilities. This can challenge entrenched negative beliefs about self-worth.
6. Gilda's experience: Gilda struggled to acknowledge the facts of her adult life due to the overwhelming nature of her parts' feelings. By practicing "owning" these facts, she began to recognize that her normal life self did have emotions and was an essential part of who she is.

Establishing Internal Communication with Dysregulated Parts

1. Establishing Internal Communication

   • Therapist identifies roles, resources, capacities, and daily activities of both normal life self and dysregulated parts.
   • Clients reminded that difficulties are expressions of parts being triggered by normal life trauma-related stimuli.

2. Listening and Responding to Dysregulated Parts

   • Normal life self listens with curiosity or compassion to emotions conveyed by parts.
   • Response is to ask parts "What are they worried about?" using the term "worry" which is non-threatening.

3. Exploring Parts' Worries

   • Initial worries expressed by parts are concrete or superficial.
   • Normal life self inquires more deeply to connect parts' fears with childhood environment where trauma occurred.

4. Maintaining Dual Awareness

   • Clients face challenges tolerating somatic reactions to intrusive thoughts and emotions.
   • Therapist assumes these challenges are part of the work, not a risk to life or a deal breaker.

5. Learning New Skills and Approaches

   • Clients may fear trying new steps or skills due to potential failure or inability to survive.
   • Therapist helps clients assess if new step is too much, acknowledges fears, or signs of readiness.

Rupture and Repair

1. Rupture and Repair

   • Infants' tolerance expands when exposed to stimuli outside comfort zone, followed by soothing and re-regulation (Tronick, 2007).
   • Attachment literature labels this phenomenon as "rupture and repair": discomfort followed by repair that restores attunement.
   • Repair fosters expectation of safety and positive feeling states.

2. Understanding Client's Response

   • Trauma-related parts may resist interventions due to fear of change.
   • Therapist should help clients notice resistance as understandable hesitation or hypervigilance.

3. Regulating Distress in Sessions

   • When clients are dysregulated, therapist's priority is helping them regulate rather than focusing on content.
   • Regulation builds attachment bonds to parts.

4. Internal Attachment Work

   • All difficulties in session become opportunities for increasing compassion and acceptance.
   • Helping clients maintain dual awareness when parts intrude.

5. Regulating Activation

   • Sensorimotor Psychotherapy interventions can be reframed to support parts.
   • Asking parts to "step back" or "sit back" helps clients maintain a window of tolerance and dialogue with all parts.

6. Validating Clients' Experiences

   • Validating clients' experiences of being ignored or unheard can help build trust and understanding.
   • Normal life self is treated as competent, caring adult while parts are described with empathy as children or adolescents.

Communicating Compassion toward Wounded Child Parts

1. Communicating Compassion
   • Believability of reassurances depends on feeling "gotten"
   • Empty reassurances can trigger emotional memories of abusers
   • Empathic attunement is crucial for successful reassurance
2. Understanding the Role of the Normal Life Self
   • Asks "hear" each channel of communication from wounded parts
   • Responds with curiosity and compassion
   • Uses appropriate language based on the part's age, feelings, and predicament
3. Exploring Parts' Feelings or Reactions
   • Inquires about fears, worries, sadness, etc.
   • Encourages normal life self to think about why the child part might feel that way
4. Building Emotional Connection
   • Asks "How do you feel toward that part now?
   • Evokes compassion and empathy from the normal life self
5. Mutuality in Communication
   • Focuses on reciprocity in the exchange between parts
   • Guides client to ask about the child part's experience of their connection
6. Validating Parts' Emotions
   • Validates event-specific emotions to build trust and relief.

Interference with Reparative Experiences

1. Reparative Experiences

   • Important to help clients stay connected to reparative experiences with their traumatized child self.
   • Deepening trust between child and adult parts can be disrupted by intruding parts.
   • Therapist coaches clients through interruptions, giving them a choice to support new learning.

2. Inner Dialogues

   • Some clients can engage in internal dialogues with their parts.
   • Reparative experiences include feeling understood, moved, warm, and safe.
   • Normal life self is coached through interruptions by therapist.

3. The Four Befriending Questions

   • Ask the part what it's worried about if you do something (go to the party).
   • Ask the part what it's worried about if people see it.
   • Ask the part what it's worried about if they don't like what they see.
   • Ask the part what it needs from you right now to not be so afraid.

4. Outcome of Befriending Questions

   • Annie felt calm at the party, no longer obsessing or shaming herself.
   • 13-year-old part felt proud and confident when Annie accepted herself.

Notice the therapist leads her...

1. Befriending Questions
   • Therapist guides client through four questions step by step.
   • First question: Tell her how badly you feel.
   • Second question: What is it like for her to feel someone's distress over having hurt her?
2. Understanding the Child Part's Experience
   • Child parts may feel nourished but hesitant or afraid to trust.
   • Past experiences of lack of caring make it hard for them to believe in new care.
3. Validating Fears and Lack of Trust
   • Therapist helps clients understand child part's fears and validate them.
   • Asking questions to evoke compassion and trust.
4. Providing Psychoeducation
   • In trauma work, therapists provide explanations due to client's lack of words for their trauma responses.
   • Past and present are intertwined, language spoken by normal life self is different from child part.
5. Avoiding Therapist Bias or Client Over-compliance
   • Clients observe effects of each intervention.
   • Asking clients to check in with parts and ask if it feels right.
6. Encouraging Embodied Communication
   • Letting child parts know feelings and body language that you understand them.
   • Using feelings to communicate presence and intention to stay.
   • Holding gently to convey they're not alone.

Building Impulses to Care

1. Young parts require care and safety, but understanding what it means to "take care of" or "make feel safe" is abstract and can be intimidating or triggering for them.
2. Concrete suggestions can help, especially when presented as a set of choices. For example, "You could tell him that you’re a grownup now—or that the bad people have gone away—or that you’re here to protect him so he doesn’t get hurt again.
3. Internal distrust and fear can hinder restoring hope and safety to child parts.
4. Protector parts may manifest as suspicious, mistrustful, cynical, or sabotaging due to past experiences or skepticism.
5. Vulnerable parts may not respond verbally, instead communicating through emotions or body responses.
6. Understanding nonverbal communications from child parts is crucial. Silence, anxiety, sadness, anger, muscle tension, numbing, or changes in heartbeat or breathing can indicate a part's response.
7. Externalizing the part and using intuition can help in communicating with silent or distrustful parts.
8. "If you had just adopted a traumatized child, and he wasn’t talking to you when you tried to get closer to him, what would you make of that?
9. Respecting protector parts and giving them control can lead to more willing engagement in dialogue.
10. "What would you need from me [the normal life self] to be willing to tell me more?
11. "I want the silent part to know that I appreciate his cautiousness."

Creating a New Purpose and Mission for Each Part

1. Protector parts in therapy:

   • Benefits when given power and control voluntarily by the client's normal life self.
   • Achieves better balance of vulnerability and feelings of mastery.
   • Allows access to young wounded or innocent parts.
   • Improves internal communication.
   • Helps client become more resourced, self-protective, and better boundaried.

2. Mistakes therapists make:

   • Giving up in the face of protector's silence, resistance, or devaluing.
   • Demonizing protector parts as interference instead of part of the work.
   • Urging clients to push through objections or ignore them, polarizing protectors and reinforcing distrust.

3. Effective therapist responses:

   • Expressing respect, gratitude, and understanding for protector parts' actions and reactions.
   • Encouraging client to do the same, promoting collaboration.
   • Persisting in efforts to make contact with fight part despite rebuffs, sending a committed message.

4. Attachment theory application:

   • Importance of resonance (mirroring feelings) and repair (addressing distress) for effective communication between parts and normal life self.
   • Avoiding "blending" with the feelings of a part or offering empty reassurances.

5. Mason's phobia:

   • Fear of getting sick leading to chronic anxiety.
   • Childhood memory of cartoon on germs and hand washing causing panic.
   • Trauma-related terms used to understand the boy's fear.
   • Mirroring the boy's anxiety and empathy, communicating understanding and compassion.
   • Offering help with watchfulness, allowing the boy to relax.
   • Demonstrating thorough scanning of environment to reassure the boy.
   • Recognizing the importance of not forgetting about the little boy within, just as Mason doesn't forget his own son.

therapist and client had to become creative

1. Creative approach needed for therapist and client when child part required more than just comfort and proximity; he sought protection.
2. Child's fundamental concern: no place was safe anymore after seeing abusive grownups at home and dangerous germs outside.
3. Translating child communication: facilitated suggestion of "taking over" the boy's hypervigilance, allowing him to rest.
4. Different needs for repair based on age, developmental stage, experiences of trauma/neglect, and animal defense.
   • Fight part: needs sense of purpose, control, and mastery.
   • Attach part: yearns for protection, love, and safety from abandonment.
   • Freeze or fear part: craves safety from harm or threat of death.
   • Submit parts: need to feel worth, autonomy, and initiative.
   • Flight part: wishes freedom from entrapment.
5. Work of emotional connection, communication, and repair of dysregulated memory states can deepen attachment bonds.
6. Repeated experiences of attunement build secure attachment.
7. Infants' calming into parent's arms generates shared felt sense of closeness, safety, and warmth (attunement).
8. Shared feelings and body sensations convey "secure attachment".
9. Opportunity for adults to "earn" secure attachment that was not available during childhood.
10. Attuned adult self provides healing experiences to wounded child parts.
11. Both client and child selves experience safety, loving presence, and relaxation in moments of attunement.

CHAPTER 11

Safety and Welcome: The Experience of Earned Secure

1. Emotional Attunement and Resonance:

   • Two individuals engage in a reciprocal interaction of emotional expression and felt resonance (Friedman, 2012; Siegel, 2010b).
   • This creates a sense of being 'felt' and two individuals becoming a 'we' (Siegel, 2010b).

2. Integration vs. Fusion:

   • Daniel Siegel argues against defining integration as fusion (Siegel, 2010a).
   • Integration requires differentiation and linkage of separate entities before connecting them (Siegel, 2010a).

3. Healing from Trauma:

   • Individuals need to connect implicit memories to triggers and link the trigger to an explicit context (Ogden & Fisher, 2015).
   • New information about the present must be linked with old perceptions shaped by the past for safety and healing (Ogden & Fisher, 2015).

4. Fostering Integration:

   • Focus on differentiating parts previously denied, ignored, or disowned (text).
   • Connect emotionally to these parts (text).
   • Provide experiences that replace self-alienation and self-rejection with self-compassion and secure internal attachment relationships (text).

5. Identifying Trauma-Related Parts:

   • Emphasis on identifying trauma-related parts connected to implicit memories, rather than recalling traumatic events (text).
   • Helping clients see their ashamed parts as 'real' children of particular ages and empathize with them (text).

6. Understanding Client's Symptoms:

   • Problems can be traced to young parts connected to specific times and events in the client's lives (text).
   • Letting symptoms and parts tell the client's story instead of focusing on described events (text).

“The Symptoms Tell the Story Better than ‘the Story’”

1. Trauma treatment has historically focused on traumatic events and memory narratives, often overlooking the story told by symptoms.
2. My colleague's patient, a 55-year-old woman, was believed to still be experiencing abuse from her deceased mother due to the therapist's focus on event memories.
3. The woman's most troubling symptom was intrusive shame and a yearning for closeness with loved ones, often resulting in conflicts and self-fulfilling prophecies.
4. The symptoms told a different story: disrupted attachment, leaving a child deeply hungry for contact but also frightened of her scary mother.
5. The therapist encouraged the woman to share childhood experiences, but remembering past pain did not heal or comfort her.
6. Mark's symptoms indicated he had learned it wasn't safe to speak or express opinions due to his past experiences of poverty, neglect, verbal abuse, and bullying.
7. Mark's symptoms also revealed he had survived by pleasing others and hiding his intelligence to avoid conflict.
8. Josh's symptoms told a story of a world where showing weakness was imperative, even as a child.
9. In both cases, past events were important for understanding and empathizing with the parts, leading to organic trauma resolution in the context of attachment repair.

Capitalizing on Dissociative Symptoms

1. Dissociative Fragmentation is a mental ability that allows individuals to split off unbearable emotions from memories and encapsulate "not me" parts and experiences. It helps children survive and adapt, but becomes pathological when it's unconscious and involuntary.

2. Medical Professionals and high-performing athletes rely on dissociative splitting for efficiency and focus without interference from emotions or intrusive thoughts.

3. Trauma Survivors may struggle in work settings due to trauma-related triggers that hijack their normal self, impairing functionality.

4. Frances, a professional woman, experienced severe dissociative fragmentation after her divorce and therapy revealed her abuse history. She was hijacked by child parts connected to the abuse memories.

5. Treatment for Frances involved acknowledging and mindfully dealing with the parts whose feelings and symptoms overwhelmed her. Creating safe places for child parts in her normal life helped improve functionality.

6. Safe Places for Child Parts can be created by addressing their needs, such as giving them a special birthday celebration or allowing them to choose what they want. This helps children feel loved and special, improving overall functionality.

7. Dissociative Splits allow individuals to maintain voluntary and deliberate separation between different parts of their personality, ensuring the normal life part's judgments don't influence the child parts' choices.

Supporting a Functioning Adult Normal Life Self

1. Josh's inner child was asked to adapt to his adult life: business office, home, wife, and children.
2. The child part observed how people treated Josh with respect and importance.
3. Mark's inner child mistakenly believed he had to attend Josh's speaking engagement.
4. Mark explained that grown-ups speak in public because they want to, not because they have to.
5. Mark proposed a plan for the child to stay home while he spoke at the meeting.
6. The child was excited about staying home with the cat and watching Mark on TV.
7. Dissociation was used as a tool for growth and healing.
8. Numerous clients have successfully undertaken normal life experiences using this technique.
9. One client was able to visit her parents without panic by leaving her parts "at home".
10. Another client finished law school by allowing her intimidated parts to stay home.
11. Clients were empowered by making their inner child parts feel protected and understood.

“Earned Secure Attachment”

1. Earned Secure Attachment
   • Evaluated based on narrative coherence
   • Coherence: integrated, regulated reflection of early attachment experiences
2. Coherence
   • Opposite of fragmented or conflicting views
   • Arriving at a place where many views come together
3. Mark's Experience
   • Agreed to spare child from frightening activities
   • Felt liberated from past, pursued career without fear
   • Offered child part a new experience: someone taking care of him
4. Narrative Coherence and Secure Attachment
   • Ability to describe insecure or traumatic attachment experiences in an integrated way
   • Not about having "good" attachment experiences
   • Involves coming to terms with the past, repairing damage, accepting missing experiences
5. Healing Story
   • Constructed to explain what happened
   • Comforting, regulating, promotes acceptance of "what is
6. Effects of Earned Secure Attachment
   • Correlated with parenting that promotes secure attachment in next generation
   • Challenges prevailing view of suboptimal attachment predicting less-than-optimal attachment experiences for next generation
7. Transformation of the Past
   • Human beings can transform implicit memories and explicit narratives of past through healthy adult attachment experiences
8. Intergenerational Transmission of Secure Attachment
   • Earned secure attachment transmits ability to offer same to next generation
   • Implies we can help clients create new legacy, stop intergenerational trauma

An Intergenerational Legacy of Secure Attachment

1. Secure Attachment endows individuals with increased relational flexibility, emotional resilience, and the capacity for interdependence. It allows us to internalize reassuring voices or presences during times of isolation.
   • Physical sense of safety
   • Emotional sense of closeness and specialness
   • "Heartbeat-to-heartbeat" communication
   • Mutual attunement between adult and child
2. Process of Secure Attachment
   • Left brain reconceptualizes emotional distress as a child's
   • Right brain responds with compassion and care
   • Feelings of closeness and attunement become reciprocal, creating a more pleasurable state
   • Left brain encodes the experience of love and safety
3. Example: Laura's Therapy
   • Unaware of dissociative disorder
   • Interpreted lack of concern as denial
   • Felt unprotected and at mercy of incompetent authority figures
   • Intuitively sensed structurally dissociated parts
   • Began to talk about young parts, connecting them to job stressors
   • Couldn't emotionally relate to parts initially
   • Seeked to connect with young parts, offering them a home
     • Hide-and-seek game
     • Gratitude and acknowledgement
     • Imaginary conversations
4. Healing Attachment Wounds
   • Deepening emotional attunement between adult self and child self
   • Creating new implicit memories of security, warmth, and closeness
5. Therapist's Role
   • Facilitating development and encoding of new implicit memories
   • Encouraging mutual attunement and deepening sense of closeness
   • Helping each partner in the relationship attune more precisely to the other
6. Benefits of Secure Attachment
   • Increased relational flexibility
   • Emotional resilience
   • Capacity for interdependence
   • Internalized reassuring voices or presences
   • Sense of closeness and peacefulness

Secure Attachment Is a Somatic and Emotional Experience

1. Secure Attachment is a physical and emotional state, not an objective goal. It's characterized by feelings of safety, closeness, connection, recognition, and understanding.
2. Secure attachment emerges from repeated moments of felt resonance and thrives on pattern and consistency.
   • Children love repetition in games and routines due to the security they provide.
3. Creating secure attachment experiences requires flexibility, a wide tolerance, and the ability to coregulate.
4. Traumatized clients have difficulty attuning to their younger selves due to automatic tendencies to recoil from painful emotions and fears.
   • The fact that these emotions and memories are not physically separate creates difficulties in knowing whose feeling is whose.
5. Blending and disowning are different strategies used for survival.
   • Blending enables quick responses, but can lead to enmeshment if not managed properly.
   • Disowning preserves the sense of self, but can lead to rejection or alienation of certain parts.
6. Attuning to all parts is essential for balance and reality-testing.
   • Identifying with ashamed, submissive, compliant parts can prevent perception of healthy anger or defensive responses.
   • Identifying with angry or suicidal parts can lead to anger management issues, self-destructive behavior, or internally recreating the early hostile environment.
7. Helping clients attune to "harder to love" parts is important for maintaining balance and promoting compassion.
8. Linda, a client, had difficulty accepting generosity and kindness due to her 11-year-old child part's belief that kindness was only for those who deserved it.
   • She also denied the existence of an angry part despite evidence to the contrary.
9. The discovery of her angry part led Linda to feel powerful, determined, and clear-headed, allowing her to stand up for herself in her professional life.
10. Accepting and trusting the angry part helped Linda create safety for herself and her parts in her corporate environment.

Earned Secure Attachment and the Resolution of Trauma

1. Earned Secure Attachment

   • Adults with this status can provide sensitive, attuned caregiving despite their own childhood trauma experiences.
   • Helps prevent attachment failure in future generations by healing old wounds and promoting secure attachments.

2. Characteristics of Secure Attachment

   • Associated with resilience, affect tolerance, ability to bounce back from hurt, stress, etc.
   • Allows individuals to tolerate grief, loss, betrayal, and other normal life experiences without compromising parenting abilities or self-soothing.

3. Comparison between Earned and Continuous Secure Attachment

   • Both types associated with similar benefits, virtually indistinguishable from childhood secure attachment.
   • Earned secure attachment allows individuals to tolerate higher levels of internal discomfort without compromising parenting abilities or self-soothing.

4. Importance of Embracing All Parts

   • Trauma survivors must overcome tendencies to fear and loathe some parts, and over-identify with others.
   • Embrace all parts, including hostile or aggressive parts, to sow the seeds of earned secure attachment.

5. Building Earned Secure Attachment

   • Healthy relationships in adulthood (spouse, therapist), parenting one's own children, and healthy relationships with "selves" can cultivate earned secure attachment.

6. Adaptive Projective Identification

   • The cornerstone of infant attachment: parents experience their baby's distress as their own, leading to repair efforts that meet the infant's needs and promote regulation for both parent and child.

Hearing the Child’s Cry

1. Child's Distress: Child parts feel distress and signal for help through discomfort. In a two-person system in one body, it's harder for child parts to be heard than via blending or reciprocal dysregulation.
2. Skills Practice: Mastering skills described in Chapters 4 and 5 is crucial for hearing the child's cry and unblending from distress.
3. Curiosity and Regulation: Curiosity helps regulate mutual dysregulation and keeps adult and child in contact, challenging self-alienation tendencies.
4. Secure Attachment: A good parent would respond to a distressed child with repair attempts. Success is measured by relief in the body.
5. Healing Fragmented Selves: Therapist's role is to "see" parts, help clients identify somatic signs of relief, and foster secure attachment experiences.
6. Reparative Interventions: Clients must provide reparative interventions for parts activated by stimuli, reclaiming lost parts and building attachment.
7. Befriending Parts: Normal life self befriends right brain-related parts, increasing communication and collaboration between hemispheres.
8. Healing as Organic Process: Healing happens naturally with the willingness to see and hear parts, guided by a compassionate therapist.
9. Appreciating Every Part: Both client and therapist appreciate every part's role in the whole, preventing "demonizing" each other.
10. Patience and Compassion: Healing requires patience, repetition, and deep conviction that healing is normal and natural.
11. Accepting Past Ages: We are every age we have been; past is part of what makes the present and must not be denied or rejected.

APPENDIX A Five Steps to “Unblending”

1. Blending: When traumatized parts get activated, their feelings flood the body, causing intense reactions that are not in line with our adult selves. This is called "blending".
2. Assume Communication from Parts: Assume any upsetting or overwhelming feelings and thoughts come from parts.
3. Describe Feelings as 'Their' Reaction: Speak for the parts by describing their feelings: "They are upset", "They are overwhelmed".
4. Create Separation: Change position, lengthen spine, engage core, or sit back to create separation and feel both their feelings and yours.
5. Reassuring Conversation: Use your wise grown-up mind to have a compassionate conversation with the upset parts. Acknowledge their fears, offer reassurance, ask what they need.
6. Get Feedback and Opinions: Check if your actions are helping, ask for their feedback, promise to remember they're in distress and be more protective.
7. Consistency and Repetition: The key to success is consistency, repetition, and a willingness to keep using this technique even on days when it doesn't work.

APPENDIX B Meditation Circle for Parts This intervention can help

1. Meditation Circle for Parts - A daily practice that encourages mindfulness meditation, promotes internal awareness, increases self-compassion, and builds trust with dissociated child parts.
2. Daily Practice: Find a quiet place to sit every day at the same time. Relax, take a breath, and make an internal announcement inviting all parts to join the meditation circle.
3. Welcome and Curiosity: Welcome each part, be curious about them, recognize their ages, facial expressions, body language, and communicate validation.
4. Listen and Validate: Be a good listener, take their fears and feelings seriously, own your role in their pain if applicable, and accept all emotions expressed by the parts.
5. Support and Validation: Provide the support and validation each part needs to assuage their fears and frustrations.
6. Focus on Today: Keep the focus on today or right now, as traumatized children have many fears and it's not helpful to open them all up at once.
7. Trust Building: Understand that some parts won't trust you at first, will hesitate to hear you, or even be angry. Be patient and assure them that you will meet every day and they can tell you more about their worries over time.

APPENDIX C Internal Dialogue Technique

1. Step 1: Focus on distressing thoughts and feelings, assuming they belong to a part. Identify the part based on its emotions and beliefs.
2. Step 2: If too blended with the part, create space by asking it to "sit back" or "relax." Confusion, overwhelm, anxiety are indicators of parts' distress.
3. Step 3: Be curious, ask the part what it's worried about. Listen and reflect its words back to reassure it.
4. Step 4: Explore underlying fears, usually rooted in "something bad will happen." Ask why that would be dangerous until you reach the core fear.
5. Step 5: Identify a corrective experience the adult can provide for the child part, such as validation, support, comfort, care, reassurance, or protection.
6. Step 6: Focus on how the adult can provide this corrective experience to the child, reassuring it of safety and presence.
7. Step 7: Practice these skills regularly to improve recovery from crises and avoid them. Every crisis results from a part getting triggered by fear or shame or anger.

APPENDIX D Treatment Paradigm for Internal Attachment Repair

1. Dissociative Disorder Clients and those with dissociative features come to therapy due to parts' intrusion on their consciousness.
2. Presenting problems reflect activated parts, e.g., depression could be a triggered depressed child.
3. Therapy promises help from an authority figure, further activating parts.
4. Therapist's role: give both sides (parts and adult self) "a voice".

At each session:

1. Tie distress to a part.
2. Switch pronouns.
3. Evoke curiosity about the distressed part.
4. Use language, tone reflecting part's age.
5. Prepare for other parts to get triggered.
6. Notice and name distracting or shutting down parts.
7. Be the voice for all parts.
8. Consider client's expressions as communications from parts.
9. Have client check with parts.
10. Invite parts to express tiredness of current feelings/states.
11. Frame interventions as attempts to help parts.
12. After each intervention, ask client to check with parts.