1. By Kathleen Martin, LCSW EMDRIA Consultant in EMDR kmartinlcsw@frontiernet.net 585-473-2119

2. Mental Health The Daily Living Action System and the Defensive Action System cooperate, communicate and work together. The person functions well. Daily Living Defensive © Kathleen M. Martin 201622/28/2016

3. When Trauma Happens The 2 action systems must manage the traumatic material in their own ways, thus reducing their ability to communicate and cooperatively respond to life. A structural divide between them is created. Daily Living Defensive © Kathleen M. Martin 201632/28/2016

4. When Trauma Happens Apparently Normal Part of the Personality Emotional Part of the Personality This differentiation is the start of Dissociation. Both parts contribute to the dissociation. The Daily Living Action System’s part of the personality is now called the Apparently Normal Part and the Defensive System’s part of the personality is now called the Emotional Part. © Kathleen M. Martin 201642/28/2016

5. Definition of Dissociation in Structural Dissociation Terms The structural division of the personality that occurs between these 2 action systems. There can’t be dissociation with only 1 action system. Dissociation is across the full personality. © Kathleen M. Martin 201652/28/2016

6. Another way of saying this is dissociation is the inability of the various parts of the personality to stay present with each other when unhealed mental contents and actions are activated. © Kathleen M. Martin 201662/28/2016

7. Non-Realization: The Essence of Dissociation Without the ability to stay present with all the mental actions involved with an event and its aftermath, the person can not fully claim: The event or parts of the event happened It happened to me My mental, emotional and behavioral actions in response to it were mine The event is now over The “me” of then is part of the “me” of now The full reality of the present moment © Kathleen M. Martin 201672/28/2016

8. Examples of Non-Realization 1) ANP believes “the car accident where I almost died did not have an impact on me. I’m fine. It is over. It is healthy to not drive anymore because there are crazy drivers out there and it is not safe.” 2) EP, age 14, believes that the trauma at age 7 “did not happen to me because I am too old. I was created long after that.” 3) EP, age 5, believes she is not angry about anything and hates the 12 year old EP for being angry. © Kathleen M. Martin 201682/28/2016

9. Examples of Non-Realization 1) ANP reports crying every time after sex with her husband. Even though she reported some intrusive images of childhood sexual abuse, she thinks she is just making that up and blames hormones for the crying. 2) Client’s husband died 10 years ago. Client has not grieved and says she has been too busy as a single parent to pay attention to it. She knows she is not emotionally available to her new lover and thinks she needs to finally do her grieving. Dissociative table found a 5 year old EP who did not know her husband had died. © Kathleen M. Martin 201692/28/2016

10. Phobia to Affect and Traumatic Material Hallmark of PTSD Hallmark of Dissociation Grows when stored trauma (EP) is activated without integration Reason why dissociation persists and grows long after the trauma is over © Kathleen M. Martin 2016102/28/2016

11. Phobia grows via Classical Conditioning What fires together wires together and What wires together fires together © Kathleen M. Martin 2016112/28/2016

12. EP and Classical Conditioning Previously neutral (internal or external) stimuli can be associated with the trauma This expands the memory representations of the trauma and its possible triggers EP is activated when these representations are triggered Once activated, there is a predictable course of thinking, feeling, response and behavior EPs do what they were programmed to do © Kathleen M. Martin 2016122/28/2016

13. ANP and Classical Conditioning Exposure to the traumatic material is aversive to the ANP and therefore avoids it With each activation of the unhealed trauma (EP), the ANP can associate more stimulation and info as aversive The ANP then retracts its field of consciousness even more to avoid this stimuli Classical conditioning continues to increase the ANP’s avoidance of the Emotional Part(s) This avoidance (phobia) may at times be involuntary, extreme and rigid © Kathleen M. Martin 2016132/28/2016

14. Example: Car Accident Car accident happens on a snowy day. The EP stores the trauma and relives it while at the same time the ANP must avoid cues of the trauma to do daily life tasks. EP is activated the next day when it is icy without snow and associates icy conditions into the memory network. ANP must avoid that activation and now doesn’t like driving in snow and ice. EP becomes activated on a sunny day and associates driving in sunny conditions into the memory network. ANP doesn’t like the activation when driving on a sunny day and develops avoidance of sunny-day driving. Taking this to the extreme, agoraphobia develops due to the ANP’s need to avoid. © Kathleen M. Martin 2016142/28/2016

15. This phobia fuels a range of the ANP’s avoidance and escape reactions preventing integration of the trauma © Kathleen M. Martin 2016152/28/2016

16. ANP and Conditioned Avoidance Behaviors Avoiding affect Detached lifestyle Avoiding intimacy Addictions: work, substances, TV, shopping, computer games, etc. Wanting a “quick fix treatment” Thought suppression, depersonalization, diverting attention Denial; daydreaming Amnesia © Kathleen M. Martin 2016162/28/2016

17. Common Behavioral Examples of Dissociative Phobias Client cancelling a session or coming late after or before the first Phase 4 trauma processing session ANP refusal to communicate with an EP. This can grow into complete lack of coconsciousness. Committing to work on a specific memory or issue but changing the subject repeatedly when redirected by the therapist ANP is insistent that “all is well” and “nothing phases me” ANP refusal to admit there are emotional parts despite the clear existence of EPs © Kathleen M. Martin 2016172/28/2016

18. Case Example: Jennifer Referred for treatment by a clinician who was not trained in trauma and dissociation but had worked with this client for 1 ½ years. Client destabilized early in that treatment due to going into the memories too early and not diagnosing and treating the dissociative disorder (DID). Client’s Catatonic EP became activated most of the time outside of sessions and client became non-functional. Treatment with the new clinician focused on stabilization, getting the ANP to stay present, time orientation and deactivating Catatonic. Once the phobias to the mental contents were treated, including phobias to other EPs, reprocessing the traumatic memories in a controlled, titrated way went well and she never became Catatonic again. © Kathleen M. Martin 2016182/28/2016

19. Treating Dissociative Phobias Definition of Dissociative Phobias: Resistance/avoidance of internal experiences This includes 1) Mental contents 2) External cues that will trigger these mental contents Phobias are protective layers that keep the person away from the unwanted mental contents © Kathleen M. Martin 2016192/28/2016

20. Mental Contents Affect, body sensations EPs and ANPs All pieces of the traumatic material including the sensorimotor information Wishes, urges (fulfilled and not fulfilled), needs, fantasies, images, etc. Self-meanings made in response to the traumas Thoughts and behaviors during and after the event Defensive strategies used to stay away from the aversive information © Kathleen M. Martin 2016202/28/2016

21. Phase-Oriented Approach to Treating Dissociation Phase 1: Engagement, Stabilization -Increase ANP’s functioning level by gradually overcoming phobias of: attachment to the therapist, mental contents, EP’s, other ANP’s. Phase 2: Reprocessing Traumatic Memories - Controlled and titrated processing of traumatic memories to facilitate integration without re-dissociation. Phase 3: Enhancing Daily Living - Integration of the personality, overcoming phobia of intimate attachment, and coping with life in non-dissociative/non-avoidant ways. © Kathleen M. Martin 2016212/28/2016

22. Treating ANP’s Phobia is the First Stage of Treatment Start with Increasing ANP’s Positive Affect Tolerance © Kathleen M. Martin 2016222/28/2016

23. Increasing ANP’s Level of Functioning and Window of Tolerance The key is to build the ANP’s ability to calm, soothe and de- activate the EPs (from re-living the past) Always start with increasing ANP’s window of tolerance for positive affect (calm) Don’t underestimate the power of calming skills: calming skills help to increase affect regulation and the tolerance of more difficult affects Giving your client more calming skills puts the ANP back into the driver’s seat Client needs many calming skills, not just one Distraction skills are also useful but not all distraction skills bring the client to calm. Help client to know the difference between calm and shut down. © Kathleen M. Martin 2016232/28/2016

24. Have an Arsenal of Stabilization Skills to Teach the ANP Positive Affect Tolerance Affect Regulation Skills DBT Skills Distraction Skills Silly Little Questions Skills to shift out of disturbance into the present Pendulation Time Orientation Skills Adaptive Self-Care Skills, including personal hygiene, exercise, eating, sleeping, energy management, etc. Good Boundaries © Kathleen M. Martin 2016242/28/2016

25. Arsenal of Stabilization Skills Skills to Observe Somatic Sensations Grounding in the Present Hypnotic and Relaxation Skills Mindfulness Skills Releasing Skills ( Sedona Method by Hale Dwoskin) Resource Development and Installation Good Coping Mechanisms Daily Relaxation Friends Satisfying Activities © Kathleen M. Martin 2016252/28/2016

26. Note: Systematic Relaxation and Breathing Skills typically do not work for this population early in treatment. Skills that call attention to the body may trigger the client rather than stabilize. Know your client. It doesn’t matter what skills work; it only matters that your client has many skills she/he likes and use to achieve stabilization. Teach your client many skills so when one skill doesn’t work, there are many skills left in the toolkit to try. © Kathleen M. Martin 2016262/28/2016

27. Working on Attachment Phobias start with the Treatment Alliance to Therapist and to Parts of Self © Kathleen M. Martin 2016 Treatment alliance must develop with the ANP Each EP And at same time ANP must develop working alliances with each EP And EPs must develop working alliances with each other 272/28/2016

28. The therapeutic approach of being non-judgmental, curious, mindful and empathic encourages the client to gradually look inside. This flexible, empathic and cooperative approach begins to develop an earned secure attachment, increasing the client’s ability to contact trauma-related mental actions. © Kathleen M. Martin 2016282/28/2016

29. Developing Compassion and Cooperation between ANP and EPs ANP’s exposure to the traumatic material in this phase is not effective because it grows the ANP’s phobia You must not allow EPs to tell their stories in this phase. You must quickly interrupt EP accounts of past traumas and explain to them that it isn’t time yet. “Their turn will come”. Use the Dissociative Table/Meeting Place to help with internal communication and relationship building Help all EPs to understand that their “jobs” were created by their one mind to manage the overwhelming events in times of danger. These “jobs” had survival value then but are no longer adaptive now © Kathleen M. Martin 2016292/28/2016

30. Treating Phobias Toward “Young” EPs Understand the survival functions which these parts are locked in (e.g. submit, attachment cry, freeze, etc) Psychoeducation that these parts are not really young but frozen in the unmet needs from the past: These needs can not be met now, they can only be healed. The needs of an adult are very different than the needs of a child. When they were a child, their survival was dependent on their care givers. That is not true anymore for adult clients. Time orientation to develop dual attention Invite them to watch and listen while ANP is out © Kathleen M. Martin 2016302/28/2016

31. Helping “young” EPs experience positive affect As a way to help time orient a part as well as increase positive affect tolerance, expose the EP to a recent pleasant event. You can ask the ANP to access the pleasant memory and activate the positive feelings associated with it. Then ask the EP if it remembers that pleasant event and if that event happened to the EP (from the EP’s perspective). You can also ask the EP if it can experience the positive affect along with the ANP (you can install this if appropriate). This can be an opportunity to begin addressing the cognitive error of separateness. 11/8/2015© Kathleen M. Martin 201531

32. Treating Phobias Toward “Young” EPs Encourage the ANP to do the soothing rather than you. It is very easy for the therapist to become overinvolved Don’t treat these parts as if they really are children. You may need to use concrete language and concepts to match their style but remember they are really the chronological age of your client Personification of the traumatic material; remember that these parts have their own ways to protect against claiming the traumatic material. Be careful to not go into the traumatic content when ANP and/or EP can’t tolerate exposure © Kathleen M. Martin 2016322/28/2016

33. More on working with Young Parts Questions such as: What is the benefit that you and the entire person get from doing this job? How is this job helpful? What percent of those feelings are from the past? What would happen if you stopped doing what you are doing? What part can help us understand how to help you know that the danger is over now? Where do you live? What house do you live in now? Remember that you are working with a system, not just these young parts. Working with young parts can take a lot of time and therapists can unintentionally fall into the trap of colluding with the cognitive error that these parts are really young. Watch your countertransference. It is so common for therapists to over function especially when a young part is caught in attachment cry. © Kathleen M. Martin 2016332/28/2016

34. Treating phobias to Perpetrator Part A perpetrator part is also known as an internal perpetrator imitator, persecutory part, or perpetrator introject and provides a protective function to not realize aspects of the trauma. The most common perpetrator part is an internal critic. Understanding the survival function (protective function) of this part’s job under the past traumatic conditions helps all parts in the system develop compassion and reduces phobias toward this part Functions to maintain the non-realization that is dissociation’s signature This part needs to gradually claim the abuse happened to this part too © Kathleen M. Martin 2016342/28/2016

35. Working with Perpetrator Parts This part is typically quite isolated from the rest of system due to the phobias of other parts toward this part. Work on this isolation This part and all other parts need to differentiate between the real-life perpetrator and the internal likeness of the perpetrator Time orientation and realization are processes that will happen over time Go slow. Sometimes you can’t access a perpetrator part for a long time. In other clients, it is the first part you encounter. Always watch what your interventions with perpetrator parts do to the rest of the system © Kathleen M. Martin 2016352/28/2016

36. Working with Perpetrator Parts Don’t get into power struggles with these parts. You must be curious, empathic, but set good boundaries. Do not be mean or dismissive. Assume they are watching you at all times. Don’t trash them while talking to other parts. Work to develop a good treatment alliance with them. Remember they often are defending against the attachment cry Remember they were a solution to a problem, not the problem. The problem was the abuse/neglect the person endured. © Kathleen M. Martin 2016362/28/2016

37. Cognitive Errors Irrational beliefs that “feel” true to the client Make sense inside the irrational logic of the client but are, in reality, not true Sometimes fit the definition of blocking beliefs Sometimes show up as negative cognitions © Kathleen M. Martin 2016372/28/2016

38. Cognitive Errors Cognitive errors are like binders in a cake mix to keep all ingredients together: they maintain the dissociation Cognitive errors were necessary when they were created to help manage the overwhelming feelings and situations But using the cognitive error today gives a meta- message that the past conditions are still happening or about to happen Therefore cognitive errors fuel: incorrect time orientation: hyper/hypo arousal: EPs continuing to do their jobs from the past; and keeps the trauma from reprocessing © Kathleen M. Martin 2016382/28/2016

39. Examples of Cognitive Errors The ANP will die (annihilation) if the ANP knows this information If I don’t ___ (do the job of the EP), then something bad will happen: e.g., get hit, abused, disintegrate, blow up, become a raging monster, be too needy, etc. The EP is a separate entity and lives outside my body The Inside Mother (perpetrator introject) is the Real Mother If I don’t cut myself then something even worse will happen I was born to be abused © Kathleen M. Martin 2016392/28/2016

40. Reframing Cognitive Errors as Channel Changers Applying the metaphor of changing channels on a TV, cognitive errors “change the channel” from the mental contents that are too overwhelming to “watch” to a program on a different channel that is more tolerable The repercussions of this “more tolerable” channel may be quite unpleasant but at least it keeps the person away from the original overwhelming mental content The job of a critical EP is a common example of a channel changer: instead of feeling the deep, raw feelings (anger, sadness, disappointment, etc.) built up in response to a critical, shaming or neglectful parent, the person can focus on “I am not good enough” and all that goes with it © Kathleen M. Martin 2016402/28/2016

41. Challenging Cognitive Errors Challenge cognitive errors to the extent that the person can tolerate and then back off to keep the client inside the window of tolerance. Then when you think it is clinically appropriate, challenge it again. This can be delicate work over many sessions. But remember, the client can’t win this battle: continuing to believe the cognitive error means the traumatic material won’t process. The following question can help to identify the mental contents that the channel changer seeks to avoid: What benefit do you get from believing that? Understanding that the cognitive error has a purpose helps the client to begin embracing the adaptive information. Join with the EP: “Your entire psyche needed you to believe that to help manage how overwhelming things were back then. This job has been so hard.” © Kathleen M. Martin 2016412/28/2016

42. Challenging Cognitive Errors ANP must agree that the cognitive error is indeed a cognitive error ANP needs skills to refute the cognitive error Dealing with the cognitive error of one EP can impact other EPs and ANP because it changes the homeostasis of the system. Deal with the destabilization this can sometimes cause. The ANP can be helpful with this re- stabilization because the ANP has a better chance of accessing the adaptive information. © Kathleen M. Martin 2016422/28/2016

43. Safe Use of Dual Attention Stimuli in the Stabilization Phase Slower and shorter sets as in RDI This is not the time to move into traumatic material. If traumatic material is activated, stop DAS and use stabilization skills to bring the client back to the present Use clinical judgment in every situation. DAS may or not be appropriate in any given moment Remember that an EP or ANP may respond very differently to an intervention than another EP or ANP. Always evaluate the effects on the system after any intervention. © Kathleen M. Martin 2016432/28/2016

44. Safe Use of Dual Attention Stimuli in the Stabilization Phase Calm Place and RDI Installing treatment gains such as development of compassion toward a part Installing and strengthening correct time orientation The decrease of phobia between and among parts Relieving the intensity of a disturbing emotion or sensation in a part Facilitating/installing the linking in of adaptive information © Kathleen M. Martin 2016442/28/2016

45. “Tip of the Finger” use of DAS Created by Anabel Gonzalez and Dolores Mosquera This is not trauma reprocessing as done in Phase 4 of the EMDR Standard Protocol This is targeting small pieces of mental contents that will improve compassion and cooperation among the parts, emotional regulation and improved daily life functioning The target is not the traumatic memory but a very small part of a disturbing sensation or emotion © Kathleen M. Martin 2016452/28/2016

46. Working on Phobia to the Traumatic Memories Exposure to the traumatic material which the person is phobic to is counterproductive in complex trauma: it just grows the phobia more Phobia to traumatic memories gradually decreases as: Communication, compassion and cooperation increase between ANPs and EPs ANP’s level of functioning increases Understanding grows regarding the survival value of the EPs’ jobs ANP can de-activate EP arousal more often EPs become more time oriented The cognitive errors that help keep the dissociation in place are identified and treated Phobias to EPs decrease (between ANP and EPs) © Kathleen M. Martin 2016462/28/2016

47. Until enough material has been processed so the window of tolerance is wider, reprocessing is titrated. Reprocessing occurs in small doses, sometimes lasting seconds or a few minutes Returning to the table/meeting place is frequent to see what has shifted and/or do necessary stabilization work Time orientation interweaves are frequent, especially early in this phase There tends to be more talk on the part of the therapist for stabilization needs until the window of tolerance and dissociative phobias are more processed Frequent return to stabilization needs is common early on © Kathleen M. Martin 2016 How Trauma Reprocessing typically happens in Complex Trauma 472/28/2016

48. All reprocessing must stop if the ANP is not present and/or an EP is just reliving the event Checking in with parts who were part of the trauma reprocessing at the end of the session is common Phobias to attachment to the therapist need to be treated as parts become more accessible to participate in the work Dealing with cognitive errors that help to keep the dissociation in place become spotlighted in the reprocessing. This may require stopping the reprocessing and dealing with cognitive restructuring © Kathleen M. Martin 2016 How Trauma Reprocessing typically happens in Complex Trauma 482/28/2016

49. More on Titrating Reprocessing Bite off only small pieces. Don’t let the client go down many channels. Come back to target more often to keep it contained to these small bites. Use smaller number of saccades in your sets of DAS Take more time between saccades. Talking between sets slows things down. But be careful with this as you don’t want to get the person out of the disturbance (only having the ANP present) so no reprocessing can happen nor do you want to change to a different memory network. © Kathleen M. Martin 2016492/28/2016

50. Common Reasons for Treatment Failures in Complex Trauma Failure to recognize dissociation in your client Allowing your client to go into the stories too soon Growing the ANP’s phobia Growing EPs’ phobias toward each other Not altering Standard Protocol procedures which result in not titrating the reprocessing well enough Insufficient stabilization prior to working on memories Not identifying and working with the emotional parts of the personality Trying to process memories while EPs are stuck in trauma time Treating parts as if they really are children Countertransference © Kathleen M. Martin 2016502/28/2016

51. References Gonzalez, A. & Mosquera, D. (2012). EMDR and Dissociation: The Progressive Approach. Kentucky. Martin, K. (2012). How to Use Fraser’s Dissociative Table Technique to Access and Work with Emotional Parts of the Personality. Journal of EMDR Practice and Research, 6(4), 179-186. Van der Hart, O., Nijenhuis, E., & Steele, K. (2006). The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization. New York: Norton and Company. Van der Hart, O., Nijenhuis, E., & Solomon, R. (2010). Dissociation of the Personality in Complex Trauma-Related Disorders and EMDR: Theoretical Considerations. Journal of EMDR Practice and Research. 4(2), 76-92. Van der Hart, O., Groenendijk, M., Gonzalez, A., Mosquera, D., & Solomon, R. (2013). Dissociation of the Personality and EMDR Therapy in Complex Trauma-Related Disorders: Applications in the Stabilization Phase. Journal of EMDR Practice and Research. 7(2), 81- 94. © Kathleen M. Martin 2016512/28/2016