Thursday, September 17, 2009

Internal Family Systems Therapy for Trauma Survivors

This is a paper I wrote for my last class - unfortunately, I hadn't read the directions clearly enough and so I wrote this paper on a therapeutic approach rather than on a specific diagnosis as I was supposed to do - so I decided to not let it go to waste and post it here. It's a little long, but I hope someone finds it interesting.

Internal Family Systems Therapy for Trauma Work

Ever since Sigmund Freud introduced his basic model of the human mind, consisting of the id, ego, and superego, psychology has recognized that the human psyche has various parts. As our understanding of the mind has increased since, the identification of parts has also become more sophisticated. According to Carl Jung, we all have complexes, fragmental selves that can “subsist relatively independently of one another and can take one another’s place at any time, which means that each fragment possesses a high degree of autonomy” (1969, p. 96-97). Roberto Assaglioli, a contemporary and friend of Jung’s, introduced the more specific concept of the subpersonality (1965, p. 74-77) to explain Jung’s complexes, a concept he continued to develop until his death in 1974. Even William James, the father of American psychology, spoke of his various selves, “The material me; The social me; and The spiritual me” (James, 1985, p. 44).

More recently, Hal and Sidra Stone expanded the Jungian complexes into more a complete theory of subpersonalities called Voice Dialogue (1989). Likewise, John G. Watkins and Helen H. Watkins have introduced the idea of ego states within the neo-Freudian tradition (1997). As far as therapy is concerned, this model is very similar to subpersonalities but, according to its proponents, ego states offers a better “theoretical understanding of the personality structure” than either the Voice Dialogue model of the Stones or the Psychosynthesis model of Assagioli (Emmerson, 2003, p. 22). There are many other models that identify and use the idea of parts or subpersonalities, including Gestalt Therapy, Alvin Mahrer’s “potentials,” neuro-linguistic programming (NLP), and the idea of self-schemas in cognitive-behavioral therapies (Rowan, 1990, p. 88-115). While many contemporary models use some form of subpersonality work, there has been very little evidence-based research into the effectiveness of these models.

One of the more recent theories to emerge on the scene is the Internal Family Systems Therapy of Richard Schwartz (1995). Schwartz began his career as a family therapist using the traditional systems model with his clients. Yet he found that after working with the family and appearing to resolve the issues, his eating disordered and/or self-harming clients did not get better:

We carefully reorganized the clients' families just the way the treatment manual prescribed, yet their binge-and-purge episodes continued unabated, powered by some invisible, inexplicable force.

Bewildered and frustrated, I broke an unspoken family therapy taboo and began to ask my clients what was happening inside them before, during and after their binges. Their answers rocked my theoretical world. They talked about different "parts" of their personalities as though those parts were autonomous beings. (Schwartz, 2001, ¶ 13-14)

Schwartz defines a part as “a discrete and autonomous mental system that has an idiosyncratic range of emotion, style of expression, set of abilities, desires, and views of the world” (Schwartz, 1995, p. 34). These parts are not completely dissociated as they might be in dissociative identity disorder (DID) but, rather, they are semi-permanent in nature, yet not always present. Each part fulfills a specific role, which is often reflected in how they are named (perfectionist, vulnerable child, pusher, caretaker, and so on).

One of the tough lessons he had to learn in dealing with these parts who wanted to harm his clients is that those parts cannot be dominated into submission. In working with a client named Lorene, who was a cutter, he spent two and a half hours persuading the cutter not to harm her and thought he has succeeded.

At Lorene's usual appointment time the following week, I opened the door to my waiting room to greet her. What I saw stunned me into silence. Running from the top of Lorene's forehead down to her right eyebrow was a fresh, deep gash. "What . . . ?" I gasped. Lorene shrugged noncommittally and moved quickly past me into the office. . . . "Why did you do this to Lorene?" I demanded of the cutter.

Lorene narrowed her eyes and looked at me with the purest contempt. "I told you she was mine !" (Schwartz, 2001, ¶ 8-9)

After this experience, Schwartz was forced to reexamine his basic approach to working with these extreme parts.

The Basic IFS Model

As he began to learn from his clients how the different parts of their psyches functioned, Schwartz realized that they relate much the same way a literal family operates. There are parts who are managers (1995, p. 48), whose job is to keep people safe in the world, to get things done, or to keep painful feelings out of awareness. There are also exiled parts (1995, p. 47), most often those who hold the painful feelings the managers do want to allow into awareness. These exiles are very often quite young and are created as a result of traumas, both big T traumas and small t traumas. Some exiles are little more than feelings (fear or sadness are common exiles in men), but other exiles are fully developed subpersonalities (most common in abuse survivors).

But there is one more part that shows up when the managers fail to do their jobs in keeping exiles out of awareness, or the exiles get activated in spite of the best efforts of the managers, and Schwartz calls them firefighters (1995, p. 50), because like real world firefighters, they only show up to put out the fire when an exile threatens to break through into awareness. “They do whatever they believe necessary to help the person dissociate from or douse dreaded, exiled feelings, with little regard for the consequences of their methods” (1995, p. 50). Many of their methods are numbing behaviors, such as cutting, binge eating, drug and alcohol abuse, or sex addiction. When a firefighter gets activated, it takes control of the person so thoroughly that when the person describes the feeling it is as though they are not present (1995, pg. 51), or in more clinical terms, have completely dissociated.

In working with the internal family of parts, the therapist must work with managers and firefighters to get their permission for the exiles to surface. Not doing this part of the work, sometimes known as bypassing, can create the kind of damage Schwartz described above. The essential thing to understand is that each manager and firefighter believes it is doing what is best for the system, to protect the individual from getting reinjured. As an example, a perfectionist manager may have arisen when the child was repeatedly yelled at for making mistakes, creating a polarized exile that holds shame and humiliation. The role of the perfectionist manager in the adult is to prevent the person from ever feeling shamed and humiliated by always doing everything right, or never risking something at which he or she may not be good. When the therapist tries to get directly to that shame without working with the manager, a firefighter will often be activated to keep those feelings suppressed.

When the managers and firefighters have been recognized and assured that their roles are respected and that their needs will be met, then the exiles can be worked with and unburdened. The unburdening process (Schwartz, 1995, pg. 108-110) is where IFS therapy achieves its positive outcomes. All of the exiles carry the “burden” of painful emotions and memories, and when the Self—the compassionate, curious, courage state of mind (Schwartz, 1995, pg. 37)—can make contact with the exile and bring it safely into the present (this is done through a kind of active imagination), then the burden can be disposed of in whatever way the exile feels is most suitable (often by burning or burying). When the burden is removed from the exile, the unburdened exile can then adopt a healthier role in the psyche, most often as a vulnerable and open child-like part of the self.

Origins of Parts in the Psyche

In each of the various psychological models that recognize parts or subpersonalities there are various ways in which those parts come into being. In some models they are innate (Freud and Jung), in some they arise as a normal part of psychological functioning (gestalt, ego states), and in some they arise as a result of trauma. This last type is where the IFS model falls, although IFS also maintains that multiplicity is inherent in the psyche.

When a young child is confronted with trauma of any kind—emotional, physical, or sexual—the nascent Self attempts to find a way to regain the love and approval of the parents. If the same type of trauma occurs repeatedly, such as physical abuse, harsh criticism, or something worse, the response will become ingrained in the child. Any similar experience will trigger the same response, even into adulthood. At this point, a subpersonality or part has formed. It is a very adaptive behavior. The psyche is simply trying to protect the fragile and vulnerable inner child, which is split off from the Self, or exiled, to use Schwartz’s term. In the most extreme situations, there will be the splitting that results in DID, but it is relatively rare that a memory or feeling is completely dissociated and unavailable. Dissociation is a spectrum, and DID is one extreme, but most splitting is not that severe.

Different traumas can evoke different adaptive responses, and not all traumas must be as serious as abuse. Little, repeated traumas can also result in splitting of the personality and the creation of managers to deal with the various situations. The Watkins make the same distinction with ego states: “one ego state may have taken over the overt, executive position when dealing with the parents, another on the playground, another during athletic contests, etc.” (Watkins & Watkins, 1997, p. 29). As stated, these are adaptive responses for a child, and the managers may be successful in preventing any more damage to the Self. Yet these same behaviors that were adaptive as a child are dysfunctional as an adult. If there is sufficient trauma that the exiles regularly seek expression, and the managers fail to keep them exiled, then firefighters will become more prominent, bringing with them their dissociation responses, whether that be cutting, starving, drinking, drugs, sex, or something else. Getting the client into some contact with Self energy is always the first priority.

Self-Leadership in IFS

In the middle of all these parts, as alluded to above, is the Self, variously referred to as the authentic self, core self, or even in some groups as Buddhanature. The presence of the Self can be identified by eight specific qualities, the eight Cs: “calmness, curiosity, clarity, compassion, confidence, creativity, courage, and connectedness” (Schwartz, 2008, ¶ 5). Schwartz offers a more precise definition:

[E]veryone has at the core, at the seat of consciousness, a Self that is different from the parts. It is the place from which a person observes, experiences, and interacts with the parts and with other people. It contains the compassion, perspective, confidence, and vision required to lead both internal and external life harmoniously and sensitively. (Schwartz, 1995, p. 40)

As much as IFS therapy seeks to work with the client’s parts, to unburden them, even more so this model seeks to teach the client how to become a Self-led human being. Because most of us have had experiences growing up where one or more of the C qualities have been rejected, shamed, or otherwise learned not to trust our Selves, regaining self-leadership is always the end-goal of IFS work.

It’s important to note that Self-leadership is even more important for the therapist working with trauma victims (child abuse, rape, incest, violence). Survivors of trauma—whether they engage in anorexia, bulimia, self-harm, chemical dependency, or something else—tend to be adept at sensing the authenticity of the therapist. Unlike many contemporary models, IFS encourages the therapist to assure the client that she or he is, indeed, cared for and liked (Schwartz, 1995, p. 102). Even when trust is established in one session, the client may return the next week and a different manager will be in charge of the situation in another effort to keep the exiles out of the consulting room. The therapist needs to be prepared for constant testing and retesting of the trusting relationship (Goulding & Schwartz, 1995, p. 249). This process is crucial to getting the managers to trust the therapist, and this is why Self-leadership is so crucial for the therapist as well—from that place of curiosity and compassion, one can truly care about the client and be authentic in doing so.

When engaging the client in therapy, however, the therapist seeks to locate and empower the client’s Self as soon as possible. The following passage explains why this is so crucial: “The IFS therapist tries to differentiate the client’s Self as quickly as possible, because the Self ultimately acts as therapist to the internal family by mediating between polarized antagonists and by restructuring relationships among all the parts” (Goulding & Schwartz, 1995, p. 162). One of the things Schwartz talks about when he lectures on the IFS model is that the client does most of the work after the initial session or two. It is Schwartz’s firm belief, after more than 25 years of developing and using this model, that the client’s Self will always know what is best for the client, so getting it into a position of leadership is crucial (Goulding & Schwartz, 1995, p. 166).

The Mosaic Mind: Working with Trauma Survivors

Working with adult survivors of child abuse (of all kinds) poses many challenges to therapists, not least of which is building the therapeutic alliance with the client. Creating an alliance with the various managers can take time, and from one session to the next, one never knows which manger will be in charge. It takes time for the parts to learn to trust the Self, often because they have not trusted the Self for a very long time, especially in cases of serious abuse (Goulding & Schwartz, 1995, p. 165). However, there is also the issue of the Self learning how to lead, and how to work with resistant parts or those that fight the differentiation of the Self and the various parts, especially the exiles (a fear of exiles revealing their secrets). Some managers may even attempt to blend with the Self (in fact, this is quite common) to prevent a loss of power over the exiles (Goulding & Schwartz, 1995, p. 167). A big part of this differentiation process will be reliant on the conviction in the therapist that the client truly has a Self that can be a kind and compassionate leader in the internal family.

Another difficulty in working with trauma survivors is polarization of parts, which typically is represented by two parts taking extreme positions. For example, a bulimic will have a part that binges on food as a way to dissociate from feelings, and the other polarized part might be a perfectionist that fears getting fat and forces the client to purge or over-exercise. The two parts will be in a constant battle for control over the system. Getting either one of them to step back and break the polarization is a challenge.

The unseen polarization frustrates the therapist, who patiently works with one part only to find that the opponent has been activated. The central truism of polarization theory is that one part cannot change in isolation if the change is to endure. (Goulding & Schwartz, 1995, p. 172)

It’s important to remember when dealing with extreme parts that they have taken those positions in an effort to protect the system, and they would rather occupy healthier, more adaptive behaviors. The key to working with extreme parts is compassion and curiosity, two of the C words that define the Self.

The most challenging parts for many therapists are the firefighters, especially if they use self-harm or starvation as their method of dissociation. One way to deal with them is to ask them to explain their conduct—why do they do what they do to the client? According to Goulding & Schwartz (1995, p. 182-187), the firefighters have a few specific reasons for their behavior: “trying to absorb trauma, using self-injury as protection, trying to imitate the abuser, trying to distract, trying to stop memories, or trying to protect other people.” They are not only protecting the system from the pain of awareness, they are also carrying the pain so that the exiles don’t have to do so. Importantly, trying to stop the firefighters from performing what they feel is their duty will fail unless they know that the exiles are safe and taken care of, and they trust that their pain will also be unburdened at some point soon. Going too fast into the exiles (as many young therapists tend to do) will generally trigger the firefighters into action. Likewise, forcing them to stop their behavior when the exiles are not yet safe, as Schwartz discovered in the passage above (with Lorene), will also trigger them into action.

In the demonstration DVDs that Schwartz often uses when he presents the IFS model, he seems little more than a guide allowing the client to dictate the course of the work. Obviously, his expertise with the model makes it look easier than it is for novices. In these demonstrations, Schwartz forms a strong alliance with his clients, allowing him to sometimes accompany his clients when they go inside (active visualization) to work with parts (Schwartz, 2003). By being Self-led himself, his clients can sense the safety of having a large amount of Self-energy in the consulting room, which allows some of the more recalcitrant parts to step back and allow the client’s Self to come forward.

Conclusions

The Internal Family Systems Therapy model represents what seems to be a breakthrough in the treatment of severe trauma. The model does not use DSM classifications, and therefore does not stigmatize clients with labels that may worsen their conditions. Once the basic concepts are understood, the model is fairly easy to work with, although most therapists wanting to use the model are encouraged to do at least one of the IFS year-long trainings.

One of the limitations in the model, as is true in many trauma treatments other than cognitive behavioral therapy, is the lack of empirical evidence of success. The growth and popularity of the model thus far rests on word of mouth and anecdotal evidence. However, the model is beginning to be subjected to research at several universities, including Colorado State University (Colorado State University, 2008, ¶ 4). More research will be needed to determine the validity and reliability of this model, but in the consulting room, most therapists only care about what works, not about studies.

References

Assagioli, R. (1965). Psychosynthesis: A collection of basic writings. New York: Penguin Books, Inc..

Colorado State University (2008). Therapists and Faculty Clinical Supervisors: Center for Family and Couple Therapy. Retrieved September 12, 2009, from http://www.hdfs.cahs.colostate.edu/

Emmerson, G. (2003). Ego state therapy. Williston, VT: Crown House Publishing.

Goulding, R. A., & Schwartz, R. C. (1995). The mosaic mind: Empowering the tormented selves of child abuse survivors. New York: W.W. Norton.

James, W. (1985). Psychology: The briefer course. Notre Dame, Indiana: University of Notre Dame Press.

Jung, C. G. (1969). The structure and dynamics of the psyche (2 ed.). Princeton, N.J.: Princeton University Press.

Rowan, J. (1990). Subpersonalities: The people inside us. New York: Routledge.

Schwartz, R. C. (1995). Internal family systems therapy. New York: Guilford Press.

Schwartz, R. C. (2003). Patricia [DVD]. Trailhead Productions: Center for Self Leadership.

Schwartz, R. C. (2008). Evolution of the Internal Family Systems model. Retrieved Sept. 9, 2009, from http://www.selfleadership.org/content/the-internal-family-systems-sm-model

Schwartz, R. C. (Sept/Oct 2001). No Contest; How a therapist learned to listen. Psychotherapy Networker, 25(5) .

Stone, H., & Stone, S. (1989). Embracing our selves. Novato, CA: New World Library.

Watkins, J. G., & Watkins, H. H. (1997). Ego states: Theory and therapy. New York: W. W. Norton & Co.


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