Sunday, March 29, 2009

Suicidal Impulse in a Nondissociative Person

The following case example illustrates the powerful influence that ego states (parts, subpersonalities) in a normally nondissociative person can have on current functioning. I present it here in hopes of drawing interest to ego state, or parts, dynamics even among those who do not qualify for a dissociative diagnosis. My client, call her Alice, overdosed on sleeping pills after leaving my office following a session which included the presence of her husband. The couple had been separated for six months and were completing the financial arrangements for a noncontested divorce. Alice had asked her husband to come to our regularly scheduled session to help her deal with the sadness and anger she felt following her discovery of pictures of her husband with a new female friend. Alice insisted that she wasn’t upset that her husband was moving on. It was she, after all, who had insisted upon the divorce, and she had had numerous dates of her own. She insisted that she was only upset because her husband had let their children know about his new friend. In spite of her protestations, however, the language she used and the vehemence of her complaints made it clear that she was indeed upset about her husband seeing another woman. Although we made an appointment for the following day, Alice overdosed that evening and was hospitalized for four days. When she returned to therapy the next week we were able, over the course of two sessions, to track down the subpersonalities involved in her devastation and consequent overdose.

There were three internal parts involved: two protectors and a wounded child part who presented as age five. The child part was the source of Alice’s devastation. The child part was not coconscious with the Self, but had some awareness of events in Alice’s life. This 5-year-old part identified Alice’s husband as her “father” and the husband’s female friend as her “sister.” For the child part the current events of impending divorce by the couple, the husband (her “father”) turning his attention to the female friend (her “sister”), and the evident replacement of Alice by the female friend (“sister”) in Alice’s husband’s (“father’s”) life was nearly an exact replay of Alice’s childhood experience of being replaced by her younger sister in her parents’ affections by the age of five. Healing involved gaining access to the five-year-old part, convincing her that the husband was not the father and the female friend was not the sister, and then unburdening the child part of her original losses. This was fairly easily accomplished “parts psychology” (See Watkins and Watkins 1997 and Schwartz 1995) approach.

The major point I want to make is that the inner worlds of normally nondissociative persons can be just as dynamic, and have just as serious consequences, as the inner worlds of the pathologically dissociated clients who fit diagnoses of DID or DDNOS. Alice scored a slightly elevated DES score of about 15 in comparison with the norm of 10. However, I am working with another client with virtually the same pattern of subpersonality influence (but without an overdose) who scored only 5.3 on the DES. Those who work within an ego state framework and those who work with Schwartz’s IFS model will not be surprised by these descriptions. Unfortunately, the larger community of workers in the dissociative disorders field apparently still dismisses the idea that normal people have dynamic subpersonality systems, too. Consequently, “parts psychology” fails to be taken into account in the major theories of pathological dissociation.

Sunday, March 22, 2009

Anger Management with Parts, or Subpersonalities

It has been awhile since I provided an overview of “Parts Psychology” on this blog, and so some readers may sometimes wonder what I’m talking about when I describe the Self in conversation with a part. Most blogs I write here are of two sorts. In the first I write about actual therapy examples, either with “normal” persons or with those who could be diagnosed with Dissociative Identity Disorder. There is not a whole lot of difference in how these systems work, except that DID persons tend to be more extreme in their presentations and their reactions. In the second set of blogs I write more theoretical pieces that may be boring or of little interest to the more casual reader. Those posts are really for me, and they help me clear my mind of conflicts I have with other clinicians and researchers who have ideas about dissociation and how the mind is organized. Today, I’ll talk about just one case, after I provide a brief overview.

Parts, or subpersonalities, are those parts of the personality that we are referring to when we say things like, “A part of me wants to avoid sweets and lose weight, but another part of me says we wait until tomorrow to begin the diet.” Or, “A part of me loves him so much, but another part of me has had it, and wants to leave him.” These parts are not just ways of speaking. They are real constellations inside the mind and can be viewed internally as real people or even, sometimes, as animals or objects. What surprises most people is that when the Self, guided by the therapist, speaks inwardly to one of these parts, the responses of the part cannot be predicted. Mick Cooper and Helen Cruthers provide a definition which some readers might find useful. Parts, subpersonalities, or subselves, “can be generally defined as semi-permanent and semi-autonomous person-like constellations of behavioral, phenomenological, motivational, cognitive, physiological and affective characteristics.” (In: John Rowan & Mick Cooper, The Plural Self [1999]).

An example from a recent session comes from a 35-year-old man who came to therapy for help with coping with his wife. He found himself so angry with her that he was considering divorce. They argued constantly. They blamed each other for the major difficulties they were having. Each of them believed that if only their partner would stop acting so stubborn and just act rationally there would be few problems. In one session the man came in especially angry because his wife had hit him with a coffee cup in a jealous rage. I asked him to think about the anger he was feeling at that moment and to notice where in his body he felt the anger most. He felt it most strongly in his upper body, especially his upper chest. I asked him then to focus on that sensation in his chest and stay with it for a moment, and then to speak to it with his thoughts and ask it (the anger sensation) to give him an internal image of itself. What came to his mind was an image of himself, refaced and angry, and with horns protruding from his head.

The part did not have a name for itself, and accepted that we could him “The Angry One.” My client thought it was “stupid” to have a conversation with the image but he agreed to do so anyway. The part’s most powerful memories, next to the present blowups with his current wife, were similar fights with his first wife. The last such memory was the one which led immediately to divorce. The fight became so intense that his wife called the police. She wanted him to go to jail for domestic battery, and so she began beating herself up so that she would look severely beaten when the police arrived. He was not arrested because the wife eventually admitted that her wounds were self inflicted. This and other extreme moments with the first wife were being triggered whenever he fought with his current wife. By the end of the session we had neutralized the painful memories of fights with the first wife so that the man could relate to his current wife only in terms of their own relationship. The work was accomplished through work with The Angry One. The process of neutralizing previous emotional baggage (memories) is called “unburdening,” and I have described it in other blogs. I will do so again in a later blog. It is just about impossible to neutralize such emotionally laden material through work on “anger management” with the external self alone.

Sunday, March 15, 2009

Parts Psychology in Overcoming Resistance to Work with Pornography

In earlier blogs I described the process of overcoming an addiction to pornography, especially internet porno. The basic process involves desensitizing the client to the powerful memories of porno use. The most important of these memories are the earliest. This work requires, in addition to the desensitization of the porno memories, that the painful experiences from which porno use is an escape, are also desensitized. In the case example below the porno desensitization was blocked by the presence of early childhood memories that an adult might say were trivial.

I had been working with a 36 year old man who found himself unable to give up porno use in spite of his working through a 12-step program aimed at eliminating the compulsion, as well as his regular attendance at a support group for men with the same problem. We had already achieved significant reduction in his porno use through work with two adult parts (subpersonalities) who were devoted to porn use. But then the man had a serious relapse while experiencing an increased work load at his job. He also discovered that his ex-wife was soon to remarry. Before our session he had “acted out” on the last three consecutive days until the early morning hours. When we checked with the parts we had previously desensitized, we found they denied responsibility for the porno use. However, we were able to “bridge” from one of these parts to the part who acknowledged his porn use during the previous three days.

We located this third porn addict in the form of a 12-year-old version of the man. Previously, we had believed that this part was limited in its role to driving the man’s frequent involvement with video games. Now, however, we discovered the part’s memory set included seven experiences with pornography between the ages of 12 and the man’s early twenties. (Note that the apparent age of a subpersonality does not predict the age of the memories held in its memory set). When my client asked if the 12-year-old part would agree to desensitize the sexual energy in those memories, his answer was a flat, “No!” Further questioning elicited the remarks, “I need them. Got to have a little fun sometimes.” He agreed that his video games were fun, but protested that they were not always enough.

With this sort of resistance to desensitizing porn memories we should expect the presence of other experiences from which porno use is an escape. Before I could suggest that we look for those experiences, however, my client said, “I’m picking up insecurity with females, and porno is a way of relating to them.” We followed this lead and asked the 12-year-old part about memories connected to that insecurity with females. The boy part had just three relevant memories: two from the fourth grade and one from the fifth grade. All three memories involved rejection. We could hypothesize that the man’s discovery that his ex-wife was remarrying triggered the memory of her rejection of him, as well as these memories from childhood. Thus, the recent porno use could be viewed as a protective response, avoiding the pain of rejection.

The first memory dated to the fourth grade when, as a boy, my client asked a girl he liked to be his girlfriend, and she refused. The second memory also dated to the fourth grade, but to a slightly later time, when he had had a girlfriend for two weeks. But when he called her at her home “she got embarrassed” and told him not to call her anymore, apparently, because her family teased her. The next day she broke up with him. In the fifth grade he also had a girlfriend. They were walking on the school grounds when he told her he loved her. Evidently, the expression of love frightened her and she broke up with him before the day was over. In just a few minutes we desensitized the 12-year-old part to the pain of these rejections. (See other blogs for an explanation of desensitization through “unburdening”). Once that was done we asked the boy part if he would consent now to desensitize his porno memories. His immediate response was, “Yeah, sure.”

Sunday, March 8, 2009

How Child Parts Can Affect Adult Functioning

A divorced man living alone came to me for help with his procrastination in work projects. He also had a problem with cleaning up after himself. Dirty laundry was on the floor; clean laundry wasn’t put away; his desk was messy, and important materials were buried under other materials that should have been filed long ago. When asked about his procrastination, the man said he felt an “I don’t want to” attitude, a “childish” attitude. Using techniques that are standard to “Parts Psychology,” the man was able to find the child part who drove his problem with procrastination.

The man visualized the child part as of “kindergarten age,” and as presenting a cartoon image of himself as a child. The part had “stubby legs, a round face, and spiky black hair.” The child part knew the adult self. “You’re the grown-up, the worker, the guy who tries to get me to do stuff.”

In general, when working with parts we want to collect the problem memories that are the foundation for the problem. In this case, however, the connection to memories was indirect, through a set of dislikes. First the child part said, “I hate to put away blocks. Because it means play time is over.” Then it was food: “I hate to eat stuff I don’t like.” And then another problem of childhood: “I don’t like to share.” Finally, it was “I hate doing homework.” In order to treat the problems we used the technique of “unburdening” in the same way we use it directly with memories. We asked the child part to focus upon his dislikes, each in turn, and then the adult self visualized the wind blowing away each of the child part’s dislikes as if they were particles of dust or sand.

Following the unburdening of the child’s problem with blocks, the adult said that the cartoon part recognized that “in putting away blocks you are actually getting to play with them. You put them in particular places in a particular ways. Clothes are the same. It can be a kind of game to put them in certain places—and it leaves more room on the floor to play. You can even have friends over.” With food and sharing, the adult emphasized to the child part, before unburdening, that he was grown up now and could decide for himself what to eat and when to share. Before unburdening the part of his aversion to homework—an important problem regarding the adult’s work projects—the adult self pointed out that there was now a “worker part” to take care of the homework, and that the child part could be playing while the worker worked. When the man asked the child part if he had other concerns he found that the part also “didn’t like to brush his teeth, wash his face, go to bed on time, or get up on time.” After unburdening these dislikes the child part recognized, “it will be nice to just run around being clean and well rested.” The adult self also agreed that the child didn’t have to be present when he took care of the grooming and sleep issues.

The adult client is now able to turn to his work projects without procrastination. He also cleans his apartment in anticipation of the possibility that his new dating life may lead to female visitors to his apartment.

Sunday, March 1, 2009

Child Development and Dissociative Identity Disorder

As I wrote in my blog last week there are serious problems with an approach which links the biologically determined “discrete behavioral states” of infants at birth to Dissociative Identity Disorder. Putnam describes the 5 states that are present at birth (e.g., REM sleep, fussy, crying) plus a 6th state that appears at about the age of 3 months and then, in a huge gymnastic leap, compares them directly to the states of consciousness found in bipolar disorder, panic disorder, and DID. However, he does not describe the process of elaboration of any one of these states into any of the mental states of early childhood that involve the use and comprehension of language. This is important because, presumably, the mental states of childhood are the states which fail to coalesce into the coherent sense of self referred to as a “developmental achievement.” Failing the achievement of a coherent sense of self the nonintegrated mental states of early childhood evidently then become elaborated as alter personalities of Dissociative Identity Disorder. (Forgive me if as a na├»ve reader I have it wrong. I am open to correction).

The problem here is not the matter of whether nonintegrated child states become alter personalities. That is a different argument. I might even agree with it. Rather, the problem is the linking of the biologically determined infants states with the socially and environmentally determined states of consciousness of early childhood. The evidence just doesn’t seem to be there.

There is also the matter of normal multiplicity. Both normal adults and children can be shown to have subpersonalities that resemble in almost every way the mental states we call “alter personalities.” The differences have to do with the autonomous switching into executive control by alter personalities and the person’s subsequent amnesia for what transpired during the period of executive control. An approach which recognizes the presence of normal subpersonalities in children might suggest that the problem in DID is to show why some children develop the propensity for autonomous switching and some do not. I am aware that some of the most respected scholars in the dissociative disorders field have summarily dismissed the idea of normal subpersonalities being directly comparable to alter personalities. It is, however, an empirical question. My book (within a couple of months of completion) on work with normal subpersonalities features extended case descriptions that illustrate how dissociatively normal people have internal self states that are difficult to distinguish from alter personalities. In my opinion any complete theory of pathological self states (i.e., alters) must account as well for the nonpathological self states of the average person.