Trauma is Parts (Part 1): EMDR treatment of complex trauma should include this consideration.
I would like to demystify and destigmatize the topic of trauma being defined as terrible events creating parts of the self that seem to live lives of their own in "trauma-time." Clients are rightly concerned about wacko therapists looking for "multiple personalities" and "repressed memories." Clients just want to feel better. I want to explain that, for trauma, "feeling better" means no longer having parts that are stuck in "trauma time." When treated in a scientific manner, that's not wacko, but often the only way forward.
What do I mean by "parts" in relation to trauma? It's not complicated. In trauma, part of the the client is desperately trying to do normal life, while another part of the client is stuck in trauma.
Why is this observation important? A study by Brand, et. al in 2016 demonstrated that when the concept of "parts" as described here is included in trauma work, there is a significant improvement in treatment outcomes, including:
-Decrease in PTSD-related depression
-Decrease in hospitalizations/suicide attempts/self-harm during treatment
-Decrease in drug abuse
-Decrease in physical pain
-Increase in social, civic, and educational progress
As you can see, working with complex trauma should include a consideration of parts. When I used to ignore this fact, I would find that while clients would have good outcomes, some disturbing symptoms would remain, like self-harm, dissociative symptoms, and physical pain. In some cases, serious PTSD symptoms returned, as all parts of the traumatized client must be treated, or you aren't treating the whole client. I have also seen this in clients who have come to me with successful trauma treatment that "wore off" after a couple of years, or which dealt with bad memories, but left disabling dissociative symptoms untreated, as I mentioned. And in my experience, the more severe kinds of complex trauma are incurable when not dealing with parts.
What are parts, and how does this relate to trauma?
OK, so, to begin with, basic PTSD inherently involves "parts" of the personality. Let's say a soldier with a perfectly normal childhood goes to Afghanistan, and is helpless during a mortar attack, absolutely unable to fight back or even see the enemy. This experience is terrifying beyond belief, but relatively "un-complex" compared to years of childhood trauma with a caregiver. The soldier's primary defense system in his personality (usually "fight") tries its hardest, but is thwarted, and the soldier remains profoundly helpless. As a result, the thwarted defense system does not re-integrate, and there is now one part of self wandering back to the USA trying to be normal--and a part of self (the fight system stuck in the memory) still in the mortar attack, living in a never-ending nightmare. When that traumatized "emotional part" gets triggered by a car backfiring, it gets very close, and the "normal part" doing everyday life starts to experience the "emotional part's" nightmare. That's a flashback--an intrusion of that "trauma-time part" (which includes nightmares, panic that gets triggered, and all of the other things we think about when we think about PTSD).
See? Trauma is parts. If it weren't, this soldier would be having flashbacks all the time, not just some of the time. There are two parts--one part of the mind is trying desperately to do normal life, called the "Apparently Normal Personality" (ANP) and a part is stuck in an endless loop of "trauma time," called the "Emotional Personality" (EP). These terms were developed long ago by a psychologist studying traumatized veterans of WWII. In the picture above, this concept of two parts of a traumatized personality is called "Primary Structural Dissociation," as seen in the first diagram.
How does it get more complex? Well, if there are lots of these experiences of helplessness, there is more than one part stuck in trauma time. Complex PTSD is "more PTSD," which means--more parts stuck in trauma time. Perhaps a person who saw their child die, was in a car accident, nearly drowned, and was abused by a spouse for 10 years--there will be traumatized emotional parts for each PTSD event. Additionally, in particularly horrible or extended situations , this complexity is due to multiple defense systems being thwarted within one event alone, resulting perhaps in one "trauma-time" part being stuck in "fight," another stuck in "playing possum" (submission), or another simply observing, endlessly trying to find a way out. This last phenomenon is why traumatized individuals often dream about seeing themselves being traumatized. This is called Secondary Structural Dissociation, and is illustrated in the second diagram above.
Interestingly, the defensive systems are well-understood by scientists who study rats--they can be identified in the brain stem, and if the "fight" system is snipped, the rat no longer has that capability. Again, psychological trauma is a head injury, which explains the similar symptoms of "TBI" made famous by famous football players.
To continue, Secondary Structural Dissociation version (lots of PTSD, more traumatized parts) gets even more complex when abuse is chronic in childhood. Children are especially vulnerable to the helplessness that leads to PTSD because they are small and dependent. Worse, they are also usually abused by their parents. Believe it or not, a primary caregiver is much more likely to be the abuser than anyone else, especially a stranger. That is, if parents aren't the wolf, tragically, they sometimes let the wolf in the door--a known and perhaps trusted person.
Let's take that apart further. When a caregiver is the abuser, a child is three times as vulnerable--they are 1) physically helpless due to immediate threat, 2) emotionally helpless (abandoned) due to the caregiver becoming a monster, and furthermore 3) feel in danger of losing the caregiver forever if they are "bad" and therefore rejected, or if they report the abuse and the parent is taken away. Also, abusers often overtly tell children these things. So children's Complex PTSD is more complex, and produces more "parts" stuck in trauma time as a result.
Even worse, emotional manipulation by abusive caregivers leads to maladaptive attachment styles, often resulting in personality disorders. Not all Borderline Personality Disorder is derived from trauma, but about 90% is. 60% of individuals with BPD also have PTSD. Also, abuse in the context of learning skills in childhood leads to maladaptive ways of living--a child with an angry alcoholic parent might find as an adult that they have to eat fast, can't talk while eating, and hoard food in their room for no reason. As a child, this was all necessary due to dad getting abusive at random times when the family was together at the dinner table. So, childhood trauma gets even more complex.
At a particular level of complexity, especially as produced in childhood trauma, these traumatized parts of self include so many systems of living other than defense systems like fight/flight, that they are actual, functional, dissociated parts of the personality that begin to act independently. They have broken away from the poor "Apparently Normal Part" desperately hanging onto daily life, but it's all one child, and that child's parts develop also, with their own histories, memories, and jobs.
This is not "Multiple Personality Disorder" like movies show. The same phenomenon of parts of the personality apparently functioning independently is seen in "split brain" individuals, who have their corpus callossum surgically removed--that's the thin structure that allows the two halves of the brain to communicate. This operation is done sometimes to stop chronic, life-threatening epileptic seizures. Experiments who that if a basketball is shown to the left eye, but not the right, split-brain people will tell you that they don't see anything. However, if you ask them to write what they see, they will write "basketball." The parts of the brain that control writing and speaking happen to be on different sides of the brain, and the left eye seeing the basketball is only able to communicate with the right side of the brain--which controls writing. This individual is not two different people, they just have parts of the brain that can't share information.
Like sharing visual information, sharing memories is also a mental action, so when psychological trauma occurs, these confusing memories are stored in parts split in a manner that corresponds to the confusion--usually around the thwarted defense systems (fight, flight, etc.), but sometimes around time periods, and in other ways. This is all to say that psychological trauma is a physical injury, and the existence of "parts" of the brain that behave independently, and are stuck in trauma time--is literally a physical injury as much as a hit on the head. Again, TBI (Traumatic Brain Injury) has PTSD symptoms quite often. It is probable that one day, surgery will be able to treat PTSD. Already, therapists I know and work with (not in this state) are using neurofeedback devices (which are like the EEG machines that doctors use) to treat simple PTSD successfully--without the client even thinking about the traumatic memory. Some are integrating EMDR and neurofeedback to treat more complex cases.
The last and most controversial point. The "Diagnostic and Statistical Manual of Mental Health Disorders, 5th Edition, text revised"--used by all psychiatrists, therapists, and insurance companies--includes a diagnosis for Dissociative Identity Disorder. It is very real, and can only be caused by the most severe childhood trauma imaginable--e.g., cult rituals, prolonged confinement in small spaces, or involvement in child pornography. I first thought that this diagnosis was created in clients by crazy therapists, then I thought it was very rare, and then I finally had to accept reality. I currently have two clients with DID, although it takes a long time to confirm this level of complexity (i.e., I may have more). DID in these two cases is the result of prolonged sexual abuse connected to cult religious practices. This is more common than we would like to believe, so DID is more common than we would like to believe. Before I knew about these things, I am sure I did not recognize many other DID cases, looking back on my career. I can see some of them now, as I think back. What separates DID is that the "emotional parts" have such heavy trauma and complex interactions, that the "normal" (ANP) part of the personality has to split to handle different tasks of daily life, just to keep it together. Which means that multiple parts of the personality, most commonly two, are (often barely) "doing everyday life," terrified of the internal chaos, and desperately trying to push it back. These clients, when acting as one ANP, often have partial or total amnesia for the time spent as the other ANP. This appears in the third diagram--Tertiary Structural Dissociation.
So you can already see, I hope, how movies and TV misrepresent DID, as people "switching" at random between various terrifying monster "alters." This is horrifyingly disrespectful. People with DID are just trying to survive, and like people with Bipolar I Disorder or Borderline Personality Disorder, can often appear perfectly normal--like anyone, they can be good friends, successful in business--like your cool neighbor, perhaps. Survivors of terrible child abuse are amazing, inspirational people! I have encouraged some of them to write books about their experiences, to give hope to the many other just like them, destigmatizing the self-judgment (or arrogant judgment of doctors and therapists) that they are "crazy" and need mind-deadening drugs.
In contrast to what is wrongly and insultingly portrayed in movies about survivors or child abuse, or individuals with DID, violent criminals are usually born with a natural tendency toward defiance, arrogance, resentment, and deception, that (if unchecked by decent parents) leads to Conduct Disorder as a teenager, and then Antisocial Personality Disorder as an adult. Often, Adverse Childhood Experiences in neglectful environments prevent good-enough parenting from socializing these tendencies out of a child by age 4. This notion can be confirmed by the experiences and diagnoses of prisoners found guilty of violent crimes. If you have any interest in this awful situation, read my blog entry on the "foster care to prison pipeline" [click here to link to this post].
However, some therapists, like movie directors and authors, go looking for DID (and this sort of thing), and this is not only nuts, but has broken lives. They might think the work is "cool." Many therapists using heavy-handed hypnosis techniques in the 90's played into a social contagion among adolescent girls dealing with "repressed memories," for instance. The father (etc.) would be put in jail, only to find out that at the time of the supposed abuse, the father had been out of the country (etc.). Unfortunately, this malpractice led to a bad name for hypnosis and the organizations involved in treating severe traumatic dissociation. Although I am insured as a hypnotherapist in NC, and have formal training, this is mostly to know how to AVOID such harmful techniques, as dissociative clients or already IN a trance state when dealing with parts in therapy. Heavy-handed, pushy techniques are the hallmark of an untalented, arrogant therapist.
Some therapists have an unhealthy obsession with complex dissociation. But picking up parts of children's minds all day is not "cool," although that sort of thing takes up most of my day. I didn't set out wanting to do that, and I wish it wasn't necessary. I thought I would have folks lie on a couch and talk about their emotions. But there are so many children abused every year that a therapist who has no serious training in trauma therapy will not be able to help half their clients. I became so frustrated that I dived in and unintentionally became the only specialist around here.
Before I sign off, I should say that there is currently much confusion on the topic of dissociative parts of the self, due to an incredibly harmful trend on YouTube, TikTok, and other social media, popularizing the self-diagnosis of "DID" ("multiple personalities"). This trend is a social contagion common to adolescent girls who diagnose themselves en masse in online friend-groups, simply making an honest effort to find out "what's wrong with them" (nothing is!!! They are beautiful human beings who likely had neglectful parents and don't fit in with the cool kids at school). I have taken cases of social-contagion DID simply out of curiosity, knowing that the answer is almost always family therapy and encouraging the kid to look past high school, and past the need to look like their friends to feel good about themselves. Social contagion DID looks nothing like the real thing, and I am happy to liberate children from the illusion that they are somehow damaged beyond repair. That work has been very satisfying--our "labeling" culture does so much harm to children, promoting group identity at the expense of personal responsibility and living a meaningful life as an individual.
In fact, the only point to complex trauma treatment is as a part of what I consider any decent therapy--to challenge and empower the client to face their fears, and to take personal responsibility for life outcomes.