A deeper look at interweaves through the lens of dissociation theory
Olivier Piedfort-Marin”s workshop considered the ‘Psychological Process of Integration of Traumatic Memories in EMDR Psychotherapy’.
We are all the children of Salpêtrière – Bessel Van der Kolk
Whenever we talk about trauma and dissociation we inevitably, whether we know it or not, touch on concepts first elucidated by the great French clinician and scholar, Pierre Janet. In Olivier Piedfort-Marin’s presentation he showed the links between Janet’s idea on trauma and present-day EMDR therapy. Piedfort-Marin brought a greater clarity to the purpose of cognitive interweaves, showing that subtle differences in wording have potentially large impacts on trauma resolution.
Piedfort-Marin, drawing on Janet’s published writings (most recently revived by Van der Hart, Nijenhuis and Steele, 2006) says that, for trauma to be resolved, the client needs to undergo two important processes: synthesis and realisation. Janet “showed how traumatic memories are encoded in the body and how these traumatic memories consist of sensorimotor and affective components which have been labelled positive somatoform dissociative symptoms by Nijenhuis (1999)and Nijenhuis and Van der Hart (1999b)” (in Howell, 2005). Synthesis describes the process by which a person is able to construct and reproduce a narrative of an experience in all its elements: perceptions, sensations, emotions, thoughts and actions. “If we have a proper core synthesis” Piedfort-Marin says, “then we are able to have an autobiographical narration of the event”. What we find as therapists in clients with PTSD is that this coherent narrative is missing. It may be that there are ‘gaps in the story’, such as when a person knows what happened to them at the beginning, something about the middle but does not know how it ended. Or there may be certain elements missing. In amnesia, for example, perceptions, sensations and some emotions are remembered but the client has no memory of actions. Filling in these gaps to arrive at a complete synthesis of the event is part of EMDR therapy.
A jigsaw puzzle
Piedfort-Marin likens the facilitation of this process to completing a jigsaw puzzle. In some (rare) cases it is very easy; the picture is missing one vital part that both therapist and client have identified and recognise. In others, it is more complex and a framework must be constructed from which, through careful work, the complete picture emerges. The thalamus, which filters the information reaching the cortex at the time of trauma, may not function normally. In such cases, somatoperceptual integration may be blocked. In other words, the client may have sensations in their bodies for which they have no explanation or understanding. Piedfort-Marin drew the analogy of using the edge pieces of a jigsaw to delineate the boundary and provide a structure within which other pieces can be fitted. This core synthesis is a natural part of Phase 4 in EMDR, as predicted by the AIP model, he says, but sometimes cognitive interweaves are required to facilitate the process.
In his example of a client who had experienced a road traffic accident, Piedfort-Marin provided a partial transcript of Phase 4 processing. In one section the client reports severe pain in her head and neck and does not understand why this is so. This is an example of incomplete synthesis, only certain of the elements being available to the client. Piedfort-Marin’s interweave is to ask the client what she remembers about her head and neck during the accident, after which she recalls that the seat belt forced her head forwards and then backwards. A piece of the jigsaw is fitted and the client is further along the road to synthesis of her trauma.
He then moved on to talk about realisation, and its component processes of personification and presentification. ‘Core personification’ is the ability to take ownership of past experience in the present time’. To illustrate this, he used another clip of the same client’s Phase 4 transcript. Here, she is unable to feel her legs and is clearly distressed, wondering whether she has lost the use of her legs. She wants to get up and walk around the room. A live poll confirmed that most of the participants of the workshop agreed they would encourage the client to get up and walk around the room. But why, asks Piedfort-Marin. After all she knows that she has always been able to walk. It is as if, he says, she has “one-and-a-half feet in the past and half in the present”. Instead, he asks her how she came to the session today and she is quickly able to personify the experience: “Oh, I see, I walked to your office” and he asks her to stay with that thought while offering BLS.
He gave us Van der Hart’s definition of “extended personification”: mental activities by which we bind and differentiate with our sense of self across time and situations. He likens this to the three prongs we use in EMDR of past, present and future. Piedfort-Marin demonstrated this with an interweave he used with a more complex client who had experienced childhood abuse. Here he demonstrated the subtlety that interweaves can have and their profound impact. “Yes, you were unsafe” he says, followed by “what about today?” The first part of the interweave is an empathic validation of the fact that the client was unsafe. Empathic because, Piedfort-Marin says, presentification is hard as it “comes with the grief of accepting what a person has been through”. The first part of the interweave is clearly in the past, unlike the second part which is forcing presentification by referring to the present: “what about today”. Another, more subtle, example is the interweave ‘yes, you were unsafe’ [past] ‘This is very sad’ [present].
This understanding is present within the Standard Protocol, Piedfort-Marin points out, when we ask the client “When you think of this experience, what is the worst part of it as you think of it now?” The PTSD client may have an apparently normal part (ANP) and several emotional parts (EPs). In a client who has been sexually abused as a child, the ANP may say something like “I don’t really know what happened. I feel terrible about it”. One EP might say “he’s on top of me” another, “he does (this and that) to me” while a 3rd might say “I deserve this”. If synthesis and realisation take place, using the eight phases of EMDR intelligently, we can hope for complete integration. That is, the replacement of the ANP by an integrated self who is able to say: “That day he was on top of me. I felt helpless. He did (this and that) and for a long time I thought I had wanted that. But I understand that I didn’t do anything bad. This was terrible and has changed my life, but I am learning to move forward now”.
Piedfort-Marin ended the presentation with a 20-minute video of his work with a client with severe borderline personality in her sixties. The video demonstrated well the process of synthesis and realisation as the client was splitting at times, unable to recognise bodily sensations she was experiencing and at times, seemingly close to being physically sick or falling off her seat. It showed the complexity that may present, and the need for careful and paced interventions (he had worked with this particular client over a 20-year period).
Van der Hart, O. Nijenhuis, E. and Steele K. (2006) The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization, Norton
Howell, E., The Dissociative Mind (2005), Routledge