Trauma and Dissociation Informed IFS with Joanne Twombly

Today on Explorations in Psychotherapy, we are excited to welcome Joanne Twombly. Joanne is a psychotherapist in private practice in Arlington, Massachusetts. She has over 30 years of experience working with complex PTSD and dissociative disorders and provides training and consultation. She has written on EMDR and dissociative disorders, EMDR and Internal Family Systems and on working with perpetrator interjects. Her commitment to helping her clients heal and to providing quality training has resulted in her becoming an EMDR consultant and a trauma and recovery humanitarian assistance program facilitator, Internal Family System certified, and an American Society for Clinical Hypnosis Consultant. She is a past president of the New England Society for the Study of Trauma and Dissociation. In recognition of her achievements and her service on committees and the board of the International Society for the Study of Trauma and Dissociation, she was honored with ISSTD's Distinguished Achievement Award and is an ISSTD fellow. Today we will be speaking with Joanne about her new book, Trauma and Dissociation Informed Internal Family Systems:  How to Successfully Treat Complex PTSD and Dissociative Disorders.

Alexia Rothman: Joanne, thank you for being here with us.

Joanne Twombly: I'm happy to.

Aníbal Henriques: So, welcome Joanne. What parts come up as you listen to your bio today?

Joanne: I don't know, maybe it's the, if you live long enough, it sounds like you have lots of accomplishments.

Aníbal: Joanne, the title of your new book, Trauma and Dissociation Informed Internal Family System suggests huge integration of IFS. It looks like you are offering IFS practitioners and therapists a body of knowledge on trauma and dissociation that you consider fundamental to integrate with IFS if we wanted to be more effective with more severely traumatized clients. So, Joanne, what exactly is this body of knowledge in trauma and why do you think it can be critical for IFS to become more effective?

Joanne: Well, I think it's critical... I mean, I started to...Well, let me just say one thing. I love shortcuts. I mean, partly I learned all these models because the people I see are in so much pain and I basically want them to be out of pain as efficiently as possible. So, you know, when I, when I did IFS training, it was like, oh no, you don't need coping skills. Everybody's got everything they need. I'm like, great. But it didn't really work with this population. And I started getting quite a few requests for consultation, people calling me up and saying, can I do IFS with you? And, I have been in IFS and it's not going well. So, and then talking to other consultants, other trauma consultants, were saying, what is it with these IFS people, you know, they don't know what I'm talking about. Their cases are a mess, what's going on? And it's primarily, I mean my, what I primarily do is work with people with complex post-traumatic stress disorder and dissociative disorders. And in that population, a lot of them have been messed up in prior treatment or they've been in a long-term treatment, not gotten any better, which is also very depressing. And, you know, getting people who are really treatable from good IFS therapists where they've been for some years, I shouldn't have to see them. And if I have to see them, then it means something's missing. And I think what's missing is an integration with the world of trauma treatment and all the knowledge base. And that's why I wrote this book. I think the only other thing that's written on dissociative disorders and IFS is the chapter I wrote a few years ago in a book edited by Martha Sweezy and Ellen Ziskind.

Aníbal: Exactly.

Joanne: So, I think it's time.

Lexi: So, going back a little bit to some of the basics. Many people who are new to the IFS model, they wonder since IFS believes that the mind is naturally multiple, and thus all of us are in some sense multiple personalities, how would you define Dissociative Identity Disorder – DID, from an IFS perspective?

Joanne: I'd say one thing is that it is confusing that they talk about us all being multiples, all having multiple personality disorders. And a lot of the people I've worked with or done consults with who have multiple personality disorder, now called dissociative identity disorder, find it insulting that suddenly everybody's saying they have multiple personalities because they don't live with the pain, they don't have that kind of trauma history. And they're like, you wouldn't say we're all autistic, or everybody in the world is autistic. Why is everybody in the world suddenly have multiple personalities? But aside from that, I think what I would say about defining DID from an IFS perspective, I mean, I think that their systems are more complex, their parts are more dissociated, they're more at risk of overwhelm and destabilization and backlash. What I describe, say, when clients ask me about the difference between me having parts and them having parts, these are on the more dissociative spectrum, is that it's like there are cement walls among the parts. And if you're in a child part, someone with a dissociate disorder can get stuck in a child part. Whereas I can be playing with the kids across the street and then get a phone call and immediately there's an easy flow from being in my playing hair monster with the kids across the street to taking a professional phone call. Whereas somebody with a dissociative disorder might get stuck there and not be able to access an adult part of them. And the other thing is that it's much harder for people to get into Self.

Aníbal: Oh, of course.

Joanne: I mean, there's different clinical things about just the general way we're taught to do IFS... Oh, this concept of parts, you know, this is exciting and it's really helpful. And being a hope merchant, all of that is very, can be very dangerous for people with dissociative disorders. And I know of people who went to an IFS therapist and never went back because they were outing them. You know, for somebody with a dissociate disorder, their parts are there to hide things from themselves and hide things from the outer world. And to hear somebody say, wow, we've all got parts, it's like danger. You know, if having secret parts, dissociated parts kept you alive through your childhood, having somebody suddenly say it's great and we're gonna work with them is profoundly scary.

Aníbal: Joanne, in the introduction to your book, you also say, and I will quote you, “I found that people with complex PTSD and dissociative disorders needed coping skills to help them maintain functioning while going through the painful work of healing. Integrating IFS with wealth of knowledge from the complex PTSD and dissociation world increases its power and the potential for healing,” you say. You also say, “if your client is getting worse and worse, if your client is struggling during the week, if your client needs increasingly more support from you, the information in this book will help you by integrating dimensions that are missing in a standard IFS training and practice.” So, Joanne, what are those dimensions that we could integrate? Can you illustrate some?

Joanne: Well, I think one thing is that IFS tends to teach that teaching coping skills is unnecessary because the IFS view is that everyone has everything they need. They have all the resources they need to heal. And, I think that from the trauma world, if what we'd say is children who are brought up with dysfunctional parents who maybe have their own untreated dissociative disorders or PTSD, have attachment disorders, personality disorders, they learned what their parents teach them and they're missing a bunch of internal resources. They don't know how to self-soothe. And that's not gonna just magically come up as things get healed or it's gonna complicate the healing. So, I think it's important to teach people coping skills so that they can use their inner resources to heal. Everybody has, most everybody is born with the capacity to heal, but it's, you know, what are the building blocks to healing? And I think a lot of these clients are missing basic building blocks and it's not as simple as getting someone in Self, which pretty much is very difficult with these people early on. So, I don't think it's as simple as, oh yeah, all the resources are there.

Lexi: And I think you're really starting to touch on the next question that I had for you. So, there may be some overlap here, but IFS is traditionally described as being different from phase-oriented trauma treatments, specifically in that it has not been considered a phase-oriented treatment. And as we were saying, traditional grounding, emotion regulation and other coping strategies haven't been recommended. And back in 2013 at the IFS annual conference, I attended your talk on working with individuals with severe trauma histories, and it was the first time that I heard a different perspective on this. And so, I was wondering if you could share your thoughts on IFS and phase-oriented treatment.

Joanne: I think that, that was one of the things that inspired me writing, slugging through and writing this book was that IFS or some IFS trainers teach that phase-oriented treatment is bad and that phase-oriented treatment therapists kick out parts they don't like, which is really confusing and isn't true. I mean, anybody who kicks parts out is incompetent and, you know, doing dangerous treatment. I mean, I've worked with people who've had therapists who tried to suppress parts and you know, that doesn't work. It leads to disaster. And I'm not even sure where that particular teaching point came from because it certainly has nothing to do with the literature. And I mean phase-oriented treatment, basically phase-oriented trauma treatment is the first phase is establishing the treatment, coping and stabilization. I mean, one thought is to keep people at their highest level of functioning possible, and if they start having trouble during the week, instead of relying on me, they have some coping skills. And what I've found is managers really appreciate that. I mean, managers grow up, they learn how to manage however they're managing, not so bad to have like their management skills refined and updated. You know, I sometimes say to clients, save my smartphone. I have a smartphone. When I grew up I had a dial phone. Smartphone is really much higher tech. We can take the ways that you cope and we can make them higher tech. And you know that I have never had a manager feel insulted because I help them learn some coping skills. And that goes for firefighters. Firefighters can be more complicated, but same thing for firefighters and exiles. And then the second part of phase-oriented treatment is, and I'm talking about working with people with more complicated trauma histories, is paced uncovering of traumatic material. So, you don't want to do it all at once. IFS tends to witness all at once and rely on exiles to be able to hold the traumatic material, you know, ask exiles to hold onto the traumatic materials so the one who's witnessing, which has some Self-energy doesn't get overwhelmed. But if traumatic material's been dissociated or there's, you know, huge amounts, then exiles might want to be able, might want to be able to hold onto it, but they can’t always, So, pacing the witnessing I think is really important. And then I always think of the third stage is whatever else, you know. I mean, in the trauma world there's some people who talk about integration and there's some people who talk about integrated function. And that's, when I think of healing from an IFS point of view, I think of, you know, a system of parts who have integrated functioning and are connected with Self so that the whole system has a way of functioning that’s smooth and nothing's being lost. There are no dark holes that someone can fall into.

Lexi: That's really helpful. And for those clients that do find themselves severely dysregulated between sessions, what kind of support do you advise that therapists give between sessions? Are there special considerations for this between session support with this population to keep in mind?

Joanne: Well, I think that's why it's useful to start out by helping them. Well first of all, with somebody with a complex dissociative disorder, they may not be willing to talk parts right away. You know, they may, I don't want to hear about their trauma history. I may ask them to tell me a couple headlines, but I don't want to risk having the lids they've had on their trauma history being blasted open before they know how to handle what's underneath it. So, I started out teaching them coping skills and teach them safe space imagery, other affect regulation skills, container imagery. And it's basically upgrading the ways that they're already, it's upgrading their ability to disassociate, so they disassociate better.

Aníbal: Well done.

Joanne: I get people coming in for consultation saying they're dissociating less. I'm not. I'm like, I don't know, I don't think that's a good idea. You want them to be able to dissociate better. So generally speaking, I don't have a lot of connection with people in between sessions. I mean, there are times when I do, especially early on, particularly if I have a client who's been unraveled in previous treatment, then you know, I'll often say, you know, we're figuring out how to work together, it's more difficult to... I don't say to them that it's more difficult to establish coping skills, but it's way more difficult to have them learn coping skills if their dissociate boundaries have been, you know, disrupted. So, I'll sometimes say that, you know, we can have more contact in this early phase of treatment and then it'll be easier for you to manage some of this stuff outside of it. I also, you know, if there's some kind of emergency, I certainly am in touch with clients in between the week, but generally speaking, I don't have much contact with them.

Lexi: It sounds like what you're saying with this use of coping skills, it's almost maybe addressing the concern that some IFS clinicians have had in terms of can coping skills be exiling to the exiles that are holding this material and from listening to you, that's not what it sounds like. It might sound like, let's set up a situation that's gonna be safer so that when that material emerges, those exiles really will be welcomed into a safe, safer situation to receive their healing rather than having it open up having them flood and having it not go so well. So, the ultimate goal is to get to them. Okay.

Joanne: And I, it's not only to get to them, but it's to start having them have choices and control really as soon as possible. Because if an exile is overwhelmed or is, you know, heavy with, I think the other thing I would say is managers and firefighters are already caring burdens and exiles have the job of holding more burdens. They're not parts without jobs, they're parts that have an enormous job and they have a lot of strengths because they're holding a huge burden that, you know, it's like walking up a, a steep hill with a huge backpack on. That is a job. But I think it gives parts more choices and control. So, if an exile is really tired and is feeling really heavy, the exile can put 90% of whatever burdens they have and a container and get a rest. If somebody needs to go to a job interview, they can put traumatic material on hold. They can have parts who are freaked out about going to a job interview, be in their safe spaces and put sound and feeling proofing up or hang out at home or whatever. And then they can go to the job interview stable. I mean there are all sorts of little ways of using, I mean, I'm talking about containers in safe space imagery. I mean there are a lot of resources, but I did a consult with someone once and she had to go to court the next day and she had a little part who confessed, it was something in her childhood that she had to confess whether she had done something wrong or not. Going to court with a part hanging out with you who's going to confess? Bad idea. We did 10 minutes, 15 minutes’ worth of safe space imagery and we made a safe space imagery for that, safe space for that part, and the part said, you mean I don't have to go to court? I said, No, you could just hang out in your safe space. And then when court's done, she'll come back and tell you what happened.

Aníbal: Amazing.

Joanne: And it went so much better. And she didn't have a dissociative disorder. This was just, and she was in IFS treatment and had she not come for a consult, she would've been in court with this little part...

Aníbal: In trouble.

Joanne: Who would've confessed, or she would've been struggling more. You know, I, and that's why I think that this book I've written, you know, covers a lot of possibilities like that, which I think are helpful.

Aníbal: Joanne, you also say that this book of yours will clear up some misunderstandings between the IFS world and the complex trauma dissociative disorders world. What are those misunderstandings? Can you say more?

Joanne: I think one is that phase-oriented treatment is bad and that phase-oriented treatment therapists kick out suicidal parts and drug addicted parts. That would be one. I was so shocked to hear that. I was like, seriously? But anyway, another one would be that, that it's bad to teach coping skills because it disses managers, you know, it's not respectful. Another one is that IFS can heal everything. That the model will heal anybody. And I disagree with that. I mean I think that the model, the way it is, it's a terrific model.

Aníbal: It is.

Joanne: I use it with everybody. It's a power therapy, but it can't be used in a straightforward way with people with dissociative disorders. So, the other thing I think is a difficulty with language is that people go to other workshops outside of IFS and they don't know how to listen to them because they're looking, they're always trying to put things in categories of managers, firefighters, where is Self, you know, and that's a difficulty. I think it isolates people who are IFS therapists because it blocks them from being able to take in other kinds of trainings or think that they're necessary at all.

Aníbal: Can be useful as well. Thank you.

Joanne: I mean, I like having a number of different ways of working with people because people are complicated and they come from different places and sometimes things don't work for one that works for another and I can just shift and flow with what the person needs. So, I think it's useful to get some other treatments.

Lexi: So, one of the aspects of IFS that I appreciate most is that it is a truly consent based model of treatment. So, we're always seeking the permission of the protectors before we do anything, especially before we work with the exiles. Because if we don't get this permission and the protectors feel like we've gone into territory that they weren't comfortable with us entering, then the client can experience backlash. And we know in some systems that backlash is mild, it's easily repaired within the client's system, within the therapeutic relationship, but in systems like we're discussing today where the protectors are in very extreme roles, the backlash can be extensive, can be dangerous. And what is even more challenging in the system with dense boundaries between the parts like you're talking about, is that we may think we're getting consent from one part to do a particular piece of work and then we find out that another part that wasn't present at the time takes an issue with where we've gone, what we've done because we didn't have their consent and now the system is struggling. So, I was wondering about your thoughts on the challenges of getting consensus, getting consent in these kinds of systems.

Joanne: One thing that's for sure is if you're working with people with a higher level of trauma, then you have to be comfortable with not knowing everything. Because it can absolutely happen that you miss something and then, you know, the person gets backlash or whatever and then the next week the person comes in and says, Oh, I was, I had a horrible week. And it's like, what happened? What did we miss something? And that can be useful because that's something I want people to ask themselves. What are we missing? And I want to be able, I mean I do my best to catch everything. So, I think that you wouldn't get very far with most therapies with people with dissociative disorders or trauma histories, unless there wasn't some kind of consent base. It just wouldn't work. And you need to, I always work keeping the system in mind. Now, one thing, and I think this was one thing that you wanted to cover. So, one of the IFS trainings says therapists shouldn't keep secrets. Well it's not really a secret, but when you're working with somebody with complex layers of parts, you don't want to meet all the parts right away. You don't want to access them. You don't want to say, okay, I want everybody to hear this. I want to work with the top layer of parts. And once we've finished working with the top layer of parts, then another layer of parts will show up. It's kind of like the unconscious says, oh they've done this work. Okay, now they can deal with this other level of difficulty and a whole bunch of other parts pop out. Sometimes I've had clients come in and they've been doing really well, and they come in looking horrible. And what it is that this new layer of parts has suddenly showed up. So, I started calling that a crisis of progress. And progress doesn't always look like a smooth line, you know, it can be pretty bumpy. And since my clients, a lot of them dissociate, they may not be able to remember that right away. So, I remind them. So, in some ways I hold the memory of what's going on, hold the memory of progress. So, I said to a woman, I'm working with a woman in her eighties who had quite a bit of IFS treatment, quite a bit of EMDR treatment on and off therapy for 50 years. It's tragic that she came to me completely unraveled. Really essentially healthy person with a horrible trauma history who's never... couldn't identify needs. And yeah, it's just difficult. But I think that you don't, I mean she has... Everybody's out much easier if a lot of the parts are not out right away. Another person I work with has over 70 parts identified. He had a therapist who was identifying parts. Not helpful because they all want to go first. I'm like, look, it's like kindergarten, you know? And you have to take turns. You can't do it all at once. That's okay. It's not that we're ignoring parts or not wanting to work with parts. It's a clear understanding that we want to work with parts so it's the most efficient healing they can have. And that's sometimes not trying to do everything at once. So, I disagree with the, that's probably another difference. I think that it's not keeping secrets in an evil way, it's keeping secrets in a protective way. You know, if a part is talking to me about being gang raped or whatever and their child parts who would get freaked out about that. I want those child parts to be in a safe space with soundproofing and feeling proofing and not listening. So, they're not picking up the affect which this other part may be able to handle. And once this other part that's working on the gang rape has basically dealt with that, gotten it unburdened, then that material can be communicated to the child parts. But what they're getting is a healed information, not raw primary trauma, terror, rage-based information that's gonna knock them for a loop.

Lexi: So, really using discernment there in terms of what should be shared amongst parts and what will go in the direction that will lead to the safest and most efficient path toward healing. Okay.

Joanne: Catherine Fine who wrote an article quite a while ago about, can't remember what she called it, but basically what she talked about was protecting the parts who work and manage daily life from the trauma work. And sometimes with more complicated people I do that. I want people to keep their day job. And I had a client who came in and she'd say, Joanne, I like you, but I hate this. I just want you to know I hate working like this. I hate not knowing what's going on. Okay, let's do it. And she'd sit down, I'd have her go to her safe space, put up sound and feeling proofing and then I'd do a chunk of trauma work with the parts who were ready to work on it. And everybody else was sort of tucked away. And she's done with treatment and she has a very high-level job. And once we got her on track from the treatment, that wasn't so good, she worked continuously and didn't need any hospitalizations and she'd had quite a lot of them before. So, you know, it's not a bad thing to keep secrets in an effort to keep healing moving along in a healthy way.

Aníbal: You also say, Joanne, this book will help readers to find strategies to strengthen and support manager's ability to manage. What do you mean exactly? Can you say more about those strategies to strengthen and support managers?

Joanne: Say you have a manager who has a belief that they have to say yes to everything and that they can never say no. So that manager is managing by being compliant and they may not be ready to unburden that idea. It may feel too dangerous, like learned helplessness. If somebody's taught that, if they do anything other than comply, they're gonna get beaten. Then they learn to, you know, just do what they're told. And so, I've had managers say, oh no, I can't give up that. I can't, I have to do everything and I'm exhausted. But I have to keep doing that. And so, I might suggest that they put that belief or percentage of that belief into a container and then we try it out. Like one woman answered her phone, she never didn't answer her phone. That may not be good English, but anyway, she had to answer it. And I'm like, well, how about if you get caller ID so at least you know who's there. And she, oh my husband won't let me. He worked for a phone company. I was like, really? But what I got her to do was to not answer the phone and call back whoever it was five seconds later. And we practiced that. We practiced it with her calling me. We practiced having her put that belief in a container. Or not a hundred percent of it, but, so she knew she was supposed to help people or else, but it wasn't quite as strong. So, she could make, do some experiments, which ended up working really well. And you know, it's just little things like that. I think managers can get exhausted and sometimes, sometimes the exhaustion isn't just about managing, sometimes it's old exhaustion. I mean, I think, you know, childhood’s where you have attachment disordered parents, you're being neglected, you're parentified, you're being beaten and raped and whatever. I mean, you know, they're fundamentally exhausting. So sometimes managers who are exhausted, some of the exhaustion is because they're busy managing and some of its old exhaustion. So, a lot of times I'll say when a part has some kind of extreme feelings, tune into that feeling, what percent of that, say exhaustion, comes from your childhood or before you were 20. And then we put that percent in a container and then the manager can manage better.

Aníbal: Oh wow.

Joanne: So different things like that.

Lexi: Thank you. It seems like you're offering them some possibility too. Instead of having to immediately and reactively employ their strategy in this rigid way, all or nothing, this possibility, let us experiment with a little bit of flexibility. See if that could be okay. Imagine that could provide some relief.

Joanne: And that it's also with that belief, it's like you have this belief that you're gonna get beaten if you don't or something horrible is gonna happen. And I might ask them, what's that look like? You know, because they'll say, oh I have to, I have to do this. Okay, but what would it look like if you didn't do it? And, you know. And then what's that fear like? Or how old does it feel that you have to do it? Well? Okay, so maybe that have to also belongs to the past or some of that have to, you know, it's good to be somebody who helps people. You have to help people differentiate too. I'm a helpful kind of person, but you have to have limits on it. I tell clients, I'm like, you know, it's like a gas station. If the gas doesn't get replenished, nobody can fill their car. If you keep helping, helping, helping, you're not gonna be able to help people because you'll run empty.

Lexi: Slightly different direction here. I was wondering, you know, so for clients with DID, you were kind of alluding to this before, they don't initially have access to Self. It can take a very long time to get access to Self. So, for a long time in IFS, at least, we're using Direct Access so we're interacting directly with each part as it presents itself in sessions. So, in your experience, how does access to Self finally starts to come about in these systems? What allows that to happen? You know, any advice on facilitating that process?

Joanne: I mostly don't talk about Self right away, but when I'm sitting with someone, I'm certainly get myself in Self. But this gives me a couple more answers to your previous question of what's different about IFS. So, in preparation for sessions, I get into Self or as much Self-energy as I can connect to. And then I sit in sessions and I feel confident that if somebody's working with me that they can get better. And so, energetically I try to fill the room with a quiet confidence, not some kind of, oh I can help you because, you know, a client who's grown up with hopelessness is gonna think that's completely bogus. So, I don't say that. And how do I know I can help? And, you know, that's just, or I understand that's another line that is not a good line to use because how the heck do you understand? I say to my clients, I'm trying to understand, or I said to somebody who is like so depressed and suicidal and she said, do you understand? And I said, I'll tell you what I'm doing. I think about the day I was the most depressed. I multiply it a bunch of times and when I tune into that I feel like I get close to understanding just how awful you feel right now. And, you know, I think that I didn't grow up that way and even if I did grow up in one of those really super difficult families, they're all different. So how am I gonna be able to understand? You know, your questions are so interesting. It makes me think of all these different things. So, I'm sorry if I'm getting lost in them.

Aníbal: That's a good thing. That's a good thing to get lost.

Lexi: Yeah, Self emerging in these systems.

Joanne: So, Self pulls for Self. So, I figure if I'm in self, I'm pulling for Self of my client. And when I'm working with people, I'm always thinking about all the parts. So, I'm pulling for Self-energy in all the parts. Because parts also have Self-energy and standard working with dissociative disorder way pre-IFS is helping parts with internal communication and compassion and you know, coordinating their efforts. Not in a rigid kind of way because you get some parts who are willing to work together and other parts who are like, fuck you, I'm not gonna work with you. And that's a quote. I'm not trying to just use bad language, I'm just...

Lexi: Oh no, I've heard that.

Joanne: I did have a couple of nuns walk out of a conference once because I was quoting a teenage with parts and said fuck you. And they were offended. So...

Aníbal: It happens.

Lexi: What happens is what happens though? It's what they say.

Joanne: It's what happens. And I think, you know, I think if we're gonna sit with people like this, we have to be able to sit with what they're talking about. But in any case, I work on parts developing Self-energy and I don't think of all the attributes of Self, I think of curiosity and compassion. But even before curiosity and compassion, these would be some of my prelist of C’s would be identifying, noticing that a part is there. So, whoever is coming into therapy who's mostly a manager, I want the manager to notice that there's a child part there that they may hate and want to get rid of. But just to notice. And sometimes the first connection, say that I have come up with to use with some people who really don't want it. I mean they're parts have caused huge problems for their whole life. And then I'm like, no, you can't get rid of them. You've been trying to do that for years. Let's try it my way. You know, we have to try something different here and you can't get rid of them, so let's try to work with them. I hate that part. I'm not talking to that part. And I'd say, well tell that part that you're working with me and I'm telling you that to heal you have to get to know the parts. And so, one of my clients said, her translation of that was that fucking bitch Joanne says, I have to get to know you and have compassion about you, but I hate you and want to get rid of you. But I'm stuck working with Joanne. So, I guess we'll be doing that at some point, but not now.

Aníbal: So amazing that one.

Joanne: Hey, it's sometimes where you have to start. And that was a good starting point. That part acknowledged that there was a child part that she didn't like. That's honest. I've also had clients come in and say, I have compassion for all my parts. And I'm like, yeah. Oh god, what part is that? Yes, that's an IFS manager part. But you have to start where they are. And so that was where, you know, that message and while that woman was saying that to this child part, I'm saying to the child part, I'm not gonna forget about you either and I know you're important. And we'll be able to work with you, but we can't yet. We will.

Lexi: And so that's like you were talking about before, working safely with that first layer of parts.

Joanne: Yep.

Lexi: But holding those other ones are there and that you intend...

Joanne: Well this might be a part in that first layer. I mean just because it's the first layer doesn't mean they all want to work together. You know, most of the time in these childhoods it's like, I mean their parents really seem to be out to annihilate their kids and if they didn't have dissociative disorders, they would just be obliterated.

Aníbal: Absolutely, yes.

Joanne: Yes. So, they can't afford to know their parts sometimes and they can't afford to let anybody else know about them. They can't afford to let the perpetrators know about them; the public know about them. So, these parts have to be very walled off.

Lexi: That's in some way kind of related to what I wanted to ask you next, because I've heard Dick and others say this, and I have seen this too in my own experience with clients with very severe trauma histories, that when they finally do start to access some Self, it can actually be a scary situation for some of the protectors because when the client was younger, when they were embedded in that abusive system, when they would display characteristics of Self, you know, courage, confidence, and even compassion, it could be activating to the people who are abusing them and could result in more abuse. So, in these systems protective parts can be uncomfortable with Self starting to actually reemerge and could react strongly to it. So, I'm wondering if you've seen that to be the case and how do you handle it.

Joanne: Yeah, it can be terrifying, you know, and it depends on the abuse history, you know, say it depends also, I mean on regular abuse histories, regular bad abuse histories and sadistic abuse histories, if you're working with somebody with a sadistic abuse history, the more they feel like you know them, the more terrified they are. Because sadists get to know their victims, so they know how to hurt them more. So, if I get to know somebody with a sadistic abuse history, it's because then I have power to hurt them, even worse than they've ever been hurt. So, I mean, I think people feeling a little bit of caring, which is why you don't want to show feelings in an intense way. Oh, I'm really sorry that happened to you. No, you don't want to say that. I care about you so much. You know, that can be very scary. So, yeah. And I have plenty of things that clients have told me about, you know, things that they did. One of my clients was practicing some kind of instrument and her father came home drunk, took the instrument, smashed it against the wall and hit her. You know, she's by herself practicing her musical instrument. I mean, how bad is that? But parents can't always handle that. And you know, it can be little things and then they stop. And one of the things that I think is tricky is that children start to learn when they're born, and parents teach them these things before they have memory. And so, I have clients who say I was born bad. Well, why did they think that? They think because as soon as they were born, they started getting messages that they're bad, everybody else is good, they're bad and that's why they're being punished. Or, you know, you're a happy baby and you get slapped or you get slapped for laughing, you stop laughing. You stop. I have a client who said when she was three, she wanted to tell her mother something. She told her mother something. She never told her mother anything again. Because her mother was so angry,

Aníbal: So sad.

Joanne: So yeah, getting into Self can be really difficult and it takes some psychoed and permission. And then, okay, so I'll talk a little bit about, I think in IFS, it's called retrieval, in trauma world it's called orienting to the present.

Aníbal: Yes.

Joanne: Because parts really get stuck in the past and other parts kind of grow up and are more or less centered in the present. And I think of it simply as, I think I use this example in my book, you know, sometimes, well someone's being raped every night, how do they go to school the next day? You know, you think about how traumatic it is to be raped once it's, you know, it's horrible. But these kids have to learn how to manage that. And you manage it by having a part who handles that and a part who handles going to kindergarten and socializes and learns. And the adaptive thing is that that part whose learns grows up and then you know, at some point has enough symptoms that they go into therapy and hopefully get a therapist who can help them start to recognize that there are terribly traumatized parts there who need healing. So, I work on helping parts come into the present and on orienting them to the present. So, one thing that I might orient parts to is that their parents are dead but, or old or live in a different state and until the traumatic material is processed, they slide back into that. But it's easier to get them back into the present. You seem like you have some experience with that Lexi.

Lexi: Oh, oh my gosh, this is all resonating so much. So much. Yeah. Yes. And I was thinking in particular of one client with a very sadistic abuse history where anytime she would show any compassion toward anyone, another person, an animal, whatever the object of her compassion was would be destroyed or severely hurt. And so she, that aspect of herself when it started to finally emerge in the therapy where she started to actually feel compassion from Self toward her parts, it alarmed her protectors who wanted to stamp that out again because anyone you show that to would be destroyed. And so it took just what you're saying, like it took, you know, some psychoeducation, some updating of the parts, what is the situation now, where are the parents now, all of that, so that the part could experiment with maybe it could be okay to allow some of this compassion to emerge. Maybe it would be safe now, it wasn't safe then, but boy was that a long process and it did involve everything you're saying. So, I was just appreciating your answer there.

Joanne: Well and then you get the... one client had moved out of state and she was about 95% done and she'd come back when there was something coming up, some traumatic thing. And so, she came back, this was the last last and it was such a confusing session. I was so mixed up. And we finally figured out that her father had told her that when she was happy and was married and had pets and a really good job, then he would come and get her.

Aníbal: Oh.

Lexi: Wow.

Joanne: Oh my god, was that a confusing session? And that came out when we thought everything was done. And so yeah, there can be these lurking things that you just don't know about. I think the backlash as sort of, there's some kind of more of a mistake or something that's more evident, but things like this can be just deeply disassociated. Or the woman who thought that, you know, because there was a telephone in my office, her parents were hearing everything we said.

Aníbal: Wow. Yes.

Joanne: So, I mean those are the more complicated people. But you know, for them I'll also say, so how much fear do you feel about that? And how much of that fear comes from your childhood? Let's put that amount of fear in a container so we can just deal with what's left.

Aníbal: Yeah. Beautiful. Beautiful. Joanne, you say your book will help readers to improve the ability to recognize and use clients innate trance abilities and to enhance the use and impact of IFS. Can you say more on these innate trance abilities and how to enhance them?

Joanne: I think that's another thing I actually just heard from someone, I'm not sure if it's true, but that Dick said there is hypnosis in IFS, but previously he had said there was no, nothing hypnotic about IFS. But people, you know, when people are being abused for one, what trance and hypnosis is the formal use of trance. So, you put someone in trance by focusing their concentration. So, pain focuses concentration, somebody who's hurting you has you in trance because you're completely focused on. One analogy is it's if you're walking through a garden and a tiger suddenly springs at you, you stop looking at the flowers, you're just focusing on the tiger that gives you the best shot at a living through it. But it's focus concentration is what trance is, and you block everything else out. So, you end up with people who have quite a, the thought is we're all born with the ability to go into trance. And that in some childhoods people lose that ability more or less. And in some childhoods it's reinforced. Unfortunately, child abuse situations tends to reinforce it. Also, dissociation’s basically a trance state. You know, it's, how else do you have dissociated parts were locked in the past?

Aníbal: You get focused.

Joanne: Yeah. And then there's normal trance states. I mean if you think about a time when you've been really like engrossed in reading a book. Like if I'm reading something that's really interesting, my husband might have to tap me on the shoulder or you know, there's a shift. So, you know, we're often in different kind of trance states as we go through our daily life. The way that I help, I identify people having, well just part switching or being stuck in one part versus another part. I mean, that's both a symptom, but it can be helpful. Like the example I gave earlier of somebody goes to a job interview, you want the child part stuck in, you know, stuck somewhere and protected by maybe a dissociative wall. So, I'm just helping them use it. Or they're sitting in my office feeling anxious and I'm like, there's really nothing here, you know, we'll agree on. There's nothing that is scary in my office. But they're feeling anxious. And I'll just say to them, you have this ability to import feelings and right now you're importing negative feelings. So, we're gonna teach you just to flip that ability that you already have so you can import positive feelings. And that's sort of a safe space imagery process. And they're already doing it. So, if they're already doing it, they have and you identify that they're already doing it, that gives them a higher level of confidence that they can do it.

Aníbal: Yeah. Amazing.

Lexi: Right.

Joanne: And that's also then how I work with witnessing. Cause I don't want to witness a hundred percent of a pool of traumatic material. I want to put 95% of it away and see how we do with 5%.

Lexi: It's really testing the waters there and then if that goes okay, the part can bring out more of the material to be witnessed.

Joanne: Well and as that 5% or 1% gets unburdened, then the person has that much more energy and they have more confidence that they can do it. I mean a lot of people don't think they can ever look at this material because it's so traumatic and they certainly don't want to. And I'm like, yeah, I don't want to either. If there were some other way of healing, we'd be all over it. But you know, just pushing things away. We're biologically wired to heal, and you can push it away. But the analogy I like, somebody else told me this, it's the pee analogy, it's like peeing, you can hold it back but only for so long then it starts trickling out, then it wooshes. You want to use coping skills, you want to be able to, you know, notice when you have to pee and go before it wooshes. Right. That's what it's like with trauma. You can put it away, but it starts to ooze out and then you can get like massive wishes of flashbacks. And there is literature that says that if somebody's managed to avoid it all until they get much older that, you know, there's a population of people with dissociative disorders in nursing homes where they don't, they can't run around and avoid the way they used to. Their friends have died off, they're alone, the traumatic material starts coming up and they look senile or they look crazy. And it's untreated dissociative and traumatic material.

Aníbal: Ok, so interesting.

Joanne: Sometimes that looks like a better life than the suffering that some of my clients have gone through.

Lexi: That's still so, so awful.

Joanne: So awful.

Lexi: I haven't seen that literature, actually. That's interesting. I have a question, kind of along a different thread here. So, we're talking about how people with DID initially don't have that access to Self. So, you're doing that work through direct access with them. So, what have you found to be the challenges in working with young parts who are then forming direct attachment relationships with you as the therapist? If there are any challenges in that when young parts attached to you directly and any tips on navigating that?

Joanne: I mostly don't want them to detach to me, I want them to detach to the person, you know, so all the work is done with an integrative I, and by integration I'm not talking about into one, I'm talking about integrated functioning. So, and I suppose that's something else, that's a difference between what I would say and what IFS, straight IFS would say parts or parts or parts. And you never get rid of parts. I'm like nobody needs 50 baby parts. You know, my client whose 50 baby parts integrated into one stronger, more confident baby part, that wasn't a bad thing. So, I think that there is some integrating, and I think that is okay. I think it's all metaphors anyway. But I like the ones that lead to healing. So if a child part comes out or I'm doing direct access with a child part, I may ask a manager or sometimes they call it what passes for Self, but it's not really Self but it's the part who's, you know, coming to therapy mostly who signed on, who maybe has the name of the body. So, I might ask them to join us. So, I might say, just follow my voice or if I'm working with you Lexi and we were somehow doing direct access with the child part, I'd say Lexi, just follow my voice and join the two of us here. So, your part, we can, the three of us can be talking and then you know, I'll say to the child part, do you know Lexi? And sometimes they'll say, I have no idea, where am I? Who are you and where am I? And I'm like, well Lexi brought you, because I work with people who had complicated childhoods and helped them feel better. You know, people with complex trauma history, trauma histories in general are more concrete. And if I'm working with someone with a lot of really young child parts, I'm not gonna use big vocabulary. I'm gonna use vocabulary that the system can understand. And I also tend to ask little parts. I say you can communicate in pictures or in words and say it's a nonverbal child part, I might say Lexi connect with that child part and let me know what she says or tell me what images she's giving. And I had a client the other day who said, I feel so anxious. And I said, check with the child part, I think that's communication. That child part is telling you how anxious she feels. She said, now I'm exhausted. Yeah, that's information. So, the communication from the child part can be an image, a feeling, a sensation, it can be words. So, I'm, as much as I can, I'm looping through the system so that I'm not just the primary person.

Lexi: That's really helpful. And it leads kind of into my next question, which you might have a similar answer for, is if you're working with these young child parts who are blended and they're presenting and they're ready to tell their trauma story and you don't have, you know, Self to do that, Self to part witnessing. So, you're doing that witnessing and unburdening phases through direct access. Would you do the same thing here, kind of looping in through the system, having maybe a manager part bringing them into witness what the child is showing about the traumatic experience or a pattern or...

Joanne: And again, it depends on the person. You know, there may be say five child parts who were involved in a specific ugly incident. So, I may ask who needs to work on this? I'd like everyone else to go to their safe spaces and put sound and feeling proofing up. And sometimes I'll get a part that helps. There will be a part who say isn't primarily involved with work or parenting. There'll be some other part that can help out and can let me know if something's not going well and can be there to remind the child part or parts that they have coping skills and that they can say we need to stop or something's going wrong. So, I'm giving them choices and control. It's a little like a driver's ed model, you know like when you learned how to drive, the guy sitting with you, it was a guy when I did it, he had the brake but he wanted me to do as much as I could and then there was a safety valve, right? So I want to be like the back to the back and a bridge, you know, I'm always bridging to the system, working well together, which may be having some of the system go to sleep for ages, you know, which is another standard hypnotic dissociative coping skill. You know, so it's not like exiling them, it's like helping everybody go better, everything go better.

Aníbal: So amazing. Joanne, you wrote an entire chapter on counter transference and the fire drill looks as you see the fire drill as a very powerful and useful exercise. Can you say more? Why does the fire drill look to you as such an important tool?

Joanne: It's that, with IFS, you want to be in Self when you're working with people, but with people who have complex trauma histories and you know, this is what I do, complex trauma dissociation, complex dissociation. So, what I'm saying may also go for other people or other goals of disorders. There's lots of dissociation in, I mean people get diagnosed with eating disorders and this and that. Lots of dissociation in those. So, IFS says you need to be in Self, you should check for Self-energy periodically during the session. And the difference I would say is that you need to be able to let yourself slide out of Self so that you can pick up nonverbal communication from the client and then feed it back to them. So, because there's a lot of nonverbal communication in this population because you know, they were told if they told anybody they'd get the crap beat out of them. Maybe they had experiences, a lot of people told teachers and then they called up the parents and then they got punished for telling. Or the parents said to them, you tell anybody anything, this is one of my clients and somebody you love will die. I didn't realize she thought I was gonna die for 10 years because she was telling me things, barely telling me things. She is very complicated, but you need to be able to be open to nonverbal communication. And I think if you're totally in Self, you're not gonna pick up on that. You need to be able to slide out of Self, pick up things like, one time I was sitting with a client feeling incompetent, like wildly incompetent. Like why didn't I, why did I say I'd see her? Why did I think I could help her? And I suddenly realized I was picking up her feelings of incompetence. And in that case, all I did was I wrote incompetent on my pad, put a circle around it and I visualized sending it back to her. I figured if I can pick up nonverbal communication, I can send it back. And she started crying and you know, that was really important. Another client, I started feeling a lot of anxiety and I said to her, I feel like there's a lot of anxiety in the room. And she said, That's your stuff Joanne. Are you giving a talk? Are you, what's going on with you? I said, I don't think so, but I'll think about it. You know, I figured these clients had to have such long antennas. Sometimes they pick up things about me before I pick them up. So, I'm like, you could be right, I'll keep an eye on it. But then five minutes later she said, you're right, there's a part who's really anxious. And so, we accessed that because you know, I felt the anxiety and then addressed it, realized that it wasn't all mine probably and addressed it. And reenactments too, I think are just really important. You know, like when something from a client's past, reenactments aren't just the client's stuff. The sense is that, you know, there's some of our stuff, how much ever much we've worked on it and the reenactment is joint. So, I mean I had a situation with the client where we were passing back and forth the victim persecutor roles and it took a while to sort out that her mother underneath some of the very abusive ways, her mother was my mother. And it was unbelievable. Once we sorted, got it all sorted out on the table. But it was really important and there was a lot of nonverbal communication flying rant. So that's why I think it's good for us to be in Self. It's good for us to notice when we're not in Self, but I think we need to be able to slide out of Self to pick up those nonverbal communications and that that's really key.

Lexi: And so, I'm wondering, so even when you're working with this population, even with good therapy, even with when necessary, some between session support, the clients may still be in situations where their exiles are overwhelming continuously. And then these protectors in extreme roles feel the need to step up and use very dangerous strategies like starvation or self-injury suicide attempts. So if a situation does reach the point where a therapist doesn't think that the client can keep themselves safe between sessions and they need a higher level of care, do you, what do you advise in terms of finding a residential program that would actually be appropriate and helpful for this population? It's a struggle I've had in the past.

Joanne: It's a struggle. There's a dissociation listserv that's accessible through ISSTD, the ISSTD International Society for the Study of Trauma and Dissociation website. And that's a question that I will, I go on and off that listserv and that's a question that I ask because, you know, sometimes they're really good units and then, you know, they change their program, they change their staff, and they're not so good anymore. Mostly what I tell clients is that if they're in a place where they can't, they don't have an internal ability to manage their impulses, that I want them someplace where they're have some external control until they can get the internal control back. So that could be a terrible hospital that at least is keeping an eye on them. Sometimes it might be a partial program, like, you know, a program where for two weeks they're doing DBT groups or cognitive groups. You know, I have fairly low expectations about who actually is good treating people with dissociative disorders. So, you know, mostly I'm managing people. I haven't had somebody who's been hospitalized in some years and it, you know, it's all, it's all about, which is not to say that I didn't want a couple of them hospitalized, but sometimes I don't have that much control. You know, I can call the police, I can give them someone's license plate information, but that doesn't mean they're gonna find the person and, you know, pull them over. None of my clients have suicided. But I think that's more a matter of luck. You know, Courtois said in a conference, she said there are two kinds of therapists, one's who've had clients suicide and one's who will, You know, we're working with a population who are really suicidal. We see them once or twice a week. There's a lot of things that can keep on top of that that can precipitate someone killing themselves. And it's not always, you know, I feel like I need to be competent. I need to do my job. And then what happens isn't completely under my control as much as I'm a control freak and would like it to be. You know, what I learned in grad school was that, you know, it was incompetent if somebody killed themselves, shame, shame. And I think that really does a disservice to not be saying, you know, you need to be competent, but once you're competent, hello, you don't have control over the world of what happens.

Lexi: Right.

Aníbal: Joanne, in your book, you say one thing the dissociative disorder world has not accomplished and is a huge contribution from IFS is to make working with parts accessible to many therapists who are never trained in any kind of ego state therapy. So, through IFS you say, the knowledge that we all have parts has become more normalized and even popularized in a way that many therapists have learned and are learning about the power of working with parts of the mind. You say, fortunately, this is where IFS is stepped in and made a huge contribution.  Do you find this as the major contribution to the field coming from the IFS or are there others?

Joanne: Yeah, I think that a lot of people are like, I would never work with somebody with dissociative disorders. I would never, you know, I've had a lot of colleagues say, oh no, I'm not doing that part stuff. And then suddenly IFS comes around and they're all like this part, that part, the other part. And, I do think they need to take it a level deeper. That the training's a little too superficial. As far as it goes, it's terrific. When I took IFS, you know, I'm not always that open about things. I thought the concept of Self was kind of like nice, but kind of bullshit.

Aníbal: Okay.

Joanne: But I've come around to thinking that, you know, we all have a Self. I think that's a nice contribution. And my clients, you know, the more dissociative, like, okay, we start working with parts that have Self, but I think that their capacity to be in Self rose through treatment to be able to get there. And then there's more integrated functioning and more Self presence accessible. I also love the language of IFS. I mean, I may criticize the vocabulary, but that process of saying, ask that little part to look into your eyes and look back at them and let them know how old you are. You know, the, how old you are and what your strengths and resources are. You know, I love that language and focus on where you feel that feeling and ask the part to give you some space or notice what you're feeling towards that part. And you know, I mean, I have my combat IFS mode, like I'd say to one client, look, drum up some curiosity towards these parts, or we're never getting anywhere. You know, it doesn't always look like meat and clean and squeaky IFS, but it's like, you know, I say sometimes I saw a dog with his owner on a path and that dog owner was saying, get over here right now. And the dog's like coward. And I'm like, you know, that was just not gonna fly. You can't do that with your parts. You have to have some kind of curiosity or you need to be saying, I'm scared of you, I want you to go away. But Joanne says, I have to get to know you. You know, there has to be some way of connecting, but I do like the way that IFS has of connecting and of some of the language, I think is just terrific.

Lexi: Yeah.

Joanne: And it's not like it's dissimilar, but you know, every time I learn something there's things that, you know, things that I take from it. I use a lot of the training I got in IFS in different ways.

Aníbal: Yeah. Joanne, thank you so much for having us. It was a joy to be here with you and Lexi and we hope we can keep meeting and sharing this model, our work and our lives. Thank you so much.

Joanne: Thank you so much.

Lexi: Thank you, Joanne.

Joanne: Obrigada.

Aníbal: Amazing.