Finally, with my encouragement, she was able to rush into the scene and take the girl away with her to a safe place. She firmly told her abuser that she would never let him get close to her again. Instead of denying the child, she played an active role in liberating her. As in EMDR the resolution of the trauma was the result of her ability to access her imagination and rework the scenes in which she had become frozen so long ago. Helpless passivity was replaced by determined Self-led action.
Once Joan started to own her impulses and behaviors, she recognized the emptiness of her relationship with her husband, Brian, and began to insist on change. I invited her to ask Brian to meet with us, and she was present for eight sessions before he began to see me individually.
Schwartz observes that IFS can help family members “mentor” each other as they learn to observe how one person’s parts interact with another’s. I witnessed this firsthand with Joan and Brian. Brian was initially quite proud of having put up with Joan’s behavior for so long; feeling that she really needed him had kept him from even considering divorce. But now that she wanted more intimacy, he felt pressured and inadequate—revealing a panicked part that blanked out and put up a wall against feeling.
Gradually Brian began to talk about growing up in an alcoholic family where behaviors like Joan’s were common and largely ignored, punctuated by his father’s stays in detox centers and his mother’s long hospitalizations for depression and suicide attempts. When I asked his panicked part what would happen if it allowed Brian to feel anything, he revealed his fear of being overwhelmed by pain—the pain of his childhood added to the pain of his relationship with Joan.
Over the next few weeks other parts emerged. First came a protector that was frightened of women and determined never to let Brian become vulnerable to their manipulations. Then we discovered a strong caretaker part that had looked after his mother and his younger siblings. This part gave Brian a feeling of self-worth and purpose and a way of dealing with his own terror. Finally, Brian was ready to meet his exile, the scared, essentially motherless child who’d had no one to care for him.
This is a very short version of a long exploration, which involved many diversions, as when Joan’s critic reemerged from time to time. But from the beginning IFS helped Joan and Brian hear themselves and each other from the perspective of an objective, curious, and compassionate Self. They were no longer locked in the past, and a whole range of new possibilities opened up for them.
THE POWER OF SELF-COMPASSION: IFS IN THE TREATMENT OF RHEUMATOID ARTHRITIS
Nancy Shadick is a rheumatologist at Boston’s Brigham and Women’s Hospital who combines medical research on rheumatoid arthritis (RA) with a strong interest in her patients’ personal experience of their illness. When she discovered IFS at a workshop with Richard Schwartz, she decided to incorporate the therapy into a study of psychosocial intervention with RA patients.
RA is an autoimmune disease that causes inflammatory disorders throughout the body, causing chronic pain and disability. Medication can delay its progress and relieve some of the pain, but there is no cure, and living with RA can lead to depression, anxiety, isolation, and overall impaired quality of life. I followed this study with particular interest because of the link I’d observed between trauma and autoimmune disease.
Working with senior IFS therapist Nancy Sowell, Dr. Shadick created a nine-month randomized study in which one group of RA patients would receive both group and individual instruction in IFS while a control group received regular mailings and phone calls regarding disease symptoms and management. Both groups continued with their regular medications, and they were assessed periodically by rheumatologists who were not informed which group they belonged to.
The goal of the IFS group was to teach patients how to accept and understand their inevitable fear, hopelessness, and anger and to treat those feelings as members of their own “internal family.” They would learn the inner dialogue skills that would enable them to recognize their pain, identify the accompanying thoughts and emotions, and then approach these internal states with interest and compassion.
A basic problem emerged early. Like so many trauma survivors, the RA patients were alexithymic. As Nancy Sowell later told me, they never complained about their pain or disability unless they were totally overwhelmed. Asked how they were feeling, they almost always replied, “I’m fine.” Their stoic parts clearly helped them cope, but these managers also kept them in a state of denial. Some shut out their bodily sensations and emotions to the extent that they could not collaborate effectively with their doctors.
To get things moving, the leaders introduced the IFS parts dramatically, rearranging furniture and props to represent managers, exiles, and firefighters. Over the course of several weeks, group members began to talk about the managers who told them to “grin and bear it” because no one wanted to hear about their pain anyway. Then, as they asked the stoic parts to step back, they started to acknowledge the angry part that wanted to yell and wreak havoc, the part that wanted stay in bed all the time, and the exile who felt worthless because she wasn’t allowed to talk. It emerged that, as children, nearly all of them were supposed to be seen and not heard—safety meant keeping their needs under wraps.
Individual IFS therapy helped patients apply the language of parts to daily issues. For example, one woman felt trapped by conflicts at her job, where a manager part insisted the only way out was to overwork until her RA flared up. With the therapist’s help she realized that she could care for her needs without making herself sick.
The two groups, IFS and controls, were evaluated three times during the nine-month study period and then again one year later. At the end of nine months, the IFS group showed measurable improvements in self-assessed joint pain, physical function, self-compassion, and overall pain relative to the education group. They also showed significant improvements in depression and self-efficacy. The IFS group’s gains in pain perception and depressive symptoms were sustained one year later, although objective medical tests could no longer detect measurable improvements in pain or function. In other words, what had changed most was the patients’ ability to live with their disease. In their conclusions, Shadick and Sowell emphasized IFS’s focus on self-compassion as a key factor.
This was not the first study to show that psychological interventions can help RA patients. Cognitive behavioral therapies and mindfulness-based practices have also been shown to have a positive impact on pain, joint inflammation, physical disability, and depression.19 However, none of these studies has asked a crucial question: Are increased psychological safety and comfort reflected in a better-functioning immune system?
LIBERATING THE EXILED CHILD
Peter ran an oncology service at a prestigious academic medical center that was consistently rated as one of the best in the country. As he sat in my office, in perfect physical shape because of his regular squash practice, his confidence had crossed the line into arrogance. This man certainly did not seem to suffer from PTSD. He told me he just wanted to know how he could help his wife to be less “touchy.” She had threatened to leave him unless he did something about what she termed his callous behavior. Peter assured me that her perception was warped, because he obviously had no problem being empathic with sick people.
He loved talking about his work, proud of the fact that residents and fellows competed fiercely to be on his service and also of scuttlebutt he’d heard about his staff being terrified of him. He described himself as brutally honest, a real scientist, someone who just looked at the facts and—with a meaningful glance in my direction—did not suffer fools gladly. He had high standards, but no higher than he had for himself, and he assured me that he didn’t need anybody’s love, just their respect.
Peter also told me that his psychiatry rotation in med school had convinced him that psychiatrists still practiced witchcraft, and his one stint in couples’ therapy had further confirmed that opinion. He expr
essed contempt for people who blamed their parents or society for their problems. Even though he had had his own share of misery as a child, he was determined never to think of himself as a victim.
While Peter’s toughness and his love for precision appealed to me, I could not help but wonder if we would discover something I’d seen all too often: that internal managers who are obsessed with power are usually created as a bulwark against feeling helpless.
When I asked him about his family, Peter told me that his father ran a manufacturing business. He was a Holocaust survivor who could be brutal and exacting, but he also had a tender and sentimental side that had kept Peter connected with him and that had inspired Peter to become a physician. As he told me about his mother, he realized for the first time that she had substituted rigorous housekeeping for genuine care, but Peter denied that this bothered him. He went to school and got straight As. He had vowed to build a life free of rejection and humiliation, but, ironically, he lived with death and rejection every day—death on the oncology ward and the constant struggle to get his research funded and published.
Peter’s wife joined us for the next meeting. She described how he criticized her incessantly—her taste in clothes, her child-rearing practices, her reading habits, her intelligence, her friends. He was rarely at home and never emotionally available. Because he had so many important obligations, and because he was so explosive, his family always tiptoed around him. She was determined to leave him and start a new life unless he made some radical changes. At that point, for the first time, I saw Peter become obviously distressed. He assured me and his wife that he wanted to work things out.
At our next session I asked him to let his body relax, close his eyes, focus his attention inside, and ask that critical part—the one his wife had identified—what it was afraid would happen if he stopped his ruthless judging. After about thirty seconds he said he felt stupid talking to himself. He didn’t want to try some new age gimmick—he’d come to me looking for “empirically verified therapy.” I assured him that, like him, I was at the forefront of empirically based therapies and that this was one of them. He was silent for perhaps a minute before he whispered: “I would get hurt.” I urged him to ask the critic what that meant. Still with his eyes closed, Peter replied: “If you criticize others, they don’t dare to hurt you.” Then: “If you are perfect, nobody can criticize you.” I asked him to thank his critic for protecting him against hurt and humiliation, and as he became silent again, I could see his shoulders relax and his breathing become slower and deeper.
He next told me that he was aware that his pomposity was affecting his relationships with his colleagues and students; he felt lonely and despised during staff meetings and uncomfortable at hospital parties. When I asked him if he wanted to change the way that angry part threatened people, he replied that he did. I then asked him where it was located in his body, and he found it in the middle of his chest. Keeping his focus inside, I asked him how he felt toward it. He said it made him scared.
Next I asked him to stay focused on it and see how he felt toward it now. He said he was curious to know more about it. I asked him how old it was. He said about seven. I asked him to have his critic show him what he protected. After a lengthy silence, still with his eyes closed, he told me that he was witnessing a scene from his childhood. His father was beating a little boy, him, and he was standing to one side thinking how stupid that kid was to provoke his dad. When I asked him how he felt about the boy who was getting hurt, he told me that he despised him. He was a weakling and a whiner; after showing even the least bit of defiance to his dad’s high-handed ways, he inevitably capitulated and whimpered that he would be a good little boy. He had no guts, no fire in his belly. I asked the critic if he would be willing to step aside so we could see what was going on with that boy. In response the critic appeared in full force and called him names like “wimp” and “sissy.” I asked Peter again if the critic would be willing to step aside and give the boy a chance to speak. He shut down completely and left the session saying that he was unlikely ever to set foot in my office again.
But the following week he was back: As she had threatened, his wife had gone to a lawyer and filed for divorce. He was devastated and no longer looked anything like the perfectly put-together doctor whom I’d come to know and, in many ways, dread. Faced with the loss of his family, he became unhinged and felt comforted by the idea that if things got too bad he could take his life in his own hands.
We went inside again and identified the part that was terrified of abandonment. Once he was in his mindful Self-state, I urged him to ask that terrified boy to show him the burdens he was carrying. Again, his first reaction was disgust at the boy’s weakness, but after I asked him to get that part to step back, he saw an image of himself as a young boy in his parents’ house, alone in his room, screaming in terror. Peter watched this scene for several minutes, weeping silently through much of it. I asked him if the boy had told him everything he wanted him to know. No, there were other scenes, like running to embrace his father at the door and getting slapped for having disobeyed his mother.
From time to time he would interrupt the process by explaining why his parents couldn’t have done any better than they had, their being Holocaust survivors and all that implied. Again I suggested he find the protective parts that were interrupting the witnessing of the boy’s pain and request that they move temporarily to another room. And each time he was able to return to his grief.
I asked Peter to tell the boy that he now understood how bad the experience had been. He sat in a long, sad silence. Then I asked him to show the boy that he cared about him. After some coaxing he put his arms around the boy. I was surprised that this seemingly harsh and callous man knew exactly how to take care of him.
Then, after some time, I urged Peter to go back into the scene and take the boy away with him. Peter imagined himself confronting his dad as a grown man, telling him: “If you ever mess with that boy again, I’ll come and kill you.” He then, in his imagination, took the child to a beautiful campground he knew, where the boy could play and frolic with ponies while he watched over him.
Our work was not done. After his wife rescinded her threat of divorce, some of his old habits returned, and we had to revisit that isolated boy from time to time to make sure that Peter’s wounded parts were taken care of, especially when he felt hurt by something that happened at home or on the job. This is the stage IFS calls “unburdening,” and it corresponds to nursing those exiled parts back to health. With each new unburdening Peter’s once-scathing inner critic relaxed, as little by little it became more like a mentor than a judge, and he began to repair his relationships with his family and colleagues. He also stopped suffering from tension headaches.
One day he told me that he’d spent his adulthood trying to let go of his past, and he remarked how ironic it was that he had to get closer to it in order to let it go.
CHAPTER 18
FILLING IN THE HOLES: CREATING STRUCTURES
The greatest discovery of my generation is that human beings can alter their lives by altering their attitudes of mind.
—William James
It is not that something different is seen, but that one sees differently. It is as though the spatial act of seeing were changed by a new dimension.
—Carl Jung
It is one thing to process memories of trauma, but it is an entirely different matter to confront the inner void—the holes in the soul that result from not having been wanted, not having been seen, and not having been allowed to speak the truth. If your parents’ faces never lit up when they looked at you, it’s hard to know what it feels like to be loved and cherished. If you come from an incomprehensible world filled with secrecy and fear, it’s almost impossible to find the words to express what you have endured. If you grew up unwanted and ignored, it is a major challenge to develop a visceral sense of agency and self-worth.
The re
search that Judy Herman, Chris Perry, and I had done (see chapter 9) showed that people who felt unwanted as children, and those who did not remember feeling safe with anyone while growing up, did not fully benefit from conventional psychotherapy, presumably because they could not activate old traces of feeling cared for.
I could see this even in some of my most committed and articulate patients. Despite their hard work in therapy and their share of personal and professional accomplishments, they could not erase the devastating imprints of a mother who was too depressed to notice them or a father who treated them like he wished they’d never been born. It was clear that their lives would change fundamentally only if they could reconstruct those implicit maps. But how? How can we help people become viscerally acquainted with feelings that were lacking early in their lives?
I glimpsed a possible answer when I attended the founding conference of the United States Association for Body Psychotherapy in June 1994 at a small college in Beverley on the rocky Massachusetts coast. Ironically, I had been asked to represent mainstream psychiatry at the meeting and to speak on using brain scans to visualize mental states. But as soon as I walked into the lobby where attendees had gathered for morning coffee, I realized this was a different crowd from my usual psychopharmacology or psychotherapy gatherings. The way they talked to one another, their postures and gestures, radiated vitality and engagement—the sort of physical reciprocity that is the essence of attunement.
I soon struck up a conversation with Albert Pesso, a stocky former dancer with the Martha Graham Dance Company who was then in his early seventies. Underneath his bushy eyebrows he exuded kindness and confidence. He told me that he had found a way of fundamentally changing people’s relationship to their core, somatic selves. His enthusiasm was infectious, but I was skeptical and asked him if he was certain he could change the settings of the amygdala. Unfazed by the fact that nobody had ever tested his method scientifically, he confidently assured me that he could.
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