Ego state integration of a Borderline Personality Disorder by runout

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									UTILIZATION OF DREAMS: BRIEF LASTING IMPRESSIONS
                                      Stefanie Badenhorst
                                           D litt et Phil
                                Psychologist in Private Practice
                  5 Scholtz Street, Strand, Western Cape 7140, South Africa
                                     Tel: (+27) 21854 8941
                                 E-mail: docstef@iafrica.com



Dreams are non-threatening ways in which the unconscious mind expresses information and gives clues
to solutions within the patient‟s own frame of reference. The utilization of dreams in Ego State therapy is
one way in which dreams can contribute to the healing process. The symbols in the dream are seen as
representative of parts or energies of the self. The different themes or characters are utilized as ego states.
These different ego states are treated as covert personality segments, which are cognitively dissonant
from one another and have contradictory goals. Therapeutic techniques are used in the resolution of
conflict between the different ego states that constitute a „family of self‟ within an individual. Case
studies with video material and a live demonstration will demonstrate how trauma, which has become
egotized, that is invested with ego cathexis, can be relieved. Our challenge is to guide development and
help people find ways to accept, be with, and learn from experience that life sends our way.
                                              TABLE OF CONTENTS




INTRODUCTION.................................................................................................................... 3


WHAT IS DISSOCIATION? .................................................................................................. 4


EGO STATE THERAPY ........................................................................................................ 5


RELATED THERAPIES......................................................................................................... 7


   PSYCHOANALYSIS .......................................................................................................... 7


   JUNGIAN VIEW ................................................................................................................. 8


   GESTALT THERAPY ........................................................................................................ 8


   TRANSACTIONAL ANALYSIS ...................................................................................... 9


DREAMS AND EGO STATE THERAPY ............................................................................ 9


CASE STUDIES .................................................................................................................... 11


   CASE STUDY 1 ................................................................................................................ 11


   CASE STUDY 2 ................................................................................................................ 12


CONCLUSIONS .................................................................................................................... 14


REFERENCES ....................................................................................................................... 15
INTRODUCTION
The utilization of dreams in therapy provides an indirect way of accessing unconscious
material. In addition, it provides a way of tailoring the therapy to the individual‟s
specific needs by using his or her own frame of reference in the healing process.
Erickson valued dreams and often made use of dreams in various ways. Dreams allow
the opportunity to relive experiences and view them from an adult perspective (Erickson
& Rossi, 1979, p. 473). According to Short, Erickson and Erickson-Klein (2005, p.19)
“healing is something that occurs from within and involves all of the body systems”.
In the health care profession, the goal of working with people is to facilitate health and
well-being.   Health professionals therefore continuously seek for efficient ways to
resolve trauma. Of course, the physical trauma of accidents and severe injuries also
have an emotional impact on the individual. However, for the purpose of this paper the
focus will be on emotional trauma. Emotional trauma can manifest in many different
ways, such as emotional abuse, physical abuse, sexual abuse and often forgotten; lack of
attachment. Attachment theory as described by Bowlby (1969), suggests that the lack of
positive attachment to a primary caregiver, usually the mother, early in life can have far-
reaching effects on the development of the young child.           The lack of emotional
availability, reliability and consistency can result in vulnerability to further trauma.
This extended, recurring or repetitive trauma is often very difficult to treat, which
require skilful therapeutic interventions often over a long period of time.
The value of dreams is widely recognized, and humankind has ascribed meaning to their
dreams for centuries, usually through symbolic interpretation, which view the content as
a whole, and often considered dreams to have prophetic value. Alternatively, dreams
are interpreted through a method of decoding, which treat dreams as a form of
cryptography in which each sign can be translated into another sign having a known
meaning according to a fixed key (Freud, 1900/1976). Although inspired by these
ideas, Freud‟s method took a different route. Today, dreams are used in many different
ways. Hartmann (1998) describe dreams as another way of dealing with emotional
material, different from the waking state; connections are made more easily and more
widely on an unconscious level. Dreams are the unconscious search for solutions of
inner conflict.
Many early contributors discovered that the human personality is not a unity (although
usually experienced as such), but is separated into various segments, unique entities
with different purposes. Janet (1907) applied the term dissociation to describe systems
of ideas that were split off and not in association with other ideas within the personality.
Jung (1969) described a complex as a group of unconscious ideas clustered together. He
also described certain, more permanent covert structures within the „collective‟ or
„racial unconscious‟ that he called archetypes. The terms complex and archetypes both
imply that personality segments are organized into unconscious patterns. Federn (1952)
was the first to apply the concept of ego states in the psychodynamic understanding of
behavior. Other researchers, notable Hilgard (1986), Phillips and Fredrick (1995),
Watkins and Watkins (1997), have contributed to the development of Ego State therapy.


WHAT IS DISSOCIATION?
Although dissociation is a term often used by psychologists and other health
professions, there are still limited knowledge and many misconceptions with regard to
the topic under professionals.       The DSM-IV-TR have the diagnostic criteria of
Dissociative Disorders; Dissociative Amnesia, Dissociative Fugue, Dissociative Identity
Disorder (previously called Multiple Personality Disorder), Depersonalization Disorder,
and Dissociative Disorder Not Otherwise Specified. Dissociative symptoms are also
included in the criteria for Acute Stress Disorder, Post Traumatic Stress Disorder and
Somatization Disorder. Dissociated states are also common and accepted expressions of
cultural and religious activities. Explanations of possession of spirits or demons are still
used in religious circles with exorcisms of evil as treatment modality. In present times
contemporary traditions still exist who believe that dissociative phenomena need to be
treated in ways of getting rid of the evil, with claimed positive results.
Dissociation does not always imply pathology.           Normal dissociation is a natural
phenomena when a person gets involved in an activity and do not hear anything else, for
example when a person reads a book, is absorbed in a television program, or
daydreaming.
In the case of trauma, there is no state available to cope with the experience and the
person may dissociate from the overwhelming emotions to survive. A child who is
confronted with emotions that is out of her experience and who does not have anybody
available to assist her to process these feelings may dissociate to protect herself from
these overwhelming emotions. For example, one child described her experience of
being cruelly humiliated by a teacher in front of her class as: “I felt as if I was looking
down at myself from the corner of the sealing.” After being exposed to trauma, children
may absorb themselves in play in an attempt to forget what happened to them, a form of
defense mechanism. Erickson supported the Freudian view on defense mechanisms; he
suggested that repression might generate new separate personalities (Havens, 2003, p.
78). These memories may be hidden away for many years and only surface within the
therapeutic process. Trauma early in life, while the child is still pre-verbal, can also
lead to the development of, often silent, ego states.


EGO STATE THERAPY
Ego state therapy, derived from the theories of Paul Federn (1952) and later developed
by John and Helen Watkins (1997), is an integration of psychoanalytic practice and
hypnoanalytic techniques.      These methods encourage discovery and exploration of
covert ego states often developed as result of childhood trauma. Dissociation from
feelings and memory related to trauma occurs as a way of dealing with traumatic
experiences. When nobody is available for a person in need to share feelings, to
understand, or support, the person often has no other skills available, which may result
in dissociation. The dissociation is initially helpful and enables the individual to cope;
however, eventually it can result in pathology and become destructive.
We all have different parts (ego states) in our selves; you are a child, a parent, and a
therapist, you can be creative, dynamic, angry or depressed. “An ego state may be
defined as an organized system of behavior, an experience whose elements are bound
together by some common principle, and which is separated from other such states by a
boundary that is more or less permeable” (Watkins &Watkins 1997, p.25). According
to Emmerson (2003) ego states are created when a person is confronted with frustration
or trauma, and no ego state exists that can respond. Many of our ego states can also be
positive and useful. As a child repeatedly uses a coping mechanism, neural pathways
are established in the brain and events that are reminders of that coping mechanism will
be channeled down that pathway to the associated ego state (Emmerson, 2003, p.7). The
person then responds in a certain way with no cognitive awareness of why they respond
or overreact to a certain stimuli, like in the case of an anger outburst or panic attack.
Ego states develop by one or more of the following processes: normal differentiation,
introjections of significant others, and reaction to trauma (Watkins & Watkins, 1997).
In case of normal differentiation, the child develops coping skills as result of
reinforcement from significant others. An introject becomes part or the child when
he/she identifies with a role model. The child often takes in the characteristics of a
person who has significant impact on the child, whom may be a critical parent or a
caring parent. Watkins &Watkins (1997, p. 16) describe an introject as “a stone in the
stomach, within the self but not part of it, ingested but not digested”. According to
Watkins, the effect of a significant individual may so alter the structure of the ego as to
leave a permanent residue, in the same way a hot iron will leave a scar on the skin.


Figure 1 illustrates the continuum where normal ego states (A, B, C) are separated by
very permeable boundaries. As we move to the right, the boundaries become more rigid
which results in more pathology (Borderline). On the extreme right, the boundaries
become so impermeable that the ego state segments have little or no interaction,
communication, or shared content (Dissociative Identity Disorder). Conflict between
the parts may manifest in the form of headaches, anxiety, and maladaptive behaviors.
The parts are healthy insofar as they are joined harmoniously to the whole. Only by
restoring the broken connections can we be healed. Connection is health.



                                               Ego
                                              States
                  A                 A                  A                    A                 A

              C       B         C       B          C       B         C          B         C       B




              Normal                                           Borderline                Multiple
              Well-Adjusted             Neurotic
                                                               Multiple                  Personality
                                                                                         DID

             Adaptive
             Differentiation                       Defensive             Pathological Dissociation



              Figure 1. The differentiation dissociation continuum. (Watkins &Watkins 1997)



Figure 1. The differentiation-dissociation continuum (Watkins & Watkins, 1997, p. 32).
Ego state therapy can be used with or without hypnosis. Non-hypnotic techniques are
useful and can generate growth in therapy, but are not as powerful as the hypnotic
techniques for accessing ego states (Emmerson, 2003, p.7). Unresolved trauma is held
in underlying ego states, which are difficult to access without hypnosis. Hypnosis is
both a focusing and dissociative process (Hilgard, 1986) and therefore allows the
therapist to focus on one segment of personality and to temporarily dissociate away
other parts.   Ego State therapy is an integration of both theoretical concepts and
treatment strategies evolved from a variety of other therapies.


RELATED THERAPIES


PSYCHOANALYSIS
Freud (1900) believed that early childhood trauma often results in adulthood neurosis.
He explained situational neurosis as repetitive inappropriate responses to a particular
type of life situation. Through psychoanalysis, the unconscious memory can be brought
to the conscious. This process was viewed as instrumental in the resolution of neurosis.
Psychoanalysis often involves a number of years, and makes use of techniques such as
free association, analysis of resistance and transference as well as dream interpretation.
Although Ego State therapy is based on these ideas, the therapeutic intervention differs
from that of psychoanalysis in that the focus is on working with the needy or
traumatized ego states (parts).      The therapist becomes the „sponsor‟ to assist the
traumatized state and empower the state to experience mastery. A „sponsor‟ implies
somebody who understands the feelings of the person in need, who is there to give
support, empower or protect the person. Ego State therapy aims rapid, long-lasting
results in a relative short period of time.
Freud was especially interested in dreams because he believed that, if he could
understand their mechanisms, he would be able to comprehend something fundamental
about mental illness. Freud believed that interpretation would lead to the revelations of
a “psychical structure which has meaning and which can be inserted at an assignable
point in the mental activities of waking life” (Freud 1900/1976, p.57). He viewed
dreams as the „royal road‟ to an understanding of the unconscious mind. Freud (1900)
argued that dreams are the guardians of sleep and that the dream protects the person
from disturbing influences of motivational urges that emerge during sleep. Several
dreams often have the same meaning and may indicate that an attempt is being made to
deal with an insistent stimulus (Freud, 1985b/1916). Freud used free association as well
as interpretation and he viewed critical objection as resistance towards interpretation.
The presence of resistance in the therapeutic process was therefore seen as indicating
that the mental life of human beings is inherently permeated by conflict. This view
corresponds with the theory on conflict between different states in Ego State therapy.


JUNGIAN VIEW
In the Jungian view, mental health (or illness) depends on the functional relationship,
achieved in the course of individual development, between conscious and unconscious
processes. Jungian therapists use “active imagination” or so called “amplification” in
working with dreams. Jung‟s own dream and Freud‟s attempt to analyze the dream
made him realize that their views are incompatible. Jung (1965) valued dreams as part
of the prima materia of his scientific work. His concept “compensation” implies that
portions of the personality that are repressed or not significantly expressed in the
waking state are the ones that appear in dreams. He viewed dreams as being transparent
statements of normal psychic functioning and explain it as: “I can understand myself
only in the light of inner happenings” (Jung 1965, p.19). Jung referred to the dream as a
“little hidden door” to the deepest parts of the self. Although his focus was on symbols
and interpretation, his own dreams served as inspiration for this work, and led to the
author‟s belief that dreams can be utilized in different ways.


GESTALT THERAPY
Gestalt therapy imply whole. If part of the whole is injured (traumatized) in some way
then the whole person cannot function fully (Perls, 1959). Gestalt therapy shares more
techniques with Ego State therapy than any other therapy. Both Gestalt and Ego State
therapy work based on bringing into consciousness the state that need facilitation. The
empty chair technique is one of the techniques that resemble techniques used in Ego
State therapy. The Gestalt therapist will ask the person to sit in one chair to explain one
aspect of the self and then move to the other chair to explain another aspect of the self.
Although Gestalt theory does not view the parts as ego states and does not explain ways
of part development, there are techniques shared by both. However, the fact that Gestalt
therapy does not use hypnosis, limits its access to underlying states.
Perls (1959) viewed dreams as an attempt to overcome frustration and believed that they
could indicate that the Gestalt has not been closed. The dream is therefore “an attempt
to become alive, to come to grips with things” (Perls, 1959, p.95). He used the empty
chair technique with dream work, by allowing the person to play the parts in the dream
and to communicate with the different parts. In becoming the different parts, this can
allow the disowning of some potential to become part of the self rather than alienation.
In the model of therapy proposed here, some of these techniques are borrowed from
Gestalt therapy and applied with Ego State therapy techniques and hypnosis.


TRANSACTIONAL ANALYSIS
The work of Eric Bern (1961) and Paul Federn (1952) has similarities with Ego state
therapy. However, while Ego State therapy believes that many ego states exist, Bern
believed that there are only five ego states in an individual. These states consist out of
two parent states, one adult state and two children states. Every person is believed to
have the same states. Transactional Analysis attempts to balance these states. In
contrast, the purpose in Ego State therapy is to learn about the idiosyncratic states,
locate and process trauma, and to improve communication between states. In Ego State
therapy, the emphasis is on the uniqueness of each individual and the fact that no two
people have the same states.


DREAMS AND EGO STATE THERAPY
Dreams are viewed as the unconscious search for solutions of inner conflict. Although
there are still contradictory opinions with regard to dreams, the value of the access to
the unconscious cannot be underestimated. Our usual repressions are at least partially
lifted when we dream and therefore the dream gives us more rapid access to usually
unconscious material (Hartmann, 1998).
The dream is the person‟s own frame of reference and provides a non-threatening way
to deal with inner conflict. The utilization of the person‟s dream is ideally tailored to fit
the person‟s own needs.
The person is dissociated from the experience and finds some objectivity in the sense
that it is a dream and one works with the symbols of the dream. These symbols are
often not within cognitive awareness. According to Jung portions of the personality
(viewed by the author as underlying ego states), repressed in the wakened state, are
active during dreaming. By working with the dream, the threatening material can stay
on an unconscious level and does not need to be brought to the conscious level. On the
other hand, the person become that part and experiences the situation subjectively,
which implies an experiential learning process. This emotional experience can allow
growth, emotional maturation and development of immature parts.          The process of
working with the family of selves, can improved communication and cooperation
between parts.
The different elements in the dream are viewed as parts and are dealt with as separate
entities. In working with dreams, the therapist asks the person to write down his/her
dreams. A recurring dream or recurring theme in the dream is often a good choice to
work with. The therapist then asks the person to tell the dream in the present tense. The
person will then be absorbed in hypnosis to communicate with the different parts. The
therapist gets to know the part and understand the needs of the part, and allow the part
to communicate with the other parts. In the same way, one communicates with all the
different parts to allow understanding of each other. In the process of understanding,
giving support, and being a „sponsor‟ for the specific part, the therapy allows safety and
cooperation to such an extend that interaction between parts can take place in such a
way that broken connections can be restored.
It is found to be a powerful method in the healing process. The different parts in the
dream are allowed to communicate to allow understanding and support in such a way
that the parts can connect and cooperate. The utilization of dreams in Ego State therapy
is but one way of using the person‟s own recourses in the healing process. The art lies
in the gentle way of connecting feeling without further traumatizing the patient. The
therapist‟s aim is to utilize the patient‟s own strength in the process to grow through
suffering and to learn from each experience that life sends our way.
CASE STUDIES


CASE STUDY 1
Lelani was hospitalized as result of a suicidal attempt, and referred by her psychiatrist.
She was diagnosed as a Borderline Personality Disorder.


Background information
Lelani was adopted as a baby, her adoptive parents got divorced before her first birthday
and she stayed with the father.     According to information available, her biological
mother died, and very little other information was available.        Her adoptive father
remarried five years later and they had a child 7 years younger than Lelani. Lelani
passed grade 12 and did Au pair work overseas for a period of three months after which
she returned to South Africa as result of her depression.


History of the problem
Lelani was depressed since her grade 9 year, she only found out about her adoption
during her grade 8 year. She complained that she feels dead, cuts herself to feel and
express that she wants to die. She feels as if “it is somebody else‟s life” and not her
own life she is talking about. She experimented with ecstasy, abused alcohol on a
regular basis and took diet pills to control her weight. She was hospitalized several
times and her parents reported that they were desperate; they feel they couldn‟t spend
more money on her. Her father threatened to kill both her and himself.


Lelani was seen for several sessions, she worked hard on her problems and made
collages and kept a therapy book where she wrote down her dreams. This was one of
the dreams we worked with.


Lelani’s Dreams
I am 21 years old. I am in front of a house with Christmas roses. I walk into the house
and down the passage. I turn right into the first door. The room is dark and there is a
baby on the bed. I am the baby. I‟ve got soft toys next to me. I leave the room and
there is a woman in the kitchen. I know her face from a photo. Outside is an old man
with a bald head and no teeth. I go back into the house through to a room and there is a
young man. His room is bright and sunny. He stands up and walks down the passage. I
follow him into the baby‟s room. He is not aware of my presence. I am invisible. He
lies down beside me. I smell brandy. He is touching the baby. The baby cries and he
walks out….


Utilization of the dream
At first, she told her dream in the present tense. Then she was absorbed in a trance state
where she then becomes the different parts or elements in the dream. The patient
usually decides which part they want to be first. She first became the woman in the
kitchen, the house was in a mess and she did not feel like doing anything. On the
request of who can help her she suggests that the young man can help. The therapist
asked for permission to talk to the young man, she then moved to another chair and
become the young man. We ask for his help, he is not willing to help because she does
not take care of his needs. We listen to his needs and then go back to talk to the woman
again, whether she is willing to take care of his needs. She complains about the baby
being demanding. We then ask the old man to assist until they can reach an agreement
and compromise to work together.
With every discussion with another element the patient move to the other chair, which
implies a deepening of the trance state. In the negotiation with the different parts,
similar techniques as in Gestalt therapy and Family therapy are used to reach an
agreement. The therapist focuses on the needs of the different parts and found some
part to take care of those needs. This allows maturation, integration and cooperation of
different parts. The patients who are often stuck can move forward and can find new
ways in coping with life‟s demands. The video demonstrates the process.


CASE STUDY 2
WORKING WITH THE DREAM
Sue is a 40 year old woman who is married to a good, intelligent and attractive man.
They have been together for 17 years but lack passion. She experiences tremendous
sadness. She was in a previous relationship where she experienced passion and she was
still longing for that. Her lover got married later on and has children; however, they
kept in contact with each other. After the work done with the dream and the metaphor
as described below, she went back for a visit to Australia where he lives.            She
experienced fulfillment with the reconnection and was reluctant to break the
relationship off again. She described her experience as: “It was like drinking water after
drought”. She was then prepared to give up her relationship with her husband to be
with him; however, he decided to stay with his family. Sue finally realized that she
needed to accept the situation and we scheduled a session to assist her to mourn the loss
of the relationship and to help her to let go.


Dream
I am at home. There is a bird in a round ball cage; the bars are round. Skit (cat) comes
down the passage to get the bird, he connects with bird and there is blood on the floor –
the bird is injured but safe. They are outside my study. I go out to help the bird; it is
very scared of me. I am feeling irritated - I am coming closer; she is flapping her wings.
She looks like she is using a lot of energy. I try again and she flaps hard – she is on the
roof. I feel defeated; don‟t know what is going to happen; she is stuck on the roof.


The patient was absorbed in hypnosis and we allowed the different parts to
communicate with each other:
Sue to the bird: I am worried about the bird. I don‟t want you to be trapped for the rest
of your life; I don‟t want you to be frightened; I think you must be very scared.
Sue to the cat: I know it is your nature; you are a gentle cat and I want you to stop the
fight.
Bird to therapist: I don‟t trust her, I don‟t know what she wants to do, I don‟t want her
to come near me; I am scared she is in lines with the cat. I am outside, leave me alone,
she has nothing to free me.
Sue: It was hard to open the bars of the cage - I did not know if I was strong enough – I
am tired.
Bird: I am sitting in the shade of the trees. I am eating and with the other birds on the
ground I have no confidence to fly.


This metaphor was used in a follow up after the work done with the dream.
The bird in the cage had lived there for a very long time. Often it would look through
the bars of the cage, out of the window to the meadows and trees beyond. It could see
other birds flying free in the open air and often it would wonder how it would be to feel
the sun on its back, the wind in its feathers, to swoop and soar and snatch mosquitoes in
flight.
When the bird thought of these things, it could feel its heart beating with the excitement.
It would sit taller on its perch and breathe deep into its bird belly, sensing the thrill of
possibility.
Sometimes another bird would land on the windowsill, resting from its travels, and look
inside at the caged bird. The traveler would put its head on one side as if quizzically
asking it self how such a thing could be. A bird in a cage. Unimaginable. And it was
at these times that the caged bird felt most miserable. Its little shoulders slumped; it felt
a lump in its throat and heaviness in its heart.
One day, the owner of the caged bird accidentally left the door of the cage open. The
bird looked through the door. It saw the birds swooping and soaring outside, the sun
on their backs and the wind in their feathers, and it felt a stirring inside. The caged
bird noticed that the window was open, and its heart beat even faster.
It considered its options.
It was still considering them at sunset when the owner returned and closed the door of
the cage.
The bird, for whatever reasons, valued security over freedom.
Primary source: David Werner & Bill Bower, Helping Health Workers Learn,
Hesperian Foundation.


Sue is now settled in her relationship with her husband. She fell pregnant, they are both
very excited about the pregnancy and looking forward to having the baby.


CONCLUSIONS
Dreams can be used in many different ways; this is one method where the elements in
the dreams are viewed as different ego states. From this point of view, interpretation of
the dream is seen as unnecessary; the unconscious mind can do it in its own way. The
utilization of dreams in Ego State therapy is one method of utilizing the person‟s own
resources to find solutions to inner conflict. This method is based on Freud and Jung‟s
ideas and borrows strongly from Gestalt therapy. Ego State techniques with hypnosis
allow access to the underlying ego state. It is therefore a non-threatening way of
dealing with material often not available in conscious awareness. This is found to be a
very powerful method to create change in a relative brief period of time.
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