Clinicians who work with complex trauma cases often find themselves challenged by issues related to dissociative parts and the appropriate use of “parts” language during treatment. Today, we wish to reflect on the following four questions, which are frequently brought up by clinicians during training and consultation.
1. What are dissociative parts?
2. How to distinguish dissociative parts from ego states?
3. When and when not to use “parts” language?
4. How to work with or talk about “parts” when patients do not feel comfortable recognizing that they have parts?
What are dissociative parts?
Dissociative parts often have a distinct first-person perspective – that is, a sense of “I, me and mine” – (Nijenhuis & Van der Hart, 2011; Van der Hart et al., 2006) as well as a sense of identity, self-representation, autobiographical memory, and personal experience (Kluft, 1988, 2006; Steele, Boon, & Van der Hart, 2017). The client’s lack of a unified sense of identity could be expressed through sentences such as, “It was her, I would never do/say such things;” “Sometimes I feel as if I’m going crazy, I don´t have control over my actions, my hands take control and I can only watch in the background;” “There is a monster inside of me, it doesn´t let me eat or sleep;” “I didn’t try to kill myself, he (referring to another dissociative part) tried to kill us,” and is often referred to as lack of personification (Van der Hart et al., 2006). Notice how clients tend to talk about parts as if they were different people, frequently using a third-person perspective to describe their inner experiences or what they see, notice or hear from their dissociative parts.
The notion of dissociative parts having their own partial autobiography and sense of identity makes a lot of sense in most cases, but it might not apply to all parts completely. First, there are emotional parts (EPs) stuck in trauma time that do not seem to have autobiographical memory or might not be able to recognize it as such because it is felt as current experience, as if it were occurring now. And second, these parts might not be experienced or described by clients as having a distinct first-person perspective – even though they do have their own perspective, limited as it may be to the time of trauma. But they can still be experienced as foreign, in the sense of the client not feeling control or being able to do anything about them. Therefore, it can be challenging to work with these parts, especially when it comes to time orientation or becoming aware of present reality.
How to distinguish dissociative parts from ego states?
Ego states have been described as having permeable boundaries, no significant amnesia, no significant separate autobiography and a sense of belonging to the person as a whole (Kluft, 1988, 2006; Steele et al., 2017). Ego states consist of mental representations that might involve some type of conflict or integrative deficits (Mosquera & Steele, 2017), but are not invested in being separate and are not experienced as such. Hence, their perspective is not significantly different from the person as a whole. These are normal phenomena that we all experience and do not indicate the presence of a dissociative disorder.
In general, ego states differ from dissociative parts in their lack of autonomy and elaboration, personal experience and memory, and unique self-representation and first-person perspective. Clients usually acknowledge ego states as part of the self, which is mostly not the case for dissociative parts, unless the client has been through significant therapy work.
In Complex PTSD and some OSDD cases, ego states may present as having less permeable boundaries, some amnesia for the past but not the present and a greater sense of literal “not me” (Steele et al., 2017). These experiences could be understood as belonging to dissociative parts, but this does not mean that they will require the work often needed with more clearly divided parts. It might be useful to think of them as more elaborate ego states or as being on the border between ego states and dissociative parts. Common statements are, “I know these parts are me, but they don´t feel like me,” “I know these are my voices, I know that I am producing them, but they don´t feel like mine,” or “When I react like that it feels as if I was acting like someone else/like my mother.” Notice how these statements reflect a first-person perspective and greater conflict around some of the emotions that may be more difficult for the client to regulate, tolerate or accept. In these cases, it can be more challenging to distinguish ego states from dissociative parts. However, if we listen carefully, we will not pick up on the phobic avoidance that is often present in more elaborate dissociative parts that have increased autonomy. In these cases, many clients experience these parts as “Not Me” and usually want “to get rid of her/him/it.” Some dissociative clients can be phobic of certain parts and not of others, while still experiencing conflict around how to relate with them or how these parts relate to other parts that are more challenging.
The language that is used by the client can offer clues that can help us differentiate between dissociative parts and ego states. With ego states, the language is often more metaphoric, especially when talking about child parts. These are often described as “the little me,” “me when I was little,” or “the hurt part of me that I still notice,” among others. These descriptions are usually stated in first-person perspective, as belonging to oneself, with no relevant conflict. Some clients may experience conflict around their “younger selves,” often related to adverse experiences, traumatizing events or the meaning of that label attached to their inner experience. For some clients, using language that refers to “the younger me,” “my little me,” “my little girl,” or “the girl I was” simply adds a distancing quality that greatly differs from the conflict in dissociative parts. When dissociative parts are present, the use of this language is not just a metaphor of their experience, but a perception of something that does not belong to the client, such as the part functioning in daily life. In addition, there is a large amount of energy often spent in maintaining the separation between the different parts.
When and when not to use “parts” language?
The language that our clients use spontaneously can help us decide whether it might be a good idea for us to use “parts” language. It is important to keep in mind that, for many clients, “parts” language is a way to introduce some distance when describing behaviors, thoughts or feelings that they do not particularly like or fully understand. This is so both in these simpler cases as well as in those that are more complex, in which these thoughts, behaviors, or feelings are felt as strange, odd, foreign and not belonging to me.
As a rule of thumb, if possible, it is always a good idea to use the client’s language from the beginning (Mosquera, 2019). On the one hand, when clients talk openly about their parts it normally is a good idea to follow up on their wording. On the other hand, when a client does not feel comfortable with the use of “parts” language, it is preferable not to use it. Some clients get defensive when they hear the word “part” and in those instances, there is no need to insist; it will be pointless and lead to more resistance or defensiveness. When a client becomes defensive or notices resistance, it is important to validate their experience and respond with curiosity and care, as such resistance and the reasons for it need to be explored in a way that the client can tolerate.
However, there are some exceptions to the rule of using the language preferred by the client. One will be when we observe that clients are using “parts” language as a way to avoid taking responsibility for their actions, using expressions such as, “I am not responsible for that behavior because this other part did it” or “It was the other me who said it; my friend shouldn´t be angry at me.” In addition, some clients may talk about “inner people” or prefer to talk about their parts in a way that gives them too much autonomy. In these circumstances, we can agree to use both ways of referring to parts: the client can continue talking about “inner people,” and we may respectfully acknowledge that and also maintain our “parts” language: “What you call your inner people and I call your parts…” or “Those parts of you that you experience as inner people.”
Overall, “parts” language can be used with the different presentations when it helps with the work we are doing, and it should be avoided when it gets in the way of therapy or improvement in clients.
How to work with or talk about parts when patients do not feel comfortable recognizing that they have parts?
When clients do not feel comfortable with having parts or have difficulties recognizing their existence, a good way to approach this issue is to explore whether they notice conflict inside or things that are difficult to explain to others and then ask them to please help us understand their inner experience. Some clients will refer to the different parts of the self/personality by using expressions such as “different me’s,” “voices,” “thoughts,” “opinions,” “conflicts in me,” “pieces,” or “fragments,” which really offers information for the therapist about how clients experience their parts. It is important to keep in mind that some of the terms used may have an excessively high degree of reality (e.g., “inner people” or “personalities”) unduly emphasizing their separateness, and others may have an extremely low degree of reality (e.g., “aspect”) ignoring the fact that parts having their own first-person perspective (Moskowitz & Van der Hart, 2019).
Using other metaphors can be as effective, especially if clients feel comfortable with them. Richard Chefetz (2015) uses the expression “different ways of being you,” which is a creative and integrative way of using an easier language for some clients. And again, even a generally good integrative way of using language can evoke resistance in some clients. For instance, those having perpetrator-imitating parts could, early in therapy, protest against having them labeled as “a way of being you.” Or parts that are emotionally involved in maintaining their own sense of separateness could even feel narcissistically hurt, being reduced to merely “a way of being.”
Summarizing, even though sometimes you may need to adapt to using a language that may not feel natural for you, what really matters in therapy is being able to communicate and explore in ways that feel comfortable for the client. Be creative when approaching this issue, since it is always possible to find personalized ways to explore and talk about the patient´s inner experience that do not involve mentioning the word “parts.”
References
Chefetz, R. (2015). Intensive psychotherapy for persistent dissociative processes: The fear of feeling real. New York: W. W. Norton.
Kluft, R. P. (1988). The postunification treatment of multiple personality disorder: First findings. American Journal of Psychotherapy, 42(2), 212–228.
Kluft, R. P. (2006). Dealing with alters: A pragmatic clinical perspective. Psychiatric Clinics of North America, 29, 281-304.
Moskowitz, A., & Van der Hart, O. (2019). Historical and contemporary conceptions of trauma-related dissociation: A neo-Janetian critique of models of divided personality. European Journal of Trauma and Dissociation. https://doi.org/10.1016/j.ejtd.2019.02.004
Mosquera, D (2019). Working with voices and dissociative parts. A trauma-informed approach. Coppel, TX: Kindle direct Publishing.
Mosquera, D, & Steele K. (2017). Complex trauma, dissociation and borderline personality disorder: Working with integrative failures. European Journal of Trauma and Dissociation, 1, 63-71.
Nijenhuis, E. R. S., & Van der Hart, O. (2011). Dissociation in trauma: A new definition and comparison with previous formulations. Journal of Trauma & Dissociation, 12(4), 416–445.
Steele, K., Boon, S., & Van der Hart, O. (2017). Treating trauma-related dissociation: A practical integrative approach. New York: W. W. Norton.
Van der Hart, O., Nijenhuis, E. R. S., & Steele, K. (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. New York: W. W. Norton.