Trauma-informed

Ego State Therapy

Dr. Michelle Nixon, EdD, LCMHC
Shiloe Mechan, Intern

Process Guided Imagery: Rapid Pain Release Through the

Healing Journey
 Definitions
Bottom up processing: Information is processed utilizing sensory input. Sensory information is processed at the mid-brain,
limbic system level.

Bottom-up treatment: Those approaches that focus on engaging the senses, emotions, and subconscious structures of the
body and brain initially in order to reduce the pain associated with distressing material.

Cabin/safe place/ dissociative table: Ego state therapy techniques utilized to observe the inner community or internal family
system. The dissociative table technique was developed by Fraser in 1991. The safe place or home base is identified in ego
state work to isolate individual ego states for a therapeutic intervention. The cabin is similarly developed in The Healing
Journey Rapid Pain Release method.

Disorders of extreme stress not otherwise specified (DESNOS): Identify symptoms of PTSD that may exist on a continuum
and may be subthreshold to the actual symptoms of PTSD (Herman,1992).

Ego State: An aspect or “part” of a person’s personality that forms to respond to a specific need(s), and possesses a unique
identity, memories, and traits. These develop across the lifespan (Lizarraga, 2016). Lizarraga, 2016)
Definitions
Ego state therapy: Interventions imposed on the internal family system or inner community of ego states, usually guided
under deep relaxation.

Higher self/hidden observer: Ego states identified as the deeper self which functions as central core (Hilgard & Hilgard,
1975).

Inner child: An individual ego state or cluster of ego states that appear during childhood.

Imprinting: the bio-physiological associations of trauma to the reactionary stance of the victim, contributing to a
“fundamental reorganization of the way mind and brain manage perceptions. It changes not only how we think and what we
think about, but also our very capacity to think” (Van der Kolk, 2014, p. 21).

Post-traumatic stress disorder (PTSD): A condition with symptoms listed and specified in the Diagnostic and Statistical
Manual DSM-5 with include exposure to or witnessing a traumatic event. It includes four clusters of symptoms of intrusion,
avoidance, negative alteration in cognitions and mood and alteration in arousal and reactivity (APA, 2013).
Definitions
Process guided imagery: Process guided imagery is a method of deep relaxation utilized to influence an internal sense of awareness to
sensation and thoughts. It is suggested that process guided imagery does not induce a full hypnotic trance.

The healing journey: Rapid pain release method (RPR): This is the method under study created by Larry D. Beall, PhD. A scripted
process guided imagery technique. The imagery includes access to individual ego states with suggestion to release pain or move pain.

Top down process: Information is processed utilizing a conceptually-driven modality which is influenced by expectations, existing
beliefs and cognitions (Cherry, 2015). The process utilizes the neurological networks primarily associated with the prefrontal cortex and
cortex.

Top-down treatment: Those approaches that focus on interacting with conscious functions and cognitive structures of the brain in
order to reduce sensitization to distressing material (e.g. mind over matter).

Trauma: The phenomena that occurs when a person’s internal resources are overwhelmed by external stimuli.

Trauma disorder: The phenomena that occurs when a person’s internal resources are overwhelmed by external stimuli which
dysregulates adaptive limbic functioning and results in enduring distress and impairment.

Vaded Ego State: Parts of personality that are highly reactive due to the effects of trauma on neural development
Differentiation in Trauma
Specific Diagnostic Criteria → Labels
Trauma

Reactive Attachment Disinhibited Social

Acute Stress Disorder Adjustment Disorders PTSD
Disorder Engagement Disorder
Image information retrieved from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (American Psychiatric Association, 2013)

VS.

General Dynamics
Event(s) + External Stimuli > Internal Resources

Distress and reduced

function
Biology of Trauma:
More than an Event- An Imprint

Activating
event

Amygdala threat Polyvasovagal Gut, adrenals, kidneys,

Dorsal vagus activated
assessment reactivity etc.

Cognitive dampening

Imprinting Somatic challenges Hormonal activation

Trauma Treatment Modalities

● Cognitive Behavioral Therapies (CBT)

● Cognitive Processing Therapy (CPT)
● Prolonged Exposure Therapy (PET)
● EMDR
● Selective Serotonin Reuptake Inhibitor (SSRI)
● Family and Group Therapy
● Brief psychodynamic psychotherapy
Challenges in
● Episodic evolution in Traumatology and
understanding of sequelae

Trauma Treatment ●
●
CBT and the Unspeakable Terror
Traditional methods and risk for traumatic reaction
● Deepening connection to trauma vs. releasing pain
● Top-down → risk for faulty neurological
reorganization (Porges, 2001)
● Severe lack of representation of new techniques (e.g.
Ego State techniques)
○ Research and Counselor Education
Challenges in
Problem: Execution, not principles

Trauma Treatment:
● Requires sufficient safety and orientation to
present

EMDR ● Dissociative → decompensation and intense

abreaction
● Blocked processing that does not resolve
● Requires careful delineation for use in practice
Challenges in +
+
Desensitization to traumatic material
Offers behavior change skills acquisition
Trauma Treatment: -
-
Limited effectiveness
Considerable symptoms remaining or return
Behavioral Methods over time (Gaston, 2015)
- Risk for significant abreaction (Gaston, 2015)
- Not more effective than other modalities
(Gaston, 2015)
Challenges in
+ Challenge unhelpful/distressing distortions
+ Concrete steps, easily manualized

Trauma Treatment: + Integrates with other modalities (i.e. ego state

therapy)

CBT +
-
Facilitate access to additional coping skills
Cognitive reassessment poorly mediates
visceral reactions (Lizarraga, 2016)
- CBT alone: Decaying efficacy over time (Shedler,
2010)
- CBT alone: leaves the injured self still injured
(Emmerson, 2003, p.195)
Ego State Theory

Thoughts/Behaviors

Ego State A Ego State B Ego State C Ego State D

Personality

Memory

Memory

Memory

Memory
Identity

Identity

Identity

Identity
Traits

Traits

Traits

Traits
Ego State A Ego State B Ego State C Ego State D

Experiences

Neurobiology
Transactional Analysis

Person A Person B

Controlling Nurturing Controlling Nurturing

Parent Parent Parent Parent

Adult Adult

Adapted Free Adapted Free

Child Child Child Child
Internal Family
Systems model Managers

Firefighters
Exiles

Self
Multiplicity:
● Individuals create ego state “families”
comprising personality

Normalizing the ● Efficient “switching” with/without conscious

awareness

Internal Family ● Expand vocabulary → increase understanding of

IFS
System ●
○ Avoid conflation with DID “alters”
Exploration of unique identities yields balance
Bottom-up Treatment: What does it look like?
Bottom-up in initial stages → reduce risk, facilitate healing (Levine, 2010, Lizarraga, 2016)

Follow-up
Reduce Pain

Training
Skills
Behaviors and
Cognitions

Emotions and Senses

Establish Safety
The Healing
● Created by Dr. Larry Beall, Ph.D.
● Process guided imagery, Not hypnosis

Journey: Rapid Pain ● Induced deep relaxation and subconscious

access

Release (RPR) ●
●
Metaphorical representation of pain
Release pain + improve part interaction = ego
strengthening
● Facilitates bottom-up processing
● Creates space for coping skill acquisition and
cognitive restructuring
The Healing
Journey: Rapid Pain
Release (RPR)

Practice-based

● Trauma
● Anxiety
● Depression
● Grief
● Chronic Pain
● Addiction
RPR:
The Stairs & The Meadow

● Induction technique, deep relaxation

● Descending a stone staircase
● 20 steps, specific relaxation prompt for each
● Further descent, deep relaxed state
● Meadow = Safety framework
● Essential: Pacing, “Take all the time you need”
RPR: The Child
RPR: Packages of Pain
Pain Reduction/Elimination technique

1) Stacking
2) Getting help (as needed)
3) Burning it down
RPR:
The Place of Rocks

Pain Movement and Releasing technique

1) Four Rules
2) Balance, not Vengeance
RPR:
The Cabin

Dissociative Table technique

● Move, Reduce, Release, or Eliminate pain

● Establishing a safe place for all parts
● Parts work
● Addressing the inner critic
RPR:
Higher Self or
Inner Advisor

Resourcing technique

1) Connect with Core Self / Executive State

2) Links past, present, aspirational selves
RPR:
Telehealth
Alterations

● Containment vs. Full release

● Light vs. Transfusion through grip
● Script Adherence
Practice-based
● Intuitive knowing: Experiencing felt sense of
“The Core/True Self”

Evidence: Key ● Autonoetic consciousness: Awareness of self

across time

Findings ●
●
Emotional reaction to the process of RPR
Physical response
● Symbolic representation of pain and energetic
release
Limitations and
● Practice-based, phenomenological strengths
and weaknesses

Considerations for ● Efficacy: Further quantitative study required

○ Assess for adequate changes in levels of anxiety,

Future Study
depression, daily functioning.
○ More test cases
● Contraindications: psychosis/schizophrenia
spectrum
● Other considerations
○ Suitability for manualization
○ Suitability for certain diagnoses (Complex PTSD,
high Dissociative Experience Scale scores)
○ Effects on overall progress in Tx plan
Conclusion
● Trauma treatment is challenging, demands
specialized approach
● Psychodynamic and psychoanalytic approach
work well
● Ego State work precipitates pain release, sets
Tx foundation
● Traumatology needs a push to explore new
methods
● Long history of practice-based effectiveness
merits deeper study
Contact Us
Dr. Michelle

akashahealing621@gmail.com
References
American Counseling Association. (2014). ACA Code of Ethics. Alexandria, VA, USA.

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental health disorders. Arlington, VA: American
Psychiatric Publishing.

Badenoch, B. (2008). Being a brain-wise therapist: A practical guide to interpersonal neurobiology. New York, NY: W.W. Norton &
Company Inc.

Berne, E. (1964). Games people play: The basic handbook of transactional analysis. New York: Ballantine Books.

Beutel, M. E. (2004). Assessing the Impact of Psychoanalyses and Long-Term Psychoanalytic Therapies on Health Care Utilization and
Costs. Psychotherapy Research, 14(2), 146–160. doi: 10.1093/ptr/kph014

Cherry, K. (2015, December 24). About Health. Retrieved April 16, 2016, from What is Top Down Processing:
http://psychology.about.com/od/tindex/g/top-down-processing.htm

Christensen, C., Barabasz, A., & Barabasz, M. (2013). Efficacy of Abreactive Ego State Therapy for PTSD:Trauma Resolution, Depression,
and Anxiety. International Journal of Clinical and Experimental Hypnosis, 61(1), 20–37. doi: 10.1080/00207144.2013.729386
References
Emmerson, G. (2003). Ego state therapy. Bethel, CT: Crown House Publishing, Ltd.

Emmerson, G. (2013). The vaded ego state and the invisible bridging induction. Intl. Journal of Clinical and Experimental Hypnosis,
61(2), 232-250. doi:10.1080/00207144.2013.753835

Emmerson, G. (March 2000: 21, 1). Ego state therapy: Its development and progress in the 20th century. Australian Journal of Clinical
Hypnotherapy and Hypnosis, 1-11.

Forgash, C., & Copeley, M. (2008). Healing the Heart of Frauma and Dissociation with EMDR and Ego State Therapy. New York: Springer
Publishing Company.

Fraser, G. (2003). Fraser's 'dissociative table technique' revisited revised: A strategy for working with ego states in dissociative
disorders and ego-state therapy. Journal of Trauma & Dissociation, 4(4), 5-28

Fraser, G. A. (1991). The Dissociate Table Technique: A strategy for working with ego states in dissociative disorders and ego state
therapy. Dissociation, 205-213.

Gaston, L. (2015, May). Limitations of Trauma-Focused Therapies for Treating PTSD: A Perspective. Retrieved November 15, 2015, from
Traumatys:http://www.traumatys.com/Limitations%20of%20Trauma-Focused%20Therapies%20(Gaston,%202015).pdf
References
Hageman, J. & Frederick (2013). Phenomenological and evidence-based research in ego state therapy: Recognized and unrecognized
successes and future direction. American Journal of Clinical Hypnosis, 56, 65-85.

Herman, J. (1992). Trauma and Recovery. New York: Basic Books.

Hilgard, E. & Hilgard. (1975). Hypnosis in the Relief of Pain. Leavittown, PA, USA: Brunner/Mazel, Inc.

Levine, P. (2010). In an unspoken voice: how the body releases trauma and restores goodness. Berkeley, CA: North Atlantic Books.

Levine, P. A., & Frederick, A. (1997). Waking the Tiger: Healing Trauma. Berkeley, California: North Alantic Books.

Lizarraga, M. J. (2016). Participant experience during a rapid pain release intervention using ego state therapy techniques (Doctoral
dissertation).

Lobenstine, F., & Courtney, D. (2013). A case study: The integration of intensive EMDR and Ego State Therapy to Treat Comorbid
Posttraumatic Stress Disorder, Depression, and Anxiety. Journal of EMDR Practice and Research, 7(2), 65-80.

Maat, S. D., Jonghe, F. D., Schoevers, R., & Dekker, J. (2009). The Effectiveness of Long-Term Psychoanalytic Therapy: A Systematic
Review of Empirical Studies. Harvard Review of Psychiatry, 17(1), 1–23. doi: 10.1080/10673220902742476
References
National Institute of Mental Health. (2015, October 31). Post-Traumatic Stress Disorder (PTSD). Retrieved from
http://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=58: http://www.nimh.nih.gov

Porges, S. (2001). The polyvagal theory; phylogenetic substrates of a social nervous system. International Journal of
Psychophysiology (42), 123-146.

Schwartz, R. (1997). Internal family systems therapy. New York, NY: Guilford Publications, Inc.

Shapiro, F. (1995). Eye movement desensitization and reprocessing. New York: The Guilford Press.

Shedler, J. (2010). The efficacy of Psychodynamic psychotherapy. American Psychologist, 65 (2), 98‐109.

Silva, J., & Fritz, E. (2012). The experiences of educational psychologists who utilise ego-state therapy to address dissociation in
adolescents. South African Journal of Psychology, 42(2), 169-181.

(Solomon & Heide, 2005)

Steinert, C., Munder, T., Rabung, S., Hoyer, J., & Leichsenring, F. (2017). Psychodynamic Therapy: As Efficacious as Other Empirically
Supported Treatments? A Meta-Analysis Testing Equivalence of Outcomes. American Journal of Psychiatry, 174(10), 943–953. doi:
10.1176/appi.ajp.2017.17010057
References
Steinert, C., Munder, T., Rabung, S., Hoyer, J., & Leichsenring, F. (2017). Psychodynamic Therapy: As Efficacious as Other Empirically
Supported Treatments? A Meta-Analysis Testing Equivalence of Outcomes. American Journal of Psychiatry, 174(10), 943–953. doi:
10.1176/appi.ajp.2017.17010057

Terpou, B., Harricharan, S., McKinnon, M., Frewen, P., Jetly, R., & Lanius, R. (2019). The effects of trauma on brain and body: A unifying
role for the midbrain periaqueductal gray. Journal of Neuroscience Research, 97(9), 1110-1140. doi:10.1002/jnr.24447

Watkins, G., & Watkins, H. (1997). Ego states theory and therapy. New York, NY: W.W. Norton & Company Inc.

Van der Kolk, B. (2006). Clinical implications of neuroscience research in PTSD. Annals of New Your Academy of Sciences, 277-293.
Retrieved October 2015

Van der Kolk, B. (2014). The body keeps score. New York, NY: Viking.

Van der Kolk, B., McFarlane, A. C., & Weisaeth, L. (1996). Traumatic Stress. New York: The Guilford Press.

Van der Kolk, B., Roth, S., Pelcovitz, D., Sunday, S., & Spinazzola, J. (October 2005). Disorders of extreme stress: The empirical
foundations of a complex adaptation to trauma. Journal of Traumatic Stress, Vol 18, Vol 5, 389-399.

Ziskind, E. L., & Sweezy, M. (2013). Internal Family Systems Therapy : New Dimensions. Routledge