Frequently Asked Questions

Ego State Therapy is a therapeutic approach that focuses on identifying and working with different "ego states" of a person's personality. These states can be thought of as distinct aspects or "parts" of oneself that hold different feelings, memories, and roles. Everyone has "parts" or sides of their personality but depending on the severity or length of a person's trauma history, these parts can become dissociated from each other, causing internal conflicts and polarization.

In the context of EMDR therapy, particularly for complex trauma and dissociative symptoms, Ego State Therapy is often used during the preparation phase to help clients stabilize and build internal communication between parts. This foundation is crucial for EMDR, which involves processing traumatic memories, as it ensures that the client's ego states are adequately resourced and that there is a sense of internal safety and cooperation.

Technically, there are specific distinctions between ego states and parts but many people use them interchangeably. Some clinicians reserve "parts" strictly for referring to the fully autonomous identities in Dissociative Identity Disorder (DID), but for this conversation I will use them interchangeably. I am loosely referring to fragmentation and rigidity of the personality in response to trauma and not a specific diagnostic category when I use the terms "ego states" and "parts" in these answers.

Complex trauma often involves chronic, repeated trauma, such as prolonged childhood abuse or neglect, leading to fragmented self-experiences and dissociative symptoms. Clients with complex trauma may have developed different ego states to cope with overwhelming experiences. These ego states can become disconnected from one another, resulting in dissociative symptoms like depersonalization, derealization, or identity confusion. Ego State Therapy helps facilitate greater harmony between these fragmented parts by fostering awareness, communication, and collaboration among them, which is essential for safely and effectively engaging in EMDR processing.

Stabilization is a crucial step in the preparation phase of EMDR, particularly for individuals with complex trauma. Ego State Therapy helps by creating a sense of safety and stability. This is achieved by identifying, naming, and dialoguing with different parts or ego states. I help clients recognize and validate the needs and concerns of each ego state, teaching skills for self-soothing, grounding, emotional regulation, and inviting parts to be updated to present time if they are stuck in the past. As a result, clients become better equipped to manage distressing emotions or reactions that may arise during EMDR processing.

Several techniques are commonly used:

• Meeting Room: The meeting room is a guided visualization exercise in which the client pictures a conference room with a table and chairs for parts to arrive and join for interaction. During the exercise I facilitate engagement between the client and the parts who arrive and between the parts themselves. As this is occurring I map out the relationships and characteristics of the internal system. This exercise is versatile and can be used to work out many issues in various ways.

• Resource Development and Installation (RDI): This technique involves strengthening a client's internal resources by identifying and nurturing supportive ego states. For example, a nurturing or protective part may be enhanced to provide comfort or safety when a vulnerable part is activated.

• Safe Calm State Exercise: I help clients create a "safe calm place" for each part to go to when feeling overwhelmed. This exercise promotes a sense of internal safety and grounding. Sometimes certain parts may not want to be present for certain situations, this provides an easy way for that to happen.

• Dialogue with Parts: This involves facilitating conversations between different parts, helping them communicate, negotiate, and develop cooperative strategies to handle triggers or distress. There a several very useful exercises that can be used to help resolve conflict and reduce fear, anger, or persecution among parts.

Ideally all parts are met with, oriented, and become on board with doing EMDR prior to beginning, however there is a sequence to it and some parts are often too fearful to emerge right away. During the preparation phase, I work with clients to identify ego states that are most protective against being activated by trauma-related material or those that feel unsafe, overwhelmed, or resistant to processing. These parts have to gain some trust that working on trauma can be safe and beneficial.

I may use guided imagery, metaphors, or direct dialogue to explore these parts and understand their needs, roles, and concerns. I look for signs of dissociation, such as blank stares, emotional numbness, or "spacing out," which may indicate the presence of disconnected or unacknowledged ego states. I also make sure to facilitate communication with any parts that are engaging in self-harm or introducing thoughts of suicide, to ensure these parts are able to postpone or redirect these protective behaviors long enough to give therapy a chance.

By addressing these parts and ensuring they feel safe and understood, it helps reduce the risk of dissociation during EMDR processing and helps prevent any harmful reactions afterward.

Yes, Ego State Therapy can be highly effective in reducing dissociative symptoms during EMDR therapy. By fostering better communication and cooperation between fragmented ego states, the therapy helps create a more cohesive and stable sense of self. This reduces the likelihood fearful parts blocking processing or dissociating when confronted with trauma-related triggers during EMDR. Ego State Therapy provides tools and strategies for grounding and self-soothing, which are crucial for clients with dissociative symptoms who may struggle to stay fully present during EMDR processing.

The duration of the preparation phase can vary greatly depending on the client’s level of dissociation, the complexity of the trauma history, and the client’s ability to develop internal safety and stabilization. For some clients, the preparation phase may take several weeks to months, focusing on building trust, internal communication, and resource development. The goal is to ensure that all ego states are adequately prepared and that the client can manage any distress that arises during EMDR processing. Moving too quickly into trauma processing without sufficient preparation can increase the risk of destabilization or re-traumatization.

Signs that a client is ready to move from the preparation phase to EMDR memory processing include:

• A strong therapeutic alliance and trust between the client and therapist.

• Effective communication and cooperation among ego states, with reduced internal conflict. Parts have safe places and are oriented to current time.

• The client has the ability to stay present and grounded during distressing discussions or exercises.

• A demonstrated capacity to use self-soothing, grounding techniques, coping skills, and support systems effectively, in session and out of session.

• Agreement from all ego states to proceed with EMDR processing, ensuring a collaborative and empowered approach.

If a client becomes overwhelmed or begins to dissociate during EMDR processing, I will immediately halt the processing and return to stabilization techniques. This may include grounding exercises, engaging in physical movement, or dialoguing with parts to understand the source of distress. I might also use techniques such as "containment" exercises to help the client feel secure.

Ego State Therapy can be revisited to address any emerging conflicts or needs among ego states before resuming EMDR processing. Although it necessary for a client to be present and inside their window of tolerance for EMDR, it is also beneficial to attempt to regulate and resume EMDR if possible after becoming overwhelmed or dissociating. If it's not possible to regulate or a client wants to revisit later, they are always in control and EMDR can be paused.

Yes, Ego State Therapy and EMDR can be integrated throughout the entire treatment process. While Ego State Therapy is primarily emphasized during the preparation phase, it can also be used alongside EMDR processing phases to manage emerging issues or conflicts between ego states. For clients with complex trauma, ongoing work with ego states may be necessary to address new memories, emotions, or symptoms that arise during EMDR. This integrative approach ensures that the client maintains stability and safety while processing complex and often deeply entrenched trauma.

At the severe end of the spectrum, Dissociative Identity Disorder (DID) (formerly Multiple Personality Disorder), is an extreme trauma response where parts of the personality have become unaware of other parts and have their own autonomy, sense of self and age, memories, personality features, and points of view. This is a distinct condition that differs from PTSD, complex PTSD (C-PTSD), or other dissociative disorders.

To give an example, we all have ego states or sides of our personality, the one who shows up at work vs the one who shows up at home. In trauma related disorders with dissociative symptoms these ego states get a little further separated from each other and become more rigid and extreme in their roles and positions. But there is generally awareness and access to the different ego states by the client, the client typically feels like themselves unless triggered, and amnesia is not occurring in everyday life. Some would refer to this as secondary dissociation.

In DID, parts become fully dissociated from each other and often chunks of time or memories of trauma are only available to certain parts. There can be multiple parts who handle daily life with amnesia occurring between them. Some would refer to this as tertiary dissociation. It's a continuum of severity with most people seeking trauma therapy falling somewhere in the middle of single event PTSD and DID.

Engaging in a Ego State Therapy using parts language doesn't mean you have DID, and you don't need to. It's beneficial for trauma work all along the dissociative spectrum. Ego State Therapy also works well for those who do have DID, and with long-term therapy DID can have a better prognosis than other mental health conditions. It's a condition shrouded in mystery, controversy, and stigma, but given the trauma histories people with DID have endured it is entirely understandable why their brain adapted to protect them in that way. The brain is a highly flexible organ and can often adapt back to safety with the right help.