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  #1  
Unread May 21st, 2005, 02:03 PM
April Steele April Steele is offline
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Default Imaginal Nurturing

This is in response to some old postings I just came across on the EMDR forum while surfing the net, and so I am responding here. Carol Ann Rowland had heard that Imaginal Nurturing (I-N) is “very soothing” but asked “if it might also be destabilizing for some, if they have a lot of fears around nurturing and feeling ‘need’.”

Sandra Paulsen responded “You nailed that one. Imaginal Nurturing is a procedure that will run afoul of many people's intrapsychic structure, because it will tangle with introjected perpetrators of highly dissociative clients, in many cases.”

Having spent the past five years deepening and fine-tuning the Developing a Secure Self approach (of which I-N is one component), I would like to respond. This is a way of working that I developed to complement EMDR trauma work to address the attachment aspect of clients’ experience. I have trained hundreds of clinicians in Imaginal Nurturing and have not heard of a single case of a client being destabilized by it. This is in spite of the fact that often people complete training workshops and use the approach improperly. On the contrary, clinicians have reported that it is valuable in stabilizing their fragile clients. I now have a book on this method which is included with the workshop to provide greater understanding and be a reference resource. (It can also be purchased separately.) In fact, far from “running afoul of people’s intrapsychic structure”, it helps to strengthen the structure in clients in whom it is inadequate and to soften the defences and strengthen the underlying fragile structure in clients who are highly defended. Sandra’s comment that it “relies upon adult ego strength to fill the gaps” reflects a basic misunderstanding of the process, as it is the therapeutic relationship (an attachment relationship) that is drawn upon to foster the developing ego strength of the client.

Carol Ann’s concern was around fears that a client might have about nurturing and feeling need. This is precisely what I-N can address. So often in the past such clients were assessed as being not ready for inner child work, when in fact this is what they could greatly benefit from *if* the therapist knows how to work with these fears and moves forward in as small steps as needed. Referring again to Sandra’s comment, I would say that the majority of clients are not highly dissociative, most of those who are can benefit a great deal from this approach, and if introjected perpetrators of highly dissociative clients intrude, ego state work is incorporated into the therapy at that point. Using the Developing a Secure Self approach does not mean dropping other approaches, but is rather a systematic way in which to weave experiences of nurturing and connectedness into the therapy to help the client develop a new relationship with self.

Last edited by Sandra Paulsen; August 1st, 2005 at 12:01 AM. Reason: Phrase deleted. Advertising not permitted.
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  #2  
Unread June 16th, 2005, 11:04 PM
Sandra Paulsen Sandra Paulsen is offline
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Default Re: Imaginal Nurturing

Thank you April Steele for responding in depth and thoughtfully to this question. I have a few brief comments:

Ms Steele has said, "the majority of clients are not highly dissociative, most of those who are can benefit a great deal from this approach, and if introjected perpetrators of highly dissociative clients intrude, ego state work is incorporated into the therapy at that point."

Of course the majority of clients are not highly dissociative. However, those few who are are the ones I am referring to whose intrapsychic structure can run afoul of the procedure. In your workshop, there was almost no mention of using ego state procedures with clients let alone dissociative clients. There was no question in the registration process for your workshop that would prequalify registrants as knowing how to use ego state methods, and no training in your workshop for how to use ego state therapy methods. So saying that ego state work should be incorporated if introjected perpetrators manifest is begging the question of how that's going to happen, and how practitioners are supposed to know that they should do that.

Unless you've considerably changed your training, ego state therapy was not a prominent part of the process. (Working only from the adult state to the child state does not ego therapy make).

Let me say clearly that April Steele's contribution is considerable, and that the Imaginal Nurturing method has many strengths and I've benefitted from learning it. However, and having used Ms Steele's method at some length as well as Landry Wildwind's and other resource development and ego strengthening methods for many years, I continue to find that working directly with introjects for complex/dissociative trauma cases is more beneficial than working from the adult ego state. People in my experience respond more viscerally and positively to a remediated introject than to a nurturing adult state.

Again, thank you to Ms Steele for her contributions and her comments here. April, please reply again if you wish. I enjoy the dialogue.

Warmly,
Sandra Paulsen PhD
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  #3  
Unread June 16th, 2005, 11:49 PM
Sandra Paulsen Sandra Paulsen is offline
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Default Re: Imaginal Nurturing

Two more thoughts:

1) Ms Steele said, "Sandra’s comment that it “relies upon adult ego strength to fill the gaps” reflects a basic misunderstanding of the process, as it is the therapeutic relationship (an attachment relationship) that is drawn upon to foster the developing ego strength of the client."

However, it is not a misunderstanding of the process, but merely a reframing of the process in different terms than Ms Steele has used. Indeed the method draws upon the therapeutic relationship, as she has said. However, it delivers the "goodies," the attachment/nurturing goodies, through the vehicle of the adult self, in the voice of the adult self. As one of my clients said to me, "that's what I've always had to do, take care of my needs myself." That client and many others have a deep and viscerally felt sense of relief when the same words (nearly) come from an improved maternal introject. That's why I prefer the latter approach.

2) Ms Steele has said, "Carol Ann’s concern was around fears that a client might have about nurturing and feeling need. This is precisely what I-N can address. So often in the past such clients were assessed as being not ready for inner child work, when in fact this is what they could greatly benefit from *if* the therapist knows how to work with these fears and moves forward in as small steps as needed."

This is a good example of the kind of dynamic that can interfere in a highly dissociative individual. For example, the reason a client might fear nurturing and feeling need is because her mother might have told her she doesn't deserve to live, let alone being nurtured or having feelings and needs honored. An introjected voice of a critical mother might stop any attempt at inner nurturing in its tracks. In Ms Steele's training, she said that this intervention has to be done over and over, many times.

In contrast, I have found that either of these two methods can usually work, namely, either 1) remediating the introject so that it is capable of supplying the nurturing in the minds eye (which I could describe if someone wants to hear it, tho I've done it in this forum before), or 2) if the external mother was just too malignant to imagine improved, then another nurturing external figure can provide the "goodies." In either case the client experiences it intensely and with enormous relief. It doesn't require extensive repetition, which is another reason I prefer it.

I'd urge Ms Steele to not conflate "inner child" work with "ego state therapy," which is similar but not the same.

ASIDE: I have opted for the professional term of "Ms Steele" here, instead of April, simply because it is the convention when we are professionals debating pointy subjects in a professional forum. However, April and I are colleagues and EMDR friends, and I'm sure that's why she is using the term "Sandra" and I'm certain that she means no disrespect by it. So readers don't need to be concerned about that. Professionals commonly have pointy headed debates about fine points of procedures.

IN CONCLUSION: I'll make this final point. The two methods are quite similar in many ways and have an identical goal of strengthening the self and providing long-yearned for felt-sense of nurturing. Both methods rely on the therapeutic relationship and that attachment to provide the vehicle for the nurturing to occur. And both methods prepare individuals for the standard trauma protocol and are an addition to the EMDR practitioner's armamentarium.

And I look forward to seeing what revisions Ms Steele has incorporated into her training since I took it about 3 years ago.

Respectfully submitted,
Sandra Paulsen PhD
Bainbridge Island WA
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  #4  
Unread June 25th, 2005, 09:09 PM
April Steele April Steele is offline
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Default Re: Imaginal Nurturing

Dear Dr. Paulsen,

Certainly I meant no disrespect by using your first name. I am new to this list, but in my 7 years on the EMDR Institute Discussion list (for professionals only) "Dr." or "Ms." has rarely been used, and as I look around this site, e.g. the CBT forum, it seems to be the exception rather than the rule.

I recognize that ego state work is the focus of your interest and approach and wish to acknowledge your expertise in this area. I appreciate your taking the time to respond to my post. I would like to briefly comment on a couple of your points.

In terms of my workshop, I have given it about ten times since Dr. Paulsen took it, and after each, I do more fine-tuning. Though the evaluations have always been high for this training, it is an improved workshop now. The approach itself has been fine-tuned; and the workshop format now includes lecture with clinical examples, one live and two videotaped demonstrations plus several mini-demonstrations, small group discussion, and two practice segments. There is also a 150-page book that is included with registration. One of the challenges I find is that there is only so much that I can put into 13 hours. Sometimes the need for ego state work will come up with I-N; most often it doesn't. I trust that clinicians working with highly dissociative clients have the training and support for doing so. Dissociation and ego state work is not the subject of my workshop and so requesting . (That is Dr. Paulsen's workshop! Moreover, if my approach is used well, with sensitivity to the individual client, the actual need for ego state work (in the context of I-N) is very much minimized. I see no problem with shifting from inner child work to ego state work when needed.

Dr. Paulsen wrote:
"However, it delivers the "goodies," the attachment/nurturing goodies, through the vehicle of the adult self, in the voice of the adult self."

This is absolutely contrary to Imaginal Nurturing. The very first principle of I-N is that the therapist speaks directly to the externalized child as well as to the adult so that the client *hears* the nurturing words. This point is fundamental to I-N work. I take the time in the workshop to demonstrate the difference, having participants take a few minutes to imagine holding a young child and telling her that she matters, that her feelings are important etc. Then I ask them to imagine the child there again while I say a few things to that child. It is a different experience. One can't be in two places at the same time. If you are speaking you can't be receiving/hearing. People typically report that they feel nurturing while they are talking to the child and empowered when they are listening to me. With respect to the client who said "that's what I've always had to do, take care of my needs myself." ... I believe this is reflecting her need to receive which is exactly what happens with I-N.

Dr. Paulsen stated:
"For example, the reason a client might fear nurturing and feeling need is because her mother might have told her she doesn't deserve to live, let alone being nurtured or having feelings and needs honored. An introjected voice of a critical mother might stop any attempt at inner nurturing in its tracks."

I cannot go over all the principles of my approach here. I simply state that I work with this sort of thing all the time (with clients whose mothers ranged from critical to homicidal) using I-N and find it effective.

Dr. Paulsen wrote that two methods she likes are "remediating the introject" and "having another nurturing external figure provide the goodies". She wrote that in either case the client experiences it intensely and with enormous relief, and that it doesn't require extensive repetition. She decries the fact that Imaginal Nurturing is intended to be used again and again.

With I-N, the client may experience "enormous relief" from one session of guided imagery, and in some cases, there have been dramatic shifts. In other cases, the client may report that it was simply pleasant. Clients with dismissing attachment status naturally do not let as much in initially as the preoccupied-status client. An experience of enormous relief is a good thing, but it is a small part of the therapy. One of the main goals of I-N is to facilitate a new relationship with self over time. I do not believe that there are quick fixes for significant attachment issues. I know that two of the therapists I most respect for their work with highly dissociative clients have told me (and others) that they find I-N to be one of the most effective techniques for working with very fragile clients. I do find that the Developing a Secure Self approach (which incorporates the therapeutic relationship seen as an attachment relationship, Imaginal Nurturing, and emotional skills development) and EMDR for traumatic memories is a very focused and effective combination.

Of course, this approach is not the only way, and some clinicians are not going to care for it. For those who do, I have found that often clinicians benefit from some consultation after using this approach with clients for a bit. Like many things, it can take a while to get the hang of it. No, it is not simply inner child work.

Respectfully,
April Steele, MSc BCATR
Nanaimo, BC
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  #5  
Unread June 26th, 2005, 12:20 AM
Sandra Paulsen Sandra Paulsen is offline
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Default Re: Imaginal Nurturing

Thank you for expanding on your comments. I found them helpful, and I'd be interested in seeing the changes in your training since I took it several years ago.

Also, to be clear, I don't care that you call me Sandra, April. I only commented because I'd been contacted backchannel by a lay reader who was concerned about "dispute and conflict and disrespect," and since this has been an issue before on this column when two professionals get in a pointy debate and the public is watching, I thought I'd clarify for the public. It IS quite a different forum than the EMDR list, which is all professionals without the public watching.

So thanks again to Ms Steele for her comments here. We've been discussing various ways to help people recover from early attachment injuries, and we agree that this is one of the thorniest and most rewarding areas to address in therapy, and that EMDR can be beneficial.
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  #6  
Unread July 5th, 2005, 11:17 PM
Carol Ann Rowland Carol Ann Rowland is offline
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Default Re: Imaginal Nurturing

Hi,

I am wondering - and maybe this is a dumb question but I can not figure this out (and to be clear, I have not done the IN workshop though I would like to - I missed it when it was happening locally) - if you are using Imaginal Nurturing with a highly dissociative client, and they are visualizing the child self being nurtured...I find that some DID clients have difficulty in doing this without switching back and forth - they can't feel the receiving and the giving at the same time.

Are there any specific protocols for using IN with highly dissociative clients? In terms of dealing with switching during it (I assume you just go with whatever comes up), or when multiple child parts are involved in the same event - does each part need to process separately? I am assuming so but find it confusing in trying to understand.

Sorry if this is confusing - I feel like I'm not being very articulate
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  #7  
Unread July 5th, 2005, 11:29 PM
April Steele April Steele is offline
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Default Re: Imaginal Nurturing

Dear Ms. Rowland,

I appreciate your interest in Imaginal Nurturing. This is an approach that I began to develop in 2000 to meet the needs of my own clients. I have spent the past five years working intensively to develop it and the broader Developing a Secure Self approach through my clinical work, studying, teaching, consulting and writing. I offer a two-day training workshop in this approach and have written a 150-page book on it.

Sincerely,
April Steele. MSc BCATR
EMDRIA-Approved Consultant and Credit Provider
Nanaimo, BC Canada

Last edited by Sandra Paulsen; August 1st, 2005 at 12:03 AM. Reason: Phrase deleted. Advertising not permitted.
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  #8  
Unread July 5th, 2005, 11:40 PM
Carol Ann Rowland Carol Ann Rowland is offline
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Default Re: Imaginal Nurturing

Hi April,

Yes I am quite familiar with some of the concepts of IN and have the first IN CD, in formats for both genders. I frequently have recommended the CD to clients for use at home, and try to incorporate IN-type imagery into EMDR sessions though I am using mostly the usual EMDR protocol - I really think that incorporating nurturance into it is important, however.

In consulting with a colleague who has taken the workshop with you, she said from what she recalled there are no particular protocols for using IN differently with clients who are highly dissociative.

I am wondering if this is the case or if her memory was simply flawed - sometimes it's hard to absorb all of the information in a workshop. I have looked at her manual but have not had time to go through it in its entirety and would be interested in knowing this before purchasing the manual as much of my caseload does tend to be clients with very severe trauma, who are often highly dissociative.

Take care,

Carol Ann
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  #9  
Unread July 7th, 2005, 12:45 PM
Sandra Paulsen Sandra Paulsen is offline
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Default Re: Imaginal Nurturing

I await Ms Steele's response with interest. In the meantime, I'd add that not only would a highly dissociative DID client have to switch between alters to do the IN work, but in many cases a punitive perpetrator introject would not allow such an intervention to go smoothly. There are blocking beliefs that stand in the way, most notably, the introject believing that they actually are the external perp, that the perp's motives are paramount and that the child self should not be nurtured or receive comfort. Pushing ahead with a nurturing intervention prematurely without adequate 1) training in working with DID clients and 2) use of appropriate ego state interventions to defuse an angry introject could result in destabilizing results. At a minimum, workshop attendees should be cautioned about these possibilities. Certainly, IN should not be touted as appropriate treatment for DID clients if administered by therapists not trained in treating dissociative disorders.

Finally, there are no controlled studies regarding ANY treatment for DID, including ego state therapy, due to the difficulty of research with this fragile and complex population. There are, however, treatment guidelines offered at www.issd.org, which are based on the collective clinical experience of the body of leading dissociation experts.

As always, I urge EMDR practitioners to study dissociative clients and join ISSD. Why? Because EMDR in any form is an associative intervention. What does it associate? That which has been dissociated. We need to understand dissociative disorders before we can claim to treat dissociative clients with EMDR in any of its variants. Excellent online training is available now through ISSD.

Respectfully submitted,
Sandra Paulsen PhD
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  #10  
Unread July 7th, 2005, 05:20 PM
April Steele April Steele is offline
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Default Re: Imaginal Nurturing

Dear Ms. Rowland and Dr. Paulsen,

Ms. Rowland: You have asked about how to use Imaginal Nurturing with DID clients. You “assume that” when they switch you just “go with whatever comes up”. You say that "they can't feel the receiving and the giving at the same time." In fact, no one can, and as I stated earlier, this is directly addressed in the very first principle of I-N. But in any case, with respect, I think that wondering about how to use I-N with a specific population without having mastered the principles of I-N is to put the cart before the horse. Furthermore, while you may or may not have had training in working with DID, I am not prepared to offer consultation on this forum, nor to discuss how to address problems that may arise in using Imaginal Nurturing with a specialized population with a clinician who has not done the training or read my book.

You also ask if in my book I have protocols for working with DID. Like the other components of the Developing a Secure Self approach, Imaginal Nurturing does not consist of protocols but rather principles. So to answer your second question, the book does not contain protocols for using I-N with DID clients (or with any other population). The work is not about plugging in a protocol.

Dr. Paulsen wrote:
“IN should not be touted as appropriate treatment for DID clients if administered by therapists not trained in treating dissociative disorders.”

I am puzzled as to why you persist in this vein. (Maybe you are confusing me with Shirley Jean Schmidt who has put forth her DNMS approach as a possible treatment for DID?) I have never even suggested that anyone work outside their area of expertise such as you are implying. (Nor am I suggesting that Shirley Jean does.) Of course that would be unethical, unreasonable, and irresponsible. For someone who has the training and experience in working with DID, I-N may be found to be useful, however, I have never “touted” it as an appropriate treatment for DID clients... or not. It may be useful at some stages and not at others. As with every client, the therapist needs to use her or his clinical judgement as to clinical appropriateness. I do have colleagues who specialize in the area of dissociative disorders who have incorporated my approach into their work. They are highly trained and skilled, members of the ISSD, and in one case receives consultation from one of the foremost experts on dissociative disorders. And of course, in each case, they use their judgement. This morning, I received a post from a consultee about what good use a DID client has made of I-N, especially in the area of self-care. With another client, it may not be appropriate.

I present my work as an approach to be integrated into one’s practice. One of the keystones of this approach is its responsiveness to the individual client and her or his needs/problems/issues and affect in the moment. One of the reasons I think in terms of principles rather than protocols is that one needs to have the flexibility to be able to respond to a dissociative client (disorganized attachment), differently from a dismissing client, from a secure client, from a preoccupied client. Moreover, the approach addresses the attachment aspects of the therapy. It does not purport to address all of the therapeutic needs of the client.

I find it frustrating to be criticized for statements I have not made, and my approach criticized for concepts that are not part of the approach. I am also perplexed by the hostile tone of your posts and thus am choosing to withdraw from this thread and this forum.

Sincerely,
April Steele, MSc BCATR
EMDRIA-Approved Consultant and Credit Provider
Nanaimo BC, Canada

See Page 2 for continuation of discussion.

Last edited by Sandra Paulsen; August 1st, 2005 at 10:28 AM. Reason: Added one line at end to point to Page 2
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