Interview with Sandra Paulsen
"Very early trauma and neglect causes injury that the young child simply has to grow around... it is no longer easy to remove"
Interview by Ben Scanlan
The early trauma and EMDR specialist talks about dissociation, ancestral wisdom, and adapting her brief intensive model of therapy to the changed world of the COVID-19 pandemic.
Hi Sandra, can you give me a bit of your background and how you ended up writing these two books we’ve reviewed?
I started out in anthropology, dropped out to work as a technical writer, then financed my return to school in psychology at UC Berkeley by starting a consulting business in business writing. I chose the University of Hawaii because they had a cultural psychology emphasis, even to the exclusion of the DSM until the predoc internship. I loved that. So, I was licensed in 1988 as a cognitive behavioural psychologist in Hawaii, was Acting Chief psychologist at the Queens Medical Centre in Honolulu. And then a friend demonstrated EMDR – or really just the eye movements – and I realized something was happening there. Got trained in 1991 and almost immediately started uncovering dissociation, which I had not heard about except as a culturally bound phenomenon such as koro, amok, ataques de nervios, latah in traditional cultures around the world. I got myself trained in dissociation right quickly, so I always used EMDR and ego state therapy together. I got Francine Shapiro’s attention to the phenomenon of dissociation but largely she accepted it only in the most severe form, whereas I was understanding the self-system of all people in terms of inner conflict and degree of dissociation and disconnect, by 1993. The first article I published was in 1995 on ego state therapy.
Can you give me some background as to how you were drawn to working with people who dissociate?
It’s more like dissociation kidnapped me, by manifesting in my practice. I could see and feel people switching in my office. Because I’d been part of an anxiety clinical team at Queens Hospital, before going out in private practice, I got referred PTSD, which people understood to be an anxiety disorder. But when you scratch the surface of severe PTSD, you find dissociation underneath in some cases. So, learned to do that to prevent harm. And I learned how to work with the structure of the self-system to optimize EMDR outcomes.
How do you conceptualise dissociation? In your experience is there a difference with the concept of “dissociation” depending on when the event, or events, happen to the person who’s dissociating?
Dissociation is what happens when something is too much to process at the time, so it is set aside. Like sweeping something under the rug if you get the phone call that the Governor is coming to tea in five minutes. It’s the right thing to sweep dust under the rug and vow to deal with it later. That’s PTSD. But if it becomes a habit, a chronic way of coping, to always sweep things under the rug to avoid dealing with the necessary painful emotions and insights and body sensations, then that becomes dissociation as in a chronic structural problem within the self. If you lobbed the garbage over a wall because the Governor was coming, well, go clean it up later and you’re good to go. But if you lob the garbage over the wall habitually, after 20 years you have a significant mountain of garbage, and lots of complications, stink and rats and illness. So severe dissociation has many complications, chronic depression and anxiety, intermittent eruptions of rage alternating with helplessness and despair, somatic alienation, phobic avoidance of mental contents, intense internal conflicts mostly around loyalty to the aggressor.
And yes, developmental stage at the time of the trauma is a dispositive element in the outcome. If one had a peachy keen childhood with loving parents, and then at age 22 was in a fiery car crash where one lay in a ditch for hours, one might dissociate for the first time as a survival strategy. But that’s much easier to treat, as simple PTSD really. It’s as if the unprocessed pain, terror, grief, is set aside in a closet and later it can be readily addressed.
But when from one's earliest age, each developmental milestone is complicated or missed because of danger, trauma, neglect, insufficient help, whether it is from malignant parents or some other circumstance, the whole self gets developed around the trauma. I have a giant cedar tree in my yard that has grown around a stone. That’s how dissociation manifests when the trauma and/or neglect starts right out of the shoot. It can even begin in gestation, if the environment is dangerous and mother can’t resonate with her developing child. I’ve seen it plenty.
Just to pick up on the last point you made there, how do you work with somebody who’s the child of a mother who couldn’t resonate with her developing child?
Oh, that’s a lot of my clients. For each missed developmental milestone, we hear the particulars of the child’s experience as it is revealed in the nonverbals, including therapist mirror neurons, the relationship field, the energy field, the client’s felt sense, and more, and then we repair it in imagination. We go sequentially, integrating from the bottom up, that is, from the beginning of life. This is based on Katie O’Shea’s model which I extended. So, the person ends of with the felt sense of getting what they needed on their own terms.
You use ego-state therapy; can you explain why this speaks to you and how you use it alongside your other modalities?
Because it works well with nearly all humans. I collaborated for a time with John G Watkins, the father of ego state therapy. I’d actually been using it before I met him, thinking I’d invented it. He liked to tease me by saying he’d stolen it from me in 1947, before I was born. But that’s how natural a thing it is, it keeps getting rediscovered. Jack called it a hypnoprojective technique. So, we ask the client to glance into the mind’s eye and tell us what they see. I use conference room technique or dissociative table, Fraser 1991, though it had also been used by others, George formalized it. What they see projected into that internal space is the very matter under discussion, including the internal conflicts or dynamics associated with that matter. It’s just so quick, so deep, so profound, for a great many people.
You mention the conference room technique and dissociative table, could you say a little more about what they entail?
Same procedure by two names. Therapist asks client to “glance” into a space in the mind’s eye, whilst in the midst of discussing an issue. What appears is a hypnoprojective representation of the dynamics surrounding that issue. Over time one loads it up with resource images such as a microphone for mute parts, a container for unprocessed trauma, and so on. It’s the x-ray to the soul Freud was looking for. I can’t imagine working without it. It goes to the heart of most things. And loyalty to the aggressor is often visually represented there as one’s parent or perpetrator.
While researching you I was struck that you offer short term, intense work over a number of days. Could you describe what that could look like, as I’m more used to the weekly, or twice weekly, model of talking therapy?
Before COVID, I only worked in the three full consecutive day format. This allows deep work, the person is less distracted by daily life, and really is motivated to allow me to do what I can do. I can immerse myself and my intuition into the task of really deeply discerning the issues, the internal relationships between aspects of self. There is a dropping down into the felt sense of the body that’s hard to do in a short session. I can train someone how to do that typically, though some are so somatically dissociated, as distinguished from structurally dissociated, that they can’t. For those, I recommend low dose naltrexone, as described by my colleagues Ulrich Lanius and Frank Corrigan. It really allows somatic access. If you mean how it's structured, we take breaks every 90 or 120 minutes, and I’m rather focused on using the time efficiently. They stay at a hotel or Airbnb nearby. My office is in the forest on Bainbridge Island, so it’s like a sweet treat retreat. It is canine assisted and equine assisted (the clients visit the horses during the breaks if they like. No riding). My office is on four acres.
You say before COVID, have you had to adapt your process? It doesn’t sound like the sort of thing that would be easy to do online…
I used to work for three full days with one person but the risk of a big viral load is too great during the COVID era. I really prefer working the long sessions because a) the client is better able to somatically drop down, and learn to do so if they don’t know how, without immediately thinking about leaving as in a shorter session, and b) I can better attend to all the threads of information in the energy field and the relationship field. In a shorter session I might forget the ephemeral threads that I may not have become fully aware of yet in a short session, but they weave a tapestry of a theme in the longer sessions. But I do like working by video too, because I’m a hermit, so it suits me. My intuition works online too, which I find odd, but I can still feel the client’s bodily shifts in my mirror neurons even thousands of miles away. The other advantage of telehealth for doing deep work is that the client is safely ensconced at home, one hopes, so they feel secure in their home field. Others prefer my retreat like setting in the forest, far from their urban environment typically. It worked better than I expected to do early trauma work by telehealth, except for the short sessions. I haven’t been able to force myself to do all day sessions by telehealth with a single client. It’s too tiring, and I’m at an age where I’m no longer willing to torture myself for a living.
I’m asking this as somebody who works in the ‘traditional’ fifty-minute, weekly way, and have only experienced group therapy over a weekend, I’m wondering whether given the, presumably, intense emotions and the definite outlay financially, is there a way to make what you offer more accessible?
There may or may not be intense emotions, typically people do weep. They are less defended or if the defences are there I work with them directly using ego state therapy, or somatic therapy. Usually loyalty to the aggressor is the rate limiting step in the work. I find it easier to work in this format, but it’s not for everyone. One does have to be discerning about who one works with in the intensive format. It’s too potentially destabilizing for DID (Dissociative Identity Disorder) individuals, so my phone intake is looking to see whether the person is safe to treat this way. Especially because they often are - or were before COVID – flying in from afar for the occasion.
How do you integrate working with your therapy dogs?
My crack team of professionals, Abbe and Coco, and before them Michelle, really are the grounding professionals. Toy poodles are smart. So instead of saying, “times up!” or “time for lunch” in the middle of the client’s poignant internal moments, I’m saying, “Coco, go say bye,” and the client is so delighted and charmed, typically, that its very smooth. Also, it’s a ventral vagal connection, to use Stephen Porges' polyvagal understanding of the resourced and connected state. So that’s all good, very good. They don’t have to work too hard. One of them is very attuned to the client’s feelings, that’s Coco. Abbe not so much; she just wants to sit in my left armpit. So one for the client, one for me. Makes it lovely. Coco is so gifted with clients, she’ll find the precise moment that a client is realizing and feeling their most poignant pain of abandonment, say, and she’ll come over, put her two paws on their chest over their heart chakra, and look soulfully into their eyes. I can connect from across the room, but Coco does it in that animal way.
I’m interested in how your academic experience looking at cross cultural psychology impacts how you work with clients?
First thing is that I have only one toe in the model of biopsychiatry. I was trained to understand that things like depression or other symptoms are there for a reason, and that there are cultural variations in how these things are displayed. This is truer with traditional/indigenous cultures, less true for the Westernized cultures which start to resemble each other. The more Westernized a people becomes, the more their identities and then their trauma response resembles Westernized identity and its pathologies. But traditional cultures often view symptoms not as pathology per se but as a sign something is out of balance, or a sign of being out of harmony with rightful living in nature, and so forth. So, whoever comes to me, as part of my intake I inquire about where they come from, or who their people are, when any immigration occurred. So, I understand if they are informed by dominant culture understandings or some other tradition, whether Native American/First Nations, or Filipino, or Black American or Black African or Chinese or Japanese. Its endlessly interesting to understand. It also influences the metaphors I choose to persuade or facilitate transformation and storytelling. It also seems to influence my intuition. As if people from certain cultural traditions of spiritual or energetic healing, and ancestors whose teachings were of that nature, potentiate my own intuition. Sometimes it feels as if the air is full of “help” from the ancients. One never knows if this is true, but if the client and I both believe it and connect that way, then surely SOMETHING is potentiated between us for their healing.
You mention using the Red Road spiritual pathway (I’m not sure about my language choice here) on your website – is this a personal thing, professional or a holistic way of being?
I don’t want to be cavalier about this, because Native American/First Nations people who REALLY truly walk the Red Road have a much harder life than I do. They are living in a collective format knee-deep in cultural traditions and ceremonies and understandings. I mean to communicate by that phrase that I’ve been learning and taking in from especially Plains peoples for a great many years. The Native way of being and understanding, to the degree I can hold it and keep it with me, informs my work in many ways. It’s also where I do my pro bono work, for various tribes and consultation to clinicians for many years. And I collaborate with my Blackfoot friend, Shelley Spear Chief, on several projects. My own people came from Norway, all of them. Well there was that one Dane eight generations back or something but he moved to Norway. But I was raised on the prairie, when it was just grass and farmlands and a couple rivers and the trees along the river. Not much urban at all. And in that growing up, the four directions, plus sky and earth, so the six directions, were the most salient aspects of life. I understand how the Lakota people made those six directions the basis of their cosmology, so I feel connected. Growing up, my play was much more about nature than toys really. The river, the mud, the trees, informed my play and also my values. That’s where I became attuned to energy, so I have a natural affinity to the plains way of being. But like I said, it’s not the same as living in community with others who are themselves Native people who are connected by shared history and ancestors and traditions. I’m not confused about that. And I’m Christian, but not fundamentalist. To me the Christ awareness is similar to what’s in the air in nature, infinite radiant love and compassion. Some Native people are Christian and some are triggered by the Church because of its role in the traumatization of Native people including residential schools and more. These are very complex subjects with much nuance and variation tribe to tribe. But I respect the traditional ways of understanding and want to help them be conserved. We have more than enough modern life, and need a little more of the ancestral understandings. Including my own Norwegian ancestors as far as that goes.
Where do you see therapy generally going over the next generation?
I wish we could grab the DSM by the spine, shake it, and have all the diagnoses shake out organized around trauma. Much, though not all, of the pathology I see and treat is a direct result of trauma, whether in adulthood, like PTSD, or early childhood, like personality disorders, or lifelong anxiety, depression, and certain other disorders. Those symptom clusters are shrines to what did and didn’t happen to the person. The particular symptoms reflect the developmental stages at which trauma and/or neglect occurred. So, for example, when I see someone who is very destabilized and dysregulated, I hypothesize about the first year of life. If there is annihilation terror, it’s the first say six months of life. If there is life long low self-esteem and anaclitic depression, that infants’ emotional needs were not met. Character disorders and traits are the first few years, often. I mean you can tie the personality traits to the developmental milestones in some cases, so trust and autonomy issues, and generalized anxiety, and dependency, and on and on. When we do the early trauma approach of EMDR, originated by Katie O’Shea and expanded by me, we can actually repair those early injuries.
Also, an initial assessment that looks to see whether the client can tolerate positive and negative affect and soma points to whether treatment needs to include somatic work to address somatic dissociation or alexithymia. Before EMDR or any trauma processing method is used, assessment of whether there are structural dissociation points to the need to use ego state therapy to address defensive structures, especially that gnarly loyalty to the aggressor. So, we have a lot of these pieces in place. But the cornerstone is adaptive information processing that pulls it all together, Francine Shapiro’s OTHER contribution. She discovered the effect of eye movements, but she developed AIP Theory. It needs to have even more acceptance, but the politics, as usual, resist change. The power that be like to keep their power. But the healing of EMDR speaks for itself. Thirty years I’ve seen so many miracles of healing occur before my very eyes, thanks to the capacity of EMDR to catalyse the brain’s natural healing tendency. The other things I’ve mentioned – somatic work, ego state work and the early trauma approach, all address various other obstacles that interfere with EMDR. There are also some other things I call Neuroaffective elements, that include Katie O’Shea’s resetting the affective circuits (she calls it reinstalling innate resources, but I call it resetting the affective circuits in honour of the late great Jaak Panksepp who founded the field of affective neuroscience, and scientifically proved the existence of innate emotional circuits). He adopted my drawing of his model of affective neuroscience and used it in his 2011 book with Lucy Bivens, Archaeology of Mind. He and I went through a dozen revisions of it until he was pleased with it.
Other Neuroaffective elements I sometimes use include cranial electrical stimulation, the soft laser stimulation which adds energy, and LENS neurofeedback. All these methods are disruptive, in that they disrupt habitual wagon rutted roads or neural pathways. They also add energy which gives the brain just the boost it needs to find a new pathway. So, all that is consistent with AIP and EMDR itself is disruptive. So, the future of psychotherapy needs to show a widespread understanding of these methods and principles, so it’s not just a few of us saying it. My colleagues Ulrich Lanius and Frank Corrigan and certain others are among the few. We don’t need to discard CBT and psychodynamic theory, by any means. But there are people reconfiguring them in terms of affective neuroscience and developmental neuroscience, such as the contributions of Alan Schor and Bruce Perry and Dan Siegel. Fun fact: Bruce is also from North Dakota and also connected to the First Nations/Plains people. So, I think we can embrace both leading edge science of affect and development and the brain, AND honour what the ancestors knew and teach if we have ears to hear.
Finally, you’ve asked for a specific picture to be included of a giant cedar tree in your yard that’s grown around a stone over the years. Can you say why this speaks to you?
I think that very early trauma and neglect causes injury that the young child simply has to grow around. Once thoroughly ensconced in the child’s developing character as milestones are impacted, it is no longer easy to remove, without the kind of procedures we use in the EMDR Early Trauma approach for implicit memory. In this picture, we can almost see how the stone has become ego syntonic to the tree, which has only known life with this obstacle and accommodation.
That’s pretty wordy, but it says something I have never put in words before, and it’s really important about my work, and a lot of people's experience in the world.