英文原文
Adults with complex trauma histories often began life with the nearly impossible task of surviving severe, chronic, inescapable trauma, while at the same time attaching to their perpetrators as best they could. This often meant going into developmental arrest at the time of traumas, and creating an internal labyrinth of "locked rooms" or ego states to hold and contain the pain and serve necessary functions for survival and to maintain attachments. The solutions are as variable as the imagination of a child. Our challenge is to understand that child’s solution, and unlock the doors to the house in order to strengthen resources, achieve developmental milestones, detoxify trauma, learn new skills and reclaim tied-up energy. This goal requires resonating with the client with empathy and appreciation, as well as a series of steps to unlock the doors of the client’s divided house.
In Assessment & Containment Phases: SAFETY & STABILIZATION FIRST. A common error is to proceed with EMDR for a dissociative client without ensuring sufficient safety and stabilization for the client. This happens either because of therapist’s falsely believing they don’t see dissociative clients in their practice, therapists failing to screen for and appropriately stabilize a dissociative client before initiating EMDR, or because of overrating the role of abreaction in curing dissociation. Trauma work is a necessary, but not sufficient, part of the treatment picture. The following are some of the other steps that should be taken and/or skills that should be in place before destabilizing a dissociative patient’s self system with EMDR. Sometimes this progress can be created with resource installation, and sometimes it can be more safely accomplished, for a given client, with imagery and/or hypnotic procedures.
Survival/Environmental safety: Does client have food, shelter, etc. Family safety: Is client responsible for vulnerable others such that destabilization is risky? Sobriety/abstinence: Is detoxification or other inpatient/outpatient treatment indicated first? Is abuse occurring now: If abuse is ongoing, client likely cannot yet give up dissociation. Ability to name affect: Alexythymia will interfere with EMDR processing. Ability to tolerate affect: Does patient exhibit phobic avoidance of strong emotion, loss of control, vulnerable child affect. If so, anger protective ego state may need to be negotiated with prior to EMDR, as well as other ego state work. Grounding ability. One or more skills to ensure patient can ground self, e.g. golden cord. Candor: Is patient truthful, so that therapist can rely on patient’s self report. Rapport: Does the therapist have an established relationship with a sufficiency of the client’s self system to count on client’s cooperation. Trust: Are there angry protective alters that will likely sabotage treatment, are they "on board." Phobic avoidance of loss of control: Do the client’s various alters/ego states understand that EMDR will involve a process of various emotions, some of which will be temporarily uncomfortable? Agreed upon emergency procedures: Does therapist have an established and clearly communicated plan with the client for between session destabilization and suicidal ideation or dyscontrol? Contract for no harm and back up plan: Is the client willing and able to contract for safety. Self control procedures including relaxation: Has the patient demonstrated an ability to utilize relaxation, self hypnosis, self talk, and internal dialogue to decrease arousal, increase containment, and stabilize between sessions. Big picture view of course of treatment: Does the client understand that the course of treatment will be a long road, with potholes and vistas, hills and valleys? That encountering painful emotions does not mean that the work has failed and the perpetrator has won, but rather that the next piece of work has peeled up for client and therapist to face together? Support network (family, friends): Does the client have someone besides the therapist to turn to in difficult times? Financial: Is the client’s financial situation and commitment such that treatment can continue without interruption at vulnerable and critical times? Medical contraindications: Any contraindications to proceeding with trauma work? Ability to tolerate positive expectancies, hope. Does the patient have a double bind operating internally such that the experience of hope is unsafe or requires internal punishment?
中文翻译
具有复杂创伤史的成年人往往在生命早期就面临着几乎不可能完成的任务：在经历严重、慢性、无法逃避的创伤的同时，还要尽最大努力与施虐者建立依恋关系。这通常意味着在创伤发生时发展停滞，并创造一个由“上锁的房间”或自我状态组成的内部迷宫，以容纳和抑制痛苦，并为生存和维持依恋关系提供必要的功能。这些解决方案就像孩子的想象力一样多变。我们的挑战是理解那个孩子的解决方案，并打开通往房屋的门，以增强资源、实现发展里程碑、解毒创伤、学习新技能并收回被束缚的能量。这一目标需要以同理心和欣赏与来访者产生共鸣，以及一系列步骤来打开来访者分裂房屋的门。
在评估和稳定阶段：安全与稳定优先。一个常见的错误是在没有确保分离性来访者足够安全和稳定的情况下进行EMDR治疗。这可能是由于治疗师错误地认为他们的实践中没有分离性来访者，治疗师在开始EMDR前未能筛查和适当稳定分离性来访者，或者高估了宣泄在治愈分离中的作用。创伤工作是治疗图景中必要但不充分的部分。以下是在用EMDR破坏分离性患者自我系统之前应采取的其他步骤和/或应具备的技能。有时可以通过资源安装来取得进展，有时对于特定来访者，通过意象和/或催眠程序可以更安全地完成。
生存/环境安全：来访者是否有食物、住所等。家庭安全：来访者是否负责照顾脆弱他人，以至于不稳定有风险？清醒/戒断：是否需要先进行解毒或其他住院/门诊治疗？虐待是否仍在发生：如果虐待持续，来访者可能还不能放弃分离。命名情感的能力：述情障碍会干扰EMDR处理。容忍情感的能力：患者是否表现出对强烈情绪、失控、脆弱儿童情感的恐惧回避。如果是，可能需要在EMDR前与愤怒保护性自我状态进行协商，以及其他自我状态工作。接地能力：一种或多种技能确保患者能自我接地，例如金线。坦诚：患者是否诚实，以便治疗师可以依赖患者的自我报告。融洽关系：治疗师是否与来访者足够多的自我系统建立了关系，以依赖来访者的合作。信任：是否有愤怒的保护性替代人格可能破坏治疗，他们是否“参与其中”。对失控的恐惧回避：来访者的各种替代人格/自我状态是否理解EMDR将涉及各种情绪的过程，其中一些会暂时不舒服？商定的应急程序：治疗师是否与来访者建立了明确沟通的计划，用于处理会话间不稳定和自杀意念或失控？无伤害合同和备用计划：来访者是否愿意并能够签订安全合同。自我控制程序包括放松：患者是否展示了利用放松、自我催眠、自我对话和内部对话来降低唤醒、增加稳定性和在会话间稳定的能力。治疗过程的大局观：来访者是否理解治疗过程将是一条漫长的道路，有坑洼和远景、山丘和山谷？遇到痛苦情绪并不意味着工作失败或施虐者获胜，而是下一部分工作已经浮现，需要来访者和治疗师共同面对？支持网络（家庭、朋友）：来访者是否有治疗师之外的人在困难时期可以求助？财务：来访者的财务状况和承诺是否允许治疗在脆弱和关键时刻不间断进行？医学禁忌症：是否有任何进行创伤工作的禁忌症？容忍积极期望、希望的能力。患者是否有内部运作的双重束缚，使得希望体验不安全或需要内部惩罚？
文章概要
本文探讨了成人自我状态在安全协议和应急准备中的关键作用，基于Sandra Paulsen博士关于EMDR和自我状态治疗在分离性连续体中的应用。文章强调了在治疗分离性障碍时，安全与稳定必须优先于创伤处理，详细列出了在开始EMDR前需要评估和建立的多个安全维度，包括环境安全、情感容忍能力、应急程序等。这些措施旨在确保成人自我状态能够有效参与治疗，防止治疗过程中的不稳定和风险。
高德明老师的评价
用12岁初中生可以听懂的语音来重复翻译的内容：想象一下，有些大人小时候经历过很可怕的事情，为了活下去，他们心里就像建了很多小房间，把痛苦锁在里面。现在治疗就像打开这些房间的门，但首先要确保他们现在是安全的，有吃的住的，心情也能稳住，不会太害怕。治疗师会检查很多方面，比如他们能不能说出自己的感受，有没有人帮忙，甚至钱够不够看病，这样才能安全地开始治疗。
TA沟通分析心理学理论评价：从沟通分析心理学角度看，本文强调了成人自我状态在安全协议中的核心作用。成人自我状态作为理性、客观的部分，在处理创伤时需要被充分激活和稳定，以协调父母自我状态和儿童自我状态之间的冲突。安全协议的建立本质上是强化成人自我状态的资源，使其能够有效管理内在的儿童自我状态（如脆弱、恐惧部分）和父母自我状态（如批判、保护部分），从而促进整体自我的整合。这体现了沟通分析中“我好-你好”的生命位置，通过增强成人自我状态的能力，来访者能更好地应对现实挑战，实现健康的心理适应。
在实践上可以应用的领域和可以解决人们的十个问题：在实践上，这可以应用于心理咨询、创伤治疗、危机干预、心理健康教育等领域。可以解决人们的十个问题包括：1. 帮助创伤幸存者建立安全感，减少日常焦虑；2. 改善分离性障碍患者的自我管理能力，提升生活质量；3. 增强个体在压力下的情感调节技能，防止情绪崩溃；4. 促进家庭和治疗关系中的信任建立，减少冲突；5. 支持职场人士应对工作压力，提高抗压能力；6. 帮助青少年处理成长中的情感困扰，促进健康发展；7. 辅助成瘾康复者维持稳定，预防复发；8. 提升应急响应人员的心理韧性，优化团队协作；9. 改善人际关系中的沟通障碍，增强社交技能；10. 为普通人群提供心理预防工具，增强整体心理健康。