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American Journal of Clinical Hypnosis
Volume 35, Number 4, April 1993
Pages 232 - 240

Ego-State Therapy: An Overview

Helen H. Watkins

University of Montana

Ego-state therapy is a psychodynamic approach in which techniques of group and family therapy are employed to resolve conflicts between various "ego states" that constitute a "family of self" within a single individual. Although covert ego states do not normally become overt except in true multiple personality, they are hypnotically activated and made accessible for contact and communication with the therapist. Any of the behavioral, cognitive, analytic, or humanistic techniques may then be employed in a kind of internal diplomacy. Some 20 years experience with this approach has demonstrated that complex psychodynamic problems can often be resolved in a relatively short time compared to more analytic therapies.

Although the concept of segmentation of personality has been mentioned in the literature for many years (Assagioli, 1972; Beahrs, 1982; Freud, 1923; Janet, 1907; Jung, 1969; Kernberg, 1976; Kohut, 1977), the specific theory of ego-state therapy is attributable to John G. Watkins. Jack, as he prefers to be called, came upon the concept of ego states from Federn (1952) and Weiss (1960), as did Berne (1961) in formulating his transactional analysis.

Together, Jack and I have developed treatment approaches dating from the early 1970s. More recently others have presented workshops and professional papers (Carlisle, 1988; Edelstein, 1981, 1982; Fraser, 1991; Frederick, 1990, 1992; Malmo, 1991; Newey, 1986; Newey & Newton, 1979; Phillips, 1991; Stewart, 1983; Torem, 1984, 1987) that carry on these therapeutic principles, each in their own individually creative way. Such progression in the advancement of this therapy has been particularly gratifying to both of us.


Theoretical Concepts

In approaching the theoretical concepts of ego-state therapy, it is worthwhile to underscore two processes that are cogent in the development of the human personality: integration and differentiation. Through integration a child learns to put concepts together, such as dog and cat, and thus to build more complex units called animals. By differentiation the child separates general concepts into specific meaning, such as discriminating between

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p. 233

"good doggies" and "bad doggies." Both processes are normal and adaptive. Such differentiation allows us to experience one set of behaviors as appropriate during a sporting event and inappropriate at a business meeting. When this separating process become excessive and maladaptive, it is usually called "dissociation."

Psychological processes do not exist on a rigid either/or basis. Anxiety, depression, and other affects lie on a continuum with lesser or greater degrees of intensity. So it is with differentiation-dissociation. Multiple personality disorder (MPD) represents that extreme and maladaptive end of the continuum that begins with normal differentiation. It is a matter of degree or intensity. We are therefore concerned with a general principle of personality formation in which the process of separation has resulted in discrete segments, called ego states, with boundaries that are more or less permeable.

Paul Federn (1952), a close associate of Freud's, made two significant contributions that are relevant to the understanding of multiplicity. First, he believed that whether a physical or mental process was experienced as apart of the self (I or me) or as an object (he, she, or it) was determined by the nature of the energy (ego or object) that activated it. Second, Federn believed that the personality was not simply a collections of perceptions, cognitions, and affects, but that these organized into clusters or patterns, which he called ego states. An ego state may be defined as an organized system of behavior and experience whose elements are bound together by some common principle.

When one of these states is invested with ego energy, it becomes "the self" in the here and now. We say it is "executive," and it experiences the other states (if it is aware of them at all) as "he," "she," or "it," because they are then currently invested with object energy.

Ego states may be large and include all the various behaviors and experiences activated in one's occupation. They may be small, like the behaviors and feelings elicited in school at the age of 6. They may represent current modes of behavior and experiences or, as with hypnotic regression, include many memories, postures, feelings, etc. that were apparently learned at an earlier age. They may be organized into different dimensions. For example, an ego state may be built around the age of 10. Another one may represent patterns of behavior toward father and authority figures and thus overlap on experiences with father at the age of 10. Behaviors to accomplish a similar goal may be uniquely different from one ego state to another, especially in true multiple personalities.


The Role of Hypnosis

Hypnosis is both a focusing and dissociative process (Hilgard, 1986). Through hypnosis we can focus on one segment of personality and temporarily ablate or dissociate away other parts. Too many practitioners today are hypnotically activating covert ego states and announcing that they have discovered another multiple personality. Although multiple personalities are usually studied through hypnosis, they should be so diagnosed only when the ego states (also know as alters) can become overt spontaneously and when the main personality is generally amnestic to what occurs when the alter is overt and "executive." When a covert ego state can be induced to emerge only through hypnosis, we do not consider this as a true multiple personality, and it should not be so diagnosed. We have commonly found ego states among normal student volun-

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teers for hypnotic studies. Because hypnosis is a form of dissociation, it is not surprising to find that good hypnotic subjects often manifest covert ego states in their personalities without being mentally ill.


Origin of Ego States

The development of ego states seems to spring primarily from three sources: normal differentiation, introjection of significant others, and reactions to trauma. First, through normal differentiation the child learns to discriminate foods that taste good and those that are not. The child not only makes such simple discriminations, but also develops entire patterns of behavior that are appropriate for dealing with parents, teachers, and playmates. They are adaptive for adjusting to school, to the playground, etc. These changes are considered quite normal, yet they do represent patterns of behavior and experience that are clustered and organized under some common principle.

As such, they can be considered ego states. The boundaries between these entities are very flexible and permeable. The child is quite aware of her/himself in a playground situation. Playground behaviors and feelings, however, are not as easily activated when in the classroom. There is some resistance at the boundaries. These less clearly differentiated ego states are usually adaptive and are economic in providing appropriate behavior patterns when needed.

Second, through the introjection of significant others, the child erects clusters of behavior that, if accepted by the self, become roles identified as one's own, but if not, these clusters become inner objects with whom he must relate and interact. For example, if a child introjects and forms an ego state around its perception of a punitive parent, that ego state (an internalized object) may be punitive on the child, as was the original parent. The individual may then experience depression or some equivalent painful symptom. The punitive parent continues to live inside the individual, even into adulthood. However, if such an introjected ego state is infused with self-energy, the individual will not suffer internally, but she/he may abuse his own children. Of course, the punitive state, if it becomes overt, may inflict external punishment on the individual -- such as self-mutilation.

The child may also introject the drama of the original parent/child object. For example, if a parent repeated nags a child to study and the child feels resistive to the nagging, it is likely that the child takes into himself or herself both the nagging parent and the feelings of the resistance. By the time the individual reaches college, the nagging and resistance may be internalized, resulting in procrastination. Finally, if the child introjects both parents who were constantly quarreling with each other, then the conflict may have become internalized as headaches or equivalent symptoms, as the two parental ego states battle with each other.

Third, when confronted with overwhelming trauma, rejection, or abuse, the child may dissociate as a survival response. For example, a lonely child may remove part of itself and produce an imaginary playmate with whom to interact. Most children with imaginary playmates discard or repress these entities when entering school. However, if such ego state is merely repressed, later conflict and environmental pressure may cause it to be reinvested with energy and re-emerge, perhaps even in a malevolent form as it did in the case of Rhonda Johnson, who, co-

p. 235

authored the book, We, the Divided Self, (Watkins & Johnson, 1982). It may then be manifested as an alter in a true multiple personality.


Research

Some experimental studies have been done that support the existence of covert ego states. Hilgard (1986) discovered that when a hypnotically deaf subject was told to lift a finger if he could still hear at some level, he did so. He also found that when the pain was presumably eliminated by hypnotic analgesia, the subject, via finger signals, reported that he could (unconsciously) perceive the discomfort. Hilgard held that this represented a covert, cognitive structural system , and he called it "the hidden observer."

We have found that when Hilgard's "hidden observers" were activated in normal college students as hypnotic subjects, further inquiry into their nature and content elicited organized ego states. In one set of experiments we activated "hidden observers" in former ego-state patients using the same procedures and verbalizations employed by Hilgard, repeating both hypnotic deafness and hypnotic analgesia. What emerged was various ego states that I had dealt with in treatment over a year earlier (Watkins & Watkins, 1979-80, 1980). However, rarely were there ego states that had not appeared in treatment, apparently because they were not pertinent to the therapy problem being explored at the time. We, therefore, consider that hidden observers and ego states are the same class of phenomena. They represent cognitive structural systems that are covert, but are organized segments of personality, often similar in content to true, overt multiple personalities.


Integration Versus Fusion

The relationship between the multiple personalities and ego states as found in normal individuals was demonstrated to us through posttherapy reactions given by successfully treated patients with MPD. In these cases, functioning normally, dissociated entities no longer appeared spontaneously. A former patient when asked about one of her personalities simply said, "She was me." The reaction was similar to what one would say if asked about one's behavior at a party the previous week. The previous dissociating boundaries were sufficiently permeable that the patient could now experience her earlier behaviors as part of her self. However, this does not mean that there had been a "fusion" wherein boundaries no longer existed. This point was well brought out by another multiple-personality-disorder patient at the conclusion of treatment. When she was hypnotized, the previous entities reappeared but stated: "We aren't separate persons anymore. We are just parts of her." In other words, the former multiple-personality patient has the same segments, but they are now separated by very permeable boundaries just as in our normal volunteer research subjects. The personality segments had become normal ego states, and the individual had simply moved on the continuum from maladaptive dissociation in the direction of adaptive differentiation.

Perhaps the most efficient treatment of multiple personalities come by aiming at integration, rather than complete fusion. If normal people are rarely (if at all) fused, then why should we aim at that goal in therapy? It has been my experience that bonding some ego states (referred to as alters in MPD) will take place spontaneously if the needs of such states are so

p. 236

similar, and those needs are addressed in therapy, that separation is no longer necessary. Forced fusion by the therapist, however, is likely to produce instability and redissociation. A more economic approach is to move our patient back along the differentiation-dissociation continuum by reducing rigidity of the state boundaries, lessening the conflicts between ego states, and promoting mutual understanding through inter-state communications, somewhat similar to what we would do in family therapy. We do not then need to struggle with that resistance that the various ego states exhibit to maintain their identity and existence, a separateness that may originally have been incurred at attempts at normal, adaptive differentiation. We recognize the original needs but turn them in constructive directions. Our therapy task becomes much easier because ego states, like whole people, fight very hard to retain their separate identities. By not challenging their unique identity but by increasing the communication of ego states with each other, we encourage an adaptive togetherness. The formerly dissociated multiple personality becomes a normal individual, differentiated into cognitively consonant ego states that cooperate in adjusting to the person's inner and outer worlds. We recognize that many MPD therapists equate integration with fusion, and in their treatment seek to eliminate separate ego states by "fusing" them into a oneness. Because normal individuals are not "fused," we believe that such a treatment goal is uneconomic and initiates much greater resistance by various alters. Who wants to be "fused?"


Therapy

Ego states that are cognitively dissociated from one another or have contradictory goals often develop conflicts with each other. When they are highly energized and have rigid, impermeable boundaries, multiple personalities develop. However, many such conflicts appear between ego states that are only covert. These may be manifested by anxiety, depression, or any number of neurotic or somatic symptoms and maladaptive behaviors. For example, we have found obesity sometimes resulting from pressures on the main executive personality by an unhappy, needy, covert ego state. Such conflicts requires a kind of internal diplomacy not unlike what we do in treating true multiple personalities. However, because the contending ego states do not appear spontaneously and overtly, they must generally be activated through hypnosis. We call this "ego-state therapy."

Ego-state therapy is the utilization of family and group-therapy techniques for the resolution of conflicts between the different ego states that constitutes a "family of self" within a single individual. It is a kind of internal negotiation that may employ any of the directive, behavioral, abreactive, or analytic techniques of treatment, usually under hypnosis. As our practice in ego-state therapy has progressed, we have recorded these developments in a number of earlier reports (Watkins (H.), 1978; Watkins (J.), 1976, 1978, 1992a; Watkins & Watkins, 1979-80, 1980, 1981, 1982, 1986, 1990, 1991). It is not unusual for human being to take patterns from their childhood and carry them into adulthood. The woman whose father was abusive who marries one abuser after another is a good example. However, such replication is also true of ego states. The abuse is repeated internally by one abusive state upon another, as well as externally. No wonder it is so difficult to change the external behavior through conscious, cognitive persuasion.

It is not unusual for human beings to take patterns from their childhood and carry them into adulthood. The woman whose father was abusive who marries one abuser after another is a good example. However, such replication is also true of ego states. The abuse is repeated internally by one abusive state upon another, as well as externally. No wonder it is so

p. 237

difficult to change the external behavior through conscious, cognitive persuasion.

It is important for the therapist not to create artifacts, because a highly hypnotizable individual is capable of producing what he or she believes the therapist may want. In our workshops we teach techniques to avoid such pitfalls. In fact, it is not wise to probe for every ego state that might possibly exist inside the patient. Such probing can lead to artifacts. What is important to uncover are those ego states involved in the therapy problem to be explored and then to discover the needs of each state so that these needs can be satisfied in more constructive ways.

Needs are often disguised by behavior quite contrary to the satisfaction of such needs. For example, a punitive state most often has a protective need. As one patient told me many years ago, "I have to hurt her, or the world would hurt her more." Such concrete, childlike thinking is very typical. The child who has been traumatized through abuse dissociates a part that remains as an ego state within the adult and continues to think as she/he did during the trauma. Time stands still for that ego state. This type of ego state needs to learn more constructive behaviors to protect the total personality.

Dependent ego states often need nurturing, which may be provided by "someone inside" in the form of one or more internal nurturing states that are encouraged to do so and are according reinforced by the therapist. Parental states may need to learn more constructive ways of parenting in order to reach their own goals. For example, "I want her to achieve" is not best effected through nagging. Furthermore, "parental" states are usually not really mature. They are often child states that try to act like the original parents, because they were introjected when the patients was a child and hence think like a child. They are reminiscent of the little girl who dresses up in mother's clothing and mimics her.

There are many ways to begin ego-state therapy. A simple method is to hypnotize the patient, either with a formal induction, progressive relaxation, or imagery. (After all, hypnosis is a focusing technique in order to reach inner resources and can be accomplished in more than one way.) Then ask, "I'd like to talk to the part that is upset by what is going on, but if there is no such separate part, that's all right." The latter admonition is to prevent an artifact. The content is determined by the information received from the waking patient. Although one should strive at all times not to suggest creation of a state by the therapist, our experience is that with normal precautions anything of significance is unlikely to be initiated. Even artifacts tend to be very transitory and disappear, because they represent no truly meaningful experience, past or present, to the patient, and with continuous, many-session therapy, fiction tends to get "weeded-out" from fact.

I often use a hallucinated room in which the hypnotized patient sits on a couch while I sit on a chair and then have the patient watch the door to see if "anyone" comes in. There is an implicit suggestion that "someone" may come in, but there is no demand to do so. An even less suggestive way is to ask the hypnotized patient, "I wonder why Mary (name of the patient) has been having those headaches lately?" Or to probe further, "I wonder if anyone can tell me about the headaches (or any other symptom)." An ego state will often make itself known.

Wherever we venture in hypnosis, I accompany the patient so that he or she does not feel alone or abandoned. Sometimes I use a table at which the patient and

p. 238

I sit together and communicate with whomever chooses to enter, thus beginning an internal dialogue. Fraser (1991) developed a systematic way of using a table in a very creative and concrete way. Sometimes an ego state will express itself only through a symptom in the body. For example, a headache may represent a communication from a particular ego state. The capability of the human brain to develop patterns to protect itself seems limitless.

If available, it is useful to contact a "non-egotized" part of the personality, which acts as an observer and is not an emotional participant. It can give information as to the internal status quo, give clues as to procedure, even be able to take the patient back to significant traumas that need releasing and abreacting. It may not be possible to contact the observer except through finger signals, but then not all ego states are verbal, either. Some are mute but may express themselves through finger signals. Some are revealed through somatization. Some are figurative, such as idealized selves. For example, one patient viewed a goddess by a pool who helped the little ones who were hurt. Such visualization may seem like an artifact, but as long as the therapist does not suggest such fantasy, the experience is valid for the patient. For individuals who were severely emotionally deprived as children, the relationship with a caring therapist may be introjected and provide an idealized self. The use of such an internal self-helper (ISH) has been described further by Comstock (1991).

In any event, to be most effective as an ego-state therapist, both nurturance and resonance (Watkins (J.), 1978) are necessary in order to form trust. Being able to think concretely like a child is also helpful, because ego states tend to think concretely and literally. However, the nurturance that heals comes from the inside of the patient as internal needs are satisfied and conflicts are solved. When the internal family is happy, the whole person is well adjusted.

The greatest need in psychotherapy today is to find ways of constructively changing maladaptive behavior more efficiently and in a shorter period of time. Ego-state therapy shows great promise in moving to that goal, where we can provide significant psychological help to more people with modest expenditures of time and cost (Watkins (J.), 1992b).


References

Assagioli, R. A. (1972). Psychosynthesis. A manual of principles and techniques. New York: Hobbs-Dorman.

Beahrs, J. O. (1982). Unity and Multiplicity: Multilevel consciousness of self in hypnosis, psychiatric disorder and mental health. New York: Brunner/Mazel.

Berne, E. (1961). Transactional analysis in psychotherapy. New York: Grove Press.

Carlisle, A. (1988). Dreams in multiple personality disorder and ego state conditions. 5th International Conference on Multiple Personality and Dissociated States, Chicago, IL.

Comstock, C. (1991). The inner self helper and concepts of inner guidance: Historical antecedents, its role with dissociation, and clinical utilization. Dissociation, 4, 165-177.

Edelstein, M. G. (1981). Trauma, trance, and transformation: A clinical guide to hypnotherapy. New York: Brunner/Mazel.

Edelstein, M. G. (1982). Ego-state therapy in the management of resistance. American Journal of Clinical Hypnosis, 25, 15-20.

Federn, P. (1952). Ego psychology and the psychoses. E. Weiss (Ed.). New York: Basic Books.

Fraser, G. A. (1991). The dissociative table technique: A strategy for working with ego

p. 239

states in dissociative disorder and ego-state therapy. Dissociation, 4, 205-213.

Frederick, C. (1990). Rapid treatment of obsessive-compulsive disorder with ego state therapy. 5th European Congress of Hypnosis in Psychotherapy and Psychosomatic Medicine, Constance, Germany.

Frederick, C. (1992). Heidi and the little girl: The creation of helpful ego states for the management of performance anxiety. 12th International Congress of Hypnosis, Jerusalem, Israel.

Freud. S. (1923). The ego and the id. New York: Norton.

Hilgard, E. R. (1986). Divided consciousness; Multiple controls in human thought and action. New York: Wiley.

Janet, P. (1907). The major symptoms of hysteria. New York: Macmillan.

Jung, C. G. (1969). A review of the complex theory. In Collected works (Vol. 8). The structure and dynamics of the psyche. Princeton, NJ: Princeton University Press.

Kernberg, O. (1976). Object relations theory and clinical psychoanalysis. New York: Jason Aronson.

Kohut, H. (1977). The restoration of the self. New York: International Universities Press.

Malmo, C. (1991). Ego state therapy: A model for overcoming childhood trauma. Hypnos, 28, 39-44.

Newey, A. B. (1986). Ego state therapy with depression. In B. Zilbergeld, M. G. Edelstein, & D. L. Araoz (Eds.), Hypnosis: Questions and answers (pp. 197-203). New York: Norton.

Newey, A. B. & Newton, B. W. (1979). Ego state therapy: Everyman a Sybil? 22nd Annual Meeting of the American Society of Clinical Hypnosis, San Francisco, CA.

Phillips, M. (1991). The use of ego-state therapy with posttraumatic stress disorder. 34th Annual Scientific Meeting of the American Society of Clinical Hypnosis, Las Vegas, Nevada.

Stewart, D. L. (1983). Ego state therapy and its relationship to the peri-natal period. First International Congress on Pre- and Peri-Natal Psychology, Toronto, Canada.

Torem, M. S. (1984). Anorexia nervosa and multiple dissociated ego states. First International Conference on Multiple Personality and Dissociated States, Chicago, IL.

Torem, M. S. (1987). Ego-state therapy for eating disorders. American Journal of Clinical Hypnosis, 30, 94-104.

Watkins, H. H. (1978). Ego state therapy. In J. G. Watkins, The therapeutic self, Chapter 22. New York: Human Sciences Press. (See also Chapters 5, 9, 10, 12, 14, & 23.)

Watkins, J. G. (1976). Ego states and the problem of responsibility: A psychological analysis of the Patty Hearst case. Journal of Psychiatry and Law, Winter, 471-489.

Watkins, J. G. (1978). The therapeutic self. New York: Human Sciences Press.

Watkins, J. G. (1978). Ego states and the problem of responsibility II: The case of Patricia W. Journal of Psychiatry and Law, Winter, 519-535.

Watkins, J. G. (1992a). Hypnoanalytic techniques: Clinical Hypnosis (Vol. 2). New York: Irvington.

Watkins, J. G. (1992b). Psychoanalyse, hypnoanalyse, ego-state therapie: Auf der suche nach einer effektivan therapie. (Psychoanalysis, hypnoanalysis, and ego-state therapy: In search of an efficient therapy). Hypnose und Kognition. Band 9, 125-143. (Trans. By Dr. Monika Amler).

Watkins, J. G. & Johnson, R. J. (1982). We the divided self. New York: Irvington.

Watkins, J. G. & Watkins, H. H. (1979). The theory and practice of ego state therapy. In H. Grayson (Ed.), Short term approaches to psychotherapy (pp. 176-220). New York: Human Sciences Press.

Watkins, J. G. & Watkins, H. H. (1979-80). Ego states and hidden observers, II. Ego state therapy; The woman in black and the lady in white. (Audio tape and transcript), New York: Jeffrey Norton.

Watkins, J. G. & Watkins, H. H. (1981). Ego

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state therapy. In R. J. Corsini, (Ed.), Handbook of innovative psychotherapies (pp. 252-270). New York: Wiley.

Watkins, J. G. & Watkins, H. H. (1982). Ego state therapy. In L. E. Abt & I. R. Stuart (Eds.), The newer therapies: A source book (pp. 137-155). New York: Van Nostrand Reinhold.

Watkins, J. G. & Watkins, H. H. (1988). The management of malevolent ego states in multiple personality disorder. Dissociation, 1. 67-72.

Watkins, J. G. & Watkins, H. H. (1990). Dissociation and displacement: Where goes "the ouch." American Journal of Clinical Hypnosis, 33, 1-10.

Watkins, J. G. & Watkins, H. H. (1991). Hypnosis and ego state therapy. In P. A. Keller & S. R. Heyman (Eds.), Innovations in clinical practice: A source book (Vol. 10, pp.23-37). Sarasota, FL: Professional Resources Exchange, Inc.

Weiss, E. (1960). The structure and dynamics of the human mind. New York: Grune & Stratton.

Received September 8, 1992; revised December 11, 1992; accepted for publication January 5, 1993.

John G. Watkins, Ph.D., and Helen H. Watkins, M.A., 413 Evans Street, Missoula, MT 59801.
Received March 4, 1990; revised December 4, 1992; accepted for publication January 12, 1993.

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