Thank you for coming. This is going to be an introduction to the Internal Family Systems Model. We're gonna talk about it as an emerging evidence-based tool for trauma-sensitive addiction recovery. I'm Zev Shuman Olivier. I am from Harvard Medical School, an addiction psychiatrist, associate professor, and the director for the Center for Mindfulness and Compassion. And I feel blessed to have the opportunity to work with such a great team today. And we're gonna start with just noting the disclosures here. I'm not gonna read them, but you can see them. And the goals for today are going to be to explain the level of emerging evidence behind the Internal Family Systems approach for people with PTSD and comorbid PTSD and substance use, and talk about some promising scientific or mechanistic, mechanisms of action, sorry. We are also gonna talk about how PTSD actually, how IFS can actually be applied for people with PTSD and SUD. And you should be able to show you a demonstration of that today. And then finally, we're gonna talk about how these different IFS techniques can help to address some specific aspects of substance use treatment, like ambivalence and shame. So I wanna start by introducing Charlie Silberstein, who is a incredible clinician, and well-known to many here at AAP. I'll turn it over to him. Thank you, Zev. So, the important part of this is that I've been training in IFS since 2012. And for me, it's been a profound experience and transformation in every aspect of what I do as a psychiatrist, as an addiction psychiatrist, as a psychopharmacologist. And so I'm gonna try and give you a very quick whirlwind tour of what IFS is about. And then we're gonna show a clip for about 20 or 25 minutes of Richard Schwartz, who was the founder of IFS, working with somebody who has addiction issues. So, I'm not gonna go into that. So the point of IFS is that the idea is that we all contain a multiplicity of parts or subpersonalities, some people don't like that term, also known in the CBT world as self-schema, or if you like the Disney world, Inside Out, which actually was a film that was inspired by IFS and IFS consulted on it. But the idea is that we all have internal parts. The problem with the Inside Out schema is that it's anthropomorphizing parts and many parts have qualities of fog or animals, but at any rate. So the idea is that these parts within us, these subpersonalities have their own ways of feeling, thinking, behaving, and they're often linked with somatic experiences and memories. I mean, think of the somatic experience you have when you're scared or that an addict has when they're thinking about picking up. So in the schema, there are three types of parts and there's a part of all of us that is vulnerable and might feel alone or abandoned. Usually these parts identify as feeling very young or sometimes teenagers. And then there are the parts that protect those vulnerable parts. And you can think of them as defenses, but they might be people-pleasing or envy or anger or guilt or shame. And these parts, these protectors, are there to protect these vulnerable parts. And there's an idea in IFS that all parts are well-intentioned. They're all there for a reason, trying to be helpful. So the idea is no bad parts. And there are two kinds of protectors. There's a protector that carries extreme energy and then wherever there's a part that is carrying extreme energy, there's a part that tries to manage that part. So an extreme part, let me give you an example of an addict who grew up in a home where they were often criticized, alone, abused in various ways. And so they have a protector that seeks comfort and that protector in adolescence might learn that alcohol is a way to soothe themselves and protect themselves. So it will do whatever it takes to feel comfortable. And then there's another part that says, whoa, don't do that. And I think we all know that from our experience as addiction psychiatrists that wherever there's an impulse to use, there's another part that's saying don't do that. And both of those parts are protecting somebody who's more vulnerable inside. And now I said there's three parts. There's a, you could think of it as four, but there's also in the IFS model, a core self. And this is a mnemonic for understanding the core self. There are, they call it the eight Cs. But the idea is that there's a core self that should be, that we want to cultivate as the conductor of the internal orchestra. So the IFS Institute used to be called the Institute for Self, what is it, Dev? Self Leadership. So the idea is that the self should be the leader of this internal orchestra. And the self, you could think of it as being like a good teacher, a good parent, having compassion, curiosity, a good psychotherapist. And as an IFS therapist, I think of the self as really doing the therapeutic work. And I'm a guide that helps the self and helps to empower the self to do the work with the parts. So you probably can't see this very well if you're in the back, but what I want to focus on is the therapy goals for each part. So one of the central things in IFS is for the core self to differentiate from the parts and to help the parts to unburden the exiles in the IFS lingo are those vulnerable parts. The managers are ones that might be trying to suppress the exile from being exposed or hurt. And the firefighter is the part that is gonna do whatever it takes to help that vulnerable part. So the reason in the lingo it's called a firefighter is the idea is that a firefighter will run into a building without any consideration of what the collateral damage is. So a part that is suicidal, say, is gonna do whatever it takes to get that person out of their unhappiness and out of their trap, even if it means killing them. So as part of the world, when TOR, in the therapy that we do, there's a kind of protocol which as you become more trained in IFS becomes somewhat flexible. But you're gonna see this in the tape with Dick Schwartz where he finds a part, he focuses on a part. And unlike most of what we do in psychotherapy, where we find a target part and spend a lot of time working with that part, getting to know it, getting to know how old it is, what its physical sensations are, what its memories are. And then in de-centering or unblending from that part, we ask the question, how do you feel toward that part, which inspires this self, the higher self, to have a relationship with the part or and befriend the part and appreciate the part that like a suicidal part, we have kind of all been trained to make contracts with people to suppress the suicidal part. In IFS, we make friends with the suicidal part and it relaxes because it feels understood. And then what are you afraid would happen if you didn't do that job that you're doing of making this person drink or feel suicidal? And the answer is often surprising. I'm afraid that I would be left alone and miserable and depressed and I wanna get out of that. So this is a schematic of the IFS unblending, which is the first six Fs. And then some of the things we do, which you're not gonna see today because there's just not time, but often there's a witnessing of what the experience was of those vulnerable parts. There's the self taking care of that vulnerable part, retrieving memories and unburdening the part, helping it to let go of the burdens it carries in integration. And we'll show you just a few minutes of integration at the end of the video, which is of Dick Schwartz who came to IFS from family therapy with the idea that we have this internal family that has relationships with each other, not unlike in that picture of the inside out world. So here is the video and we'll talk in 23 minutes. Great. Can we turn the lights down? Yeah, so welcome. Did you have something in mind you wanted to start with? I don't have like one target in particular, but the conversations that we were having, I had, I feel like a bubbling up with many, many different parts because these are topics that I have a lot of thoughts and opinions about. Okay. So maybe just take a second and focus inside and just ask which of those parts wants attention right now first. I think the first one is a part that feels anxious about becoming vulnerable in a group. Yeah. Okay. Yeah. And again, if it's worried about judgment, I won't be judging you, I promise. And this group has seen a lot of vulnerability and I hope you're trusting now more that others aren't gonna be judging you either. So see if that helps the part or if it needs more. This part isn't really afraid of judgment, it's more like looking to impress, like it wants to say really smart things and have people be like, ooh, that was really, you know. Okay. And how are you feeling toward it as you notice it? Kind of a sense of humor. Yeah. So does it need any more to step back or is it willing to take the risk that maybe you won't be so impressive? Yes, that sounds like a terrible proposition, but it's stepping back. And then who's next? I think that the part that came to mind first is a self-like part that I call the yogi. Uh-huh, great. So go ahead and find that one in your body or around your body. Yeah, I feel it sort of in the sheath of my skin. So kind of throughout the field of the body, but just kind of on skin surface level. Okay. And as you notice it, how do you feel toward it? Grateful. So let it know that and see how it reacts to your gratitude. There's a softening of the skin. Good. And just ask what it wants you to know about itself, Esteban. That it has my best interest at heart. Uh-huh. Okay. Yeah, and how does it manifest? What does it do in there? It coordinates basically systems of healing and wellness and practice. Okay. So that all sounds valuable. But ask it what it's afraid would happen if it didn't do this job. Yeah, well, it's saying I would fall apart. And it's funny because I'm feeling it very much that skin kind of full body sheath is like an exoskeleton that's holding me together. Okay. And ask for a little more clarity about what it would look like if you fell apart. I would devolve back into unbeneficial habitual tendencies and addiction. Okay. So it's trying to keep that at bay. Yes. Okay. So again, let's extend a lot of gratitude to it for getting you out of that and getting you involved in these healthy practices. It's also verbalizing a second purpose, which is to optimize my potential. Uh-huh. That sounds good too. But ask it this, if we could go to those parts it's so afraid would take over that, you know, did have you in addiction or whatever else they did, and we could heal them so they didn't need to do that anymore, would this one have to work so hard? Probably not. And would it give us permission to do that? Yes. Okay. So are you up for going to the addictive part? Yes. Okay. So find that in your body or around your body? Yeah. Where do you find it? In my eyes, in my mouth, in my solar plexus and in my genitals. Okay. And how do you feel toward it? Did you notice it in those places? Very cold and distant. Okay. So I understand that you've worked hard to get some distance from it and why you would feel cold toward it. But let's see if the parts that make you feel that way would give us the space to get to know it and maybe even help us. Maybe help it. Because it's hard to do that when you're cold and distant. Yeah, it's a lot of parts. It's basically like just an outcast from the system. Many parts are against it. Yeah, a lot of parts are organized against it. Yeah. Okay. So I get it's gonna be a stretch to let us help it, but just see if they're willing, just for a little while. All they gotta do is open space to let you get curious about it. Yeah, they can do that. All right, good. So focus on it again and tell me how you feel toward it now. I feel pity. Pity like compassion pity or? No, like pity, like you're an ugly little thing. Okay. All right, so we're gonna ask that part also to give us some space. Because it's hard to heal a part like this with that attitude. Yeah. Yeah, it's okay. We can work with it. Okay. How do you feel toward it now, the addictive part? Somewhere between compassion and sadness. Okay, let it know. And let it know we just want to get to know it a little better. And ask what it wants you to know about itself. Basically, it's saying, if I wouldn't have kept this ship together, it would have sunk a long time ago. Does that make sense to you? Yes. So, if it's possible, extend some appreciation to it for keeping you going. Keeping the ship from sinking. And see how it reacts to your compassion and your appreciation. I'm trying to. There's another part that's interrupting. It's a thinking part. And it's saying, yeah, but we don't need that anymore. Yeah, we get that. And let all your parts know that our goal isn't to give this one more power to do what it did. Our goal is to help it out of the role that it's stuck in. So, they don't have to fight it anymore. Yeah. To see if they're willing to give us that space again. Yeah. All right. So, go back to the appreciation of it, if you can. I'm noticing it's a little closer now, too. Good. Yeah. How many feet away would you say? It was very far. It's like 40 feet. Now, it's maybe like 20 feet away. All right. Good. And do you see it in there or just sense it? Yeah, I see it. It's red. It's like a hunchback. Okay. All right. So, let's just see if there's anything else it wants you to know now as you're closer to it. I guess it's... I guess it's wanting respect. Uh-huh. And it wants to be appreciated for its ingenuity and resourcefulness. Yeah. So, tell it that's partly why we're there is to show it respect and appreciation. And how is it for it to not be vilified and to be respected? What's that like for it now? Totally foreign and surprising. Yeah. Kind of doesn't know what to do with it. Okay. It doesn't have to do anything with it. Just, you know, just take it in. And it said earlier that it kept the ship from sinking. So I'm assuming that means it was protecting something. So ask more about what it was trying to do, what parts it was protecting or protecting you from. Yeah, well, it's saying that it was protecting like the treasure in the ship, basically the cargo. Okay. That makes sense too? Yeah. Yeah, and is that cargo still vulnerable? Is that cargo okay now? Ask it. Yeah. It's saying that it kind of, it understands that the situation has changed, but it doesn't trust that the cargo is safe. Okay. Okay. But if it did trust that the cargo was safe, would it be interested in changing its role? It would, but it just can't understand how that's possible. The ocean is a very large and scary place with things in the dark beneath, and that doesn't, how could it ever rest easy? Uh-huh, okay. All right, so I get that. But would it give us permission to go to the cargo so we could explore how safe it is? Sure. All right. All right, Esteban, so go ahead and focus on those parts that it was protecting, and find them in your body or around your body. Yeah, they're in the heart, solar plexus region. Okay, and how do you feel toward them? They're very tender. There's, it's almost like the, it's just innocence. It's just what those parts are. Yeah. Okay. I'm sorry, I have to sneeze. So let them know you feel tender toward them, and see how they react. And there's some softening. These parts don't really feel like they have much sentience. Okay, well, don't presume that. Just keep letting them know that you're there, and you feel tender toward them. And just see if there is something they want you to know about themselves beyond their innocence. They want me to know that they are valuable, even if they're not valuable in helping to navigate the ocean. Okay, how do you feel toward them as you hear that? I'm open to it, I understand. So let them know you value them, you understand that. And just see what else they want you to know. They want me to know that they've been here for a very, very long time. Like, since you were very young, or for lifetimes? Potentially lifetimes. Okay. Okay, let them know you get that too. Anything else they want you to know? Yeah, well, they're taking a shape, almost taking the shape of like a system of trees that are very kind of ancient and don't communicate much, but they're doing a lot of, they're kind of the lungs of the ship. Mm-hmm. Okay. They do the breathing. Okay. So they're essential in that way. Yeah. How are you feeling toward them as you hear all this, as you get on this, you see it? Yeah, a lot of softening, a lot of openness, and sort of awe. Mm-hmm, good. It's all really good. Let them know. Mm-hmm. And whatever else they want you to get about themselves. Yeah, their intention is just to bring nourishment, just to feed. To feed. To feed you in particular, or? To feed the parts. Ah, okay. So they're trying to bring nourishment to the system. Yeah. Okay. Let them know you appreciate that, too. They're letting me know they're very afraid of axes. Oh, being cut down by axes. Or just damaged. Damaged, yeah. Okay. And Esteban, see if they, if there's anything they wanna show you about where this fear came from in the past. I'm getting nondescript images of school playground. It's more like noises and shapes and colors and bodies moving. Uh-huh. So let's stay with that. Just tell them you're really ready to know what happened there. As much as they want you to go. Yeah. So they're showing you things about the playground? Yeah. Would you like to keep it private or can you share? I can share. Go ahead. What are they showing you? They're just showing... I guess I was 11 and nothing traumatic, just kind of joining a new school, moving to a new country and being really... just feeling unsafe. How do you feel toward that 11 year old as you see him there? A lot of compassion. All right, let him know. And let him know you're ready to get how scary that was for him. Yeah. Just stay with it. Anything he wants you to see or sense or feel about it? Yeah, he's showing me the eight year old who went through the same thing. Okay, good. Yeah, we're ready to get it from both of them. Just a lot of confusion. Very sensitive. These parts that feel very, very sensitive, almost like anemone. And they had their sensitivity betray them. In what sense? As they opened up and reached out into the environment, they experienced pain. Yeah. Enough times that they just retracted. Yeah, so tell those boys that makes sense, that they would do that. And how painful that was to have to go from being innocent and sensitive to being so protected and shut down. They're showing me that it wasn't so much like a traumatic event, more like just many, many paper cuts again and again, just continuously assaulting the system. That's right. We don't need a traumatic event. So just tell them everything they want you to get about it. It's very valid. It was good to hear that. Yeah. Yeah. Now I get the paper cuts on the playground. Totally get it. They just wish people were more friendly. Makes sense, yeah, of course they would. They wish they knew the language. They wish they knew how to move. Yeah. In ways that other people moved and say the right things, like other people said. Yeah, and not knowing all that. What did that make them feel about themselves? That they were dirty or broken or just alien, not belonging, separate. That's a horrible feeling for kids those ages. Horrible feeling. Just lonely, very lonely. Yeah, that's right. So let them both know you're getting how horrible that was for them. And just see if there's any more they want you to get about it, either of them or both. A lot of powerful and confusing sexual feelings. Yeah. What was that like for those boys? Scary. Yeah. Scary, like they didn't know what they'd do with it or didn't know what it was about? Scary because they felt it was wrong to have those feelings. Got it, got it. Does that make sense, Esteban? Yes. So let them both know you get why they would feel sinful or something or bad about feeling those things? And confused? The word that's coming to mind is tainted. Tainted, yeah, dirty, yeah. Damaged goods. Exactly. That's right. And also just kind of damaged goods in a way that, you know, fundamentally flawed, not reparable. Uh-huh. Yeah. So keep letting them know you're getting this and how bad that was for them to walk around feeling that way. Yeah, it felt like carrying around just a bag of bricks or rocks, just very heavy and uncomfortable. Uh-huh. And ask if they do feel like you're getting this now or if there's more. Just how exhausting it was to try to adapt to a new environment with these kind of carrying these bags of rocks or with a hand tied behind their back or just not being able to just really proud. I think we'll stop there. I'm going to show you. Tom should have gone to the second, just the ending of this, but Tom is the AV guy. But before we go just to the end of it, I just want to point out that what you've seen is that we've found a target part. We've focused on it. What Estefan has done is to unblend from that part and have a relationship with it from this core self and begin to heal it. In the next half hour, which you won't see, Estefan explores really some very severe traumas that occurred despite the fact that a protector in him said that this was not severe trauma. There's a retrieval bringing him, these boys, out of that place that they've been hidden for years. But let's move on to the ending where we come back to the addict. Just feeling proud, just feeling good to be in their bodies, feeling able to move, feeling like they can trust a grown up, feeling like they can trust each other, and that they're not alone. Perfect. This is at the end of the session. And now let's bring in the addict part to see them now that he doesn't have to take care of them. Yeah. See how he reacts. Yeah, he has a lot of fondness, a lot of care. He knows these parts really well. He's like their babysitter. Uh-huh. He's really happy to see them so happy. That's great. Is he ready to consider a new role? Or is there more healing that has to happen first? He is ready to consider a new role, but he'd like to stay close to the boys. Yeah. So he wants to stay at the house there with them? Yeah. So that's good for you? It can be good for me. And good with you. I mean, you're okay with that. Yeah, it can be okay with me. I'm feeling still some small amount of hesitance, but open to trying. All right, well, with that, let's bring in all the other parts who had attitude about him. Yeah. So they can really see who he is. And how much he really saved you, but how much he doesn't want to do that now. Yeah. He's being really clear. He's saying, you know, I want to take the boys on excursions, nature walks, want to bring them to the museum. And I think the other... How are they reacting? Yeah, the other parts just didn't realize how much he was doing and how he was really protecting this precious cargo. That's right. That's great. I think that he was protecting Joy. Uh-huh. So, does that feel complete for now, Esteban? It does. It feels like it'll take more time to heal. That's right. It does feel complete. Yeah, this is the beginning of a process that will continue. Yeah. So, let them know this is just the beginning. They're all going to get a lot of attention. It's a lot of gratitude, a lot of togetherness. Beautiful. Okay, let's stop there and we'll turn it over to Zev to give you the- Yeah, so come on back out here when you're ready. I'll stop there, but it gives you a sample of what it's like to see an IFS session. We could talk about it for a long time, but you're going to get the research data instead. Thanks for your attention. We're going to take you on a quick tour of the emerging evidence now that you've seen an example of how this is used for folks with substance use and trauma. And we're going to talk about some mechanisms, and then we'll come back and we can have a conversation at the end about what you saw. So important to say, in 2022, there were 12,000 trained IFS practitioners in the US. So this intervention has already been widely disseminated, but there is minimal research. So this was the first paper by Nancy Shattuck that was done with patients with rheumatoid arthritis, actually, where they found that people had improved quality of life, reduced depression and symptoms, and increased self-compassion. But it was 15 individual 50-minute sessions in 12 groups over nine months. There was another early study that was done comparing IFS to basically the treatment as usual in a college mental health program, which was a CBT and IPT-based program. And they found that IFS basically was similar to other evidence-based treatments. I've been a mindfulness researcher and understanding mindfulness and compassion, which I saw coming into play in the IFS work. But it was when I saw, before this was published, the data from the study from Hillary Hodgdon, that this was in a single-arm study, but they took 17 people who had PTSD and childhood trauma. They had 16 weekly 90-minute individual sessions. These were private practice cases, not in a community clinic. And you can see it was largely white college-educated folks. But the scope of the reductions in PTSD symptoms here on the clinician-administered PTSD scales were dramatic, with effect sizes of 2.81 at 16 weeks and effect size reductions of 4.46, which if you know, for behavioral studies, is about 10 times what we often see in other types of behavioral studies. So that got me really interested in thinking maybe there would be a signal here. But we had a different mission because we were in a community health center with a incredibly diverse and socioeconomically-stressed population with multiple traumas and ongoing trauma. And we wanted to see, would this, could there be a model that could actually work in the healthcare system? So we developed a group-based model with 16 weeks of 90-minute sessions in a group of 12 to, you know, about 12 people, and with some individual counseling every other week to ensure safety. And so this is a study that we did. We ended up enrolling 15 people in this proof-of-concept study. And this has been, everything I'm showing you now has been published in the American Psychological Association's flagship trauma journal, which is called Psychological Trauma. You can see it was largely female, 60% white, 40% black or other, 20% Hispanic. Most people had at least, the mean events were 7.4 traumatic events. So a highly traumatized population, primarily physical assault, sexual and unwanted sexual experience or sexual assault. And about a third had childhood physical sexual abuse. What I'm showing you here is a table from our, of our main aims, which basically demonstrated a 0.9 Cohen's D effect size reduction in CAHPS-5 total severity. So that's a large effects reduction in overall PTC symptoms. As you know, there are different criterion for PTSD, and in this case, for the cluster B and C symptoms, we saw the largest effects size reductions. So that's on intrusions, re-experiencing nightmares, as well as reduction in avoidance symptoms in particular. And we found that based on the CAHPS-5 and the PCL-5, that 53% of the population had a clinically meaningful response or reliable change by week 24, and I'd say that that's on par with other evidence-based treatments for PTSD. We also looked at some comorbidity, and we found that not only did PTSD have large effects size reductions, but so did anxiety. The cat D.I. is depression. We also saw a reduction in the cat, this is expedited adaptive testing, for suicide risk had a large effects size reduction of 0.9, and the ITQ-DSO, which is the International Trauma Questionnaire, measuring disturbances of self-organization that are common in complex PTSD, we also saw large effects size reductions. So this is emerging evidence, it's an exciting signal that we're continuing to study. Interestingly, we also looked at disassociation, wanting to make sure that this did not worsen disassociation in patients by talking about parts in this way. And in fact, what we saw is that disassociation reduced with large effects size. It's a 1.3 effects size reduction, and in particular, they're driven by depersonalization and derealization decreasing. In fact, people's experience of dissociation may be that they are exiling certain parts, and those parts perhaps are trying to force themselves back into their awareness. So in the group, as they're getting to know all their different parts, they actually can welcome in all the parts that may have been kind of disassociation firefighters, as Charlie was talking about. So this got us interested in trying to do more to understand potential mechanisms of IFS, especially this first part, which is what you watch, which is this unblending as people begin to be able to relate to their parts and to be able to foster this core self capacities to be mindful, compassionate, curious, and calm. And we particularly wanted to look at these mechanisms, and these are the mechanisms coming from our mindfulness research, emotion regulation, decentering, inner compassion, and self-related processes. I think most people kind of have a sense of what emotion regulation is. I'm not going to go into all the details, but I want to take a look at the bottom and that we're all doing emotion regulation in different ways, whether it's through changing the meaning of things, through reappraisal, taking perspective, distancing humor. We might be also, but however, there are maladaptive ways of regulating emotion, which might be suppressing the emotion or trying to avoid the emotion through substance use. These are unhealthy or maladaptive emotion regulations. And so we use the difficulty in emotion regulation scale, which helps to measure adaptive emotion regulation versus maladaptive emotion regulation skills. And what you can see here is that over the course of 16 weeks, people reduced their maladaptive emotion regulation in this study. And so the other mechanisms, I think, help us to explain that in some ways. So decentering is a concept that is actually very popular in the mindfulness literature and the CBT literature, and it's the ability to step outside of one's immediate experience, thereby changing the very nature of that experience. You may have heard it called metacognitive awareness, cognitive distancing, self as context in the ACT literature and cognitive diffusion. But it's basically this capacity to step back and to be able to look at your mental content without identifying with it. And to be able to get some distance from it and then be able to relate to it. And by doing that, it starts to change. And what we found is that in this study with the PARTS program, which is the group program of IFS, that actually the capacity for decentering from experience increased over time. This is a neuroimaging study, it's not ours, but other people are trying to look at and understand what's happening in the brain when people decenter from experience. So you can see here that they basically had two different, let me see, does this work? Oh no, it didn't work. Oh, there it is. People, they had two different tasks that they gave people to either really experience their body sensations and be in the emotional experience or to distance themselves from the event, looking at the thoughts like they're from the outside. And what they were able to find here was that actually this area of the angular gyrus, which is involved in self-related processes in a sense of self, was actually involved. And so you may have heard him talking about Dick in the video about how far is the part now? How far away is it now? What's interesting is if you stimulate this area of the body, you'll actually have an out-of-body experience. And I think part of what is going on in decentering is we're actually getting a sense that we are outside of whatever that experience is. And then we can relate to that experience without being caught up in it, right? This is one of our other faculty members, Chris Germer and Kristen Neff, and they developed the Mindful Self-Compassion program, where self-compassion is defined as the process of turning compassion inward and being able to turn to oneself, to be able to recognize mindfully if you're suffering, to be able to turn towards yourself with self-kindness instead of self-criticism that many of us are very good at. And be able to understand that when everybody suffers, we're not alone, and be able to deliver that compassion inwards. And part of what you saw him doing between the parts was let them know that you understand that. Let them know that you're here with you, creating a lot of internal compassion and space. Because when you are recovering or trying to recover from substance use disorder, you've had stigma, judgment, you have your own judgment of trying to control the out-of-control parts. And so the system gets polarized and gets accelerated through the conflict. But if you can create that space for compassion and bring that core self forward with a compassionate presence, all the parts can settle down and they can actually relate to each other instead of acting in relationship to each other. So what you can see here is that in our study that actually the people reported increases in self-compassion, which likely helped emotion regulation. This is from actually a study of our mindful self-compassion program for people with chronic pain. But what you can see here is that in that study within brain imaging, as people's self-compassion goes up, we see changes in their dorsolateral prefrontal cortex when they're in self-critical situations. So people are able to actually emotionally regulate a self-criticism and down-regulate that and reduce the impacts that it has. And so my guess is that we are engaging a similar mechanism here in IFS. So we took that into a larger RCT. This is a pilot RCT to try to be able to get effect sizes for how this might, to see if the effect sizes we saw in the proof of concept study would be consistent and to look at the acceptability and feasibility of the interventions in a group compared to an attention-controlled placebo group. However, both groups had individual psychotherapy of eight sessions, and the control group was led by the lead trauma therapist in our system, Suswana. And the control intervention was led by the lead trauma therapist in our system. So we randomized 30 to each arm, either parts or nature-based stress reduction for trauma survivors. And when we just look at, at first, that acceptability and feasibility, we saw that people were able to attend the parts groups. In fact, an average of basically 13 sessions as far as completers, and about 80% of people in the parts group completed the group, as opposed to 47% in the control group. So I think one of the things that's important to say is that in this population, this was 60% non-white or English speaking as a first language group. In our mindfulness groups, we have seen that engagement has been more difficult and attrition has been more difficult as there's increased diversity in groups. And I think people see that a lot in substance use treatment as well. And so this was a group that was majority-minority and had really incredible engagement and retention and people felt welcomed. I think they felt like they could bring all their parts into the room no matter what their identity or their background might be. And it also had a great way of holding whatever might come up about feelings of difference. That could be just another part that's in the room and it made space for it in a way that sometimes can be difficult in group psychotherapy. And you can see here, I've never done a study like this. We had no study withdrawal, zero in the IFS parts group. By the way, parts stands for programs for alleviating and resolving trauma and stress. And whereas we did see obviously a higher study withdrawal in the control group. The parts group also had higher credibility, higher expectancy after four weeks that they would get benefits from the program. I'm going to show you this. So the groups did similarly as far as trauma reduction or reduction of PTSD symptoms. And both groups had large effect size reductions in PTSD symptoms on the order of effect size of one to 1.2. But this is what's interesting just in due to time that I want to show you is that the reductions that we saw in PTSD symptoms over 16 weeks in the parts group correlated strongly with the reductions in maladaptive emotion regulation, which was not true in the other group. And again, I'm not going to get into everything about this group. Both groups had reductions or increases in self-compassion. And self-compassion also was correlated with reductions in PTSD in both groups. But that's the reason why we had another group was to be able to show that, to be able to see if we could identify what mechanism might be happening in the parts group that is not happening in the standard group. And so emotion regulation is what stood out. So I'm going to pass it along to Dr. Dilara Ali. So I'm going to talk to you today about results that come from a pilot study that adapted the parts intervention for those with comorbid PTSD and SUD. So let's see, how do we do this? Great. So I don't really need to tell this group about the prevalence, really the staggering prevalence of SUD in the US. And we've heard a little bit in previous sessions about the association with trauma and how high that is. The other thing that I want to say is that trauma does create a complex and heterogeneous set of symptoms. And it impacts treatment for SUD. So there are many behavioral therapies which tend to fall into two categories, which I've listed here, present-centered and past-focused or trauma-focused. And the most common and well-known are the exposure therapies in the past-focus. In present-focus, things like mindfulness-based interventions and CBT. So seeking safety is one of the most popular. So although that there are some systematic reviews that do show modest efficacy benefits for the past-focused therapies or treatments, these exposure ones, the benefit is really offset by high dropout, costly training, attrition, lack of completion. And I'm showing you some examples here. In this one, 62% of folks were considered completers. There was a 52% completion rate. And this is true also even in some of the present-centered ones. And so you can see that that comorbidity does make it complex. And it's worth mentioning, though, that something like seeking safety without exposure has a benefit to PTSD symptoms and SUD symptoms. So you can get a benefit, even though there is a slight performance gain in the exposure therapies. The last thing I want to say, and this, I think, is actually the most important piece because it speaks to the dropout rates that we're seeing here. Oops. Let's go back. And that is patients are not homogenous, right? They are diverse in their needs, they're diverse in their everyday vulnerabilities, and they're diverse in the way that they relate to treatment. And I think that's really important. And we see when we look at patient preferences that they want integrated modalities. They want a whole person focused treatment and they want simultaneous treatment. And this, to me, suggests that we need to develop more treatments. If we have heterogeneous expression and we have patients that are different, require different things, they're not gonna respond to this, not everyone is gonna respond well to the same treatment. So this motivates why this trial took place. Okay, so this was a modification of that 16-week PARTS program. We shortened it to 12 weeks because we know that there is high attrition. It had six individual sessions, unlike the previous one, which had eight individual sessions. And as I said, it was based, as Zev said, it was based on internal family systems and it's a group-based, group and individual-based. There were two aspects of acceptability that we looked at. We looked at affective attitude, that is, what was the mean acceptability at week 12? And we had an expectation, an a priori expectation. And then we wanted to see if there was satisfaction. The second thing we looked at was feasibility, both intervention and study protocol. And we had two exploratory aims, and that was to look at the reduction in PTSD symptoms. And in this case, we looked at craving, the craving scale. It's worth mentioning, as Zev said, that we had a very diverse population. I'd say it was incomplete, but it was more diverse than what we typically see in that we had a fairly balanced gender population. We had Hispanics, 40%, white, 40%, Asians, 20%. And the main substance use here was drug use, and it was primarily sedatives, opioids, and marijuana. And as Zev mentioned, this is fairly consistent, the trauma load was very high, seven events, and primarily physical and sexual assault. And I also do want to mention that as a pilot study, it was quite small, so we only had a sample size of 10. So we did meet our acceptability criteria, both in overall acceptability and in satisfaction. So this just shows the different answers, whether it was completely acceptable to completely unacceptable with the participants on the bottom. And then on satisfaction, whether you would actually recommend this program to a friend, again, strongly agree, strongly disagree, and this was the participant count. In terms of intervention feasibility, we did see 70% of the participants complete the intervention, and they completed eight of the 12 sessions. On average, 60% of the participants completed nine of the 12 sessions. In terms of the dropouts, we had three folks drop out. One became pregnant, one had a serious family illness and wanted to continue but was unable, and then one person actually formally withdrew. So in general, we met, I would say, reasonably our feasibility protocol, our feasibility aim, excuse me. This is really interesting to me because it kind of, again, matches or tracks with what we saw in the two other part studies, and that is we saw PTSD symptoms drop, and it was, I would caution, I have a stats background, so I'm highly conservative about these things, and I would caution drawing huge conclusions, but I think it indicates that there is worth, it's worth investing in a larger study in that we saw the scores of PTSD drop even with a very conservative analysis, and then we saw craving scores as well, which was quite unusual, and I was not expecting that. And it was a much smaller effect size, and there's higher variance in the ways in which people responded. So again, as I said, we did meet our, we demonstrated acceptability and feasibility with reductions both in the PTSD symptoms and craving scores, and as I said, it does indicate it's worth actually pursuing and investigating a larger study, probably with control groups. I'd say trying to achieve more complete diversity, increasing objective measures of substance use, which we didn't have, and just, I think just doing a better job of a comprehensive randomized control study. All right, so that's it for me. Oh, I forgot one last thing. Actually, the most important thing, how could I forget it? So when we do these studies, the most important thing is to really hear from the patients because that's really where the rubber meets the road, and we had a small qualitative component, and these are two quotes from participants. One of them said, parts helped me face my dark parts with curiosity and compassion. I learned that my true self is good and wise, and that the answers will reveal themselves if I am patient, persistent, and present. Help is on the way. I learned to listen to and trust myself. And the second one, I learned the value of my protector parts and how my anger comes from a firefighter part who fears and doesn't understand the value of crying and feelings of vulnerability. Thanks, Dilara. So as you hear this, you're hearing the schema, the underlying set of premises, schemas we use them in things like CBT, we use schemas in DBT, so there's a grounding, a foundational aspect. Then Zev showed data as well as Dilara about effectiveness. But many of you might be wondering, how does this sort of look maybe in a sort of setting, maybe it's outpatient. So this is an example. So, oops. So, let's see. Oh, okay. So I'm gonna leave this quote up from Dilara because this one is an important, especially that first part. So patient comes in on an inpatient unit and they've been misusing alcohol for most of their life. They've had basically experiences in their past, in their childhood of physical trauma and sexual trauma. And what happens is that now in your mind, if you can keep the schema in mind that Dr. Silverstein showed you, but also you can think in a neurologic way, right, neuroscience way, that when a person experiences trauma, there's overactivity of the amygdala. That's just the very basics. In addition to everything else, replaying the memories and a sense of avoiding anything painful. At that point, there's a little bit of a whiteout in the mind. And what's a really efficient way to avoid painful feelings? Well, as Zev shared, one of those could be dissociation, but typically in our society, using a substance. So let's say if it's alcohol, it's opioids. Now then the reward pathway, and in this case, especially in case of trauma, the reward pathway is a little bit of a misnomer because the reward, if you may, is really to quell the pain. So then the system gets primed and we're in a very classic sort of a behaviorism territory. But as time goes on, of course, it's insustainable. Of course, there's a tolerance that develops. In the old days, they used to call it dependence, et cetera. So what IFS is able to do is in a case like this, that if you can introduce the schema. So first of all, we know a lot about positive psychology. We know about strength-based approaches. It's really not a sort of disorder-oriented approach. If you recollect from the beginning of this presentation, that if you go with a certain trust that your self-energy, what in many times could be referred to as your sort of mature state, your ideal state, so to speak, it's got it, it's got it. It's very much in the present because many of our patients with trauma, they end up going back to the past. So that's an anchoring effect to say, this is not a disordered state forever. You're here in the present. But it also doesn't deny that you experienced this pain at a time when you were highly vulnerable, where you were not able maybe to fight it or to navigate it in a same way as you may today. So that impasse can be really calmed if you can apply these simple techniques as a clinician, where as you sort of think of those layers, right? There's that self-energy layer. Then there are the protector layers. Now, again, you can label them as you like in this rubric, which has the evidence. It's labeled in these sort of ways of firefighter as well as manager. One way you can think about it is one is, as Zev said, right? Firefighter just goes, goes for it, right? And Charlie said that. And a manager sort of manages it on a day-to-day basis, right? How do I not get my boss upset at me? Those type of things. But ultimately, what they're trying to do is protect that very painful part of you that doesn't have the confidence that it will be protected in event of a crisis, of adverse exposure. So really, it's connecting that confident, calm, courageous, sort of equanimous part of you with, and it's not even a part, that aspect of you, with assuring that entire system that one, that pained aspect of you can have that support, does not have to live a life of constant anguish and worry. And the second part of it is to assure those mechanisms, call them firefighters, managers, that they don't have to overwork. They don't have to be constantly in a hypertrophic state, which, as we know from physiology, is not a sustainable state. So I just wanted to sort of say that these patients that I've been able to apply it on inpatient units, having that ability to have the psyche not simply being seen as a monolithic self, because that creates some problems, right? If I trust myself, that's fine, but most patients don't end up in that place who have been using substances or other non-sustainable ways. So having that map for them, and as you saw in the video demonstration, it really allows a sort of different sort of mode of processing. So it takes that default mode that we saw in the psychedelics lecture and sort of gives a little bit of space. And we see that whether it's in a more dynamic sense of a mature self or DBT sense, a wise mind. So it allows that space of observation and a inter-system communication that then, as the evidence shows, has been shown, especially with patients with trauma, but in general with others. So I just wanted to sort of say that in my experience as someone who's completed a level one training, that it has had some pretty significant benefits. And really I've seen those benefits in inpatient settings, which are sort of a very time circumscribed way where people come in in a fair bit of crisis. So just wanted to mention that as a real world example or series of examples, and we'd be happy to take questions. Hi, I have a quick question. I guess it could be for all of you guys. Is the goal to identify the parts and integrate them into the self so that all of those parts are no longer existing and it's just the self? Or it's everybody always exists at all times and then the self's just like. No, the goal is for parts not to carry so much burden and to soften. Not to have to be so extreme in their behavior as to need to cuff themselves or to drink or to be consumed with anxiety. And the healing comes from the relationship between the self and the part and negotiating between, let's say, the manager who says don't drink and the firefighter that says do whatever it takes to get out of this. And if you can help that vulnerable part to feel safer, then both the part that needs to do whatever it takes and the part that says don't do it can both relax. And the goal is not to eliminate parts because that wouldn't be possible, but to get the parts to soften so that the wise self, DBT speak, can be the orchestra conductor. It's interesting in your question because we come from this perspective of wanting to get rid of the symptom or somehow make it go away. And in fact, one of the fundamental things that people learn is that all parts are welcome. So when parts no longer feel like we're trying to get rid of them, they can feel more comfortable letting go of whatever the burden is that they're carrying or their role, and then the roles can shift. So in this case, the part that was trying to protect the little boys and the joy instead of going out and using can now be in charge of helping bring joy in a different kind of way, and it's happy to do that. I think there's also, just to add to that, this idea of harmony in the system. If you've ever had to be in charge of a team, and there are different team members that have different goals, and you can't actually achieve your vision if everybody's going in a different direction. And so once you can harmonize that team, you can achieve a vision, and you can achieve functionality and whatever it is the vision is. And so that's the idea, essentially, is to harmonize within the system so that you can be more functional and you can achieve whatever your goals are, your values. Mona. I was just wondering about how you conduct that in a group setting, since it takes a lot of time and sort of back and forth and feedback and introspection that we saw. How are you able to establish that and do that in a group setting, and what time frame are you using? So we have 16 90-minute groups in the PTC study, 12 in the parts SUD. And the first stage is primarily focused on helping people learn how to understand the model and then how to unblend from their parts. So we have something kind of like what you watched called the centering practice. As you saw, he was doing that in front of a group of other people, right? And so parts will come up. Like, oh, I'm worried that people might be judging me. What we invite everybody to do who's witnessing in the group is to sit with a compassionate stance towards the person that is being willing to model and to monitor their own parts that come up. And what's incredible about that, that makes I think group IFS even better than individual IFS. I don't have data on it though, so I acknowledge that. Or different and promising, maybe I should say, is that we see that people in the group will see somebody having an internal system and parts that are in conflict and they notice the same thing's happening for them. And then when they're done with their 20, 30 minutes of going through that process, the other people in the group will all tell them what parts they noticed, which parts they identified with. And so it can be kind of difficult. It can take a little while when you're first starting IFS to start to be able to notice your parts. But when you do it in this way in a group, it actually kind of supercharges it because you can start to understand that, oh, other people have that part too. I don't feel ashamed about that part. It really increases the self-compassion. And Laura, do you want to add anything else? Because you're leading a group right now. Yeah, and very much like a mindfulness-based intervention where you have guided meditations, we do guided experientials where you're helping individuals to unblend. So it's very similar. So it includes that. That's the process of helping people do that. And then the process of checking in and- We do maintain six individual sessions over the course of the time. And the goals for that is initially to make sure that people are bringing up whatever they, if there's issues in group, that they have a place to work that through and get support for those parts so they can then bring it back to the group. But also, as people get along, there can be the desire to unburden these exiled, vulnerable parts. Some people are able to do that in the group, and some people would prefer to do that in a more private space. We do ask people if they're unburdening something in a group or if they're talking about a traumatic experience that they don't talk about the details in the group. And they go through that process kind of within. And so the individual sessions are often used for that as well. That's similar to, because I did CPT in groups, but the trauma narrative was private. Yes, yeah. Well, the trauma doesn't have to be private. We just ask them not to talk about the details, and people are able to do that. I would just add, if any of you choose to be trained in IFS, you would have a group experience that probably has some similarities, and as Zev was saying, this energy of the group and the group experience is profound and very powerful. I think none of us who've gone through trainings come away without feeling like, in some ways, it's been transformative. Vinod? Thanks so much for this session. It's really wonderful, and one of the really exciting parts is the data that you're bringing to this. I mean, IFS has been around for a while, but there hasn't been as much data as there could have been, so this is great to see. I initially had sort of the previous question, but I want to take that a little bit further. When you have had these two different protocols, the 16-week down to 12-week version, you've lost time. You've lost opportunities, and I'm curious as to how that's affected the process insofar as the leaders go. Also, I can imagine, I mean, this is a time-limited protocol that you're implementing, and as an administrator, it's really hard to get people to step away from treatment sometimes when they're engaged. So let me take this, because the reason why we got support to develop an entire part service now at our hospital system is because many of our patients with complex trauma have had individual therapists for six years, or 10 years, and they're still needing support, and the system is trying to figure out how do we possibly meet the needs of access when all these people, we don't want them not to be treated. So they were willing to explore this kind of group model, and the way that our continuum works is so after 16 weeks, or after 12 weeks now, as I think that the data is suggesting, people can then go into an advanced group where they don't have as many individual sessions. So we have, what is it, two to three individual sessions for the next 12 weeks, and then after that, people actually don't have any individual sessions or a group leader. And so we've seen this happen now with two cohorts, where they go through, in the study that I showed you, the first pilot, it started with 15 people, but we had six people who continued to be a group afterwards, meeting weekly without a group leader, all with complex trauma having had individual therapy for a long time, but not getting better, and they're taking care of each other, and they're meeting. Once during the year, they asked the group leader if they could come back and just join the group and have one group to kind of work through something that was emerging in the group, but they're doing the practice with each other and witnessing each other, and getting better. You know, I think that you can see a meaningful clinical response in a similar amount of people in the IFS group and in the control group with the standard, you know, trauma treatment. What was interesting, though, was there were six people in the IFS group that nearly totally resolved symptoms, and we didn't see that, it was more consistent, but moderate, you know, shift in the control, so I didn't show that, but I probably could have. But I think that it speaks to the idea that for certain people, they are getting really far, and then we don't, and they don't need more treatment, but we are trying to look at this continuum, where isn't it great if we can have a practice that within six months, people can feel like they can, within a community of other people who they feel connected to, self-manage complex PTSD and PTSD symptoms. So I think that's where we're going. Can I just, before the next question, I just want to add to the answer about the question of what's the ultimate goal? The ultimate goal is for people to unblend, to de-center from this part that takes over, and to come from a place of relatedness, connectedness to other people without needing to use defensive mechanisms to distance the world, and to engage with the world in a kind and compassionate and creative way. And to allow the exiled parts to rejoin the system, and be part of the system, so there's nothing that has to be protected anymore. And then when you show up, you show up fully, and you know, that's the core self of you, that's compassionate, clear, calm, courageous, can be how you are connecting with others in the world. Lady in the back, say your name and welcome. Hi. Thank you so much for this intro to IFP. IFS. IFS, sorry. No problem. I'm Jenny. I'm an addiction psychiatry fellow, and I trained at a residency program that was pretty focused on psychodynamic psychotherapy. And I'm just curious, because I remember being taught sort of like the timing of the intervention or making an interpretation in psychodynamic psychotherapy really matters, and that when people are identifying with an emotion and sort of close to it, that is sort of a time when the interpretation may be more effective and drive psychological change, whereas in the data you presented on parts, and I imagine a lot of other mindfulness-based psychotherapies, it's more like this distancing, observing, that is effective in driving change. And I'm just wondering if you feel like that's dichotomous or if it could be integrated into like a larger understanding of how psychotherapy works. Or maybe if there are different populations that respond to one versus the other. So I was taught from a psychodynamic perspective that one of the goals is to stay equidistant between ego and superego as an addiction psychiatrist. And so it's not to side with any of them, but it's to be able to be with all of them and to have each aspect be welcome and without you siding with it. And that allows it to change. So I think the interpretations, I think that what we're doing by de-centering is not abandoning somebody but helping them to have perspective on their experience so they can see what's there and they can able to warmly be with their emotions as it arises. And I'd argue that actually a person's ability to be compassionate in the moment is going to be even more impactful than a therapist's if they're able to do it. And so what we're doing is training people how to become their own internal interpreter, their own internal warm, loving presence with whatever's arising. And then blending gives them the capacity to do that, the de-centering, because they're able to see it and they're able to be with it with inner compassion. And that allows them to be able to hear from the part what it needs. And when they kept asking, how do you feel towards it, what they're doing is noticing it. We can get caught up in parts when we're thinking about it, caught up in... You could think about it if you're psychodynamically trained as ego and superego, I mean, we're talking about three things here, but there are many more than three parts. And every system seems to get set up this way from an IFS perspective. And so if you can, as a therapist, be able to be compassionate with these different parts, the polarizations between them can drop down, they let go of what they're holding. I want to add to that, too. In psychodynamic, the therapist is the expert, is the one who does the interpretation. And this is a very different model where it falls more, I guess, along the lines of the relational schools or the intersubjective pieces, where the client or the patient that comes in is the expert on their system, and you're just the guide. You could see in Dick's guidance, there was very little interpretation. It was all the patient that did it, and that's a really important piece. And then the second thing I would say is there's a fair amount of internal reparenting that's happening in what you saw, and this is very much in line with, I think, attachment theory, but from an internal perspective, that is, building that capacity for a sense of trust, a sense of containment, a holding environment, much like Winnicott talks about, that kind of environment, the good enough mother. That's what this is, the good enough parent. That's what this is, I think, doing for these people. I mean, it would have been hard to imagine a better interpretation of the treasure in the bottom of the boat. The patient came up with that himself, and that's what helped it open up for him. Here's one more question here. It sounds like a real goldmine, and so I think you kind of answered a lot of what I was thinking, but I love what you said about the IFS in your bio, Dr. Alley, about IFS for socio-political transformation, your thought on that. It's kind of a big picture. Anything else to add other than what you said, or? Well, I would say that one, so I'm in the process of doing qualitative interviews with these patients that have gone through not only the part studies, but also the clinical service, and one of the most amazing things that I hear over and over again from these folks is that they have very difficult relationships with family, because this is where the interpersonal trauma has happened, but over and over again, I hear them say, because I've been able to develop that inner compassion for those vulnerable parts, I can see how when I'm interacting with others that their parts are showing up, and so I have a different view. I can do, I guess what they're saying is I can mentalize. I have the ability to see that other people have different perspectives, and I can appreciate that that may not be how I want to be, but I can see their parts, and I may take a different stance then towards them, and so that's what I hear over and over again. So in terms of sociopolitical transformation, I would say this is a highly relational framework, and this idea of being connected to yourself allows you to be connected to others who may not be the same in terms of the way that they are in the world, and then there's just one other thing I want to say, that one of the most attractive things for me about this model is the idea of a sociocultural framework that leads to burdens that are legacy burdens. That is, you have intergenerational trauma, you might have stereotypes, stigma, all of those things that you carry as someone who has substance use disorder, and what this model does is it allows you to explore that from a much more agentic perspective, meaning that you get to see and understand and interpret yourself how that has affected you. So in terms of that, that's how I would end. Okay, yeah, that's awesome. I don't want to take up your time, but just leave it with a question. In that light, do you feel like addiction might be a disease of, not the person, but actually relationships? I'll back up. No? What's that? Well... Too crazy? What's that? I think we know that from neuroscience that there are kind of opposing networks and processes that are happening in the brain that end up in conflict, and I think that the subjective experience of that and the way to navigate that could be through this part, the conflicts between these different systems that emerge. There's one more question. I just want to say, if people are interested in IFS work, you can look up Dick Schwartz' book was number two on Amazon last year, no bad parts for as most popular psychology book. So there is a lot of writing out there. At our Cambridge Health Alliance Center for Mindfulness and Compassion, we do have a continuing education program where we're doing a level one and level two training, so Sanju joined our last one, so thank you for doing that, and we have been trying to make... There is a 7,000 person waiting list for IFS trainings internationally right now, so it's actually really hard to get in, but we are trying to make a special opening for the first few slots for AAP members over the next year or two, so I just wanted to mention that. Keep an eye out in case you hear about it, or if you're interested, you can go to our website and sign up and let us know. There's one more question. I think people can leave if they want to, but we want to stay and be available to you, and we're happy to answer your last question. I hope you can. Dave, kind of with a question about what these parts appear to act as. Are they characters that appear to be present in all of us? Are they characters that emerge in response to unusual trauma, or are they metaphors, knowing the literary power of a metaphor? Are they metaphors by which people can learn things that they need to learn about themselves independent of whether these are real characters or not? Do they serve as teaching metaphors, or is that whole conceptual stuff just the wrong question? Did you want to take this? You know, it's an interesting question that comes up not infrequently, but I think for most of us who've had the experience of IFS, it really feels like there are entities inside of us that probably inhabit different parts of our brain with whom we can have real relationships, and establishing those relationships is a great source of healing. So I don't think of it as just a metaphor. It doesn't feel like a metaphor. It feels, I mean, I feel like there's a part of me speaking to you now, and there's another part of me that, you know, that was trying to take a nap earlier today and felt so anxious about this that I couldn't let myself sleep. They have, you know, a protector who's like, no! You know, and I assume that there are different parts of the brain, like you would see in a psychedelic experience, that parts of the brain that are communicating with each other in new ways. This has been a question that I think a lot about, and one aspect that has arisen that sort of helped me answer this, is that if you simply think of this as a metaphor, what's the relationship you would have with that metaphor? And if that's the case, then how might that translate externally to how you relate to others? Right? And so I think that's the answer for me, anyways, is that I would rather have a respectful and attuned relationship, and so therefore I can't treat them as just metaphors. I would also argue that what parts are is less important than the idea that the core self exists, because I think it's incredibly healing for patients to be able to understand that they're not just this part that they've been blended with, or this other part that they've been blended with, trying to not be blended with the other part, but actually that within them is a compassionate, calm, courageous beingness, and that you can see that, and they can find it, and they can tap into it. You know, Stephen Ross is here, thank you for being here, you know, was talking about the power of, you know, the spiritual power and the spiritual experience of the self-transcendent experience that comes with psychedelics, and I'd argue that what we're helping people do when they unblend and then be able to feel that presence of their core self there is a similar experience to what's happening in the psychedelic journey, and once you've had that experience... We do have some really interesting, you know, like, data, she don't want me to say it, but it's like such a small signal, but it's really interesting to me that people that have experienced increases in that bliss factor during the IFS program seem to have a lot, a lot, you know, a lot of change as far as the symptoms, and I think that that's what, you know, people are talking about in psychedelics, at least for, you know, substance use. So anyway, that's not something to publish or to hold your hat on, it's just a small data that we're looking at, trying to figure out what to look at next, but yeah, so I guess that's it. Anything else? Let me just say one more thing. We could have a whole hour spent on IFS and spirituality, because once you start to communicate with different parts of yourself, you can communicate with entities beyond what you think of as yourself, and there are experiences that most of us who've done a lot of IFS have that feel as extreme as a psychedelic journey, and there's no question in my mind, and I don't know, maybe Steve Ross can answer this, if there's evidence for it, but I think that there's no question that it increases connectivity in the brain, and that there's increased neuroplasticity after these extreme emotional unburdenings. That's something we'll have to test, so I don't know if there's no question, but there's definitely a good question to ask, and for us to test the measure, yeah. Thank you. Well, we'll be up here, if you have more questions, feel free to come up, and we'll let everyone go, and feel free to come up to any of us during the rest of the time, we can talk to you about it more.

Internal Family Systems

IFS Model

trauma-sensitive

addiction recovery

Zev Shuman-Olivier

Mindfulness and Compassion

Harvard Medical School

PTSD

substance use disorders

subpersonalities

core self

emotional wounds

Richard Schwartz

addictive behaviors

proof-of-concept study

vulnerable exiles

protective parts

no bad parts

self-compassion

emotional regulation

PTSD improvement

substance use disorder