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Gregory, C, Jenaway, A, and Lee, M. 2023, Integrating ideas from Internal Family Systems Therapy into Cognitive Analytic Therapy, Reformulation 56, p.4-10
Introduction
Internal Family Systems therapy (IFS) has been growing rapidly in popularity with both therapists and patients in recent years. Although a significant evidence base is not yet available, initial studies suggest effectiveness in depression (Haddock et al., 2016), childhood trauma (Hodgdon et al., 2022) and a reduction in symptoms of rhemautoid arthritis (Shadick et al., 2021).
The authors of this paper have various levels of training and experience in using IFS and all three of us have found that it can add something valuable in both the reformulation and working phases of CAT.
This paper is based on a workshop of the same name presented by the authors in November 2022 and introduces some of the basic principles of IFS. We describe how we have been using it in our CAT work with a real felt sense of benefit with those we are working with. We acknowledge that only a relatively superficial comparison can be made in a paper of this length and encourage anyone interested to read more or to apply to go on an introductory IFS course. We hope it will pique colleague’s interest and inspire you to think about, and bring into dialogue, how in the short-term focused model of CAT we can influence some of the more challenging difficulties people face.
History and basic principles of IFS
Richard Schwartz, a trained family therapist is the founding father of IFS. In the 1980’s when working with people with eating disorders and self-harm, he observed that the more he tried to get the individual to overcome and ‘silence’ the self-destructive behaviours, the more marked the problematic behaviour became.
In response to this ‘backlash’ he began to explore ‘talking with’ and in particular ‘listening to’ the ‘destructive part/s,’ discovering, as he did so ,that these parts had important things to say and a story to tell. In this process of exploration other parts would often reveal themselves. Many of these parts were ‘stuck’ at a much younger age than the true age of the client. The behaviour of these apparently harmful and non-socially acceptable parts seemed to be a profound attempt to protect the client in some way. Schwartz noted, to his surprise, that these ‘protector’ parts began to settle when genuine attempts to help and understand them were made and the good intentions of their actions acknowledged. This observation, alongside the idea that one could interact with the different parts of a person as if they were an ‘inner family’ (hence Internal Family Systems) became the foundation stones of his work. And, as in family work, the aim is not to silence, nor get rid of a problematic member, but to create a space in which to understand them, listen to their point of view and get them back into dialogue with other family members/parts and in doing so, through this facilitated integration, heal the (patient’s) system.
Importantly, Schwartz also discovered that parts would spontanteously transform to their natural and less extreme roles when they felt the presence and energy of the patient’s Self (see below) and were able to develop confidence in it, thus a core focus of IFS is (re)building internal relationships between Self and parts.
In summary there are several core principles to IFS including (Schwartz 2019):-
Our minds, even healthy minds, are ‘multiple’ and consist of ‘subpersonalities’ or ‘parts.’
Our parts carry ‘burdens’ i.e. emotions and memories, from earlier life traumas which drive their behaviour.
Parts consist of two kinds of protectors, called managers and firefighters, and the vulnerable exiles.
Exiles are young parts which hold our pain and trauma (shame, hurt, fear etc), i.e. burdens
Manager and firefighter parts have formed to protect ‘the system’ from experiencing the pain held by exiled parts, with managers working to keep the exiled parts out of awareness (i.e. imprisoned), while the firefighters take action (sometimes quite extreme) if the exile escapes and their associated pain comes into the patient’s awareness
Parts, in their desire to protect the system, may blend with Self and overwhelm it.
The relationship between Self and Parts
In addition to these principles, some of which have obvious resonances with the CAT model (see below) Schwartz and Sweezy (2019) describe the central place of the ‘Self’ (capital S). In this model the Self is understood to be present, regardless of our previous experiences and is both undamaged and undamageable. Any apparent absence of the Self, is as a consequence of parts having blended with it, obscuring it, much like a solar eclipse. The therapeutic work in IFS is that of helping the patient’s parts ‘unblend’ from the ‘Self,’ allowing it to take up its natural role of ‘Self-leadership’. When in ‘Self’ the individual operates from a place of calm, clarity, connectedness, courage, compassion, creativity, confidence and curiousity, known as the 8 ‘Cs’. Surprisingly, just asking the identified or target part to pull back, to allow some space and not overwhelm the client so much, often results in a visceral, internal shift in the client, producing a noticeable change in the client’s ability to access other feeling states, and so to participate more fully in the session.
Within this internal family, without sufficient management by the Self, the firefighters’ and managers’ attempts to protect the system from the distress of exiles can become increasingly polarized. However a central tenet is that whatever their actions, these parts are acting to protect the system, hence the expression ‘no bad parts’ (Schwartz 2021). This profoundly non-judgmental position, and indeed openness, to engage with the efforts of the parts seems to be a particularly helpful stance, and perhaps preferable to CAT language of target problem procedures, problematic reciprocal roles, feared places on the map, terms that we may share with patients and which scaffold our own thinking. The aim in IFS therefore is to understand, accept and befriend these parts, i.e., patterns and roles, rather than to try to form or develop new roles. This understanding has lead to a profound therapeutic paradigm shift with Schwartz advocating that the traditional, and assumed essential, role of stablising and grounding the patient before processing traumas is less needed. In the presence of Self the patient can safely connect with, for example, the ‘dissociating’ part and negotiate access to the exiled parts to offer a healing ‘unburdening’.
Since integrating these concepts into clinical practice, one of us in particular (ML) has felt the embodied truth of this very powerful, often spontaneous ,healing potential of ‘Self’ and witnessed some remarkable transformative moments with patients with little to no therapist intervention once parts trust ‘Self’.
Comparison of IFS and CAT
A careful comparison of the theoretical and clinical overlap and differences, between CAT and IFS exceeds the remit of this paper. However, the most obvious point of difference is IFS’ understanding of Self. The CAT model holds the position that the self forms as part of a gradual developmental process, growing out of the interpersonal, family, cultural and other systemic experiences of the infant, and so can be damaged by adverse experiences. By contrast, IFS sees the “self” as closer to a spiritual entity, almost like the client’s soul.
However, other aspects of the model sit well with CAT. Parts are easily located on a CAT map; for example, burdened exiles can be seen as the ‘felt experience’ of the child pole of a reciprocal role (RR), ie the core pain of the client. While the adult (doing) pole of the RR and RR-procedures can be seen as manager protectors and CAT dilemmas seen as polarized parts using different ways to try and protect the client. Lastly, firefighter parts are often the roles that are triggered when the client’s typical procedures or ‘managers’ have failed. Under these circumstances firefighters work hard to try to bring an overwhelmed client system (‘an unleashed exile’) back in a state of homeostasis.
Using IFS in the room – The 6 F’s
Exploration of and a conversation with parts using the ‘6Fs’ is the first stage of IFS, see table 2.
An example might be exploration of a ‘striving manager’ part. The client is guided to find this part, to focus on it and to flesh it out e.g. where is it located? Does it have a bodily presence and if so where? With encouragement to connect to the somatic qualities. The therapist then explores how the individual ‘feels towards’ the part. This is the key question from Schwartz’s perspective as it enables the therapist to determine if the individual is in Self, i.e. is their attitude towards conversing with the part captured by the ‘8C’ characteristics. If so, the client’s response will reveal, for example curiosity or compassion. Answers which reveal fear or a desire not to engage indicate that another protector part has stepped in, necessitating a process of asking that part, and perhaps successive proctector parts, to move aside, until the Self can be accessed. These other parts, who have been asked to wait to oneside, are invited back at the end of the process to give their views. This process may take some time, and with complex patients may not be straight forward. It also necessitates the therapist remaining in Self, separating themselves from any of their own anxious or other parts (procedures or roles) that may have stepped in, for example a part wanting to step in to try and fix the problem. Once the patient is in Self again, further exploration involves beFriending the part, i.e. getting to know it from this open stance with questions such as:
“How long it has been acting in this role?”,
“When and why did it come into existence?”
“How old is the part and how old does it think the client is?”
This can be very helpful and revealing. The part may state that it came into existance when it was very young, with an associated belief that the patient is also much younger than their real age. Encouraging the patient to update the part about their actual age i.e. a ‘reality update’ can be a very powerful experience for the younger part. The final ‘F’ question, the fears of the part are then explored, a step that often reveals information about the exile it is protecting. This process is scaffolded by the therapist providing explicit information to the client that all parts have positive intent and that there is no plan to get rid of them.
These 6 questions can offer the client new and profound insights and understanding about the roles of the parts,. This can facilitate, in CAT terms, access to the non-judgemental ‘Observing Eye’, and a much deeper felt sense of a new and healthier RR that might be described as ‘kindly and genuinely listening to myself’ leading to ‘feeling deeply understood and accepted’. While exploration via the 6Fs of the parts can be undertaken after basic introductory courses supplemented by reading Schwartz’s and others’ books, the next phase of IFS, i.e. working with exiles directly and their ‘unburdening,’ requires further training and supervision and is beyond the scope of this paper.
Using IFS in the reformulation phase of CAT
One of us (AJ) frequently uses IFS in the reformulation stage of CAT to try and get to know a particular reciprocal role. For example, a client who repeatedly says they “beat themselves up” if they make a mistake could be invited to see if they would like to spend a bit of time getting to know the “beating up” part better. This can help to slow things down, to pay closer attention to how that part thinks it is helping and why it came into existence. The client and therapist may both have an “aha” realization at how important that part has been in helping the younger client survive or get to where they are today. Understanding this can lead to a shift and an acknowledgement that it isn’t necessary to get rid of that part , but to help it soften or be less extreme in it’s behaviours. This information can then be captured and used to enrich the reformulation letter.
Using CAT in the working phase of CAT
Another of us (CG) has been using the 6Fs of IFS during the working phase of CAT with success.
The majority of us will have experience of patients who have particularly harsh, critical or dismissive roles and who may struggle to access compassion towards themselves. An exit reciprocal role (RR) such ‘ feeling more at ease’ in relation to ‘just compassionately noticing’ can remain very cognitive, an idea without any felt sense of the experience. Finding ways to work with this in short-term therapy is important and many therapists have turned to ideas from Compassion Focused Therapy (Gilbert 2010) and Acceptance and Commitment Therapy (Hayes 2016) to support their work.
In a number of instances using the 6Fs has facilitated a deep understanding and compassion for this critical, often parent derived role/part, with significant and enduring change, which can then support the exit RR created with the patient. For example, a patient who had incapacitating morning anxiety in relation to his concern about his performance at work, had worked hard at introducing and using a kindly and supportive self-to-self (top-down) RR ‘voice’ as an exit to balance the parent-derived ‘judging and demeaning’ to ‘judged, useless and fearful’ RR, and was engaging with bottom up ‘breath work,’ and had made some progress. The work took a significant step forward, to the point of extended periods of complete cessation of his anxiety, after using the 6Fs to explore the judging and demeaning ‘manager’, understanding, respecting its efforts, changing a desire to get rid of the part and bringing awareness to the part that he was no longer 10 years old. He reported that using IFS was “an emotional and deeply revelatory experience”. He continues to support himself in this way when judgement is activated.
Does IFS add anything to CAT and, if so, what?
There are a number of ways that IFS can support CAT therapy and two are mentioned here:
IFS provides an intense experience of exploring, in the present moment a ‘part’/role/procedure with focus on the embodied quality, with a genuinely compassionate and curious stance when in Self. The fact that using the ‘6Fs’ can reveal a number of manager parts moving in to protect the system, which then need to be asked to move aside or share their concerns for the client, suggests that the patient may not be in ‘Self’ when in a general, more cognitive discussion of RRs and hence the possibility of a truly transformative compassionate response is less likely.
Although only referred to briefly in this paper, the therapist also needs to be in Self as far as possible. Wanting a particular outcome, or response, from the client is an indication that a part of the therapist has stepped in. Striving, rescuing and worries about ‘not getting it right’, can all be seen as parts of the therapist, wanting to help. Therapists can learn to notice this and to ask their own parts to “step aside”, to trust their own Self to handle the situation. These parts may be familiar as one’s own procedures and roles or may have been created within the therapy relationship, hence supervision is essential. IFS offers a simple question that the therapist can dip into many times during a therapy session – am I in Self? . If the answer is “no”, then the therapist will not be operating from the 8Cs. Briefly thanking the part(s) and encouraging them to move aside can lead the therapist back to a place, without agenda, where a different level of listening and exploration can take place, facilitating a central tenet of CAT i.e. ‘not joining an unhelpful relational dance’.
Summary
IFS is an interesting, relatively new therapy and clearly resonates with some therapists and patients. We have introduced some of the basic principles of IFS and how they may be used within a CAT therapy. CAT, an integrative therapy which takes an open and collaborative stance, recognizes that therapists may turn to other models to support the working phase of CAT. Some of the principles of IFS have an overlap with CAT but there are also significant differences.
We look forward to responses from other interested therapists.
References
Gilbert, P. (2010) The Compassionate Mind. Little Brown Book Group
Haddock, S.A., Weiler, L.M., Trump, L.J. and Henry, K.J. (2016). ‘The Efficacy of Internal Family Systems Therapy in the Treatment of Depression among Female College Students: A Pilot Study.’ Journal of Marital and Family Therapy, 43(1), pp. 131-144.
Hayes, S.C., Strosahl, K., Wilson, K.G. (2016) Acceptance and Commitment Therapy. Guildford Press
Hodgdon, H.B., Anderson, F.G., Southwell, E., Hrubec, W. and Schwartz, R. (2022). ‘Internal Family Systems (IFS) Therapy for Posttraumatic Stress Disorder (PTSD) among Survivors of Multiple Childhood Trauma: A Pilot Effectiveness Study.’ Journal of Aggression, Maltreatment & Trauma, 31, pp.22-43.
Schwartz, R. (2021) No Bad Parts. Sounds True Inc.
Schwartz, R. and Sweezy, M. (2019) Internal Family Systems. Guildford Press
Shadick, N.A., Sowell, N.F., Frits, M.L., Hoffman, S.M., Hartz, S.A., Booth, F.D. Sweezy, M., Rogers, P.R., Dubin, R.L., Atkinson, J.C., , Friedman, A.L., Augusto, F., Lannaccone, C.K., Fossel, A.H., Quinn, G., Cui, J., Losina, E. and Schwartz, R.C. (2013). A Randomized Controlled Trial of an Internal Family Systems-based Psychotherapeutic Intervention on Outcomes in Rheumatoid Arthritis: A Proof-of-Concept Study. The Journal of Rheumatology, 40 (11), pp 1831-1841