The CIPOS Method

- A procedure to
therapeutically reverse
dissociative processes while
preserving emotional safety
EMDR Netherlands
Annual Conference, Ede
March 29, 2008
Jim Knipe, Ph.D
Colorado Springs, Colorado
EMDRIA Approved Instructor
EMDR-HAP Part II Trainer
jsknipe44@earthlink.net

Traumatic memories result from a failure of the

natural information processing system of the brain
Relatively normal, integrated pretraumatic personality
Trauma: overwhelming and stressful
event(s) that cannot be integrated into the
persons whole sense of self
the information processing system fails

Adult
Perspective
and Adult
Sense of Self
Present
Orientation

Traumatic Memory -- Intrusive

reliving experiences not just
visual flashbacks, but negative
cognitions, age regression,
physical sensations and emotions
that have a right nowquality

EMDR Standard Protocol for resolving traumatic memories

--- Eight phases, focusing on negative memory material with
Bilateral Stimulation (BLS)
-Adult Perspective
-Present Orientation
-Present Safety
-Positive Resources

Dual attention
stimulation
with BLS

Trauma memory
- image, negative cognition,
emotion, physical sensations

--Resolution of traumatic memory

--Integration of traumatic event into the
individuals life story
--Increased self-esteem

This is how EMDR works in the absence of severe

ego state conflicts or defensive processes

Dissociation between ego states occurs on a

spectrum.

Co-conscious, integrated self -----------

Fragmented, dissociated parts of self
n

Within one person, ego states can be associated, and co-conscious,

Or partially co-conscious

Or dissociated and fragmented, with little or no awareness of each

other.

Video : Directly Targeting an Avoidance Defense

A traumatic abreaction is contained through
avoidance
The clients orienting response is stimulated as
a way to return from traumatic re-experiencing to
present emotional safety
With present orientation re-established, the
client is able to access traumatic material and
resume processing
Video segment begins during first set of EM

A difficulty in using EMDR with potentially

dissociative clients:
lAlternating

stimulation invites post-traumatic

material
lDeeply

dissociated memory material can emerge

and overwhelm the clients sense of being safe in
the present.
lThe

memory can feel more real than the real

situation the client is in
lSolution:

Create enough safety and orientation to

the present, so that the client can maintain dual
attention -- One foot in the present; one foot in the
past.

Back-of-the-Head Scale (BHS) -- 1

n

For clients who are potentially dissociative, the

degree of orientation to the present situation can
be assessed through the use of the Back-of-theHead Scale (BHS).

Completely present -------------------

Completely dissociated
(30 cm in front of face)
(back of head)
n

This procedure is introduced to the client during

the Preparation Phase, before any Desensitization
of trauma has been attempted.

Back-of-the-Head Scale (BHS) - 2

The therapist says:
n

Think of a line that goes all the way from here

(therapist holds up two index fingers about 30 cm
in front of the Persons face), running right from
my fingers, to the back of your head.

Let this point on the line (therapist moves fingers)

mean that you are completely aware of being
present here with me in this room, that you can
easily listen to what I am saying and that you are
not at all distracted by any other thoughts.

Back-of-the-Head Scale (BHS) - 3

nLet

the other point on the line, at the back of

your head (therapist points to back of own
head) mean that you are so distracted by
disturbing thoughts, feelings or memory
pictures that you feel like you are somewhere
else your eyes may be open, but your
thoughts and your awareness are completely
focused on another time, or place or
experience.
nAt this very moment, show with your finger
where you are on this line.

Back-of-the-Head Scale (BHS) -- 4

n
n

n
n

For dissociative clients, a way of measuring and

expressing a familiar aspect of their mental life.
The closer to the most present end point of the
line, the safer it is to do trauma work with bilateral
stimulation
Clients seem to be able to easily assess the full
range of dissociated experiences
It is necessary for the client to point to a position
at least three inches in front of the face, in order
for trauma-focused work to proceed (may vary
from client to client).
Use the BHS throughout the therapy session to
insure the client is staying present while
reprocessing disturbing memories.

The method of Constant Installation of

Present Orientation and Safety (CIPOS)
n
n

Used in conjunction with the BHS

Bilateral stimulation is used to strengthen or
install, in the clients awareness, a clear
subjective sense of being present in the safety
of the therapy office.
May be used in the Preparation Phase, or during
the actual Desensitization of a particular highly
disturbing traumatic memory.
As the persons present orientation is constantly
maintained, processing of the memory can
proceed with much less danger of dissociated
abreaction

The method of Constant Installation of Present

Orientation and Safety (CIPOS) -- 2
n

Steps in the CIPOS method

1.

Obtain full permission from the client, and

other parts of the system, to work on a highly
disturbing memory. Be sure there is time in the
therapy session.
Insure the client is aware of objective reality
(i.e. the present situation in the therapists
office, including the objective safety of that
office. This cognitive orientation to present
reality does not have to be accompanied by
feelings of safety, but it should be clear in the
clients intellectual understanding.

2.

The method of Constant Installation of Present

Orientation and Safety (CIPOS) -- 3
3.
n

4.

Before accessing traumatic material, strengthen the

clients present orientation by some or all of the
following:
Simple questions When the client responds to these
questions, the therapist says, Think of that, and
initiates a short set of bilateral stimulation, to strengthen
the clients present orientation.
The therapist might say, Whats good about being here
right now, instead of somewhere else? Whatever the
client answers, install with BLS.
Stimulate orienting response, with a game of catch with
a pillow or tissue, holding a drop of water or an ice cube
in the hand, or alternately counting to 10 and humming a
song.
The BHS can be used to assess whether the client is
feeling orientated to present safety

The method of Constant Installation of Present

Orientation and Safety (CIPOS) -- 4
5. When present orientation is sufficiently
established, the client is asked if they are willing
to go into their memory image for a very brief
period of time (e.g. perhaps only two to ten
seconds), with the therapist keeping track of the
time.
6. This is essentially a carefully controlled
dissociative process.
7. Immediately following the end of this period of
seconds, the therapist instructs the client, using
soothing but repetitive and emphatic words, to
Come back into the room now, until the
clients eyes open and they are looking out into
the room again.

The method of Constant Installation of Present

Orientation and Safety (CIPOS) -- 5
8. When the clients eyes are open again, the therapist gives
encouragement (Good, or Thats right.) and then
resumes the CIPOS interventions, with statements like,
Where are you right now, in actual fact? with the
answers followed by short sets of bilateral stimulation.
The CIPOS interventions are continued until the client is
able to report, using the BHS, that they are once again
oriented towards the present reality of the therapists
office. At this point, Step 5 can be repeated.
9. As this procedure continues, the client develops
increasing ability to stay present as well as greater
confidence and a sense of emotional control in
confronting the disturbing memory. This opens the door
to the use of the standard EMDR Desensitization
procedures, i.e. of directly pairing bi-lateral stimulation
with traumatic material.

CIPOS Method sequence of procedures

BHS: Fully present ------------------------------------------ Dissociated
Orientation to
Present Safety
Paired with EM
Repeat 4+ times

Orientation to
Present Safety

2-10 seconds of
deliberate dissociation into
traumatic material in a way
that preserves present
safety No EM

2-20 seconds of deliberate

dissociation into traumatic
Paired with
material while preserving safety EM
No EM
Continue repeating as necessary
while preserving dual attention

Orientation
to Present
Safety

More than 20 seconds in

trauma with EM
Standard EMDR EM sets

Video Example: Use of CIPOS and BHS Methods to Assist in

Trauma Processing in a Client with Dissociative Identity Disorder
53-year-old transexual male, 16 year history of
psychotherapy, many diagnoses
Living as a female for the 13 years prior to this session
From age 3 throughout childhood, many separate instances
of sexual abuse, with different perpetrators, some violent
The targeted incident in this session was identified by the
client as the worst one
The client became aware of the incident as an intense
flashback, the night before the session
This incident was the touchstone event for the negative
cognition: If I say no, I could die.

Three adult male pedophiles forced the client, age 4,

to go to the top of a steep cliff. They placed the child
in a large oil drum, and told him he would be killed if
he did not submit to abuse.
The night before the recorded session, the client
called me , very upset.
We considered hospitalization, but the client was
able to contain the affect by talking on the phone
and by drawing a picture of the trauma.
The adult ego state is Kelly. The child ego state
reliving the trauma is Little Rickie.

Video Demonstration: BHS and CIPOS with a DID Client

Little Rickie
ego state

Kelly
Host ego state
Oriented to the
present
Able to access
present safety

All the little ms

-reliving the
abuse
-Intensely
intrusive
-Destabilizing
of the Host ego
state

Considerations in using the BHS/CIPOS

procedure
Not for every client or every situation of trauma
processing -- Use only when the client is unable to stay
present while thinking of a trauma
At every opportunity, acknowledge the clients
increasing ability to return to present orientation and
safety, more and more easily
Even after the client is able to reliably maintain dual
attention processing, all the other tools of EMDR
(cognitive interweaves, targeting of psychological
defenses, etc.) may still be necessary

Resources
International Society for the Study of Dissociation (2005). Guidelines
for treating dissociative identity disorder in adults. Journal of
Trauma and Dissociation, 6(4), 69150.
Knipe, J. (2007) Loving Eyes: Procedures to Therapeutically Reverse
Dissociative Processes while Preserving Emotional Safety, in Forgash, C.
and Copeley, M. (Ed.s) Healing the heart of trauma. Springer: New York.