Trauma & Attachment Therapy

Narcolepsy and EMDR Processing

A client has given me permission to post about her situation: the effects of Provigil, Prozac, and time on trauma processing:

 

Round 1, 15 years ago: She was bright, effusive, and had the odd habits of jerking her head up to look around and writing down everything I said. We worked for eight months using EMDR to clear the PTSD from the physically and emotionally abusive marriage that she had escaped 17 years before. She seemed dissociative, but in a strange way, staring off, then going to the head jerk. The EMDR worked, the flashbacks stopped, the client, satisfied, went off.

 

Round 2, 10 years ago: After her narcolepsy diagnosis, she started taking Provigil. A few days later, the flashbacks from the abuse began again, and she returned to therapy. We went after the abuse, in greater depth as more details arose. Again, we cleared all we could find, and she left therapy feeling good.

 

Rounds 3 – 5: I saw the client through the illness and death of a sweet boyfriend, and various stressful work situations. Then as she became more constitutionally anxious, then obsessive, which became manageable when she started Prozac.

 

Round 6: last week: Planning her 45^th high school reunion, to which her abusive ex-husband had been invited, brought up the next round of distress over the marital abuse. SUD 10, when she thought of him. She processed through fear and rage, bringing up memories that had not arisen in rounds 1 or 2. She left, after a 60 minute session, feeling safe, calm, and able to ignore him, if he came to her reunion.

 

She and I think that whether or not her narcolepsy was a dissociative response, the Provigil allowed her brain to stay on task with the trauma processing, and that the Prozac with the Provigil keeps even more of her brain online and on task in trauma processing. She and I would love to hear if other people have had similar reactions with these medications affecting the depth of trauma processing.

Avoidance, AIDS Dementia, and Chosen Families

Last Wednesday I flew down to Fresno, CA, and flew back up with an old friend who, after battling AIDS for 25 years, is losing the fight. R''s brother and a few other friends and I have been managing his care up in Seattle for the last week.

R is one of my favorite flavors of people, a skinny nervous person, smart, funny, charming, talented, and relational. He has also had OCD since I met him in 1980. The OCD, related to a bipolar diagnosis, manifested in several ways, eating disorders, an inability to get out of the house without carrying half his belongings with him (the bag-lady syndrome "what if I need something"), and extreme indecision. The OCD also carried avoidance behaviors. R. avoided conflict, asking for what he wanted, and anti-retrovirals. He would get busy controlling the minutiae of his life while avoiding the big issues. In the last few years, he would worry incessantly about his belongings in storage units, while not chasing down the health care that he needed. Several of his Seattle friends offered to fly down to help him. He couldn't accept their offers because his appearance (another obsession) wasn't up to par, his apartment wasn't clean, and he would have to take care of them (another compulsion.)

Two months ago, R got pneumonia and began to show signs of dementia. His California social worker, Frida, and I talked him through getting on an ambulance to the Emergency Room. We both thought for sure that he would be admitted, but he was cut loose with some heavy-duty antibiotics and sent home. After a few weeks of daily calls by the Seattle support group, he had managed to take his pills daily, but was obviously losing his mind. A month ago his brother flew down and took over. 10 days later his brother's boyfriend drove down to help. R. was emaciated, covered with KS, and had about 2 minutes of short term memory. He didn't know where his own bathroom was. He didn't finish a meal without constant reminders. Last week I flew down and flew up with him. He was hospitalized at the best AIDS hospital in town and will go to Bailey-Boushay, a state of the art AIDS care facility, with loving staff and loving volunteers and really good art.

My feelings are extremely mixed. My lovely, vain friend, has a wasted body and a wasted mind. He's in pain much of the time. I'm grieving. I'm sad. But we have him now, he won't die alone, and he's in the best possible care, so I'm relieved, too. I'm also, clinically, fascinated by the dementia process (when I'm not frustrated by it or laughing.) R. can remember people and activities from 30 years ago. He can charm nearly every nurse and doctor who comes in the room. He remembers, at this point, all the people who love him and whom he loves. His right brain is working pretty well. His left brain doesn't tell him where he is, anything that happened in the last 6 weeks, what day or time of day it is, or the name of the person in front of him whose name he just asked. He is often sweet and charming. The more confused he is the snarkier he gets. He is very sarcastic, especially with his long-suffering brother. R. confabulates what he doesn't know. His brain makes up stories to fill the holes in his memory. Some are quiet elaborate. I haven't seen R in 8 years, nor has he been on a plane in that time, but evidently we've been on several long trips together. His brain told him that he has an apartment in a neighborhood of Seattle, not Fresno, and he wanted me to take him out of the hospital and take him home. Much of the time he thinks he's in Fresno, despite the view of Puget Sound out the window. His friend, Joe, says, "is that Fresno out the window?" and R. replies, "Oh, we're in Seattle." R., the compulsive care-giver, asks for back and foot rubs, tells the doctors that he wants us in the room to supply information that he won't remember, and has allowed us to talk him into many medical procedures. The right brain relational trust is working, even though the left brain thought process is not. His sentences are complete. His syntax is perfect. He knows his social security number. And he doesn't know who visited him or what vile procedure they just did or that his body is wasted or that he has AIDS. The KS constantly suprises him. (Advanced Kaposi's Sarcoma looks like an archipelago of red, mountainous islands everywhere but his feet, hands, and face. Sometimes it hurts like hell, sometimes it itches, sometimes it's hot to touch.) He asks, "Why am I so weak? Why do I hurt?"  "Honey, you have advanced AIDS." "When did that happen?"

Back in the 80's, I lost about a hundred friends, clients, mentors, colleagues, and neighbors to AIDS. I started the AIDS Mental Health Network, which gave free training to therapists about psychosocial issues, safe sex, dying, resources, anything we needed to know. It was before the AIDS agencies arose and we were flailing to find information and the skills we needed to take care of all these dying young men. Back then we created care committees: chosen families of caregivers that ran errands, cleaned houses, did pharmacy runs, took the person to the doctor, and generally hung out. There was no internet, so we communicated by phone, and sometimes by a log at the PWA's (person w/ AIDS) house. R. has an AIDS nursing home to go to, the Lifelong AIDS Alliance, and a group of about 5 people, including his brother, who are the support team. In the 80's, PWA's died within 16 months. R. has lived with AIDS for 25 years, at least, and is in the last stages with good medical and social support.

Mindfulness Through Pleasure

Mindfulness is a major goal of psychotherapy. We want our clients to be able to savor the moment free of intrusive memories or worries about the future: Right Now. There are many ways to bring a client to the present moment: teaching mindfulness meditation, body awareness, or playing what do you notice? ("Name 3 things in the room that are red, 3 things you hear, 3 sensations.")

Some of my more anxious clients find that their obsessiveness scuttles attempts to meditate ("Am I doing it right? This is stupid? What am I supposed to be focusing on? I can't do it!). Body awareness reminds them of what could go wrong with their bodies. ("What if I stop breathing?!) I'm teaching these folks to make state changes through noticing pleasure. Here's how it works:

"Look around the office. Look out the window. Notice what catches your eye. Notice what's fun to look at or that you enjoy seeing. Stay with whatever it is, as long as it's interesting or pleasurable. (Usually they start to smile and to relax at this point.) When you're ready, and only when you're ready, look around for something else that pleases you. Stay with that object or view until you feel like moving on. Stay with it as long as you like. Great!" (We usually do 3 objects or views. I say that my eye can be pleased by looking at the angles on a molding, or 3 planes coming together in the corner of the room. I only have art that I like and little objects scattered about to look at. I tell them how much I like to look at the big tree across the street. This kind of pleasure can be a new experience for some, and quite profound. For others, it's not new, but consciously using it for mindfulness or self-soothing might be new.) "Now notice how you're sitting on the couch. Could you do anything to make that more comfortable? Try sinking into those cushions. How's that? Try sitting straighter or sticking this pillow behind your back. What feels the best? What fabric feels the best under your fingers? How about your hair on your hand? Do you like that texture?" (Crew cuts win this one!) Hang with what feels the best. Can you imagine the next time you take a shower, totally feeling that hot water, and enjoying it? Can you imagine being worried about something that you don't have power over, and finding something pleasing to look at or feel or smell or do? Think of something that might happen at work, and soothing yourself with something you enjoy. Think of something that happens at home, and coming back to yourself and this moment with something pleasing. If you commute, think of the irritating drivers and the waiting, and how you can shift your body in the car for your best comfort, and look at something interesting, a cool car, the view, a cloud, a bumper sticker, and while still paying attention to driving, have a little pleasure vacation."

People do this homework. And it works, even with the most anxious. And it doesn't feel like work. And they learn both mindfulness and painless state change. It doesn't clear underlying trauma. It doesn't take away an anxiety disorder. But it's a nice, easy habit to take on.

Trauma and Temperment

I recently took on several new clients and am on my 3rd session with several new people, I'm struck by how much temperment affects people's experience of trauma. Some people have iron constitutions. It's hard to scare these people. It takes a truly life-threatening trauma for them to experience PTSD symptoms.

Others are traumatized by a harsh look, a trauma once-removed, or an unmet expectation. These folks, often with anxiety diagnoses, need more trauma processing sessions, more containment, and more reassurance than the other kinds. I can take all the factors I know into account: attachment history, prior trauma, culture, etc., and temperment stands out as one of the strongest predictors of posttraumatic symptoms. I wonder why it's so little researched and so rarely discussed. Elaine Aron's The Highly Sensitive Person, speaks to this issue. Is there anything else out there?

If any of my readers know of research or resources about the effect of temperment on the experience of trauma, please leave me a comment. According to the stats there are 100's of you lurking on this site. Please speak up!

Therapy During Troubling Times

More than half of my clients have mentioned the economy and/or the election in the last two weeks. Some of them are in real world trouble, having lost jobs or facing foreclosure or eviction due to the "downswing" Many are troubled by the divisive discourse in the political realm. What do we do when the real world intrudes on the inner world in our offices?

1. If you, the therapist, have lost value in your retirement/savings/house value/security , notice what you're feeling and up your own self-care. Take more walks, see your friends more, have places outside your office to get support and voice your distress. Keep breathing and remind your clients to keep breathing.

2. Validate and normalize your clients' concerns. Don't tell them "it will be all right". You have no way of knowing that. If they are in great financial difficulty, you can explain the grief cycle: "When you realized that you were laid off/losing your house/facing eviction, you were numb. Now you are in the angry/blaming phase of grief. Notice that you can be angry at anyone, including yourself, in this phase. Notice the anger, feel it, and try not to take it out on yourself or your beloved, in the meantime. The sadness should hit after a while. That's often mixed with hopelessness. Don't confuse the hopeless feeling that goes with grief, with your life being truly hopeless. Hopelessness is a feeling, not a state of being. Feel it, all. We'll process it in here. You'll go through stages with it. You need to function to deal with this mess, so we'll keep the feelings moving and unstuck, so you don't shut down and lose the ability to deal with it."

3. Clear the trauma of the situation, in whatever way you have to do it. I've used EMDR, Brainspotting and Somatic therapies to help clients deal with "the moment I realized I couldn't retire this year./when I got the foreclosure notice/the layoff notice/etc."

4. Don't minimize, but do collectivize: "As you feel your fear about X,Can you connect with the 10 million homeowners going through this same thing? Your situation is yours and it sucks. And you can notice that you're not going through it by yourself."

5. After you've validated their emotions and moved the trauma, bring in the resources. "How did you get through the last bad thing? What strengths got you through it? Where do you feel (each strength) inside? Think of a time you used intelligence/ stubborness/creativity/etc. and it worked for you. Then think of a time you used (another strength) and it worked for you. Now imagine using those strengths to get through this awful time."      Don't forget external resources--friends, family, welfare, etc.

6. Some clients need action plans. If they're panicked, they can't think. Help them think, after calming them down.

7. Clients who already worry about everything are going to worry about the economy, even if they're financially secure. I've asked, "How much are you picking up on the free floating anxiety out there? How much is yours versus how much is out there? What's yours about? Let's deal with that.

8. Politics. I live in lefty-liberal Seattle. My clients' political distress tends to be in a few veins: "What if he (Obama) doesn't win?"  "What if someone shoots him?" and "I can't stand the polarization. They're saying I'm not a real American because I'm not White/Conservative/small town/working class/straight/Republican! I'm so mad."

For the first two-- losing Obama, one way or another, I ask, "What if?" We talk grief and it usually leads to a plan about defeating the next guy.  For the other, I ask them to define American, and ask them if they qualify. (All say yes.)

"Do the small town conservative people qualify?" "Yes".

"Are you going to demonize them the way their leaders are demonizing you?" "Of course not."

"Then who are you mad at?" (Most say one leader or the other.) "Let's process that anger." And after that, we think of what they could do to empower themselves to be/feel American. Many say, "volunteer for a politician."

If I were dealing with a distressed, feeling hopeless conservative client, I'd validate her feelings, discuss the grief process, clear the trauma, and imagine what she'd do next.

9. Summing up: Validate and normalize the grief and distress. Move the trauma and  grief, as many layers as you can. Connect them to the collective angst. Help them tolerate their anxiety, but differentiate it from others' anxiety. And let them feel about the poliitics, while acknowledging their identity.

Mother Jones said, "Don't Mourn. Organize."  I say: Mourn, then organize. If appropriate.

Procrastination

According to Daniel Goleman, in Vital Lies, Simple Truths, (1995, Simon & Schuster), when we avoid thinking about or doing that which makes us anxious, our brains reinforce us  with really pleasant chemicals. Thus we have epidemics of procrastination and avoidance.

    With this in mind, I've developed several strategies for my avoidant and procrastinating clients. I tell them to:

1. Make a list of your favorite avoidance behaviors (computer games, cookies, tv, shopping, addictions, etc.)

2. Whenever you start thinking of doing the behavior, or actually doing it, ask yourself, "What am I avoiding?"

3. Think about the avoided thing. Then notice what you're feeling. (Anxiety, frustration, daunted, shame, anger, etc.) Stay with the feeling.

4. Then, just do it! If you can do it right away, great. If not, make a definite plan for a definite time. Feel the anxiety. And do the deed.

5. Apply positive reinforcement when it's done. You can use the harmless things on the avoidance list as reinforcers, after the task is complete.

I often use Jim Knipe's subversive Level of Urge to Avoid with the hard-core cases. He has clients think of how good it would feel to do the avoidance behavior, instead of the thing avoided. Then he has them do EMDR bilateral stimulation while they think about avoiding the task. The clients usually start feeling worse and worse. He subverts the "inappropriate positive affect" until they begin to think about doing the task. Then he point the EMDR Standard Protocol at the anxiety tied to doing the task. Then he has people imaginally rehearse doing the task with more EMDR. It works wonderfully. (In "Targeting Positive Affect to Clear the Pain of Unrequited Love, Codependence, Avoidance, and Procrastination". EMDR Solutions: Pathways to Healing. 2005, Norton)

In my mind, avoidance is all about affect tolerance. My most anxious clients have the most affect to avoid, and are the most avoidant. If their anxiety is a 9 on a scale of 10, they have more endorphin payoff for not working on their taxes/confronting their s.o.s/starting project X. If I can get them to feel their distress, and work it through, then they get the deeds done. The more they get done, the less good they feel about avoiding.

 

 

 

PTSD Has Genetic Aspects

http://arstechnica.com/journals/science.ars/2008/03/18/study-identifies-gene-x-environment-link-to-ptsd  is a link to a website that discusses the connection between a stress-related gene and the likelihood of developing PTSD.

The new issue of the Journal of the American Medical Association features an article by Dr. Kerry  Ressler and several co-authors found that specific variations in the gene appeared to be influenced by child abuse. That interaction strongly increased the chances for adult survivors of abuse to develp signs of PTSD. The worse the abuse, the stronger the risk in people with the gene. (Though that might be true in any population.) From the Seattle Times: "The results of the new study suggest there are critical periods in childhood when the brain is vulnerable to 'outside influences that can shape the developing stress-response system'. . .Dr. Thomas Insel, director of the NIMH, said the study is valuable for the light it sheds on military veterans. He said the results help explain differences in how two people see the same radside bomb blast. One simply experiences it as a bad day and goes back to functioning. The later develops paralyzing stress symptoms." See below for the Seattle Times link: http://seattletimes.nwsource.com/html/health/2004291429_ptsdgene19.html

The Instinct To Heal

My new favorite book is Instinct to Heal by David Servan-Schrieber (Rodale, 2003). It is simple enough for most clients and innovative and interesting enough for most clinicians. I recommend it to psychiatrists, any kind of physician or "alternative" medical practitioner and all psychotherapists.

Why? Instinct to Heal gives clear explanations, references to good research and, in many cases, directions for many mood-altering treatments including guided imagery to shift heart-rate coherence; justification and dosage for Omega 3/Fish oil supplements; sufficient exercise to change mood; dawn simulation lights; EMDR & acupuncture (no self-help instructions included) some Gottman-researched communication protocols; and the Stuart & Lieberman's BATHE questions--to help doctors and others quickly and efficiently connect, get the information, and validate and strengthen their patients. It's all good stuff. It follows research, Servan-Schrieber's clinical experience, and common sense. He made it clear, concise, and practical; my favorite kind of clinical book.

I've been hearing many researchers speak about heart-rate variability and coherence for many years. Simply, our heart-rates are constantly changing depending on changes in our activities, thoughts, state of digestion and other physiological changes, moods, and arousal states. According to research if you want to live a long time, avoid heart attacks, and avoid depression and anxiety, your heart rate should vary in a smooth, regular way, instead of a jerky, erratic way. There is tons of research to back this up. Do a search online, or buy Servan-Shreiber's book if you want the citations. You can buy computer software, with a little hardware to test your or your clients' heart-rate variability, and get slightly more complicated software to use your computer as a biofeedback device to create smooth "coherence" in heart-rate variability. Or you can simply, with or without high-tech help, use Servan-Shrieber's guided imagery for heart rate coherence. I've modified it a bit. Here it is from pages 53 and 54:

• "Take two deep, slow breaths. . . Keep your attention focused on your breath right up until you have finished exhaling and then let your breathing pause for a few seconds before the next in-breath begins of its own accord. The point is to let your mind float with out-breath right up to the point where it lightens up, becoming mellow and buoyant inside your chest.
• . . .In about 15 seconds after your breathing stabilizes, center your attention on the region of your heart. Imagine that you are breathing through your heart (or the center of your chest, if you don't feel or "see" your heart). As you continue breathing slowly and deeply (but effortlessly), visualize--and really feel--each inhalation-exhalation passing through that key part of your body. Imagine that each intake of oxygen nourishes your body and each exhalation rids it of the waste it no longer needs. Imagine the slow and supple movements of inhalation and exhalation that bathe the body in this purifying and soothing air. Imagine that they are helping your body make the most of the gift of attention and respite it is receiving from you. . .
• Become aware of the sensation of warmth or expansiveness that is developing in your chest, and in fostering and encouraging it with your thoughts and your breath. (This feeling may not come immediately, with more practice, it will.) One way to encourage the heart is to draw on a feeling of gratitude or of love for another being. You might think of a beloved person or a pet or a peaceful scene from nature. Or you might think of when you were in the "zone" in a sport: swinging a golf club or running, or doing a downhill run on skis. You may notice yourself smiling or feel lightness or warmth or expansion in your chest."

Servan-Schreiber suggests people do this daily. He says that people can enhance heart-rate coherence in other ways. Exercise or yoga or meditation can do the trick. He says, "Coherence in heart rhythm affects the emotional brain, fostering stability and signaling that everything is working order, physiologically. The emotional brain reacts to this message by reinforcing coherence in the heart. Coherence in the heart and the emotional brain stabilizes the autonomic nervous system, both sympathetic and parasympathetic." He talks about depressed or anxiety-disordered clients who lost all their bad symptoms with this technique. And he says that it doesn't do the complete trick for everyone. Some people need light, Omega-3's, better relationship, and even medication before they turn the corner. But isn't this a sweet place to start?

Buy the book, recommend it to appropriate clients. And use some of his practical techniques yourself.