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.

Is addiction a form of dissociation?

I read an article about how naltrexone, an opiate suppressant, curbs the urge to engage in kleptomania. I've had dissociative clients who have successfully used naloxone and naltraxone to vanquish their endogenous (internal) opiates, in order to be able to stay present and process traumatic events, instead of switching or spacing out completely. (See EMDR Processing w/ Dissociative Clients: Adjunctive Use of Opioid Antagonists by Ulrich Lanius, in EMDR Solutions: Pathways to Healing, 2005). I've also had success using ego state work with addicts, alcoholics, and people with compulsive/addictive behaviors. Here's my theory: Opiate Antagonists work on dissociation because much of dissociation is run by endogenous opiates. When addicts think of their drug or behavior of choice, they begin to enjoy their endogenous opiates. When they engage in their drug or behavior it gives them an even better high. The neural pathways to the repetitive addictive behavior become wide and strong, until they become ego states. When people in recovery talk about "my addict", they refer to this strong ego state. Integrate the ego state and help heal the addiction.

So how does this work? Have clients bring up the last time they were frantic to use, or the last time they did use. "Where do you feel that inside? What's the feeling? Float back to the first time you had that feeling. How old is that? What was happening then? Can you bring your adult back to that time/that kid? What do you need to tell that child? You're with her. You can fly her up to the present time. She's with you all the time, now, and you're with her. Can you tell her that now, as a competent adult, you can tolerate those enormous feelings? Can you show her how you have learned to soothe yourself without that drug/behavior? How's that kid doing now? (Do whatever it takes to calm her down.) And are you ready to hug her into you now and forever?"

There is usually a frantic little child and often an angry/protective teenage part. Sometimes there are several "parts" involved in different pieces of the addiction. It has worked on several clients.

A.J. Popky and Jim Knipe have protocols that seem to fit my opiate theory. Popky developed the Level of Urge to Use. Knipe spun off the Level of Urge to Avoid. In both of these you have the person imagine whatever triggers them to use a drug or to avoid a task and to feel how good it would feel to use or avoid. Then you do eye movements and watch the good feeling start to fade away. (DeTUR, an Urge Reduction Protocol for Addictions and Dysfunctional Behaviors by Popky, and Targeting Positive Affect to Clear the Pain of Unrequited Love, Codependence, Avoidance, and Procrastination-- both in EMDR Solutions: Pathways to Healing, 2005, Norton.) You target inappropriate positive affect in both cases. When the positive affect (the good endogenous drugs) fade, you target the distressing affect underneath, and the trigger stops being a trigger. I've done this many times, for many addicts. It works amazingly well.

I've watched clients and people in my private life turn into unrecognizable demons, sociopaths, and screaming or pleading children while in thrall to their addictions. The dissociation/opiate theory explains these behavioral shifts. Please comment and give me your opinion about this theory.

UCLA 2009 Trauma Conference Day 1, van der Kolk & Shapiro

Day 1: Bessel van der Kolk is lovely. He's humble, he's funny, and he is the premiere researcher on the neurobiology and/or efficacy of trauma treatments in the world. And cute and brilliant, of course.

Here are nearly random gems from 3 hours of notes:

With trauma, there are no stories, only sensory experience: images, affect, and tactile, olfactory, and auditory experience. Bleure (1920): People can't hold the memory of the trauma--can't tell the story. The solution is taking action against the person who hurt you or telling the story over and over. (Prolonged exposure). Bessel says "No. Telling the story is not enough!" Later: "When people are into their trauma, they cannot talk about it. They become dumbfounded." Because Broca's area in the brain shuts down. "When the left brain shuts down, we must shift to right brain processing."

"Our job as trauma therapists is to bring the frontal lobe on line." (He said that GW Bush showed himself to be a "limbic" president with his "Let's kill them all" speech after 9/11. "A dangerous limbic-run man.")

The body relives and reinstates the initial trauma state, even the stress hormones.

Exposure therapy "blasts people's brains with the trauma and drives them crazy. That's supposed to be good for people?" And said the CBT literature is full of the treatment triggering suicide attempts, substance abuse, and worse symptoms.

He talked about his amazing EMDR vs Prozac study. 80% of adult onset trauma completely cleared PTSD & Depression after 8 weeks of tx. Prozac people felt better until they stopped taking the drugs. EMDR folks got better and better for months after tx and stayed that way. Cool study and he had trouble getting published despite 3X the success of CBT. Politics.) http://www.emdr.dk/artikler/07_kolk.pdf

Bessel and many of the top child psychiatrists and psychologists are lobbying for an new DSM 5 diagnosis: Developmental Trauma Disorder:  http://www.traumacenter.org/products/pdf_files/Preprint_Dev_Trauma_Disorder.pdf 

It's much needed. I have so many clients who need this diagnosis! (gai

Developmental Trauma Disorder

A. Exposure

1. Multiple or chronic exposure to one or more forms of developmentally adverse

interpersonal trauma (abandonment, betrayal, physical assaults, sexual assaults, threats to

bodily integrity, coercive practices, emotional abuse, witnessing violence and death).

2. Subjective Experience (rage, betrayal, fear, resignation, defeat, shame).

B. Triggered pattern of repeated dysregulation in response to trauma cues

Dysregulation (high or low) in presence of cues. Changes persist and do not return to

baseline; not reduced in intensity by conscious awareness.

•Affective

•Somatic (physiological, motoric, medical)

•Behavioral (e.g. re-enactment, cutting)

•Cognitive (thinking that it is happening again, confusion, dissociation,

depersonalization).

•Relational (clinging, oppositional, distrustful, compliant).

• Self-attribution (self-hate and blame).

C. Persistently Altered Attributions and Expectancies

•Negative self-attribution

•Distrust protective caretaker

•Loss of expectancy of protection by others

•Loss of trust in social agencies to protect

•Lack of recourse to social justice/retribution

•Inevitability of future victimization

15

D. Functional Impairment

•Educational

•Family

•Peer

•Legal

•Vocational

---------------------------------------------------------------------------------

Bessel talked about vagal nerves (see Porges--later) and said that you can change the way you feel by changing the state of your body (thus our affinity for alcohol, drugs, and sugar.) Drugs, tai chi, karate, yoga, meditation and exercise manipulate the vagus nerves. Do yoga, etc. to affect the state of your body.

"Emotional Regulation is the most important issue in psychotherapy."

Cloitre 2007: '"If treatment relationship lead to affect regulation, the patient gets better."

In a study with chronically traumatized clients: 8 weeks of Yoga class beet 8 weeks of CBT with 28 hours of homework.

In PTSD, the thalamus goes offline. The thalamus orients you to where and when you are in a autobiographical context. Much of the brain goes offline when immobilized and there are no available receptors for attachment or problem-solving.

"Thinking has no avenues of access to the emotional brain. (You can't talk yourself into loving Dick Cheney, whatever the incentive.) . . . Traumatized people don't have a sense of being deeply present because the anterior singulate is off-line. . . Keep clients oriented to 'now' in themselves: 'How does your body experience that feeling?' . . .Help clients process what's inside of their here and now consciousness."

Trauma survivors see the trauma or the "bad thing" as outside of themselves, not as their own response to something that happened. "Bring attention to the body, to internal landscape: What's the sensation? Where do you feel it? What happens if you try something? Take a deep breath, right now. Do TFT tapping on the collarbone spot. . . Notice what comes up and remember how it will come to an end. How can we give the miserable, alone, frightened part of you some company? . . . Tell her you know how terribly lonely it was."

"You can't do trauma work without people deeply observing their own level of consciousness and then deeply connecting on the outside with you."

"The emotional brain runs the show." Feelings should be guides rather than a source of terror.

Bessel spoke of the importance of EMDR and Somatic therapies in working with trauma and showed a moving video of a formerly DID client who was "organized" by neurofeedback. "EMDR is the opening for understanding trauma. You can't do trauma treatment without EMDR or something else that knits the sensory experiences together."

Part II: Francine Shapiro, the brilliant maven of EMDR, looking well and energetic.

Much of what Francine said was material you can find at emdria.com or the EMDR Institute website: The Adaptive Information Processing model and the steps of EMDR treatment. Today I heard her say some different things: The importance of targeting the "small t" traumas. Much of the trauma that can severely impact a life does not fit the criteria for PTSD. She gave many examples of people who developmentally stopped at some distressing, non-life threatening event, until an EMDR session, years later, released them. (It happens. I've seen it many times.)

"Neurophysiology does not equal destiny." There is neuroplasticity in adult brains. Shrunken hippocampi grow again, after the trauma is resolved. Don't give up! A study: 8 sessions of EMDR, 20% increase in hippocampal growth.

Beliefs are a manifestation of trauma. CBT/Exposure = extinction. EMDR = reconsolidation. In prolonged exposure, the memory of the rape doesn't change, but get a competing new memory. But the clients relapse when around a trigger, because the old memory is still there. EMDR reconsolidates memory changes, so the initial triggers won't work.

"Processing dysfunctional and positive memories are the focus of EMDR treatment. Process the negative and integrate the positive. Every positive attunment or modeling by the therapist links the positive information in. . . You need to have positive adaptive memory networks for tx to work."

Process: Family of origin issues, memories that are encoded; Defenses, i.d. the earliest childhood event that caused that pathway to develop; cognition, process the memories that created the cognition--the cause is the encoded earlier event; Somatic/Emotive, "When's the 1st time you felt that way?"; Developmental, "What events derailed attachment?"

(I'm getting too tired to give you all the rest, so I'll hit a few highlights:)

ADHD: some of it is PTSD, some real ADHD.

Body dysmorphia: usually from childhood humiliation, sometimes just one comment. Clears with a few sessions. (There's a chapter in Solutions II about this.)

Small t traumas cause more pathologies than PTSD.

Axis II (personality dx's) are a constellation of attributes, each rooted in earlier events.

Borderline Personality Dx: Cool stuff-- too much to write. But Axis II is moveable and cureable if you go after the childhood antecedents. (I know because I have ex-borderline clients and ex-narcissists.)

If you are treating kids, treat the parents attachment issues and the kids get better. Include in this: targeting the non-bonding event with the child, then make a story about an easy pregnancy, each trimester, an easy delivery, the first breath, first hours, coming home -- better than real life, and install it.

In family systems, you can treat the family of origin issues in every one, all the behavior. Teach skills after the trauma is gone, when it can sink in.

Depression. Yes, See the first 5 chapters in Solutions II.

Phantom Limb Pain. Yes. See the PLP chapter in Solutions I--Wilson

Grief: "There is more positive recall of the loved one after EMDR (for traumatic grief) than after CBT. (Sprang, 2001)

EMDR increases resilency and engenders a new sense of self.

 

 

EMDR Solutions II, for Depression, Eating Disorders, Performance and More

Yesterday I held my new book in my hands. It's hard for me to make meaning of 14 months of work being encapsulated in a 1 1/2 pound book. As I paged through it, I recalled the process of writing; my appreciation of the content of other people's chapters; editing squabbles; waiting, waiting, waiting for late chapters or late edits to show up in my emails; and my immense relief at each ending. The first ending was when my chapters were complete (EMDR with Depression, with OCPD, with Medical Trauma, with Multiple Chemical Sensitivities.) The next ending was when all the chapters were finally in. The next ending was after the first and second edits, by me then by my writer-mother, when I emailed all the chapters in. And last ending was after the re-editing by writers and then again by me.

One of the perks of editing a compilation is that I get to learn the material, really well. I never read a chapter 4 times before I did these books. There are 7 chapters about eating disorders. I am suddenly well-versed. I knew what to do, and successfully did it, when a fledgling anorexic client walked in the door. I know much more about working with early childhood trauma, performance issues, and targeting intrusive images. And I knew next to nothing about Positive Psychology and Coaching. Now I have a clue!

This book is about 200 pages longer than the last, and has units of related material: 5 chapters on depression, 7 on different aspects of eating disorders from affect tolerance to desensitizing desire, 5 on complex trauma, 3 chapters on Medically Based Trauma, and stand-alone chapters on performance enhancement, coaching, positive psychology, sex offenders, and religion/spiritually attuned clients. It's a better book than Solutions I. More depth, more heft. (Though it's not "bigger", because the pages are thinner.) It's even prettier than #1.

Tomorrow, I'm off to Los Angeles for the UCLA-sponsored Trauma Conference. I want to hear about the cutting edge affect theory heralded in the materials, so that I might jump start my next book: Trauma Treatments Sourcebook. I plan to blog about what I learn at the conference. Stay tuned.

If you're in Seattle mid-April, come to the book signing for book # 2. If you're in Seattle in spring of 2011, come to the signing for #3, if all goes well. I'll let you know the dates, as I know them.

The book comes out at the end of March. It's sold over 800 advance copies. I'm amazed.

NYT's PTSD in Iraq Vets article: Counting the Walking Wounded

The New York Times published this article today. If you haven't starting gearing up to work with soldiers, get some training now. There are online trainings, in-person trainings, and books. You can even start by watching movies: In the Valley of the Elah is supposed to be a great one. Understand that, so far, EMDR has been statistically superior to any other training for PTSD in soldiers.

Counting the Walking Wounded

By LAWRENCE M. WEIN in the New York Times

Published: January 25, 2009

Stanford, Calif.

Related

Times Topics: Veterans and Post Traumatic Stress Disorder

THE American troops in Iraq daily face the risk of death or injury — to themselves or their fellow soldiers — by homemade bombs and suicide attackers. So it is not surprising that post-traumatic stress disorder is a common problem among returning soldiers. But how many, exactly, are affected?

This question is key to determining how large an investment the Department of Veterans Affairs needs to make in diagnosing and treating the problem. The United States Army's Mental Health Advisory Team, which conducted a survey of more than 1,000 soldiers and marines in September 2006, found that 17 percent suffered from P.T.S.D. Similarly, a Rand study put the number at 14 percent.

But these estimates do not take into account the many soldiers who will eventually suffer from P.T.S.D., because there is a lag between the time someone experiences trauma and the time he or she reports symptoms of post-traumatic stress. This can range from days to many years, and it is typically much longer while people are still in the military.

To get a better estimate of the rate of P.T.S.D. among Iraq war veterans, two graduate students, Michael Atkinson and Adam Guetz, and I constructed a mathematical model in which soldiers incur a random amount of stress during each month of deployment (based on monthly American casualty data), develop P.T.S.D. if their cumulative stress exceeds a certain threshold, and also develop symptoms of the disorder after an additional amount of time. We found that about 35 percent of soldiers and marines who deploy to Iraq will ultimately suffer from P.T.S.D. — about 300,000 people, with 20,000 new sufferers for each year the war lasts.

Consider that only 22 percent of recent veterans who may be at risk for P.T.S.D. (based on their answers to screening questions) were referred for a mental health evaluation. Less than 40 percent of service members who get a diagnosis of P.T.S.D. receive mental health services, and only slightly more than half of recent veterans who receive treatment get adequate care. Those who seek follow-up treatment run into delays of up to 90 days, which suggests there is a serious shortage of mental health professionals available to help them.

Proper P.T.S.D. care can lead to complete remission in 30 percent to 50 percent of cases, studies show. Thorough screening of every soldier upon departure from the military, immediately followed by three to six months of treatment for those who need it, would reduce the stigma that is attached to current mental health referrals. The Rand study estimates that treatment would pay for itself within two years, largely by reducing the loss of productivity. This is the least we can do for our veterans.

Lawrence M. Wein is a professor of management science at the Stanford Graduate School of Business.

 

 

EMDR for Veterans: Write a Letter

The EMDR International Association, (EMDRIA) is urging its members to write a letter supporting EMDR treatment for soldiers and veterans. The EMDR Humanitarian Assistance Program has been offering and doing volunteer-run, inexpensive Basic trainings to the military and the VA. EMDR has been accepted by the Department of Defense as one of two effective/allowed treatments.

What's the problem? There is hostility on some of the lower levels of bureaucracy towards EMDR. It's new. It's not what they've always done. And some think that anyone professing PTSD is a weenie slacker. Also, some of the people who have lucrative contracts teaching cognitive behavioral techniques to military and VA clinicians are threatened financially and ideologically by EMDR. HAP trainings are much cheaper then what they're doing for profit. And, according to them, EMDR is either woo-woo bullshit (despite all research) or just another form of exposure therapy.

What can you do? Write a letter to your national senators and congressperson. It's easy, because here's a link to a sample letter and the addresses and how you can do your own if you want to personalize the sample letter: http://www.emdria.org/associations/5581/files/Writing%20Letters%20To%20Congress%202009.pdf

And here's a link to an article germaine to the letter: “Providing EMDR Mental Health Services for the Military” . You can print it and send it with your letter, if you'd like.

This is a worthwhile endeavor. EMDR works with trauma and works with soldiers. I know. I've done sessions with Korean, Vietnam, and both Iraqi war vets.

Phantom Itching Cured With EMDR

    A long time client came back to see me. She'd been ill and after weeks in bed, depression had colonized her, again. She mentioned, " that it's stupid, but what was really bothering me is this itch on the back of my head." She'd been to the doctor, who found nothing wrong with her scalp, used dandruff shampoo and cortisone cream, to no avail. I explained to her that her itch could be like phantom limb pain. I'd read Atul Guwande's New Yorker article http://www.newyorker.com/reporting/2008/06/30/080630fa_fact_gawande?currentPage=all about intractable itching. Guwande said that researchers found that when a nerve cell that could report itching dies, the brain starts sending signals that itching is occurring. Since nothing is actually happening to the skin, there's no way to shut it off. It mentioned cases of people causing damage to themselves scratching. One poor woman actually scratched through her scalp and then her skull and did brain damage to herself in her sleep, and was hospitalized, in restraints.

    I explained that this kind of itching sounded like phantom limb pain--the brain sending pain signals out, about body parts that aren't there anymore, and that EMDR can sometimes eradicate the pain. Let's do it! We did.

    I had her focus on the day the itching started, and then the sensation itself. We did the standard EMDR protocol set-up, and I handed her the bilateral hand buzzers. The itch started moving around on her head, a good sign. She cleared emotions about it, and kept feeling it transform and move. As it faded, I suggested she talk to her brain about the itch, based on the article: "Brain, you think I've got lice or fleas over there. I don't. There's nothing there. Stop telling me there is! There's no vermin!" She laughed and told her brain to stop. I had her visualize the scalp she had--whitish pink and healthy. By that time, the itch factor had gone from a 6 out of 10 to a 2. An email yesterday, 5 days later, let me know that the itch had gone completely away.

Tinker, R & Wilson, S. 2005.The Phantom Limb Pain Protocol in R. Shapiro, EMDR Solutions: Pathways to Healing. Norton.

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.

 

 

 

EMDR and Depression poster

I applied to the EMDR International Conference to lead a 3-hour workshop on Treating Depression with EMDR. I wrote four chapters about it in the new book, EMDR Solutions II, for Depression, Eating Disorders, Performance, & More. Instead of a workshop, I was invited to do a poster. I know how to write. I know how to talk. I never had to put four chapters in an understandable form that fills an 8 foot X 4 foot poster and can be seen at 5 yards away. It took about 20 hours, including half-learning a new program (Power Point), formatting nightmares (why did the text size keep changing?), and pruning all my case examples, wit, and nuance from the basic information. It’s still too crowded, but understandable. If you want to see the content of the poster on EMDR and Trauma-Based Depression, Mood-Disorders, and Attachment-Based Depression go here:

Download DepressionPoster-1.pdf

Here are the other chapters. They’re in to Norton, the last laggards have sent in the “artwork” for their charts. And Norton’s copy editor is ready to find 1,000 errors that I missed in 3 edits, and still won’t find them all.

Unit I: TREATING Depression

1.Introduction to Assessment and Treatment of Depression, Robin Shapiro

2.Trauma-Based Depression, Robin Shapiro

3.Endogenous Depression and Mood Disorders, Robin Shapiro

4.“Shame is my Safe Place”: Adaptive Information Processing methods of resolving chronic shame-based depression, Jim Knipe

5.Attachment-Based Depression: Healing the “Hunkered-Down”, Robin Shapiro

UNIT II: TREATING EATING DISORDERS

6.The Why of Eating Disorders, Andrew Seubert

7.Integrating Eating Disorders Treatment into the Early Phases of the EMDR Protocol, Janis Scholom

8.The Neurobiology of Eating Disorders, Affect Regulation Skills, and EMDR in the Treatment of Eating Disorders, Linda J. Cooke & Celia Grand

9.Treating Bulimia Nervosa with EMDR, DaLene Forester

10.Image is Everything: The EMDR Protocol in the Treatment of Body Dysmorphia and Poor Body Image, DaLene Forester

11.Addressing Retraumatization and Relapse When Using EMDR with Eating Disorder Patients, Janet McGee

12.Desensitizing Desire: Non-Verbal Memory and Body Sensations In the EMDR Treatment of Eating Disorders, Catherine Lidov

13.The Case of Mistaken Identity: Ego States and Eating Disorders, Andrew Seubert & Judy Lightstone

UNIT III: PERFORMANCE, COACHING, AND POSITIVE PSYCHOLOGY

14.EMDR and Performance, David Grand

15.EMDR and Positive Psychology, Ann Marie McKelvey

16.EMDR and Coaching, Ann Marie McKelvey

UNIT IV: Solutions for Complex Trauma

17.EMDR Friendly Preparation Methods for Adults and Children, Katie O’Shea

18.The EMDR Early Trauma Protocol, Katie O’Shea

19.Towards an Embodied Self: Integrating EMDR with Somatic and Ego State Interventions, Sandra Paulsen & Ulrich Lanius

20.Direct Targeting of Intrusive Images: A Tale of Three Soldiers, Elizabeth Massiah

21.Attachment, Affect Tolerance, and Avoidance Targets in Obsessive Compulsive Personality Disorder, Robin Shapiro

UNIT V: TREATING MEDICALLY-BASED TRAUMA

22.Clearing Medical Trauma, Robin Shapiro

23.Treating Birth Related Post Traumatic Stress, Katherine Davis

24.Treating Multiple Chemical Sensitivities with EMDR, Robin Shapiro 

UNIT VI: MORE EMDR SOLUTIONS

25.EMDR With Sex Offenders in Treatment, Ronald J. Ricci & Cheryl Clayton

26.Using EMDR with Religious and Spiritually Attuned clients, Martha S. Jacobi

EMDR Solutions II for Depression, Eating Disorders, Performance and More

Dear Readers,

Excuse me for the dearth of posts this summer. Last night I sent in the the 26 chapters, "Front Matter" and Glossary for the book on which I've been spending 20 or 30 hours each week. I had whittled my practice down to two days each week. I belayed most of my social life. I lived at this computer. I had few other topics of conversation.

This is a big, fat book. Ten chapters more than the last one. Some chapters were easy to edit, on time, about EMDR, and clear. The others took the bulk of my time; some sent in changes until the last possible moment. The writing itself was fun. I've done enough of it that I have a lot of neural networks that light up and interact with each other--when I get going, it's like taking dictation from someone who is smarter and funnier than I am. I actually like editing, it lights up the part of my brain that likes word games and crossword puzzles. I didn't stop when I shut off the computer--I noticed spelling and grammar errors everywhere. In my experience, that function will calm down in a few weeks.

It's weird to send the baby off to its new home in the Norton computers. My brain woke me up at 5 to harangue me about the book. "Let me sleep! It's done!"

Here is the some of the introduction of the book:

 

The real name of this book won’t fit on the cover. It is EMDR Solutions II for Depression, Eating Disorders, Performance, Coaching, Dissociation, Attachment Issues, Complex Trauma, Somatic Therapy, Early Trauma, Medically-based Trauma, Sex Offenders, and Spiritual Issues. As EMDR matures, its clinicians are targeting the trauma at the heart of, or secondary to, nearly every emotional or behavioral malady. As clinical research shows us the confluence of temperament, attachment history, affect, and trauma in every complex client (Siegel, 1999, Schore, 2003 and many more), clinicians have found new ways to direct the EMDR’s Standard Protocol toward their healing. This book contains a broad sample of creative solutions to many clinical conundrums.

In the beginning, I imagined a Depression unit, David Grand’s Performance chapter, and a mixture of unrelated chapters. I put the word out, contacting the writers from EMDR Solutions: Pathways to Healing, online communities, and people whose work I knew about and admired. As the chapters came in, they fell into natural units.

 

Unit I: TREATING Depression

In the last decade, I’ve spent many hours explaining the signs of endogenous, trauma-based, and attachment-based depression to consultees. When I was invited to Boise to do a four hour training about EMDR in the treatment of Depression, the material was right on the top of my brain. I couldn’t go wrong quoting the results of Bessel van der Kolk’s groundbreaking study of the effect of EMDR on trauma-based depression or using Stephen Porges Polyvagal theory (2001) as a starting point. When I brought in my own clinical experience, I had a unit. Jim Knipe offered his Shame-Based Depression chapter and I knew that this master clinician would bring a great new perspective to EMDR treatment. He did. When Katherine Davis sent me her chapter, I thought it would be about Post-Partum depression. Instead, it was about Post-Partum PTSD (often disguised as depression) and it moved to the Medical Trauma unit.

 

UNIT II: TREATING EATING DISORDERS

Andrew Seubert wondered if he could invite the Eating Disorders Special Interest Group (EDSIG) to contribute overlapping chapters. A unit was born. When I read through the Eating Disorder (ED) chapters, I saw that they had applications for any disorders of desire, compulsivity, anxiety, affect dysregulation and affect avoidance, and dissociation. I hope that all of you take in these chapters. Any of them will improve your clinical skills, even if you never plan to work with ED clients. The unit includes DaLene Forester’s clear and elegant overlays of EMDR’s Standard Protocol to treat specific eating/body disorders for her two chapters on Bulimia and Body Dysmorphia. Other chapters deal with diverse pieces of the Eating Disorder (ED) puzzle. Andrew Seubert gives a survey of the etiology of EDs. Janis Sholom addresses early phases of the EMDR Protocol. Linda J. Cooke and Celia Grand dig into the Neurobiology of EDs. They give an illuminating tour of the research showing the physical and neurological bases of the disorders and how to use that knowledge to help clients regulate their affect. Janet McGee writes about how to future pace and contain the inevitable relapses in ED treatment. Catherine Lidov illuminates the nature of Desire and what to do when it goes awry. Andrew Seubert and Judy Lightstone wrote separate sections of the Ego State and ED chapter. They contrast their creative and useful approaches.

 

UNIT III: PERFORMANCE, COACHING, AND POSITIVE PSYCHOLOGY

I admired David Grand’s performance work for years and was delighted when he agreed to contribute a chapter. His fifteen guidelines will help you guide athletes, performers, and others through the blocks that keep them from doing their best. Ann Marie McKelvey had written a rave review of EMDR Solutions: Pathways to Healing in the second issue of the EMDR Journal of Practice and Research. At the end, she complained that there were no chapters about Coaching or Positive Psychology. So I asked her for one. She gave me two . I paired them with the Performance chapter since all emphasize positive function, rather than dysfunction. I placed this positive unit between the ED and Complex Trauma units in order to give you readers a break from deep, dissociative trauma. Anne Marie became the cheerleader of the entire project. I hope that her enthusiasm infects you, too.

 

UNIT IV: Solutions for Complex Trauma

I asked Katie O’Shea if she would contribute her Early Trauma Protocol. As she began to write she realized that she had two different chapters, the Early Trauma chapter and one on Preparation Techniques, including a thorough and understandable explaination of the EMDR process, affect “containers”, and emotional resetting. Sandra Paulsen and Ulrich Lanius each wanted to write a chapter on Somatic Therapy and Ego States. I had them talk to each other and they decided to collaborate. Sandra is one of the “big names” in Ego State/Dissociation work in EMDR. Ulrich is a master of translating obscure brain research into EMDR-friendly methodology. They are both master clinicians. Their chapter is a brilliant synthesis of research, somatic therapy, and treatment of dissociation. Elizabeth Massiah works with Canadian soldiers. She shows us how to work with clients who suffer extremely intrusive images. And I write about treating Obsessive Compulsive Personality Disorder, a disorder of affect-tolerance and avoidance. If I had seen the Preparation Techniques and the Embodied Self/Somatic chapters earlier in editing process, I would have put them at the beginning of the book. I suggest that you read them first, since many of the other chapters refer to “containers” (Preparation) or “ego states” (Embodied Self).

 

UNIT V: TREATING BODILY AND MEDICALLY-BASED TRAUMA

 

Bodies get sick, get injured, and sometimes have babies. EMDR can clear the PTSD that arises from illness, developmental body processes, giving birth, injuries, and the medical treatment for them. I wrote a chapter about treating a variety of medical traumas. Katherine Davis contributed one about clearing traumatic stress from the birth process. And I present a protocol for using EMDR to treat Multiple Chemical Sensitivity. It’s amazing what EMDR can undo!

 

UNIT VI: MORE EMDR SOLUTIONS

Ronald J. Ricci and Cheryl Clayton share their experience and advice about working with Sex Offenders. If you don’t plan to work with this population, read it anyway. You will learn even more about affect tolerance, denial, and working with other clinicians and systems.

Martha S. Jacobi’s chapter about Religious and Spiritually Attuned Clients shows us how to elegantly navigate through issues of belief and spiritual community. It takes a broad topic and gives us precise interventions.

 

Using Solutions II

 

 

This book is a manual for doing EMDR with diverse client populations. If you took both parts of the EMDR training and have experience and knowledge of a specified client population, you should be able to use the procedures with few problems. If you aren’t schooled in EMDR (the Basic training is at least 50 hours long), get the training before you mess up your clients with this powerful psychotherapy! If you know what you’re doing, know your client well and remember that the therapeutic relationship must be strong before you try any technique, you will find uses for many of the solutions in this book.

You might think about reading about your specialties and skipping the rest of the chapters. Yet, I hope you read them all. There are gems in every chapter. Even if you don’t work with eating disorders, you can use many of the techniques in that unit with other addicted, dissociated, or complex clients. If you don’t work with offenders, Ricci and Clayton’s chapter speaks to trauma treatment in complex cases, impulse control and other issues that are germane to many clients.

Research considerations

 

 

                EMDR’s Standard Protocol has stood the test of peer-reviewed research and hundreds of thousands of individual clinical experiences. EMDR’s full protocol is empirically validated when used on Post-Traumatic Stress Disorder (PTSD). Most chapters in EMDR Solutions focus on trauma targets and thus conform to the research. Some of the uses in this book must be labeled “experimental”. When the writers point EMDR toward a non-trauma target, it may work very well or even be the most efficacious use of EMDR in a specific circumstance. Any readers who would like to do research on any of the topics should talk to the writers. 

 

Case histories

 

            Every case history in EMDR Solutions is either a composite or is here with the client’s permission. All names and life circumstances are changed in order to preserve anonymity.

 

Chapter conventions

 

 

            What the therapist says or should say to a client is in italics, with or without quotation marks. Occasionally, italics are used for other emphases, and I’ll leave it to you to know the difference. Numbers are written out, unless they refer to SUD, VoC, NAS, dates or dosage levels. Common EMDR terms are capitalized, especially those referring to a step of the Standard Protocol. If you’ve forgotten some of the terms, there’s a glossary near the end of this book.

 

Attribution

 

 

Francine Shapiro created and named EMDR, the Standard Protocol and most of the common EMDR terms. (For which we are forever grateful.) Assume attribution to her and her invention in every chapter. Her definitive guide to EMDR is Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures (Second Edition). If you are an EMDR clinician and you haven’t read it; go get it now!

 

REFERENCES

Porges, S.W. (2001) The Polyvagal theory: Phylogenetic substrates of a social nervous system. Physiology & Behavior, 79, 503-513

 

Schore, Alan. 2003. Affect Regulation and Disorders of the Self. New York. W.W. Norton & Company

 

Shapiro, Francine. 2001. Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures (Second Edition)

 

Siegel, Daniel. 1999. The Developing Mind. New York. Guilford Press