Trauma & Attachment Therapy

Kristof on Chronic Traumatic Encephalopathy, the Brain Disease Plaguing Veterans

Nicholas Kristof writes about the brain disease that may be underlying the suicides of Iraq & Afghanistan war veterans: http://www.nytimes.com/2012/04/26/opinion/kristof-veterans-and-brain-disease.html?_r=1

NYT's Article: Stimulants given to soldiers may increase PTSD.

Dr. Richard Friedman in "Why Are We Drugging Our Soldiers" shows the correlation between Ritalin and Adderall prescriptions and increased PTSD. He cites several studies showing that these drugs enhance the memory of fear-provoking events. Scary and makes all kinds of sense. Read it!

NBC's Awake: Creative Grief Avoidance

It starts with a horrible car crash. Jason Isaacs flips his car in a California canyon. Either his wife (in one reality) or his son (in the other) dies in the crash. Every time he sleeps, reality switches. He has two therapists, one for each reality, who are set on proving that their particular realities are the correct ones. Isaacs plays a cop who uses information from one reality to inform his cases in the other. He either has a grieving teenager or a wife (way too beautiful for any reality) who refuses to grieve. Somehow it all works.  

One therapist is pedantic, one more experiential. None of them do somatic work or EMDR or brainspotting. In all of the protaganist's sessions, I was itching to ask him where he felt the grief and what he was telling himself about his culpability in the death(s).  I'd love to see EMDR clear up this problem. But then there would be no series.

Prediction: At the end of the season, we'll find out that he is either 1. In a coma and dreaming it all and or 2. Grieving the loss of both his wife and his son.  I'm going to keep watching to find out. And I'm going to keep itching to see effective affective therapy in either reality.

P.S. The most emotionally true show on TV: Smash. And the most fun.

Francine Shapiro in the New York Times on EMDR Research

Three years ago, while I was at the at the Olympus Women's Spa celebrating the publication of EMDR Solutions II, a woman in the same jacuzzi interrupted my conversation to attack me about my obvious misperceptions about EMDR. "Everybody knows it doesn't work . . . it's woo-woo-bullshit . . . and it's just exposure therapy, anyway . . . and there's no good research about it."  She was a researcher of cognitive and exposure therapies. When I tried, gently, to refute her, she spit on my friend and me, in her rage. Today, in the New York Times Health, Consults blog, Francine Shapiro has brilliantly refuted every point. Read the article here.  HAH!

In Ego State Therapy, Let the Client Run the Internal Show.

Twenty-seven years ago, when I worked with my first DID client, I became the "go to" person for soothing the young, distressed ego states. As a result, I was on-call 24/7, never took longer than a week's vacation, and was constantly fielding emergencies. Finally, a savvy consultant told me to put the "oldest, wisest part" of the client in charge of all distressed, younger, or destructive alters. What a relief! Within three sessions, the client could self-soothe, make adult decisions, and deal with new alters as they popped up. (This was a complex ritual abuse case with lots and lots of parts.) Therapy sessions became case consultions. I worked with the most adult parts of my client to create safety, internal communication between parts, internal and external boundaries, and good, safe rituals of orienting "new" parts to the present and giving them the rules.  The therapy wasn't over then, it lasted 10 years, through trauma processing (which got more efficient when I learned EMDR), lots of sorting out "then" from now, the grief process about her awful losses, and coming to terms with her current life.   The client still contacts me every 9 months or so for a tune-up session.

So, all of you who work with parts: If you help the oldest, wisest, most nurturing parts run the show, the client gets to do more of the work, feel effective and in charge of his or her life, self-soothe, and heal faster. If you want to communicate with younger parts, ask an adult, the adult, or the "team" to ask about or talk to the part. "Can you go inside and tell me how that 2-year-old part is doing now? . . .Can you remind her that you are always there for her so she's never alone again? . . . That she's safe now. . . And that she lives with you in your nice house. . . ."

I do ego state work with 85% of my clients and I rarely speak directly to any but the presenting adult. The only time I do, once a decade, is when I'm working with a new client, who pops into a part I don't know that's amnestic for the rest of life. (The ultimate "Oh S--t!" moment of therapy.) Then I introduce myself, if the part doesn't know, explain that we're in my office, and gather information: age, name, and what it needs, or what it does and "Did you know that you're part of John?". Then ask for "Adult client", to come back. Sometimes, with a count of three. It's always worked. If the presenting client doesn't remember the situation, I offer to set up an introduction. When I do, I refer to the presenting adult, team, etc. as the boss.

Most ego state work is much less dramatic. I often ask people to tell me how old something feels and if they can talk to that 3-year-old, 5 y.o., etc. part. Most people can do this. It doesn't take formal dissociation. For the dissociative disorders of complex PTSD, Axis 2 diagnoses, DDNOS, and DID, formal ego state work, combined with EMDR or Brainspotting or Somatic work for trauma, in conjunction with attachment-based therapies are always called for.

The Names of Love

The Names of Love is a hilarious, serious, heart-breaking, heart-warming French movie that I recommend to everyone. It deals with generational PTSD, Holocaust survivors, war survivors, culture, temperament, politics, art, political correctness, and sex as a positive political tool. (Did I say that it was French?) Here's a website: http://www.namesoflovemovie.com/

One plot line shows a survivor of childhood sexual abuse, treating her body as a tool for her political ends, until she meets a man who truly sees and accepts her while adoring her. (I've heard many survivors who were prostitutes or used sex as a means to other ends who said, "But that is what I'm for."  

Another character, who saw her parents dragged away to a concentration camp, brought her fearful silence into her marriage, infecting her non-Jewish husband and her child. That child, the male lead, is able to open up and speak the truth when he is finally seen, reflected, loved, and well laid. 

And it's a romantic comedy, so you know how it ends. This is my favorite movie since UP! It's lovely. And you must stay through most of the credits.

Trauma and Trauma Therapy: Interview on "Public Exposure"

I was interviewed by Stan Emert on his cable TV show, "Public Exposure" a few weeks ago. Here is the YouTube link to the show:  http://youtu.be/KsFoHFQxx4o  Topics include trauma definitions, PTSD, EMDR, Ego State Therapy, and a minute of traumatic grief.

Due to a neck injury, I've been unable to spend more than a few minutes at a keyboard in the last few months. I hope to resume posting on this blog after I learn to write with Dragon, a voice-recognition program.

Another Nice Review for Trauma Treatments Handbook

Tim Brunson at the International Hypnosis Research Institute wrote a nice review of TTH. He liked the book though he thought it didn't have enough hypnosis in it and wanted it to discuss research and wished the "Self-care for Trauma Therapists" chapter was longer. Otherwise he said extremely positive things about the book and me personally.  Here is the link: http://www.hypnosisresearchinstitute.org/index.cfm/2011/1/21/The-Trauma-Treatment-Handbook-Protocols-Across-the-Spectrum

The King's Speech

Some of the best therapy I've seen on screen is in a great new movie, The King's Speech. Geoffrey Rush plays Lionel Logue, an Australian speech therapist who tackles the debilitating anxiety-driven stammer of Colin Firth's, "Bertie", who become the king of England on the eve of World War II. 

The film shows the stifling lives and roles of the Royals, and the intense pressure on them from their subjects, the Anglican Church, their governments, and each other. It shows how a therapist to the King has to tear down the class barriers in order to make a strong, attached therapeutic relationship. Logue creates the frame be insisting that "Bertie" come to his office ("My castle, my rules."), be on time, and be addressed by his family name, rather than "Your Royal Highness". He sits close, and mixes standard speech therapy with elements of somatic and expressive therapies (some of which are riotously funny) and holds the therapeutic relationship above all. He watches his client carefully, and crafts his client-centered therapy and the environment in which the King must give his speeches to his client's needs. Logue leads his client to uncover the childhood traumas that precipitated the stammer, and the family dynamics that kept it going. And he uses brilliant and funny strategic therapy to hook his recalcitrant client into therapy, and keep him there.

Helena Bonham Carter plays Bertie's supportive wife, Elizabeth, and is excellent, as usual. Derek Jacobi is the Archbishop of Canterbury, with whom Bertie finally shows his adult and kingly differentiation. Michael Gambon plays King George, Bertie's father, as a well-meaning, impatient, worst father a stammerer could have. (It's strange to see Dumbledore be jerk.) Guy Pearce plays Edward, Bertie's brother who abdicated the throne for a woman Mrs. Simpson (Eve Best).

I knew a lot of the history, and I painlessly learned more of the particulars in this wonderful movie. The King's Speech is suspenseful, beautifully acted, funny, sad, and hopeful. I hope you see it, too.

 

 

NYT's Article: A Typical Suicide of an American Soldier

James Risen writes about a soldier, Staff Sgt. David Senft, with PTSD who kills himself in Afghanistan. The article lists many things that predict successful suicide:

• Senft came from a distressed "broken" family.
• He had many attachment disruptions in childhood.
• He had been on multiple tours of duty.
• He had PTSD from a trauma early in his deployments
• He had attempted suicide before.
• He'd been hospitalized by the Army, because of former suicide attempts.
• The Army deployed him, anyway.

The military's mandate for suicide prevention completely failed this man. Read this sad story to know him and know the details.

Living with the Awareness of Evil

    I've had to confront evil again. In my every day life, I see it all the time. 60% of my clients have been sexually, physically, and emotionally abused by the adults, mostly their parents, who were in charge of them. As a consultant I hear therapists' most horrific cases. I read the newspapers.This political election is particularly ugly and full of disingenuous lies and distortions. African paramilitary continue to rape, murder, and hack off limbs. The wikileaks site has sent out another torrent of how people in power misused it to torture and murder. Members of our local Stryker Brigade are on trial for having tortured, then murdered Afghanis, for fun. And greed continues overpower humanity everywhere we look.

But it gets worse. I attended two conferences in three weeks, EMDR International Association (EMDRIA) in Minneapolis and International Society for the Study of Trauma and Dissociation (ISSTD) in Atlanta. The ISSTD conference is smaller and often more scholarly than EMDRIA, 400 people, many of them researchers. Most of the EMDRIA presentations were upbeat: How to use EMDR to cure schizophrenia, depression (mine), shame, dissociation, etc. At ISSTD, some of the research-based presentations were about dysfunction with no talk of cure. Dr. Martin Teicher presented research on how different kinds of child abuse affect brain structures and which developmental windows impact brain structures and function the most. He didn't discuss neuroplasticity and how we fix these things. Then Ellen Lacter presented "Torture-Based Mind Control: Psychological Mechanisms of Installation and Continued Control" with Alison Miller and Ada Sachs throwing in their awareness of torture in ritual abuse. The single most distressing thought that stuck with me is that the worse the torture, the more the victim becomes attached to the perpetrator. 

M. Scott Peck defines "evil" as something possible only when one human doesn't see another human as a human being. I'd like to add that for evil to occur, one human has to have power over another and see that other as an object, a means to an end. Evil isn't a new idea for me. My step-father, Peter, was a survivor of the German Holocaust. I was beat up by neighbor kids for being Jewish. I work with the effects of abuse every day. And I spent 20 years clearing the trauma and dissociation of one ritual abuse client. But learning about the number of organized groups that are "breaking people", intentionally causing dissociation through torture, set me back and left the conference stunned and hunkered down.

How did I get through it this week?

1. I reminded myself to feel it. When I connected inside, I felt my fear, grief, and anger about what we humans are capable of doing to each other. Focusing on the affect, and allowing it to move through.
2. I moved my body, feeling the aliveness in it as I walked.
3. I noticed the beauty in fall leaves and incoming clouds.
4. I connected with other people: my sweet husband, my mom, my friends.
5. I went to my consult group and spoke about my distress.
6. I joined the ISSTD Special Interest Group that deals with Ritual Abuse and Mind Control.
7. I reminded myself of the good works in the world.
8. I gave money to some politicians I see as helpful and good.
9. I'm going to the local Rally for Sanity (based on John Stewart's DC rally), with the sign "Therapists for Sanity". (Irony is very helpful to me.)
10. I played sad music and inspirational music. Aaron Neville was helpful. So was "One Love, One Heart: Let's get together and feel all right."
11. And I reminded myself of my limitations. I can help a limited number of clients, write books slowly, and consult to a limited number of people. I can't stop the abuses of the world. I can continue to respond to them.

It's worked well. I've been back for 6 days and I'm breathing fully, feeling more hope than despair, and about to have a book party for the my newest trauma book: Trauma Treatment Handbook, my contribution to healing trauma and making people whole.

Staff Diaries Prevent PTSD in Surgical Patients

I've written about medical trauma, especially surgeries, creating PTSD. This article shows a simple way to prevent traumatization in some instances. 

Video with Amen brain scans and EMDR treatment of PTSD

Here's a 6 minute video of a Gulf War soldier's PTSD diagnosis with brain scans and then treatment with EMDR. He had a scary childhood, fear for his life in combat, and then was retriggered by witnessing a horrible accident. 

Trauma Treatment Handbook: Protocols Across the Spectrum

My copy of the new book arrived today. Here is what Diana Fosha says about it:

"This is a thorough, accessible, and very practical book, filled with resources and sound ideas, filtered through the intelligence and experience of a savvy, compassionate, down-to-earth, and very experienced clinician. It is like a travel guide to the land of trauma and trauma treatment: if you are new to it, it will orient you to all there is to do and see; if you're a frequent traveler, it is a worthwhile reminder of all that is out there, above and beyond the familiar places you always visit. Once could ask for a better guide. I highly recommend it."

I explain trauma, complex trauma, dissociation and how to assess them and prepare for treatment, and all the kinds of treatment that I know about from the main-stream to the obscure. I talk about working with military, sexually-abused, and relationally traumatized people, and how to take care of yourself while doing the work.

 Some of my heroes comment on it. Dan Siegel wrote the introduction, despite my lack of research. Diana Fosha, Stephen Porges, Kathy Steele, and Onno van der Hart wrote very nice blurbs on the back. I'm humbled by their support.

This is the first book written completely by me. I'm amazed to be responsible for synthesizing so many people's therapies in one book. The design is great, and the photos, by Doug Plummer (my beloved) are gorgeous.

How Trauma Therapy Works, a Video

Here is a 9 minute video of me talking about how trauma therapy works. Expect more pieces of this video in the future. My husband, the videographer and photographer, Doug Plummer made the video.

NYT's article and video about military women with PTSD.

Video of military woman with PTSD: Video

Article about military women with PTSD: Article

Check out Damien Cave's article in today's New York Times. Women are less likely to be granted disability on the grounds that they weren't in combat, even though they are seeing plenty of action in Iraq. Unrecognized, they feel shame about having the flashbacks and aggression that characterized PTSD and are even less likely to seek treatment than male soldiers.

 

Self Care for Trauma Therapists

As trauma therapists, we are privileged to watch our clients’ trauma fade from terrible, here-and-now experiences to mere memories; their dissociation shift to integrated presence, and their pain disappear. We are also privy to the gut-wrenching details of rape, accidents, war, and story after story of child abuse, domestic violence, and horrible neglect. The more terrible the abuse and the more dissociated the clients, the more they project the actual emotions of their trauma into us. Some therapists become grim. Some avoid complex trauma clients. Some help their clients avoid expressing affect in the sessions. Some burn out and leave the profession. Here are some ways to keep yourself whole while doing this important work.

1.   Do your own work. If you’re not able to tolerate your own history and your current affect, you won’t be able to tolerate the despair, rage, shame, and grief that move through many trauma survivors.

2.   Learn mindfulness. Meditate, do yoga, do chi gong, do breathing exercises. It will help you “stay in the chair” while witnessing whatever is there to see. Learn to breathe and ground yourself while being with anything.

3.   Know yourself. If you start a session in a state of equilibrium, and you start feeling rage or exhaustion in the session, guess that it may be the client’s rage or dissociation. If you then say “What are you feeling right now? There’s something in the room.” The client is likely to say, “Oh, I’m angry, I guess it’s about X.” or “Oh, I was just spacing out.” When you know where you are, you’ll know when you are being drawn into someone else’s experience and use it for their benefit.

4.   Know the signs of burn out:

a.   You aren’t excited to go to work.

b.   You talk only about work and have no other interests.

c.    You treat everyone on earth like a client.

d.   You dream about clients, all the time.

e.    You’re angry at clients for being the way they are.

f.     You feel shame for your human limitations.

g.   You have vicarious PTSD: flashbacks, anxiety, depression, avoidance around client material.

h.   You want to drink, gamble, or otherwise dissociate after work.

5.   Get support.

a.   Join a supportive consultation group. (Not just about the technique, but about you, too. And no shaming allowed.)

b.   You might get individual consultation for the most troubling cases. As a consultant, I’m going step-by-step with a few consultees with their most fragile, barely tractable cases. It’s good for the therapists and good for the clients.

c.    Increase your therapeutic arsenal. If what you’re doing isn’t working, find something else that does.

d.   Do your own work. Hire a good trauma therapist who can help you clear your vicarious trauma.

6.   Develop other interests that have nothing to do with therapy. Make sure some of them involve unmitigated joy.

7.   Do things that bring you into your body: Run, stretch, work out, dance, do yoga.

8.   If you have any control over your schedule, limit the number of the most complex, dissociated, abused, unstable clients. And don’t put them all on one day.

9.   You will probably learn your tolerance the way most of us do, by exceeding it. Once you know, keep your own boundaries. Follow the Platinum Rule: “Fill your own cup first, then give away what’s left over.” And another rule, “To Thine Own Self Be Nice.” Trauma is compelling, but don’t let it run your entire life.

10.  Watch out for grandiosity. You can’t fix everything. Know your limits.

11.  If you have a spiritual practice, use it to support your work. Ask whatever higher power you have for help when stuck.

 

 

UCLA Trauma Conference Day 2: Dan Siegel, Mindfulness

Daniel Siegel: A System's View of Disintegration & Integration

(He's still cute, he's still brilliant, he speaks in easy-to-remember aphorisms and he's still heartful. What's not to like?)

"Integration is the linking of differentiated parts. The concept is useful for assessment, tx planning and therapy. . .Presence is absent in trauma survivors. Presence begins with us as therapists."

P.A.R.T.T.T.T  
when fully
Present we can
Attune to the client or others and
Resonate with others and develop
Trust which is important because it activates the smart ventral vagus so the social engagement system turns on so that we can
Track what's going on in moment to moment experience which allows the
Truth to come out and creates
Transformation/healing.

We help clients become open systems: self-organized: chaotic moving toward complexity, flexibility and adaptable: energized and coherent. System acheives complexity by linkiing differentiated parts. Coherence comes from integration. (Thank God for systems theory in social work school in 1979! I understand this stuff!) When not integrated we move toward rigidity (avoidance), chaos (flooding) or both.  It's all about the mind regulating the energy and information flow. "The mind is in the whole body and among people: it's embedded socially/relationally and embodied." "What I am is a process of regulating energy and information flow, not limited to our bodies and right now and this relationship. The ripple effects after we leave or die are also who we are." (My woo-woo teacher says the same thing. So does Hillel, sort of.)

Calming exercise: Put one hand on your heart, the other on your abdomen. Hold them there for a while. Try switching hands to see if you prefer one over the other. Most people do.

Your right hemisphere contains the storage of autobiographical information. PTSD is impaired integration. Long story about how a past trauma impeded on the present and how mindfulness allowed him to integrate the past event and stop reacting to the trigger.

"There's a distinction between awareness and mental activity: Awareness is the infinite possibility of neural firings."

In trauma, mental activies get locked into rigidity and chaos and pull humans into limited possibility. With unresolved trauma, rigidity and chaos imprison the person's possibilities. Good therapy transforms the brain of the the client to totally shift their center of attention and stay present to the self and watch self and make sense of it. The labeling of the internal state downregulates the limbic system. The client knows that "this" is not "that". Integration is the capacity to sit with core awareness and sit with anything that comes in. You can use mindfulness practice to help people distinguish between mental activity and true awareness. Ventral integration--being touch with the bodily state: Track it and you transform. Supress it and it screws you up.

"Liberate the innate drive of a complex system to integrate. Interpersonal integration: We are designed to be interdependent and interconnected. There's hope for we as humans to move from chaotic & rigid states to integration, kindness, and peace.

(Thank you, Rebbe Dan.)

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

After Dan, Martha Stark, a child psychiatrist spoke about Optimal vs Traumatic Stress. Traumatic Stress overwhelms and disrupts. Optimal Stress provides the impetus for transformation and growth. Optimal Stress--you need enough to stimulate adaptation and growth but not enough to overwhelm the system. In therapy, challenge when possible and support when necessary. (My brain was full and I took a walk.)

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

The Question and Answer period at the end of the day was worth the price of admission:

Dan Siegel: Txist attunement helps clients widen their ability to be with emotions and curiosity; integrates the experience; brings openess; widens the window of affect tolerance and acceptance and love, and moves away from rigidity and chaos. Be safe but not too safe: push the limits of the window of tolerance.

Francine Shapiro: Schizophrenia is sometimes misdiagnosed. Not all psychosis is genetic. Some is trauma-based, early and not-so-early childhood. If you target the negative experience, set up information processing. If they have positive networks to go to, the trauma will clear. Do processing if the client can stay present during processing (maintaining a dual awareness) and have positive experiences to call on. Otherwise spend as much time as you need to set up those positive networks. Truly schizophrenic people can be traumatized by their disease or by abuse, or disrupted attachment. Go after those targets if the client is resourced enough.

Pat Ogden, to Dan: Too much attention to mindfulness doesn't develop relational capacities. Dan to Pat: If you improve mindfulness, people have the capacity to connect. Capacity for the parent to be with his/her own self and material predicts the kid's secure attachment.  Teach people to harness the social capacity of their brains.

Steve Porges: We've developed to deal with humans, but school teaches/rewards dealing with objects. Psychiatry depersonalizes relationships. We need to teach social interaction: develop exercises. Play tempers mobilization states. We need more exercise that is face-to-face. Treadmill running teaches mobilization, badly. (I disagree.)

Bessel van der Kolk: Med school kills empathy in trainees. (Cited research)

Francine: EMDR and Dreams. Same brain process. (Robert Stickgold) Customize sets by attuning to clients needs. Goal is to take the REM state further than it goes in sleep. Images change in each set as new positive information comes in. . . Early therapeutic intervention for early humiliation would help people immensely. We need to teach parents and educators the impact of humiliation. (Jim Knipe and I wrote chapters about using EMDR on these issues to clear depressionin Solutions II.) The window of tolerance closes because of these childhood negative experiences.

Bessel: EMDR is hypnagogic, like sleep with very rapid associative processing. . . But people need to move, to play. EMDR has no movement. People need to complete the movement. But, research shows that EMDR clears 83% of the trauma. Movement-based treatment doesn't have the same success.

Martha Stark: Did EMDR with an insomniac client over a suicide attempt. In processing she remembered that at the last minute she saved herself, and the meaning about self changed for the better. Her insomnia disappeared and she started to remember her dreams.

Skipping some -- too tired.

Dan: Mindfulness creates secure attachment to the self. It's a way of being. Mindful awareness is brain hygiene, not a religion, should teach it in schools, to doctors, and create empathetic practitioners.

More in the next few days. Steve Porges read this blog and told the other presenters about it. I got some interesting attention today.

 

 

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.

"The Post-Traumatic Stress Disorder Sourcebook"

I'm reading piles of books in preparation for writing a trauma therapy survey book. My friend and colleague, Barbara Hinsz lent me Glenn Schiraldi's The Post-Traumatic Stress Disorder Sourcebook. (McGraw-Hill, 2000) It's a great self-help book, one of the best I've seen. Schiraldi's a good writer. I never wanted to fix his sentences. He's simple without being simplistic. He gives a great description of dissociation. He talks clearly and cleanly about therapy. (Giving CBT, EMDR, Counting, and TFT good "marks", describes many other self-help and therapeutic techniques, and gives the same warnings I do about prolonged exposure.)

If you have a client who wants more information and some good self-help advice as an adjunct to therapy, suggest this good and wise book. And if you have suffered a trauma, and are still feeling the after-effects, read this book. I just bought one for myself.

Waltzing With Bashir

Ari Folman has made a beautiful and devastating movie about trauma, dissociation, and war. As a young Israeli soldier, he was in the 1982 Lebanon war. When a friend came to him with troubling memories of that war, Folman realized that he had no memories about being in Lebanon. A therapist friend told him to ask fellow veterans about what happened and Folman interviewed people until his own memories came back. The movie is animated. It flips between "talking head" interviews with middle-aged men at home, and their younger selves in Lebanon. The animation is amazing; the music, perfect; the characterization of the various soldiers/veterans makes them totally human.

You see the trauma and the men's attempts to cope with it. One man,was considered a genius as a teen. As an adult  he hides on his Dutch farm, constantly stoned.  Some seem untouched. Others still devastated.

As the movie unwinds, you see the event begin to come together--The assassination of Bashir, the Lebanese Christian Falangist leader, led his followers to slaughter men, women, and children in a Palestinian refugee camp. The Israelis, their allies, were supporting the Falangists to "find the terrorists". By the time the Israelis understood what was going on, and the word finally got to the Israeli leadership (slowed down by idiocy and disbelief), it was too late. The last few minutes of the movie are film footage of bodies and wailing women in the camps. There is no other resolution. Nothing to make us feel good.

The movie brilliantly portrays what trauma looks like. Its director also directed the original Israeli In Treatment , which portrays among other things, the therapy of a soldier who inadvertantly bombed an orphanage. I wonder if he was compelled to do In Treatment, before he remembered what he forgot about his own war experience. Here's a link to some "stills" from the movie, and an interview with Folman.  http://lukeford.net/blog/?p=4343 My favorite lines in the interview are, "Having made WALTZ WITH BASHIR from the point of view of a common soldier, I’ve come to one conclusion: war is so useless that it‘s unbelievable. It’s nothing like you’ve seen in American movies. No glam, no glory. Just very young men going nowhere, shooting at no one they know, getting shot by no one they know, then going home and trying to forget. Sometimes they can. Most of the time they cannot."

Evidently the movie brings two distinct responses from some Israelis: "Folman should be shot as a traitor for bringing up the incident."  Or "It's good, he's finally showing the world that it wasn't our fault." My response and the response of the two Israelis with whom I watched the film, was devastation and hopelessness. In the light of our despair over the recent attack on Gaza, we were stunned. We had to walk in the cold wind, swing on swings, and watch children play in order to bring ourselves back to here and now in our safe Seattle neighborhood. Today, I'm back to thinking that the little we do as trauma therapists makes a differences. As Hillel said, "If you save one person, you save the world." I need to keep this always in mind, or I get paralyzed by the trauma we humans create.

Babette Rothschild: The Body Remembers

The name of the workshop was "The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment".  The main point was: therapists do too much trauma therapy too early and should do much more preparation before they do the "memory processing" and should often do no trauma processing at all. She talked alot about helping people regulate their physiology by 1. "Talking about recipes or baseball" 2. Tracking their sympathetic and parasympathetic responses 3. Using cognitive techniques to separate past trauma, experienced as flashbacks, from here and now reality  4. Using some simple toning techniques to ground and feel the body. 5. Noticing external and internal resources.   Then she left out "making the experience of trauma go away."  The physiology was old hat: sympathetic and parasympathetic instead of vagal nerve tone, wrong information about the hypothalamus, etc.

I like trainings in which the presenter turns the fire hose of information on me and I have to swallow all that I can. This wasn't one, by design.  Rothschild says that she wants people to get the theory and then extrapolate what to do, out of that. She wants to go slow so that people can take in what she's saying. I agree with her suggestion that clinicians learn at least 3 trauma techniques and then figure out which ones will work with which clients. And I felt that we could have learned what she had to say in about a third the time, so I'm still disappointed. She is in private practice and doesn't take insurance. She seems to do therapy as if there is all the time in the world and that her clients must be ever protected from their distress.

As someone trained in about 10 kinds of trauma processing, I agree with having many techniques. And I think you should have enough technique and interpersonal containment to halp your clients move through the trauma, not just learn to calm down when you have it. Yes, you may need a long preparation phase and you need to have a stable client before you start. And the processing phase is important. Done well, it makes the trauma go away, a good thing.

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.

 

 

Principles of Trauma Therapy, Briere & Scott

I'm doing research for my next book, Trauma Treatments, and just finished John Briere and Catherine Scott's Principles of Trauma Therapy: A guide to symptoms, evaluation and treatment. (Sage Press, 2006). It's a good book, full of common sense and practical advice about trauma survivors. Briere and Scott do a good job explaining the effects of trauma and the way it manifests in different kinds of people. They mention temperment, a subject neglected in much of trauma therapy. Since Briere comes from a psychodynamic background, he emphasizes the importance of the relationship as a component of healing (backed up by Alan Schore and Dan Siegel, my heroes.) And he does a good job of explaining the "therapeutic window" in which trauma treatment occurs: between too little and too much activation of traumatic material. He lays out an amalgam of cognitive and relational therapies called the self-trauma model. He mentions Acute Stress Disorder, the precursor to PTSD. And he has a comprehensive chapter on medications and trauma. It's nice. and it's not enough.

Through-out the treatment section, I kept thinking, "You're missing the body! You're missing affect! Get out of your clients' heads and into their experience!" I wanted to drag Briere out of the book, teach him EMDR and movement work, and let him loose with his magnificent skill set and deep understanding. As he talked about trying to keep people from running out of the room during exposure therapy, I wanted to say, "Tap on them!" When he talked about how people are often traumatized by exposure therapy and often leave therapy before they're healed, I had the same feeling. I used to do exposure, I was trained at a rat-running behavioral undergrad school (U of Iowa) and a CBT-oriented MSW program (U of Wash.) And when I learned EMDR, I finally had a tool that made the trauma go away, quickly enough that people didn't need to run out of the room.

If you are just starting out as a therapist, you might read this book to get the broad view of trauma, it's effects, and good common sense ways to begin treatment. Then go get trained in EMDR, body-centered therapies, and Brainspotting. You'll be ready to do good therapy with traumatized people, hitting all the bases. 

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.

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

Trauma Lecture

I'll be giving a lecture about trauma, PTSD, Structural Dissociation, the Polyvagal theory and the use of EMDR to impact PTSD on Saturday morning, May 17 from 9:30 to 12. Frank Kokorowsk will copresent with a dynamite multi-modal trauma treatment that he's been using with homeless people. There are 2 CE's for everyone and it's sponsored by the WA State Coalition of Mental Health Professionals and Consumers our main advocacy group with the legislature.

Register at wacolition@verizon.net (email your name and phone).

or go to wacoatlition.org for the website

May 17, 9:30 -12 Good Shepherd Center 4649 Sunnyside N, Seattle

Soldiers Project NW II

I went to an organizational meeting for the Soldiers Project NW(SP)last night. Forty-two people were there. Therapists from all over the Puget Sound region, one from Yakima, and even one from California. About 10 were veterans. Several had worked for the VA. The rest were people who heard about it and wanted to help. Several expressed despair or shame at the current level of services available for soldiers and veterans and excitement at the possibility of righting the situation.

Trisha Pearce and Lisa Weinberg convened the meeting. They've been working since October to connect with the LA-based project, a 501C3, which started the first chapter. They invited Michelle (whose last name I didn't get), a social worker from the Seattle VA to talk about the interface with VA. SP volunteers will work with people who either don't qualify for, or don't want to interact with VA and the military for mental health needs. We'll work with active duty, honorably and dishonorably discharged soldiers and their families and friends. We can refer appropriate people to the VA for services, if they want to be referred.

There are seven simple rules for SPNW volunteers:

1. You agree to provide one hour a week of mental health support or tx at no charge.
2. You agree not to accept donations, insurance payment or barter for services provided.
3. You agree to educate yourself on the effects of trauma, war and the treatment of combat PTSD and how to refer for veteran's benefits. If you work with families, children, or women you will educate yourself on their special needs.
4. You agree to screen referrals to determine whether they are appropriate your scope of training, and, if not, refer them back to the SPNW referral system.
5. You agree to conduct this pro bono work with the same high ethical and professioanl standards as in your general practice.
6. You agree to keep in touch with SPNW about your availability and practice info.
7. You agree to maintain appropriate malpractice insurance that covers your work with clients (including those seen at no cost through this project) in private practice.

These are the most simple and elegant membership rules I've ever seen. They all make sense, and they don't dictate how to do the therapy. The only other rules I heard were about the neccessity to be licensed or on the licensure track.

There are plans for support and training of we therapists. I requested information on Traumatic Brain Injury, about which I know little. I offered to do a basic traumatology workshop. The conveners gave us piles of paper full of information, including many information-filled websites for clinicians and active duty people, veterans, and their families. I think that EMDR HAP could get involved, since it's a non-profit, and will be contacting the main office soon, to find out.

If you want to join, volunteer in some other capacity or want more information, contact Trisha Pearce at  soldiersprojectnw@yahoo.com .

The Soldiers Project, Washington

Nicole Brodeur featured "The Soldiers Project"  in her Friday Seattle Times column.  This some of what she said:

" Trisha Pearce, who lives in Stanwood, is starting a Northwest chapter of The Soldiers Project, a network of licensed mental-health counselors who offer free psychological treatment to active-duty soldiers, National Guard members, reserves, veterans and their families.

The nonprofit Soldiers Project was founded in 2004 by Los Angeles psychiatrist Judith Broder, who was moved to act after seeing a performance of monologues written by an active-duty Marine and featuring Iraq veterans.

Some 35 percent of Iraq War veterans seek counseling in the year they return. This year, the U.S. Department of Veterans Affairs will spend $3 billion providing mental-health care to about 1 million veterans.

That helps, Pearce said, but the VA's culture of bureaucracy alienates some veterans.

Others don't want to get in any deeper with the military. Or they don't want mental-health issues to be on their records. Or they were dishonorably discharged and aren't eligible for benefits.

Then there's the National Guard: "They're not coming back to a military base," Pearce said. "They're in Baghdad one day, and then they get off the plane and they're home in Bellevue and their wives want them to clean the gutters.

"They are not going to come back and be who they were."

Before she can help them, Pearce must first build a network of psychotherapists willing to volunteer at least one hour a week to soldiers in need.

Once that's done, clients could call or e-mail and, within 24 hours, receive a response from a clinician who will gauge their needs, then search the database of therapists.

On April 28, she will hold an informational session for therapists from 7 to 9 p.m. at University Lutheran Church in Seattle. (RSVP to soldiersprojectnw@yahoo.com).

The project has given Pearce a new purpose and forced her to abandon the antiwar sentiment she embraced in the 1960s. "We should all be saying, 'We're here for you,' and support veterans by making it simple for them to get psychiatric care," Pearce said. "It should be our responsibility, like paying taxes, to go out of our way and do something."

The Soldiers Project started in Los Angeles and has offshoots in Chicago and New York, and of course, Seattle. Check out the LA website at  http://www.thesoldiersproject.org/ for more information, or better yet, if you'd like to start your own chapter in your town.

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

ISREALITY Video: "Color Red"

Nancy Lieurance sent me a link to an amazing video, "Color Red" (like "code red") In ten minutes, Shahar Ben, an art therapist, shows how she uses music, EMDR bilateral tapping, and movement to help Israeli children through Gazan rocket attacks, healing and releasing trauma during the attack. It's brilliant work and I defy you to watch it without tears.

Here's the link: http://www.israelity.com/?p=4533

Here's another if that doesn't work:

http://www.youtube.com/watch?v=34GYNxhn7SU