Trauma & Attachment Therapy

Gottman & Navarra: Couple Recovery Development Approach Workshop

John Gottman and Bob Navarra gave a useful workshop about working with couples in recovery from addiction, in Seattle yesterday. Here are some of the take-aways:

• "Mastery, Not Perfection" A wonderful thing to say to anyone learning a new skill ,is the "perfect" thing to say to recovering addicts, who are likely to be perfectionists. (I often remind them that "the ideal is the enemy of the real.")
• Recovery destabilizes the family system, and can replace alcohol as the "organizer" in the relationship. Couples and families need to discuss what happened when the partner was using, how things are different now, what everyone feels about it, and what both partners need now. New recovery is a perfect time to break up the alcoholic "Don't Ask, Don't Tell, Don't Feel" rules and and replace them with open, differentiated expression and mutual support. (This was frowned upon in the bad old days of recovery work, leading to this joke I heard 25 years ago: "What's a 'slip' in Al-Anon? . . .A moment of compassion.") 
• Gottman and Navarra's approach looks at 3 recoveries: the addict, the spouse, and the relationship. It emphasizes the centrality of the relationship, not just the addict staying clean. It looks at current and historical Family of Origin influences on the individuals and their relationship. It helps each partner learn to care for self and the other in "co-existing recoveries." 
• Couples learn to "create shared meaning; help each other to make life dreams come true; manage conflict; take a positive perspective; turn towards each other; share fondness and admiration; and build Love Maps." (Love Maps is a Gottman tool for couples that have them know each other, from favorite colors to worst traumas.)
• Gottman ran through his "4 Horsemen of the Apocalypse", the actions that predict divorce: Criticism (he teaches whining rather than blaming--"I'm unhappy" vs. "You're a jerk".) Defensiveness, Contempt, and Stonewalling. I had forgotten that he sees Stonewalling as a response to a Dorsal Vagal shut down reaction: flooding. He teaches people to self-soothe so that their physiology can handle the conflict.
• If trust is the number one predictor of marital happiness, how do you build it? Teach attunement. Let the answer to "Are you there for me?" be "Absolutely" and be able to show it by listening, comforting, and showing up, even during conflict. 
• Great acronym: ATTUNE: Awareness, Turning toward, Tolerance, Understanding, Non-Defensive Responding, Empathy. Gottman says that "Bonding created by turning toward any negative affect and fully processing conflict and failures to connect . . .has the power to create trust."
• Never avoid conflict: process it and it's gone. Avoid it and it sticks around forever.
• Gottman showed us part of his "Recovery Kit" for post-fight or post "regrettable incident". It's swell. For $2, you could have a great tool for helping your clients out of fights, and to send home with them, when they understand the simple but effective steps. (it's Gottman's, so it's impeccably researched). Here's the order form from Gottman: http://www.gottman.com/57329/579672/Books-DVDs-and-Workshops/Recovery-Kit.html.
• Navarra spoke about breathing exercises for self-soothing, and how couples can talk about recovery with each other. They both spoke about the importance of positive affect: Gottman, about using humor; Navarra, about bringing up what's working, what's good, and what each person likes. He spoke about the couples' needs to note their shifting identities as couples, and as a result of recovery; shifting boundaries and being choiceful about what they are, and importance of discussing new rituals of connection, old family scripts, and what they want now.
• A nice workshop (despite some A/V and organizational issues).
• John Gottman is the godfather of couple research and couple therapy. You can find out about his great books, DVD's, handouts, and workshops at his Relationship Research Institute: www.rrinstitute.org  My husband and I read a Gottman book to each other on our honeymoon.
• Bob Navarra's research about couples, addiction, and recovery is lovely, and a great antidote to the idea that the addict has a separate recovery from his or her family system. His website is www.robertnavarra.net  He's got a Gottman blog and a recovering couples' blog on his site.

Dissociation Often Caused By Disrupted Attachment

Andrew Leeds' Sonoma Psychotherapy Training Institute posted a great article on its blog: Developmental Pathways to Dissociation. They quote Dutra, Bianchi, Siegel, and Lyons-Ruth saying that ". . . lack of positive maternal affective involvement, maternal flatness of affect, and overall disrupted maternal communication were the strongest predictors of dissociation in young adulthood." Read the whole article here:  http://www.sonomapti.com/sonomaptiblog_files/developmental_pathways_to_dissociation.html

When Encouraging "Self-Care" Feels Like a Brush-Off

Dr. Kathleen Young, writes in her wonderful blog: Treating Trauma in Chicago, about when self-care is interpreted as abandonment. Read the article and the comments, then look at the rest of this great blog: 

http://drkathleenyoung.wordpress.com/2010/11/08/does-self-care-mean-others-dont/

Imaginal Nurturing, Ego States and Attachment

I've taken two different versions of April Steele's Developing a Secure Self course. Each time I learned more about creating good, strong, attachment experiences in clients with unfortunate childhoods. (Most of my caseload!) April teaches assessment, therapeutic stance, and has scripted protocols for bringing clients' loving adult attention to their infant and toddler selves. Clients can take home Cd's of the soothing protocols to enhance their experience of loving containment. Most of my attachment disordered clients loved them. A few, with phobias of their smaller selves, hated them, until we did enough trauma work that they could accept all parts. No matter what kind of therapy you do, April's training manual and scripted Cd's are very helpful.

April just came out with a distant learning course, complete with DVDs of lecture, power-point, and wonderful client videos. Because she's "practicing for retirement", she's no longer doing in person training. Here's what she says about it:

"Imaginal Nurturing, Ego States, and Attachment: An Integrated Approach to Early Deficits is the most up-to-date material on the Developing a Secure Self approach. It is not simply a video of a workshop you were unable to attend, but rather was created specifically for distance learning. In it, you will have the opportunity to "sit in on" segments of numerous sessions with a client who generously allowed some of her therapy to be videotaped to foster the learning of other therapists in the Developing a Secure Self approach. Many other clinical examples are given throughout the training. There are also two experiential segments so you have some personal experience of what you will be asking clients to do. 

The 12-hour program consists of 6 DVDs, 2 CDs, and a comprehensive 53-page manual. It requires only a DVD player and CD player. More information is available at http://april-steele.ca/training-information.php or you can contact April directly at [email protected]."

It's $200 and for a bit more you can get 12 CE's for taking the post-test.  I think everyone should have this training. If you need consultation after the training, April is available by Skype or phone from her home on Gabriola Island in British Colombia.

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.

Lessons Learned While Writing A Book for Psychotherapists

I'm 13 chapters into writing Trauma Treatments Handbook, Across the Spectrum. Here's the advice I'd give anyone doing the same thing:

• Get a second screen for your computer. Keep the reference page, internet search materials, etc. open on the second screen. It will save you days of searching for the right open file.
• Start the reference list on the first day of writing. Write the reference first, then refer to it in the text. Do it on a separate page.
• Figure out who you're writing for and address the book to them. I have a range of imaginary readers, from clueless, but bright, grad students to informed therapists. I try to keep it simple enough for the students and entertaining and interesting for the rest.
• Use your own voice and use active voice. It's hard to read academese. Don't try to impress anyone with how much you know. It's not the point. Make it accessible.

• Don't worry about people hating it. Some will. I'm writing a book that will piss off every true believer, by showing the usefulness of every trauma technique that I know about, and by talking about the shortcomings, too.

• Take some time to only write. I just took two weeks off, writing about 5 hours a day. I was able to hold all the chapters in my mind and let the obsession take over me: waking at 3 and 5 a.m. to scribble notes. Up at 6:30 with my brain ready to go, moving things from one chapter to another. I finished 4 chapters, including one very long one. My brain needed time to nail the structure of the book.

• Make a list of acronyms to put at the end of the book. I've wanted every therapy book to have them. Put them on the list the minute they pop up in the text. I'm up to 3 full, double-spaced, pages of acronyms and 9 pages of references, so far.

• Talk over difficulties with anyone who is around. Everytime I began to tell my husband about a quandry, it solved itself before I was done explaining it.

• Use the thesarus on dictionary.com

• Read many sources.

• Share milestones with your friends, virtual or in person. Let your publisher know too. They worry about books not being on time.

• If you don't know something that you want to include, ask everyone. I still don't know where Kluft said, "The first integration, isn't." Do you? Or was it Kluft?

• Enjoy the process of writing. Let the "alter" that writes take over and type. It's easier than torturing yourself over every word.

• Don't fall in love with your words. Reread. Edit. Reread. Edit. Reread. Edit. But don't worry. Your brain knows. Trust it. And trust that there will be mistakes in y our book. Despite you, your professional copy-editor and your friends.

• Back up everything to an external hard drive, every day. Every done chapter, send an email with attachments of all chapters to a few friends who don't live in your town and ask them to put the attachments on their hard drive. If you have gmail, as I do, you can send the attachments to yourself and they'll live in the gmail "cloud" of servers. Losing a book is a terrible thing. BACK IT UP!

• Exercise, get massage, socialize. You live in a body with needs. Take care of yourself.

• A book is a great excuse to neglect your blog. Sorry everyone!

Addiction, a form of dissociation, II

Ulrich Lanius, a clincial psychologist, researcher, therapist, and writer in Vancouver sent me this:

"The connection between dissocation, depression and addiction is a fascinating one and more likely than not  related to attachment. An article written by Bessel van der Kolk some insight into this:

http://www.cirp.org/library/psych/vanderkolk/

For more intensive reading, Alan Schore describes the effect between attachment and infant trauma and how they lead to traumatic stress syndromes:

http://www.trauma-pages.com/a/schore-2001b.php

There is little doubt that dissociation is in part mediated by an excessive release of endogenous opiates/endorphins. Animal studies that mimic neglect also suggest that animals that have experienced lack of caregiving have fewer opiate receptors. This likely  leads to lack of pleasure and sometimes intolerance of positive emotions, a common phenomenon in human beings that have experienced attachment trauma and who suffer from depression.

Addictions can be seen as an attempt by the addict to make up for impaired functioning of their own opiate system. Except that the pleasure derived is short lasting and commonly leads to negative outcomes in the long run, health or otherwise.

Another exciting development in the research on opiates are the effects of opiate antagonists on immmune system disorders but also potentially positive effects on depression. A review paper can be found here:

www.ldn4cancer.com/techpapers/ldn_for_disease_prevention_quality_of_life.pdf  "

Thanks Ulrich!

UCLA Trauma Conference Synthesis

I escaped the conference yesterday, and am typing in the dark this morning beside my snoring husband. I can’t see my notes, so let me tell you my impression of the conference:

Trauma impacts the right hemisphere of the brain. Helpful trauma therapy targets the right brain. Left brain cognitions and interpretations don’t have much impact on the right brain. (So said Alan Schore in 500 quotes, yesterday.)

How do we, as therapists, help traumatized people heal? We use our attuned relationship with them to keep them present and socially engaged. If they are socially engaged, now, they’re in a meyelenated ventral vagal state and can’t go dorsal/shut down /immobilized or too ventral/ mobilized/ hypervigilant. Connect. Attune. Not just with your words: "I hear you say that you’re scared." Attune with your body. "I feel your fear in the room." Then help your clients locate that sensation. "Where is it in your body?" Then stay connected with them as they mindfully explore what it’s like to be scared, while connected to you, and tracing the affect through their body. If you’re Pat Ogden, you will have your clients try out the movement that they didn’t get to do when the bad thing happened. (I have a movement tx background and incorporate this in what I do.) If you’re Diana Fosha, you’ll use the power of your connection and your brilliant countertransferential language to do hold the clients in your therapeutic embrace while they move through the trauma. (I use her language all the time – in the moment self-disclosure as containment and dual attention, cool stuff.) If you’re Francine Shapiro, you will make sure that client have a deep, attuned connection with you, while bringing cognitions, affect, and sensations into consciousness, applying periodic eye movements, and deeply connecting during the breaks between, while the clients watch their minds clear the trauma. If you’re Dan Siegel, you’ll teach your clients mindfulness, so that they can get fully present, so that they can socially engage, be present with the trauma, and let it move through with whatever techniques you use. If you’re Bessel van der Kolk, you might do any of the above, and you’ll send them to Yoga class, to become re-embodied.

What are the threads that run through this varied work?

1. Presence. Getting into the here and now experience of body, affect, and thought. That includes clients being inside the Window of Tolerance: not overstimulated, not immobilized (dorsal vagal), not over-mobilized (unmeyelenated ventral vagal). Present and capable of connection so that the work can move through them.

2. Dual Attention: In EMDR, it’s the bilateral stimulation. In Yoga and in Ogden’s work it’s the attention to bodily experience. In Fosha and good relational analytic work it’s the relationship that keeps one mind on the present and the other on the traumatic past.

3. Affect while in relationship: In all of this work, clients have affective experiences while "held" inside the window of tolerance and a therapeutic relationship. It’s not that the affect is "discharged", though it might be. It’s that it is felt; not avoided; witnessed; survived; and transformed into a memory, no longer a developmental catastrophe.

4. Relationship with self and the other: Tolerance for one’s own affect and history. Capacity for relating to others.

You have just read the thesis of my next book, Trauma Therapies. I already had it, and was validated and heartened by what I heard, every moment. The next wave of therapy is Right Brain, Mindful, Affective, Embodied, and Relational.

The husband is up and it's time to go. I'm on vacation for the rest of the week. Imagine me bird and scenery-watching on the California coast, self-regulating with no set schedule. I want to see a Condor, this time.

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.)

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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.)

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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

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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 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

WALL-E, a Story of Attachment

WALL-E, the new Pixar movie, is the perfect anthropomorphic attachment story. It's also a great movie and funny as hell. The first half, and most of the rest is an amost silent movie. Our hero, is a trash compactor robot who lives with an indestructible and graceful cockroach for company. He watches "Hello Dolly" video daily for 700 years while creating pyramids of trash on an empty, toxic Earth. When a probe robot, EVE, shows up, his latent "right brain" capacity for attachment is awakened. He wakes hers up, too. And the robots' attempts to follow their directives and their robot "hearts" save the human race. And did I say it's funny? And if I were Walmart, I'd sue Pixar. The world was run and destroyed by an enormous retail conglomerate that turned humans into docile, inert, disconnected babies. 

Pixar's brilliance turns ugly monsters, toys, animals, fish, and trash compactors into seekers of love, connection, and attachment. At the end of every movie, they list the babies of the production crew. Yes they are technically brilliant, Yes, they know how to write compelling narrative. But they know how to create characters who make the movements, vocalizations, and gestures of  yearning and connection. My husband and I were delighted to find ourselves weeping during the lost and found moments of this movie. While our left brains delighted in the subversive construction of the corporate run future, our right brains were constantly engaged with the growing intersubjectivity between machines and machines, machines and people, and finally, people and people. (Intersubjectivity: when you know that I know that you know that we're feeling the same thing at the same time. It's what makes attachment, and therapeutic repair of attachment deficits, work.)

See it. Take the kids, if any. They won't get the corporate jokes, if they're little, but the giggles and cries of alarm around me let me know they got the important stuff. And I think there's a message about rampant consumerism in there, somewhere. 

 

Jim Marshall on Psychotherapy and Religion

This is from an email sent by Jim Marshall, a great psychotherapist, deep thinker, and good soul:

"I was delighted to see that there will be a section in your book on EMDR and Spiritual Issues. Back in 1992, Francine asked me and a clinician from California to lead the EMDR and Spirituality Special Interest Group starting at the 2nd annual conference that year. That same year I had presented a paper to the second annual conference of the American Association of Christian Couselors entitled "EMDR--A Godsend in the Healing Process".  The cool outcome was that eventually the Christian therapy community got hip to EMDR and a few folks out at Fuller did PhD dissertations on it, but my own grad school, Wheaton College hasn't done squat (per the irony of being a faith-based program that overvalues well-designed studies yielding scientific evidence before fully exploring a new treatment). That was a long time ago. Anyhow the topic continues to be a very conscious daily focus for me and i will look forward to any chapters devoted to it.

An observation: I have NEVER observed EMDR to prompt change or cognitive shifting away from or contradictory to the person's spiritual orientation, meaning both their affective bond with God and their theology (i.e., their view of the nature of God, the Person of Christ, and the nature of the relationship He desires) UNLESS these were both distorted and contaminated by transferences (e.g., Heavenly Father/earth dad). With the clearing of those transferences, their theology did shift, i.e., it became more accurate/attuned to an orthodox Christian theology centering on a Gospel of love versus a conditional, punitive, shaming theology. Also, it has always been fascinating (per Paul Vitz, NYU) to observe how clients' theological formation through early adulthood (with shifts and changes, embracing/abandoning certain faith traditions) is powerfully influenced by the nature of their early attachments, and reinforced or reshaped by later attachment experiences."

Jim Marshall
http://www.mastercare.net

Dan Siegel's Parenting From the Inside Out

The Reading Group (Brena Lever and I) met last week to discuss Parenting from the Inside Out by Daniel Siegel and Mary Hartzell. At that moment Seigel happened to be meeting with the Dalai Lama, Dan Goleman, and some other child psychology types, about a mile from my house, to discuss how to grow compassionate children. We were lucky enough to be able to watch the discussion on cable. You can watch it yourself on your computer (and most of the 15 Dalai Lama events) at http://www.seedsofcompassion.org/ .

We had time to discuss the book. We were both surprised by it. I had expected Dan-Siegel "light", a book I could hand to any literate parent, for step-by-step attachment instructions. It was Dan-Siegel "medium". The book is not an easy read, except in contrast to Siegel's other books. I would give it to well-educated, analytical parents. Or I would assign specific readings, with possibility of reading more.

Siegel and Hartzell recognize this. Each chapter has 3 parts. An explanation of an idea, with one or more case examples. A brief list of "Inside-Out" exercises for the parent to do. And a longer section "Spotlight on Science" for people who want to know about the mechanisms of trauma and attachment. A hurried or less educated person could read the first part and work with the exercises. A motivated, less hurried, and more scientifically oriented person could read every word, as we did.

It's a good book for understanding how our own traumas and attachment styles can impact our ability to see and respond to our children, and that we need to do our own work to develop a "dual awareness" of our old stuff and our real here-and-now kids. It's a good book "Seigel-medium" from which to learn about attachment styles, attachment research, and the impact of parental attachment patterns on their kids' attachment styles.

My favorite concept from the book is "earned secure attachment", the getting of a healthy attachment style from therapy, mindfulness, and/or good later attachments. "Earned secure attachment" is what we want for our clients, and, in many cases, ourselves.

Here's what our two-person group thought: Therapists should read this book, because it's the easiest book that Siegel has written. Inside Out has covers all the regular Siegel topics, but less academically. Then they should explain the concepts to their clients, and work their clients (using many possible therapies) through their traumas and into earned attachment (if needed) and into an awareness of the necessity to mirror, support, and share joy with their children. They can suggest this book to bright, educated, curious parents. They should avoid giving it to people for whom it would be too frustrating.

April Steele's New Book

April Steele has updated her self-published book, and every therapist should have it. You don't have to know EMDR to use her techniques. Her CD's are wonderful, too. She's a treasure, and since she's "practicing for retirement", she's no longer teaching workshops. If you want her materials, order them from her. Get the whole toolkit. It's worth it!

Here's the blurb:

The Book

Developing a Secure Self: An Attachment-Based Approach to Adult Psychotherapy (2007) presents an approach that evolved out of my search to find a focused way in which to address directly the needs of my clients that are rooted in early insecure attachment relationships - a way that is as direct as EMDR is in processing traumas. This approach has three components:

- an attuned therapeutic relationship seen as being one of attachment

- Imaginal Nurturing - ego state work that includes guided imagery

- emotional skills strengthening

Developing a Secure Self (DSS) creates an attachment-focused context for EMDR trauma processing without compromising the integrity of EMDR protocols.

The 175 pages of this handbook include principles, dozens of clinical examples, sample Imaginal Nurturing scripts and organizational tools. It is in a convenient three-ringed binder so pages can be readily removed for clinical use, personal notes can be added, and pages delineating any further developments in this approach can be added eliminating the need to purchase an up-dated edition.

A table of contents can be seen at http://www.april-steele.ca/handbook.php.

Differences between editions

The first two editions came out in 2004. The changes in the second edition were primarily editorial, making the book more reader-friendly. Both were written for EMDR therapists. The 2007 edition is for all therapists, but maintains the references to EMDR and the section specifically on incorporating Imaginal Nurturing into EMDR trauma work.

In the past few years, I have provided both consultation and therapy for EMDR therapists who have taken my training or read my book. That experience allowed me to bring to the new edition an awareness of what people did not seem to be getting about this approach which is primarily how to weave it through the therapy rather than doing periodic Imaginal Nurturing interventions. Therefore, in this version, there are more examples of how this ego state work is woven into the therapy as a whole.

If you already have an earlier edition... 

there is an 11-page update available for a nominal charge of $5. There is no need to buy the new edition.

Developing a Secure Self Therapeutic Toolkit

The toolkit is comprised of the book and all four Imaginal Nurturing CDs. It provides you with an opportunity to expand the learning from the book to experience Imaginal Nurturing guided imagery yourself. The CDs were developed for clients to use between sessions and can be loaned, given, or sold to them. Information about the CDs including a sound clip is available at http://www.april-steele.ca/tapes.php.

To purchase

Books, CDs, and toolkits can be purchased at  http://www.april-steele.ca/purchase-products.php using PayPal or credit card.

MYSHRINK.COM

myshrink.com is a fantastic website/blog full of information about therapy, bodymind connection, anxiety, and depression. It has some of the most cogent explainations I've seen. It's a great resource for clients as well as therapists. It's written and overseen by Suzanne LaCombe, a therapist in Vancouver, BC. She writes clearly, has a sense of humor, and doesn't fall back on academic-speak. If she did EMDR, I'd be soliciting her for a chapter, about anything she wanted. Check it out here.

The Neuroscience of Psychotherapy

The book group discussed The Neuroscience of Psychotherapy by Louis Cozolino (W.W. Norton & Co. 2002). We liked it. Cozolino's book is easy to understand and moves along nicely. It is packed with information about the brain. Its case examples were great, though too few.

Cozolino writes about brain structures--the triune brain (lizard, mammalian, human), the left-right split, the effect of good attachment on brain growth, and the effect of trauma or poor attachment on brain pathology. He refers extensively from 2 out of 3 of my favorite "brain geeks": Seigel and Schore. He calls on theorists from the analytic traditions (Winnicott, Alice Miller, Freud) to discuss developmental and pathological processes. He talks about "neural plasticity", the ability of the brain to grow and adapt long after early "sensitive periods" or developmental windows. (That's why psychotherapy or new life experiences can change the brain.)  He quotes good research to discuss good therapy, which he says (and I agree) is neural growth and integration which is enhanced by:

"1. The establishment of a safe and trusting relationship. 2. Gaining new information and experiences across the domains of cognition, emotion, sensation, and behavior. 3. The simultaneous or alternating activation of neural networks that are inadequately integrated or dissociated. 4. Moderate levels of stress or emotional arousal alternating with periods of calm and safety. 5. The integration of conceptual knowledge with emotional and bodily experience through narratives that are co-constructed with the therapist. 6. Developing a method of processing and organizing new experiences so as to continue ongoing growth and integration outside of therapy." (p.27)

We liked it, and everyone thought there was a lot missing. The title: The Neuroscience of Psychotherapy: Building and Rebuilding the Human Brain, has very little discussion of psychotherapy. I was hoping that it would reiterate how Exposure therapy dampens amygdalur function, while EMDR integrates it. I wanted to get the scoop on Stephen Porges's Polyvagal theory and how looking into someone's eyes is a different for them when they're mobilized, immobilized, or in a myelinated ventral-vagal relational state, and how to move them from one to another. I wanted to get the lowdown on which therapy modality might best fit which disorder. (Yeah, Yeah, Cozolino does say that it's the relationship, more than the modality, which I know and say. And I still want to know what to do.)

EMDR has a nice one paragraph mention near the end of the book. Our group of 4 contained 3 EMDR/Brainspotters and 1 cognitive behaviorist/ Brainspotter. We could see EMDR fixing many of the manifestations of brain dysfunction, throughout the book. Cozolino had a great description of what's happening in the brains of people with Borderline Personality Disorder (p. 282-3) without talking about Dialectical Behavior Therapy. We all wanted him to know more about more therapies than he did when he wrote the book. And he didn't.

Read this book to get an easy-to-read rundown on brain function that pertains to therapy. Then read more. Look up Stephen Porges and Polyvagal theory, there are lots of articles online. Read Dan Siegel. Go to Dan Siegel & Marion Solomon's attachment conference at UCLA/Lifespan Learning Center every March. (I think of it as the brain geeks-with-hearts meet hearts-with-big-brains conference.) And remember, that everytime you interact with clients, you're truly messing with their brains.

Reading Group: The Neuroscience of Psychotherapy by Cozolino

The next book in the reading group will be The Neuroscience of Psychotherapy, by Louis Cozolino (W.W. Norton, 2003). It's easier to read than you might think, and written by a psychologist, not a medical person, who struggled through the medical/scientific texts in order to bring we clinicians the good news. According to Cozolino, we are "rebuilding the brain."

The group meets on Friday, November 9 from 10-12 at my Seattle home. Contact me for directions. Bring a lunch if you'd like to stay later to socialize.

Obsessive-Compulsive Personality Disorder

We all know what Obsessive-Compulsive Disorder (OCD) looks like: repetitive rituals, obsessive thoughts, and the people who are thinking or doing the compulsive thinking or behavior and know that they're not being rational. Obsessive-Compulsive Personality Order (OCPD) is something else. People with OCPD are detail oriented, to the exclusion of the big picture. They are obsessed by control. They may get involved with organizational details, the minutiae of tasks, or tasks that have very little to do with what most needs to be completed in their jobs, their studies, their homes, and in their lives. Many OCPD folks are prone to angry outbursts when their environments, kids, or coworkers don't go with the program. They may be very nice, but they're not usually capable of intimacy.They are the nightmare managers from hell. They often don't keep or rise very far in employment. though they work half again as many hours as any other employee. And nothing is ever right with anything. Expect depression, anxiety, and either massive pollyannish denial or massive criticism of everything, including you.

Avoidance of anxiety is their not-conscious organizing principal. Here's how it works: If I need to get the big job done, and I feel anxiety when I think about the big job, I'll bring my attention to this little task that's not so scary and I'll do it perfectly, for hours. Working on the little task makes me feel better. (Dan Goleman's book Vital Lies, Simple Truths: the Psychology of Self-Deception descibes the biology of this phenomenom.) When I take my attention away from that which makes me anxious, the pharmacy in my brain gives me really good drugs. This is why procrastination and self-distraction are so popular. If I don't work on the scary task, I'll feel better, instantly. If I keep doing the intricately complex avoidance behavior, my brain keeps giving me good endorphins. If I've been self-medicating since childhood, by focusing on unimportant tasks, instead of anxious or checked-out or angry or controlling or absent mom and my own loneliness, I'm going to build a big neural net of reflexive avoidance/distraction behavior.

In my opinion, here's the etiology: First, there's a mom, who for some reason can't connect well with her child. Non-connecting moms, be they passive or screaming, are frightening to kids. If a kid learns to distract him or herself by focussing on little tasks, she can dissociate/self-medicate away the terror of being all along and taking care of him or herself. What he or she doesn't learn is the non-dissociative self-soothing techniques that arise from the attachment dance of connection, backing off a bit, and reconnection. So the child's only self-regulation comes from distraction/dissociation.

How do you treat these people? Mostly, they don't come to therapy, and you won't get the chance. Good therapy is the opposite of avoidance, the pathology keeps them away. However, once in a while, someone gets "drug in" by their spouse, or employer, or even their own miserableness and the work begins.

They will try to control the session and keep you focused on the unimportant details. Don't let it happen. Get more assertive than you usually are, or you and your client will unhappily spin your wheels for months. Since I start most clients off with Maureen Kitchur's genogram-based intake with its predetermined list of "nosy, snoopy questions", (EMDR Solutions) I'm able to keep the initial sessions on task, and then share what I think much of the therapy will be. Then work on four things:

1. Staying on Task in the sessions: Make and keep a strong alliance. Show your compassion and your grit. When they change the subject to some small distress of the day, say "Oh that's so upsetting when that happens! Let's go back and get the underlying material, so this won't have to be so distressing later on."

2. Work on Affect Tolerance and Self-Soothing: Tell them we'll start with one-pound hand weights and work up to the big feeling. Teach them containerizing of emotions, mindfullness techniques, relaxation, and containing their own inner babies. (April Steele's Imaginal Nurturing is wonderful for this, as are many kinds of ego-state work.)

3. Use EMDR or Brainspotting or whatever you have that works to target the early childhood relationship with the caregivers. "Imagine looking into your mother's eyes when you were an infant. What do you notice in your body right now, as you imagine your mom?" Clear whatever comes up. Go through all the ages until there's no distress.

4. Finally, target the avoided things. I adore Jim Knipe's Level of Urge to Avoid in EMDR Solutions. Knipe would ask these clients, "How good on a scale of 1-10 would it feel to completely avoid that big project by focusing on sorting out your sock drawer?" "Where do you feel that feeling in your body?"  "Stay with it." While applying a bilateral stimulation. Often the "inappropriate positive affect" (the endorphins) go down by itself and the clients are left with the somewhat appropriate feeling of dread about what they've been avoiding. Then target the dread about the project, clear it, and have them imagine doing the damn thing, step by small step. And then imagine what having it finished would feel like. Aahhhhhh.   If the inappropriate affect doesn't go down by itself, I often two-hand it. (Also in Solutions.)  "In one hand, hold how good it will feel to continue avoiding the project. In the other, hold the consequences for not doing it." Apply bilateral stimulation, and your clients are very likely to feel their discomfort and then be directable to clear it.

I won't kid you. These people need a long therapy. They've been reinforcing avoidance in themselves since babyhood and you and they have a lot of neural networks to rewire. And it's possible, with a good alliance and good attachment and affect work to create clients who can choose avoidance (vacations, breaks, movies, Spider Solitaire) and relationships and getting their real work done, over reflexive busy work, blowups, inadequacy, and loneliness.

Long-Term Clients

I've been in practice since 1981. During that time, I've seen around 1000 clients and in the last decade consulted to other therapists about at least a thousand more. DSM diagnoses are one way to describe clients. Another way is by the length of time they stay in therapy. (Not counting analysands) Here is a list of clients, by length of time spent in therapy.

• Fly-over: never a "customer", leaves after a few sessions because it wasn't his idea to come, or the therapist isn't a fit (lost one because I wore Birkenstocks in the 80's), or she's too scared to stay.
• Questioner: Needs something normalized. "Am I crazy because. . . I'm grieving/I like to have sex the way I like it/I just moved and I don't immediately have new friends, etc." This client needs information about normal human behavior and reassurance that a trained professional finds her/him sane. (Not to be mistaken for a client with underlying issues who tests you with this kind of question.) One session.
• Three-session wonder: The famous (and extremely rare) well-attached car accident victim who clears the trauma in two sessions and comes back to praise you wildly on the third. I've treated about 20 of these in the 14 years that I've been doing EMDR. For them, therapy is penicillin: Take a good dose, and the symptoms go away.
• The Next Developmental Step Client: She's at the cusp of differentiating from her family of origin/partner/workplace and finding out how to be herself. If she's reasonably well attached and reasonably untraumatized, she'll be around from three to eight months. If more traumatized or with an abusive or alcoholic or otherly dysfunctional family and/or attachment issues, you might be seeing her from months to a few years.
• Big "T" Trauma client. She takes some time. If she was raped more than once or injured badly in the accident, or spent too many months in that war zone or horrible work environment, you have months to a few years of work. Best case, you nail the root trauma early (that molestation by the neighbor) then the rape, then work on integrating it all and dealing with her current, hopefully safe, life. Worst case: despite your thorough intake, you keep finding more and more suprise antecedents and the current life stays unsafe and in flux, and you spend three or four years getting her life in order and trauma moved through.
• Horrible attachment, relatively light trauma: Years of finding the baby parts that go into shut down or cling or fight or flight. Years of helping him own the baby and hold the baby and soothe the baby, instead of reflexively disappearing or pushing you away. He de-hunkers. He connects. He finds someone else with whom to connect. He learns self-regulation. He leaves therapy, after checking 6 times that he can return, if necessary.
• Bad chemistry clients. It depends. If she gets on the meds and "feels like myself again" and the good feeling stays, say goodbye and thank your favorite diety.    If he only gets depressed in the summer. You may see him for a year or so, the first go round, and then every time he goes down. You'll remind him to call his medicator person for a medication adjustment, and help him cope with the affects and effects of the bipolar/major-depressive dx/schizo-affective dx. In every round of therapy, you'll help him clear some more trauma and help him reset his thoughts (there's nothing wrong with Cognitive Behavior Therapy, when you need it.). When he's back on the horse, you review what you both learned, and cut him loose until the next round. If he's more chronic, fighting debilitating chemistry with little respite, or rapid cycling, you become insulin. The attachment relationship is paramount. Attachment to you may be thing that keeps this client around. Each interaction raises hope, reregulates your client, gives them an experience of being witnessed and loved. You won't fix him. You will help him cope. If attachment disruption and trauma created the depression, therapy can, finally, nail it. And it will often take years. If it's 95% "bad brain", you need to hold to your presence as the most healing tool you have. Use all your tools: CBT, EMDR, adoring your client, cheerleading ability, and connectivity. Work with them to try yet another med, keep exercising, keep eating well, get to work. Find them the best psychiatrist in town. And settle in for a long-term relationship.
• Severe dissociation with awful attachment and horrible trauma: Settle in for the long haul. You and the therapy are both penicillin and insulin. It may take months or years to make a good, trusted attachment relationship. It may take just about the same years to stabilize your client. Then you can tackle the trauma with some good penicillin (EMDR, Life Span Integration, Brainspotting, etc.) And tackle more trauma, and more trauma, and more. Then you can help her integrate all the changes. It's 10 years later. She's in a good relationship; has a better job; can have sex; and finally can say, "How do I know if I'm done?" She's making her own insulin. She may come back for another dose of penicillin. Maybe more than once. But you did your job.

As a trauma therapist,I get to see my merely traumatized clients move through material quickly. They may go from debilitated to functioning to joy in a few weeks or a few months. These people connect quickly, don't "slap" me, have appreciation, and leave grateful. If I'm working with someone with poor attachment, thus poor affect tolerance, and, often, poor relationship skills, I have to keep my whole job description in mind: The relationship is paramount, the trauma healing can go forward only when the client is ready. It will happen as it can.

I have a huge box of therapeutic tools. I can and will try every one of them. I can seek more tools. And the relationship is paramount. If I'm attached to the client (which I must be), I'll feel his hopelessness and despair. I must metabolize it, and when it's digested, find a way to hold it, without buying into it. As a consultant, I'm constantly helping consultees metabolize their clients' despair. "Yes, it's a long therapy. And you want to take the pain away. And the client is really hard on you. And that's what this kind of client is like."  I normalize. I empathize. I give examples. We work with the countertranference. And we find where the client and therapy are, developmentally, name it, and surmise what the next steps are. As the therapist holds her client, the consultation holds the therapist, offering insulin so that the therapist can metabolize another month of a long therapy. Then we talk about the client again.

Flamboyant gay adoptive parents

Who says it's not natural? http://scienceblogs.com/grrlscientist/2007/05/gay_flamingos_realize_their_gr.php

Intersubjectivity and Contradance

I went to a local contradance last night. For the uninitiated, contradance is a New England-based, 200-year-old social dance that has spread around the entire U.S. and some of Canada. It's easy, fun, aerobic, has participants of all ages, and is, for most, absolutely relational. Every three minutes a dancer is thrust into the arms of new people, then comes back to her partner, then the next new people. Eye contact is part of the dance. Connection is mandatory. Flirting encouraged.

Because the whole room is doing the same steps in time with the music, while gazing into someone's eyes, and feeling the same feeling, joy, it may be the most intersubjective dance form. (Intersubjectivity, necessary for growing capacity for attachment, is when two people are aware that they are both aware that they are sharing a feeling, right now, together.) There are times when the whole room stomps or claps as one. Other times when you run into a person whose playfulness and joy wholly match yours and you are transported to the heights of positive affect. I imagine that oxytocin levels, in all participants, are at record highs. (Oxytocin is the chemical that arises in new moms and babies, and at orgasm. We don't attach very easily without it. Luckily, we make it ourselves.)

Each set begins with a caller directing the action. "Swing your partner", "do-si-do", "left-hand star". Then as people grasp the pattern, the caller stops, and the dancers continue the pattern, first with this other couple, then with that one, right down the line. When the left brain stops thinking about the steps, the right brain takes over. The smiles begin, the energy rises, the band plays faster, the joy pulses through the room.

Last night, there were five 20-year-old girls, new to the dance, milling at the side of the room. Ever the social worker, I taught them the basic dance steps, and thrust them into the arms of random men. I watched them struggle with the steps. (It takes about 3 "sets" to really pick it up.) Then I watched them connect, and connect, and smile, and then glow. I don't think it was just the aerobic activity.

I can never go from work to a dance. I'm too open to my "therapy brain" and I diagnose everyone, right down the line. On non-work nights, I'm able to leave the therapist at home, and connect with the joy of it all. I recommend  contradance for clients who want to do something fun that doesn't involved drinking. I send people who have enough attachability to tolerate the eye/human contact and who can tolerate some positive affect. If your person has an anxiety disorder or very low self-esteem, they may not tolerate the learning curve. I suggest these people get a few lessons before they hit the dance floor. I warn other clients that they will be completely lost for the first few dances, and then they'll catch on. They do, and come back triumphant. You may want to try it yourself, before you refer your clients. But only if you want more contact, more community, and more joy.

To see some photos and links to contra web sites, click here.

"A General Theory of Love"

A General Theory of Love (Lewis, et al. Vintage Books, 2000) is a brief, poetically written, easily understood book about attachment. I read it several years ago, and it was just as enjoyable to read it again. The reading group liked it too. We all recommend it as an introduction to attachment theory and to thinking about psychotherapy. It's not a "how-to" book, go to Fosha's Transforming Power of Affect for that. It's not comprehensive, go to Allan Schore for that. It has flaws, which I'll discuss later, but first let me sing its praises for a while.

• The language is gorgeous. Sentences chosen at random: ". . . But insight is the popcorn of therapy. Where patient and therapist go together, the irreducible totality of their mutual journey, is the movie." (p.179) Too many therapy books are written in academese, as if the passive voice and too many clauses per sentences were required.
• It uses easy to understand metaphors and examples to explain hard to understand concepts.
• It's brief, 230 double-spaced pages.
• Wonderful quotes from fiction, poetry, and philosophy abound. (I like that kind of stuff.)
• Lewis et al. say over and over that the relationship is the most important element of psychotherapy and then explain why.
• It's been around long enough that you can buy it for less than 8 bucks on Amazon.com.

Nothing is perfect, and neither is General Theory. While Lewis and company do a lovely job of explaining implicit and explicit memory, they make a (mistaken) big fuss about what they call "recovered memory". They don't write about and probably didn't know about traumatic memory. When an event causes high bodily and emotional arousal, it is encoded differently in a different part of the brain. (If I could remember where I know that from, I'd tell you. I think it was from Bessel van der Kolk.) It could be, "It was my 5th birthday and there was a PONY! It's the only thing I remember about that year." Or it could be another kind of state-dependent memory: sex abuse, seeing one's best buddy shot, or other traumatic memory. These state-dependent memories (and often, repressions) are well-documented and not worth arguing about for this trauma therapist. Lewis & friends don't discuss trauma. "Trauma" is not in the index. And since trauma can be a huge disruptor of attachment, I think it should have been given some time and space in the book.

The second problem with AGToL is its excoriating of every therapy that isn't the way they do it. Okay, they rip apart old-time Freudian analysis, with its emphasis on not responding. They quote Freud, "'The physician should be opaque to the patient, and, like a mirror, show nothing but what is shown to him.'. . .But since therapy is limbic relatedness, emotional neutrality drains life out of the process, leaving behind the empty husk of words." So far so good. That's anti-attachment therapy. But they ignore all the good relational work that newer analysts are doing. Then they go after cognitive behaviorism. If practiced outside of a relational context, it can also be deadly to clients. The problem is, that they don't look at what other therapies are supposed to do. Yes, limbic-relatedness is necessary for every good therapy. And some therapies are around to help make PTSD go away. Some help disordered thoughts become more orderly. Some enhance performance. Technique does matter, depending on what your client wants to accomplish. Use the therapy that works, as long as you do it in a relational context! So there!

Still and all, it's a good book and a worthy read. If you do practice from a relational base, it will make you feel even better about it. If you don't yet work that way, it tells you why you should. If I were teaching a basic therapy class, this would be the first book I'd assign.

Positive Affect

Happiness, Joy, Giggles, Aha!s,Shared Humor. What place does positive affect have in therapy? In my opinion, a big one. Delving deep and bringin to consciousness avoided trauma responses, anxiety, anger, hatred, and shame are important elements of any therapy. First you find them, then you process them in some way, so that the client is neither run by their defenses against these affects, or by the affects themselves. But where do go from there? Stephen Gilligan says it's Life's job to make every human being experience every feeling that any human being could feel, and that it's each human's job to allow those feelings to flow through, unimpeded. (workshop, 1996). That includes the positive affects.

When I do EMDR, good feelings often spontaneously arise as the client clears the traumatic experience. When a client says, "I just feel so much relief, now!", the therapist says, "Go with that!" and processes it, like any other experience. The "Installation Phase" of the Standard Protocol, includes bringing the client's positive cognition "in" while applying bilateral stimulation. I often boost that with a direction to "bring that into every cell of your body." In David Grand's Brainspotting, you might have the client visualize a color that goes with the positive affect, and watch it grow as you clear the other not-so-fun affects and experiences.

In AEDP, Diana Fosha's technique, you might ask, "What was it like to share that happy moment with me and to know that we both were feeling it at the same time?" (acknowledging intersubjectivity) This "nails in" the experience to both the reasoning/verbal left brain  and the emotional right brain, while it enhances the affect. In AEDP, therapists share their internal good feelings about the experience of the client. "I'm deeply touched that. . ."  "I got a warm feeling right here when you said . . ."

Most of us use positive affect spontaneously. We smile at the client in the waiting room and exchange how nice it is to see each other. We laugh at the ironies of life, together. We celebrate victories. I'm quite fond of handshakes or high fives when a client reports success from their week. "The nightmares are gone." "I finally stood up to my coworker." "I really felt out from under it this week."

Sometimes a client who has made great progress will report anxiety upon feeling better. Some folks, with truly horrible trauma, may experience terror or nasty introjected abuse, upon "feeling better". On further exploration, you will often find that

• They don't have much experience of positive affect and lack much right brain wiring for its regulation. (In which case you need to bring more and more experience of it into the room and let them coregulate it, with you. "Bring that in, breathe deeply, ground yourself. What's that like."Do it a lot.)
• They weren't mirrored in it as kids. (See above, also a lot.)
• They were punished by an anxious parent who couldn't tolerate high spirits. (Clear it!)
• They live with someone who because of their own childhood issues, can't tolerate joy or giggles in their partner. (Clear it and teach differentiation.)

There is a difference between real joy and joking or fake happiness as a defense. I have an aquaintance from an alcoholic family who is happy, happy, happy. Underneath she's pretty angry and terrified. Those feelings leak out sometimes. She's been in therapy for about a year and is starting to get congruent, and much easier for me to be around.

When I have a client who is charming me with defensive "unreal" "positive" affect, I might say, "Stop for a moment. Scan your body now, and notice what sensations are there. Is there something underneath this story? What's the feeling?" It's always there. With someone else, I might say, "I usually feel connected to you, and I don't now. Is there something inside that you're not connecting with?" When they burst into tears, it's hard not to say, "Bingo!"

From the minute I see the clients in the waiting room, until they walk out of my door, I'm ready to share in whatever authentic affect they experience. I'm always on the lookout for the "good stuff". Always wanting to enhance it and bring it to consciousness. If they have no capacity, we spend many sessions building it. If it's scary, we clear the fear. With some people, we collaboratively use humor to regulate otherwise intolerable traumatic incidents.  Client: "It completely sucked! My childhood was a horror movie!" Me (in snotty adolescant voice) "Well, yeah!"  The client laughs, and dives back into the horror show for more processing, crying as he goes through it, and connecting with me, throughout.

When I work with couples, I'm on the alert for signs of collaborative joking, giggles, shared smiles. If there isn't any, I know that they're in trouble. I ask about it. "When did the laughter go away?" That usually brings jointly shared authentic sadness into the room, a place of connection. And a place to start from.

Diana Fosha's "Transforming Power of Affect"

The Tranforming Power of Affect (Basic Behavioral Science, 2000) is the best therapy book I've read in many years. It is a readable, comprehensive, and creative survey of attachment research and how to apply it to your adult clients. Diana Fosha comes from the Short Term Dynamic Therapy lineage of Davanloo and Malan, and adds to it attachment-informed use of self to help propel clients forward. I have no training in STDP and just a little in AEDP, Fosha's Accelerated Experiential-Dynamic Psychotherapy. The book gave me tools I can use.

The book group liked it. Most of us found the prose a bit dense, but understandable. All of us said that our work had already changed from the reading. We agreed that her therapeutic lens included attachment awareness, affect awareness, and the therapist's own relational experience with the client. Her techniques were many, and way cool. We are now all finishing our sessions with, "What was that like to do this piece of work together?" We are either feeling validated for how we already use ourselves in the sessions, or doing more of it. This therapy puts the space between the client and the clinician in the center of awareness and process.

What does Fosha do that I like: She uses her self. She uses the body. She teaches attunement. She teaches several new ways to make sense of the client's material/behavior. She keeps clients in their experience. She is collaborative with her clients. She's real. Her therapy is backed-up with research and it is (informed) intuition. Her descriptions of human interactions are exquisite. And her asides in describing interactions with patients can be quite funny.

I do think that Fosha uses process awareness as a kind of dual attention. I like that, it works. AEDP processes relational trauma, pretty well. I think EMDR is more efficient for many kinds of trauma. (I know that Fosha is trained in EMDR and uses it on occasion, though it's not mentioned in the book.) There is no overt mention of dissociation, though she discusses the phenomenon as defense and "disorganized attachment." Her techniques have caused some of my most dissociative clients to "disappear". I think AEDP can help keep other, less dissociated folks in the room.

I'd like to be able to explain the techniques, but, they are so nuanced, that I fear to put broad, unexplored, descriptions on this blog. Read the book. Six good therapists in Seattle think you should. If you have seen Fosha speak at conferences and were unimpressed, read the book anyway. She's one of the few people who writes better than she talks. If you are going to take Fosha's 5-day AEDP immersion class, read the book first, you'll get more out of the class. The videos in the class are worth the price of admission. I think if you simply watched the videos, you'd become a better therapist, though you might not know why. It's good stuff.

Mobilization

As I travel up the California coast with my husband, I am watching our interactions through the new lenses I obtained at the Attachment Conference. My high-strung husband goes into "mobilization" when stressed. (According to Porges, his myelenated vagal nerve switches on, he starts looking for danger, every stimulus is suspect, and bcomes unable to connect—first no safety, thus no connection) So if we are lost in yet another strange town, or in a hurry to catch the dawn/dusk light for his photographs, I lose my sweet, connected guy. He’s told me many times that when he is in this state, "Everything is a problem to be dealt with, including you." Van der Hart would explain it, in his somatoform theory of dissociation, as Doug being in a flight or fight state. Either way, it’s helpful to get another lens through which to see what is happening "over there" in my beloved.

What happens to me when Doug switches out of the relaxed, playful, relational self into the hypervigilant, self-protective self? I’ve had various responses, depending on my baseline state, self-awareness, and patience at any given time. I’ve hunkered down to wait until it’s over (a favorite childhood reflex in an intense family). I’ve complained and told him to relax (this tends to escalate both of us, I can get mobilized, too. Then it’s real fun at our house). I’ve worked to get Doug physically grounded and present (the fix-it caregiver in me does this and it has worked). I’ve consciously noted the state and given him space, without shutting down (more and more in the last several years). And I talk it over with him. This has varied results. Doug, in this state, sees most stimulus as attacking. Gottman would say that he was flooded. So would I. Humor can disarm that, sometimes,

"I am the evil enemy whose only thought is to make you miserable."

"How did you know what I was thinking?"

"I’m a trained professional."

"And you put up with me anyway!"

"Yeah, I can’t help it. I’m attached."

At this point Doug may still be hyped up, but not in complete mobilization. He’s relational. I’ve got my guy back. The one who sees me as evil has disappeared. I don't have to do "hunker" or "protest" of "fix it" or even mindful space-giving. Relief!

Day II: UCLA Attachment Conference Day 2

John Gottman on Meta-Emotions

John Gottman is the relationship research guru of the world. He’s studied thousands of couples to find out what makes happy and long-lasting relationships and what makes miserable short-lived ones. Today he talked about research he did with Lynn Katz, starting in 1985 on Meta-Emotions: thoughts and feelings about emotions. They identify two kinds of people:

"Coaching" people like to notice emotions, talk about feelings and needs, like to ask questions about emotions, accept and value emotions, and use their emotions as a guide about what to do next.

"Dismissing" people avoid and minimize negative emotion. They are into "the power of positive thoughts". They rarely acknowledge needs. They’re into a "suck it up* philosophy. They hold negative affect (anger, sadness, despair) as dangerous. If their kids have negative feelings, they think either the kids are bad, or else they parented incorrectly. They believe that you can have any emotion you want, through will.

Two "coaching" people, if married, are likely to stay married, with high intimacy and high marital satisfaction. Two "dismissing" in a couple are likely to stay married with low intimacy and high satisfaction. A "mismatch" couple, with one of each, is 85% likely to divorce, without intervention.

On a different topic, Gottman said that in couples who are likely to stay happily married, they say: "Yes". "I agree." "You may be right." And "Good Point", much of the time, in verbal and non-verbal ways. Bids for attention, in these marriages, are accepted 86 % of the time. In a disasterous marriage, the majority of the time, people say: "No." "No Way!" "Ridiculous!" Couples who "turn toward" are likely to stay together. Couples who "turn away" or "turn against" are quite likely to divorce withing 6 years. In a "mismatch" marriage (see above), there is more turning away, more secrets, betrayals, attachment injuries, and eventually, violence. These are low intimacy and low satisfaction marriages.

Gottman’s blue print for what couple’s therapy needs to be:

1. Emotionally Focused.
2. Psychoeducational skills including regulation of negative and positive affect and turning toward bids.
3. Make conflict constructive by managing power, cooperation, accepting influence and partner’s anger and other affects.
4. Build the friendship with sex, affection, shared adventure, fun, play, intimacy, romance, and passion.
5. Create intentional shared meaning: purpose, rituals, goals, values, legacy, holidays, etc.

His Conflict Blueprint:

• Postpone persuasion until each can summarize partners’ stance.
• Each partner must assume similarity. If I question my husband’s motives, I have to question mine. If I think I’m being noble, I have to consider that he is noble, too.
• Validate & listen.
• Speaker: I statements Listener: postpone agenda
• Both sooth selves.
• Compromise.
• Explore the dreams behind the conflict.
• Repair the regrettable interaction.

He said more, but I couldn’t write fast enough. Here’s one thing that stuck with me from the question period: Gay couples, both male and female had more positive affect and humor than straight ones; less power issues; were more fair to each other; could talk more easily about sex; and were generally less defensive.

If you want to know more, read John Gottman’s many books. One of my favorites is 7 Principles For Making Marriage Work.

Sue Johnson: Hold Me Tight, a model of Adult Love

I wrote about Sue’s EFT model in an earlier post. Here are some gems from today’s lecture.

• Couples come into the session in a primal panic. You have to shift them from primal panic to calm safe connection.
• The attachment system is pre-eminent.
• Attachment issues are existential questions: "Do I matter to you?" "Do you see my pain? Do you care?" "Will you be there for me?"
• Clients who haven’t ever experienced "felt security" or who haven’t seen a good relationship still fight for connection and love.
• Intimate relationship is the best source of resilience and growth and hope for the future.
• Fighting is often separation "protest".
• There’s no such thing as overdependency or true self-sufficiency
• The cure for an attachment injury is to know that your partner feels your pain on a body level. Then there is a possibility of forgiveness and connection.

Several of my favorite teachers are at this conference. Diana Fosha, Dan Siegel, Pat Ogden. In my opinion, Sue Johnson would be the most fun to have to dinner. She’s hyper-present, funny, intelligent (they’re all brilliant), and down to earth. When asked why she represented men as more alexithymic (feeling phobic), she said that she grew up in an English pub, and the men all were in touch with their feelings after the second beer, sometimes too much so. Gottman then chimed in that his statistics showed that men were much more avoidant of feelings and intimacy by a vast percent. Then went on to explain it with cultural and sociobiological explainations.

Jude Cassidy, an attachment researcher

• People open to the pain of the past function better in relationship with partners and children, because they’re not so busy ignoring their own pain. If they ignore their pain, they won’t be able to see and respond to others’ pain.
• If you can regulate pain, you can be present with it, and respond to others’ needs, not just your own needs to shut off your feelings.
• People need a secure base from which to explore and a safe haven to return to.
• 3 kinds of secure bases: Important relationships in childhood; adult romantic relationships; and therapeutic relationships.

I’m too tired to go on, and there’s a third day to come. I hope to write more about Jude Cassidy and tell you about Dan Hugh’s amazing attachment work with kids. Maybe tomorrow.

UCLA Attachment Conference, Day One

I’m at the UCLA/Lifespan Learning Institute’s Attachment Conference. This year it’s called The Healing Power of Emotion: Integrating Relationships, Body, and Mind. Today, about 500, tomorrow and Sunday, about 1000 people will sit in a ballroom while a firehose full of information is directed at us. We will try to swallow all that we can. At the end of the day, there is a panel discussion of the participants. They take questions from the audience and from each other. Sometimes it’s very scholarly. Sometimes, it’s almost a brawl. The brawl, of course, is more fun.

Stephen Porges started off the day with a lecture on his research: "Application of Polyvagal Theory to Clinical Treatment". Most of it was in understandable English, because Porges is a U of Illinois professor and knows how to teach. According to the conference bio, "his polyvagal Theory of Emotion led to the discovery of an integrated neural system that regulates social engagement behaviors." His lecture today focused on the need for face-to-face interactions for bonding to occur. When there’s a violation of the interaction—someone doesn’t make eye contact, when a supposed intimate is speaking, the speaker experiences distress: anger/shame/alienation. Safety creates proximity creates contact creates bonding. There might be more bonding in sleeping together than in sex. Porges commented on the dysfunction in the Seinfeld rule, "No sleepovers!" (We know that those people were all attachment disordered!)

I can’t recount the whole lecture, but I can give you tidbits:

• Facial muscles go down to the heart. Talking, listening, and smiling calm us down.
• Two vagal nerve systems. The old one, from lizard days, shuts us down completely. It’s the one from which we can swoon, be literally scared shitless, or become selectively mute, when distressed.
• The new vagus is linked to face and is protective of mobilization systems. It works socially.
• Our nervous system can relax us through the meyelinated vagus, if we are experiencing safety; mobilize us, through the sympathetic and adrenal system, if we sense dangere, or completely immobilize us, through the old, lizard unmeyelinated vagus, if we think our life is in danger, feigning death like a mouse fooling a cat. (Doug, out birding during the day, caught and pet a horned lizard, who didn’t move at all. It was in the immobilization vagal phase.)
• Social behavior enables us to function better.
• Social engagement systems: prosody (tone and music of our voices), gaze, facial expressivity, posture during social engagement, mood, affect, and behavioral state regulation.
• Environment can be interpretted, based on our state.
• Borderline cutters, in a study, lost vagal control of their hearts while watching emotional videos. Controls, did fine.
• Very autistic kids attend to low (more frightening) tones. They stay scared and "mobilized" most of the time and try to soothe by doing weird stuff, not be connecting with others. If you play them music with all the low tones filtered out, over time, they will become socially engaged, like normal kids. I saw the video, it was way cool.

Then there was Dan Siegel, talking, again, about mindfulness. At last year’s conference he was gushing about a meditation retreat, as if he’d invented it. I love Dan Siegel. He’s brilliant, sweet, a great lecturer, a good writer, and a wonderful clinician. But I wasn’t the only one shaking my head at his response to what I’ve been doing/knowing for 25 years. He is compiling research on what meditation actually does. He will be big in making it even more mainstream.

• He spoke about getting clients to become aware of the SIFT, Sensations, Images, Feelings, and Thoughts.
• He teaches mindfulness to clients so that they can change their states.
• Contingency: Person A sends a signal. Person B perceives, decodes and responds in a timely and effective manner. (That’s how you get healthy attachment or a good therapy.)
• Mindfulness training is great for ADHD. (I’m going to send my ADD clients to meditation class when I get home.)
• Mindfulness is: The capacity to be present as an experience is happening; Non-reactivity; Not clinging to judgements; The ability to label & describe one’s internal state; and Self-awareness, awareness of one’s awareness.

Then there was Pat Ogden. She was a student of Peter Levine, who has taken his work farther, by bringing in more of an attachment slant. I’ll write about her in a few months, when we read her book. Her videos, when they worked, were inspiring.

The final speaker was Robert Neborsky. He’s loud, brash, and does the scariest and possibly most effective brand of therapy that I know about, Intensive Short-Term Dynamic Psychotherapy. He showed a video of his work, excerpts from a 15-hours-in-one-week therapy with a hunkered-down guy, a middle-aged abuse survivor. He carefully pushed the guy through every defense against affect, every time. He took no prisoners. He went for the kill. And within hours, he had the client enacting killing his horribly abusive father, and getting over his affect phobia. The therapy looked horribly mean and the client didn't act like he was being abused. He was having breakthroughs all the way through the work. In the break afterward, people had lots of reactions, from admiration, to "Take his license away."

At the panel discussion, an audience member, from a psychoanalytic background, shared his distress about Neborsky’s work. "It left no room for the client. . ." There was scattered applause. Dan Siegel and Bob Neborsky both lauded the questioner for his bravery, then spoke about the efficacy of the technique. (Short Term Dynamic Therapy has been well researched. It works.) Neborsky said that his clients look good, even many years later and reiterated his rule: "Longer therapy is not better therapy." He talked about his "holding" coming from his spot-on interpretations. And that clients love him and love the work.

Neborsky’s ideas about good therapy:

• Strong alliance
• Help clients confront what they avoid
• Revive Hope
• Create a sense of mastery over Past, Present, and Future
• The patient owns the therapy.
• The therapist is a biofeedback loop, and helps the client recognize, feel and structure his anxiety.

Therapy doesn’t work when there’s

• Too much talking and not enough feeling
• Too much defensive feeling and not enough thinking
• A failure to help the client regulate anxiety
• A failure to generate anxiety
• A collusion with the client’s defense.
• Giving too much (over-involvement)
• Giving too little (under involvement)

The most fun question of the panel discussion: A man described how Pat Ogden was able to express her dismay over her video breaking down, take care of the audience, take care of herself, switch to another hard drive and seamlessly use an unedited video for the presentation. He asked Pat how she handled the situation with such grace, then asked Dan Siegel how Pat handled the situation with such grace. Siegel’s answer: "Mindfulness."

More "Healing Trauma"

Our book group has just finished Solomon & Siegel's Healing Trauma: attachment, mind, body, and brain. It is one of the most difficult books I've read, and quite rewarding. The first four chapters by Dan Siegel, Hesse/Main et. al, Allan Schore and Bessel van der Kolk speak to research about the interactive nature of attachment/brain growth, and the necessity for those interactions for we humans to learn to regulate affect, connect to others, grow empathy, and more. We just finished the last four chapters, which describe four different approaches to therapeutically moving the "small-t" traumas that created the disordered attachment. See January 14 & 28 posts for more detail.

Francine Shapiro writes about EMDR and its Adaptive Information Processing Model. She is the founder/discoverer of EMDR. Her rigor in pursuing research and holding EMDR therapists to researched interventions has given EMDR iron-clad credentials in the therapy world including acceptance by the APA, DOD, VA, and many other credentialling bodies and insurance companies. In her chapter Shapiro describes how EMDR works: "The goal of EMDR therapy is to forge new connections between the unprocessed memory  and more adaptive information that is contained in other memory networks." (p. 199) and ". . . EMDR catalyzes a learning process and metabolizes the experiential contributors to clinical problems. (206) She presents a case of a "large t" trauma, resulting in Post Traumatic Stress Disorder, in an earthquake survivor, and the trauma's ties to childhood themes of lack of safety and chaos. Then she tells of an amazing case, a 14-year-old guy with a "classic attachment disorder" who avoided eye contact, touch, and social contact. "EMDR was used to target the anger he felt toward his parents. During the session, he remembered. . . being dropped off at a day care center at 3 years old. There, he became terrified that his parents were never coming back. The experience of that day was locked into his system, and he kept people at a distance. Processing was rapid because Todd had a loving home and many other positive expereriences in multiple memory networks. As the negative experience was integrated, associative links were made to these other memories, and Todd became a loving and affectionate child." (210) If Todd had been neglected and abused for years, treatment would have taken much longer. After 13 years of practicing EMDR, I've cleared hundreds of attachment-related injuries in clients. I've seen people lose their "Axis II" diagnoses, and become able to connect, self-regulate, have boundaries, and come to positive affect (happiness), when they didn't have it before.

Diane Fosha's chapter is "Dyadic Regulation and Experiential Work with Emotion and Relatedness in Trauma and Disorganized Attachment". Fosha, a scary-good clinician developed accelerated experiential-dynamic psychotherapy (AEDP) marrying attachment/relational sensibility/techniques to Davanloo's short-term dynamic psychotherapy. AEDP includes intentional use of the therapist and the therapist's affect to move the client along, direct attack on defenses, and absolute containment at all times. I'll talk about it more next month, when our group reads Fosha's book, The Transforming Power of Affect. Let me give you the headings in her case example: Setting Up the Focus of the Work; Identification and Clarification of Defenses Against Affective Experience; Experiential Work to Deepen the Visceral Experience of the Categroical Emotion of Anger: The Emergence of Fear; The Breakthrough of Fear; Corrective Experience: Affirming the Patient and Taking Off the Pressure. (That's one session!) In the next session: The Subsiding of the the Fear, the Operation of the Reflective Self Function, and Accessing of Emotional Resources; The Undoing of Dissociation: Adaptive Access to Anger; then Outcome. So Fosha helps clients go from Defense to Core Affect to Core State, masterfully. More next monthabout her.

Robert Neborsky's chapter is A Clinical Model for the Comprehensive Treatment of Trauma Using an Affect Experiencing-Attachment Approach. He speaks of the difference between a recently traumatized person with good attachment, (distressed, but metabolizes the experience and moves on) and a person with poor attachment, in whom old defenses and old emotions are activated, and not regulated nor cleared. Neborsky, another student of Davaloo's, states that short-term dynamic therapists believe that "the patient must experience his or her genuine feelings from the past in the present." (292) He adds his own component that "a patient leaves the intitial interview with a coherent narrative of the origin of his or her psychopathology." (293) He explains the STDP model, his additions and presents an edited transcript of 6 hours of therapy with insecure attachment. His full-bore attack on the client's defenses was amazing, as was the connectedness he kept, throughout.

After reading Fosha's and Neborsky's chapters, I noticed that I was confronting my (non-DID) clients' dissociative responses more directly and more clearly ferreting out the affect that underlied the dissociation. It worked wonderfully with four different people. (I wish I could say more on a public blog!) I noticed that Fosha and Neborsky get to the same place as EMDR does with their therapies. They go for the cognitions, the affect, the body feeling, and make people talk about it. I think that the "dual attention" in their work is the therapeutic relationship. EMDR ought to take place in the context of a good therapy relationship. It works better if it does. And I know a few people, intense relational holders, who sometimes drop the bilateral stimulation, they can "fosha" a client with their connection, and lead them through to what Francine Shapiro calls : "The basic goal of treatment, to acheive the most comprehensive effects possible, in the shortest period of time, while maintaining stability, within a balanced system. This goal is achieved when the distressing memories are processed and integrated withing adaptive memory networks, and when all past, present, and future aspects are addressed." (202) It's nice that there are many paths to the river, all using affect, connectedness, and here-and-now orientation to get there.

EMDR with Attachment

Here's a session I do with 7/8 of the clients who walk in the door. You are a baby in your mother's arms. Look up into her face. What do you see? With whatever they say (her disappointment, anger, depression, adoration), I have them process it. If it's adoration or love, I ask them where in their body they respond to it and what the feeling is, and then do some kind of bilateral stimulation, and install it. If it's disappointment, or "she's spacing out", or "she doesn't want me," I set up the Standard Protocol: What does that say about you? What would you rather believe? What feeling? Where? and off we go. It is often the core injury of the attachment issue. It often clears in that first session, resetting much of the client's self-beliefs. Nearly every client can do it. I'm not asking them to remember (very few of us remember anything about being a baby.) I'm asking them to imagine it, and then targetting the subsequent affect. Maureen Kitchur in EMDR Solutions says that's you can't always get a good cognition from an early target. She says, that if you can't get the negative and positive cognitions you should skip it, do the processing, then say Now that you've cleared that, what would you like to know about yourself now and for the rest of your life.

"Attachment Injuries"

My favorite concept of this 2-day part of Yolanda von Hockauf's Emotionally Focused Couples Therapy training is "Attachment Injury". Yolanda says that these injuries are "characterized by an abandonment or violation of trust" when one partner is very vulnerable (really sick or otherwise emotionally devastated) and the other partner is inaccessible or unresponsive. The "injured partner experiences a very high level of distress, followed by and existential decision point, such as, 'I'll never count on you again.'" The event and each partners' responses change everything, the bond is changed, their belief about the relationship is changed. To see the abstract of the article, click here. I couldn't find the whole article online. If you do, let me know!

While Yolanda took us through Sue Johnson's steps for working through the Attachment Injury, I thought of clients, friends, and literary examples. How many times have you heard the stories of the husband out getting laid or drunk, while the wife gave birth in the hospital?  The borderline client who takes her partner's every failure to contain her, as such an injury? Some affairs? The "last straw": ". . . and that's when I realized that I was done." First it's hot. Then it's deathly cold. Then it's over, spatially, or just emotionally.

I'm glad to have a name and search pattern for the concept. I can think back to many couples, now divorced or otherwise split, that might still be together, securely attached, if someone had had the tools to lead them through the injury, and back to connection.

"Dehunkering"

I've been using a new diagnostic category, though I haven't seen it in the DSM-IV-R: Hunkered-downedness. Hunkered-down clients are a few inches shorter than their natural heights. They often look younger than their natural age. They can be appeasing. They can be hyper-vigilant. On the other hand, they can be somewhat dissociated. All of them have been a little depressed, some more than others. Their complaints may include procrastination, inability to make decisions, and general confusion. They have all been nice people, easy to be around. They are rarely assertive.

I do an intake with a genogram, paying special attention to attachment issues. All of these people had rigid or highly critical moms. When I explain, often at the end of the first session, that due to the history and current issues and presentation of the client that he or she has the "hunkered-down" diagnosis, they usually relax and agree. One person said, "You see me."

What to do? I usually ask them to think of a current interpersonal situation in which they are in this state, and then "float back" to the earliest time they ever felt that way. It's usually sometime between 2 and 4 years old. It's Mom, saying, "I'm ashamed of you." or "Stop it!" or similar words. The feeling is caved in, shame, inhibition. The cognitions are about being unworthy or unlovable or damaged goods.  If they can't remember, I'll guide them: imagine that you're 2 years old. You're exuberently dumping clothes out of drawer or banging pots. Mom shows up. Look at her face. Hear her voice. That gets them right there.

I use a combination of EMDR clearing with some Brainspotting thrown in, to clear the event. I've done up to six sessions on this event, alone, before it clears. During the last session of processing the "hunker", I watch the client's body change. The neck becomes vertical, instead of horizontal. The shoulders come back while the chest sticks out. The chin comes forward. Today I saw a man stop looking like a boy. In a way, it was like the incredible Hulk, coming out of a little man's body, except it was an incredible man. He felt it. I saw it. We install: I'm worthy, I'm lovable, I'm acceptable.

Then we finish the processing, by doing a body scan, and noticing the difference in this body. Then come back to a current "hunkering" kind of situation, and use the future template: dealing with the situation with the new body and new brain.

The next time, the clients come back and brag about their weeks. They're different in many spheres: assertiveness, stick-to-it-iveness, decision-making. It's very cool work.

Healing Trauma, reading group report

The reading group had its first meeting. We discussed the first four chapters of Healing Trauma: attachment,mind, body, and brain edited by Marion Solomon and Daniel Siegel.(W.W. Norton & Co. 2003) It's a difficult book. Several chapters speak about brain physiology. Several are in "academic speak" in which all sentences must have at least 10 clauses and must be in passive voice. And the content has necessary (though not perfectly written) bases for understanding what is happening in the minds and brains of poorly attached and/or traumatized people and what to do with them.

Dan Siegel's first chapter is An Interpersonal Neurobiology of Psychotherapy: The Developing Mind and the Resolution of Trauma. Siegel uses complexity theory to define Mental Health as the maximal complexity that the brain and mind can have: maximally stable, adaptive, and flexible. Not too rigid, not too chaotic. Some of his main points are that

• Experience changes brain structure. A connecting, congruent, responsive parent allows a baby to develop the hardware for self-regulation (including affect tolerance), meaning, and communication on overlapping circuits. Other kinds of parents can get kids to develop blind spots, dissociative responses, or chaotic or ultra-rigid circuitry.
• Communication inside an attachment relationship is the main experience that regulates and organizes and develps the circuits of the brain that mediate self-regulation and social relatedness. . .We connect by sharing emotional states.
• Therapy works by letting the therapist be an attachment figure in an interactive relationship the enables the coregulation of internal states. Later the clients (like growing children) can regulate their own emotional states.
• (p.38) To create a secure attachment you need 1. Contingent (responsive/understanding) communication 2. Reflective dialog on the contensts of mind (feelings, thoughts, memories, beliefs, etc.) 3. Repair (when there's a rift or miscommunication, it's acknowledged and the parties make attempts to move forward and reconnect.) 4. Emotional communication that creates an experience of empathy and compassion (positive emotions are amplified, negative ones are soothed) 5. Coherent narratives (when we can speak about something with coherence while feeling, but not being overwhelmed or shut down by emotion, we're doing o.k. with it.
• Coherent narratives. See above. An incoherent narrative about childhood events (even in an otherwise articulate parent) predicts disorganized attachment in the person's children. I've known about this work for years, it's explained in detail in this chapter and in the next.
• Clinical applications. (p.45) "Patient should be given the sense of safety in which traumatic states are re-experienced, communicated and altered in more adaptive patterns" resulting in better integration of information and energy flow. (p. 47) "Effective therapy is an emotionally engaging and transformative experience that enables . . .integration to occur. He says in bigger words that the normal human emotional response is therapeutic. Staying sane and staying connected to your clients while they work through hard experiences is good therapy.

There was much more in that chapter. It made me think of Dan Siegel's comment, at the 2004 Attachment Conference. He'd been asked, in front of a thousand of us, what he thought about EMDR. He said that EMDR was a bilateral brain therapy, but not because of the hand waving or other bilateral stimulus. When we set up the protocol, we first stimulate the amygdala and hippocampus, by bringing up the trauma. Then we connect in the left frontal brain, by asking about cognitions, go into the right brain to bring in awareness of feelings, hop to the left brain to name the feelings then back to the right brain to bring up the body map, then to the left brain again to name the place.       

One more Siegel thing. He wrote a lovely book, with Mary Hartzell, for parents: Parenting from the Inside Out. It explains his brain integration ideas, almost in English, and gives clear instructions in using what is known about attachment to do better parenting. (And better psychotherapy, too.)

Eric Hesse, Mary Main, Kelley Yost Abrams, and Anne Rifkin cowrote Unresolved States Regarding Loss or Abuse Can Have "Second Generation" Effects: Disorganization, Role Inversion, and Frightening Ideation in the Offspring of Traumatized, Non-Maltreating Parents. A title and a synopsis all in one! If you can't figure out why your client, who has pretty nice parents, turned is so dissociative, borderline, full of scary thoughts/anxieties, or incredibly codependent, look to their parent's histories. If a parent had unresolved grief or trauma that leaked out in little dissociative lapses or sad/scared looks when nothing particularly sad or scary was going on, the kids could have learned to space out, take care of the parent, or become unable to self-regulate. They have a good description of disorganized attachment (beyond the scope of this article!) and how the kids got that way. They back it up with concrete research. It explains a lot of the people I see. They don't say much about clinical implications. Here are my suggestions for any poorly attached clients:

  Building Attachment Functions

a.      Sit close.

b.      Mirror affect and attention.

i.         Tone

ii.       Intensity

iii.      Backing off, when they do

iv.     Engaging when they do.

c.      Model positive affect: excitement, humor, happiness

d.      Create opportunities of intersubjectivity: knowing that you are in synch, experiencing the same feeling at the same time.

e.      Be a constant object. Be consistent, session-to-session in limits, attention, etc.

f.        Let yourself feel your client inside of you—experience their somatic experience.

g.      Use resource installation (RI) of any past experience of attachment, feeling connected, cared for, loved, and/or understood.

Utilization language Kitchur (99/00)—from M.Erickson:  Use the clients’ metaphors, belief systems, and experience when explaining, encouraging, etc. 

I'll write more later.

Disorganized Attachment

I'm reading Healing Trauma: attachment, mind, body, and brain (2003,Solomon & Siegel, W.W. Norton & Company) It's a dense compilation of deep articles. The title of the chapter I just read completely describes the 50 page article: "Unresolved States Regarding Loss or Abuse Can have 'Second Generation' Effects: Disorganization, Role Inversion, and Frightening Ideation in the Offspring of Traumatized, Non-Maltreating Parents", by Erik Hesse, Mary Main, Kelley Yost Abrams, and Anne Rifkin. The point is that reasonably good, reasonably responsive, non-abusive parents can create disorganized attachment/dissociation in their kids, by scaring them when the parents 1. Space out in the midst of an interaction 2. Act scared of their kids (not in play) 3. Act scarily toward their kids (not in play and for no apparent reason) 4. Act scared for no apparent reason.

They didn't discuss the treatment implications. Upon completing the chapter, I immediately thought of the work of Maureen Kitchur, April Steele . Both are EMDR therapists (Maureen in Calgary, April on an island off Vancouver Island,  both have developed ways to work with adults who have very early trauma. Maureen Kitcur might have a client focus on a the idea of gazing into her mother's eyes, as an infant. She'll ask the client to notice body sensations and emotions, then will clear any distress with EMDR. Kitchur developed the Strategic Developmental Model for EMDR, which includes working with "develpmentally impactful" material from a client's life. In some circles, her name has become a verb. I "kitchur" most of my clients, using her intake of "nosy, snoopy questions" to fill in develpmental and traumatic information, then "clearing off" the traumas in developmental order. I developed some of my cultural and generational trauma protocols as offshoots of Kitchur's work. I'll target things that happened to people's great-grandparents, years before the clients' births: "Think about the pogroms your family experienced in Russia. What do you notice in your body, now? What emotion goes with that feeling? Go with that."  I've seen some anxiety disorders disappear when the generational traum goes away.

April Steele has developed Imaginal Nurturing, guided work that helps clients recieve internal attachment experiences, for their infant and toddler selves. She sells CD's and a manual of the work (including solid, understandable information on attachment theory) on her website. I use a combination of Kitchur's work (clearing the attachment-related trauma) and Steele's work (putting in what clients didn't get the first time.)  on most of my attachment-impaired clients, to good avail.

Using straight EMDR, I've targetted people's fear of their children (when the parents acted like appeasing kids around their little ones) and aggression towards their children. The processing always goes back to their own childhoods, sometimes to their own infancies. Not a big surprise.

It's validating reading the painstaking research about "Unresolved States". It shows that my teachers, Kitchur and Steele, have been barking up the right trees, and so have I. It also shows that the parenting books and the teachers of basic therapy  frameworks were right: consistency is important. Presence is important. Self-awareness is key. If you're going to be a parent, or a therapist, for that matter: Show up, be consistent, and don't let your own unresolved stuff roll over your kids or your clients.

UCLA Conference

If you are interested in learning about the science and practice of psychotherapy with some of the best minds in those disciplines check out The Healing Power of Emotion: Integrating Relationships, Body, and Mind. It's on the UCLA March 9 (the pre-conference day) and March 10-11 (the conference). Marion Solomon puts these on through the Lifespan Learning Center. This year's luminaries include Diana Fosha, John Gottman, Daniel Hughes, Sue Johnson, Bob Neborsky, Pat Ogden, Jaak Pensepp, Stephen Porges & Dan Siegel.

You don't have to choose whom to see. The entire conference happens in one big room with one big stage. The great minds listen to each other. At the end of each day, they gather on stage and talk about what was said. It's especially fun when they disagree.

My work changes everytime I go. I get new eyes with which to look at my clients and understand about what is happening in their brains and bodies and how best to respond. I'm a better therapist, consultant, and teacher for it. I'm going to all three days this year. If you're going, send in your money, soon. Sometimes it sells out. If you go, wear layers to take off. The lecture hall gets pretty warm with 1000 therapists in it.

Matching

At Thanksgiving, I connected with Julie, my favorite 6-year-old. Julie was born intense: easily aroused, prone to shrieking hysterics and hard to calm. Julie has a much more than "good enough" mom, a proponent of the family bed, nursing until the children weaned themselves, and extremely responsive. Her three older children, 23, 21, and 8 years-old are self-soothing, age-appropriately independent, and show great attachment in every way. Julie does not have the self-soothing thing down. Her mom tries to reason with her. The more calm Mom gets, the more hysterical Vivian gets, in about three different rounds.

Ed Tronick at the 2003 UCLA and LIfespan Learning Institute's annual attachment and psychotherapy conference, showed us videos of babies and their moms. When the babies screeched, if the moms were calm, the babies screeched louder, becoming almost psychotic-looking. If the moms matched the babies in tone and intensity, saying things like, "You're so mad right now." Or using no words, but matching the babies' voice, the babies calmed right down. If mom had a blank face, the babies completely freaked, escalated more, then in a few minutes seemed to dissociate.

When I returned from L.A., I tried this technique on other people's babies (I have no kids), distressed clients, and my husband. I taught it to couples, especially the partners of attachment-impaired clients. It worked! One client of mine, who went into instant rages, and continually escalated, would calm in less than a minute when adequately matched. My husband, Doug, used it on a screaming baby on the airplane. The mom thanked him, while he explained the technique. I use it with positive affect, too. I've gotten absolutely gushy in matching my clients' enthusiasm. I'm building their tolerance for feeling good.

Back to Julie. I told her mom about the research. Twenty minutes later, Julie ran into the kitchen screaming. Mom responded in the same tone and tune, "That really upset you. It's not fair!"  Vivian calmed instantly. The next time, when the screaming was of an incredibly high pitch, the mom said she didn't want to match that. Later, however, the matching technique was used and worked.

According to Tronick, in mom-kid and therapist-client relationships (when they're working) "each individual attempts to adjust their behavior to maintain a coordinated dyadic state or to repair a mismatch." (Tronick & Cohn, Infant-mother face-to-face interaction: Age and gender differences in coordination and occurrence of miscoordination. Child Development, 60, 85-92) Our Vivian doesn't seem to have the right brain hardware of many her age mates. Her mother's exact matching, according to folks like Schore and Siegel, will help her build that hardware. I predict, based on the research, that each time Julie''s mom matches her, Julie's going to grow some right brain neural networks that allow her to self soothe the way her siblings have been able to. I predict a happier mom, too.