Trauma & Attachment Therapy

New blog and a new book

I've got a fancy new website at emdrsolutions.com. All of my old blog posts and all the new ones will be there. The full address is https://www.emdrsolutions.com/ It's easy to read and easy to use. I look forward to seeing you there! And Doing Psychotherapy came out last week. It's the newest book and it's full of everything I wished they would have taught me in graduate school: 1. How to stop and and how to end a session, or a therapy. 2. How to make goals, and meet them. 3. How to work with anxiety, trauma, depression, and many other problems. 4. How to take care of yourself. 5. How to deal with marginalized populations, abuse survivors, and more. 6.How to pick which, of many therapies to use with a client. 7. Even a bit of how to argue with insurance companies. https://professionalbooks.cmail20.com/t/ViewEmail/y/B3BB66A7B9693018/9DB5899D0880DA9CEBAD456BEB5F1DD6

My History with Ego State Therapy

I wrote this as a prologue to the Greek version of Easy Ego State Interventions and realized that it will make a good post:

I have been looking through the lenses of ego state therapies since 1981. During that year, my first out of graduate school, I took a course in Eric Berne’s Transactional Analysis and learned to identify the “Parent”, “Child”, and “Adult” parts of myself and my clients. It was useful to notice when I, and other people, were coming from our kid states, our introjected parent states, or our chosen, skilled, present-oriented part of self.

In the same year, I read and took classes in various hypnotic techniques, and learned my most used ego state intervention: “Go inside, and find that part of you that (1) having that feeling/ (2) having that belief and/or (3) can tell you when in your life that belief/feeling started.”

My consultant, Thom Negri, gave our group the experience of finding our own inner children, and promising to care for and protect them.  I’ve used this intervention with nearly every client, and learned new twists from April Steele and others, which I continue to use.

Before I learned EMDR, in 1993, ego state therapy was my best tool for healing trauma. I would direct clients to compare their present-day safe selves with their past stuck-in-danger selves, and to rescue the endangered younger selves. After I learned EMDR, I continued to interweave ego state interventions with the new therapy. I, and many others, found that the more dissociation a client had, the more necessary ego state interventions were for both preparation and interventions. With some unstable clients, straight-forward ego state interventions are still the treatment of choice.

In 1988, I started working with my first client with dissociative identity disorder (DID). She had been ritually abused and had at least thirty parts, many of which had no awareness of each other, or the present day. I read every book, took every local training, and started spending more on clinical consultation than I ever collected from that client. Learning how to work with her dissociation informed my ego state work with everyone else. I began to see the “parts” in borderline personality disorder and other attachment-challenged clients. I became more adept at getting all clients to talk to their parts. And, of course, I learned just how brilliantly complicated work with a DID client could be.

In 2006, when van der Hart, Nijenhuis, and Steele’s The Haunted Self, was published, I got a lovely roadmap for perceiving and healing trauma and dissociation. A more accessible book, Treating Trauma-Related Dissociation, by Steele, Boon, and van der Hart, came out in 2017, and is now the bible for working with DID clients.

I’m grateful to be providing this work to therapists in Greece. Ego state therapy can be of use to nearly every client. Seeing and treating people through the “parts” lens is often transformational. Intractable problems can melt away when therapists see the stuck child parts in the dysfunctional adult. I hope you find this work as useful as I have.

Easy Ego State Intervention Workshops

Dear Readers,

Ego state work has been around since before Freud, and in latter years, has been the main stay of many practices. Interventions can range from "How old did you feel when you were yelling at your wife?" to "Let's identify those dissociative states that take over your body." I've been working with this stuff since I became a therapist, 38 years ago, and have read, been taught, taught, and written about it, extensively. It's one of the most versatile tools and lenses through which to see clients that I have.

In January, I expanded my 2-day Ego State training to 3 days and presented it in near London, England. there was time for practice, demonstrations, and some case consultations. Participants raved about the workshop, saying things like "I know MY parts now!" "I know exactly what to do with many of my clients!" "This is the most practical workshop I've taken!" There is special info for EMDR practitioners, but you don't have to know EMDR to take the workshop and get credit. EMDR practitioners get 12 hours for EMDRIA and 12 for their profession. Others get it for their profession.

I'm  giving it several times this year. 

• 4 days in Milan,Italy.  May 10 -13 https://www.international-isc.com/wp-content/uploads/2017/12/brochure-shapiro-ing.pdf
• 3 days in Seattle, WA, June 8 - 10 https://www.eventbrite.com/e/easy-ego-state-interventions-seattle-tickets-44375863402  
• 2 days in Des Moines, Iowa October 20 and 21st, link to follow
• 3 days in Boston November 9-11, link to follow

Here is what I cover:

• Distinguishing Healthy/Flexible and Dissociative Ego States (and map your own)
• Overview of Ego State Interventions
• Identify Vagal States
• Use Embodied Ego State Interventions (includes practice)
• Clearing Trauma (includes practice)
• Theory of Structural Dissociation
• For EMDR practitioners, distinguish when EMDR, when EMDR and when both are the treatments of choice
• Tools to work with sexual abuse, and then bring back healthy current sexuality
• Work with Attachment Issues, including April Steele’s Building a Secure Self (practice)
• Couples Therapy
• Calming Over-Active Immune Systems, Multiple-Chemical Sensitivity (possible demo, if someone has one)
• Pain Protocol
• Shame (practice)
• Suicidal clients
• Resourcing (including installing your own “team”)
• Healing Personality Disorders
• Working with Dissociative Identity Disorder

If you can't get to a workshop, you might read Easy Ego State Interventions or sign up for one of the many good trainings on this subject. It's good stuff to know!

Three Articles for Introverts

These articles refute the myths that introverts are anti-social, shy, and wimpy. My resident introvert husband endorses both of them.

Carl King's review of The Introvert Advantage (How To Thrive in an Extrovert World), by Marti Laney, Psy.D. called 10 Myths about Introverts.

A funnier, snide 2003 Atlantic Article by Johnathon Rauch called Caring For Your Introvert.

There's a long 2010 Psychology Today article by Laurie Helgoe, Revenge of the Introverts, that has been endorsed by many clients, who linger in the waiting room after sessions to finish it. 

Read at least one of these. It's useful to understand the temperaments of your clients, so that they can understand and accept who they are. There's a lot of overlap between introverted people and Elaine Aron's Highly Sensitive People, and those whom I call "skinny, nervous, people". I see every client through the lenses of temperament, attachment, trauma history, gender, class, and culture. We need to take all aspects of our clients into account, in order to fully see them, and treat them skillfully.

Psychiatric Diagnoses: The Epidemic of Mental Illness

The New York Review of Books carried and a scathing and mostly right-on article about the medicalization and over-medication of mental illness by Marcia Angell. It's a review of three books about the history of psych meds, the power of the drug companies, and the minimization of psychotherapy. Read it here.

Another Nice Review for Trauma Treatments Handbook

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

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.

Why We Do Trauma Therapy

Here is the last paragraph of the Introduction to Trauma Treatments Handbook, Protocols Across the Spectrum. You're seeing it before the publishers do. Before I send it in, do you have anything to add about why we do this work? I'll publish what you write, unless it's spam.

 

As trauma therapists, we are privileged to use all of our selves to help people heal from deep wounds. We connect deeply, from the heart, all day long. We use our detective brains to puzzle out what is happening with our clients and what do about it. We enjoy helping the grateful single-trauma survivors get quickly back to their lives. We dig deep into our skills while slowly and carefully helping our most dissociative clients into their new, healed selves. We continually learn new skills from the innovators in our field and in innovative collaboration with our clients. We hang out with colleagues who love their work and support ours. Throughout each therapy we are delighted to hear, “I finally know it’s over!” “I feel like ‘me’ again!” “It wasn’t my fault, I was a little kid when that happened.” “I’ve got my body back!” “I can have sex again.” “I didn’t have one nightmare all week!” “Thank you for letting me get completely here and now!” “I’ve got my life back!”

 

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!

Bainbridge Book-Signing Party

Book Signing Party!

On Beautiful Bainbridge Island

June 14, 2-5PM

 

Sandra Paulsen, Ph.D & Robin Shapiro, MSW, LCSW will be there to sign and read excerpts of their 2009 books. We may have a special guest reader, Yaak Panksepp.
Bring your checkbook if you want to buy a book. Save shipping costs!

Location: 9054 Battle Point Dr. NE, Bainbridge, Island, WA 98110
At the log house in the woods of Sandra Paulsen, Ph. D and Tim Iistowanohpataakiiwa, MA. Weather permitting, there will be a campfire in the pasture with the horses.

From Seattle: Take the Bainbridge Ferry to wy 305, turn left at the third light--Sportsman's Road--and an immediate right on New Brooklyn. The next light is Miller Road, turn right, go two blocks, then left on Battle Point Drive. Follow the S curve to the very top of the hill. Turn tight at the big cedar mailbox at 9065 Battle Point Dr., and veer right at the fork in the driveway. If you pass Bainbridge Gardens on the left you have gone too far.

From Poulsbo: Take Hwy 305 across Agate Pass Bridge to the first light. Turn right on Miller Road and veer left. Go straight for several miles. Turn right just past Bainbridge Gardens, onto Battle Point Drive. Follow the S curve to the very top of the hill. Turn tight at the big cedar mailbox at 9065 Battle Point Dr., and veer right at the fork in the driveway.

Presented by Sandra Paulsen, Ph. D. and the Bainbridge Institute for Integrative Psychology.

For more information:
206-855-1133
[email protected]
www.bainbridgepsychology.com

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

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

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

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

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

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

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

"The Post-Traumatic Stress Disorder Sourcebook"

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

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

Phantom Itching Cured With EMDR

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

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

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

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

Trauma and Temperment

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

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

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

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

Dear Readers,

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

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

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

Here is the some of the introduction of the book:

 

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

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

 

Unit I: TREATING Depression

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

 

UNIT II: TREATING EATING DISORDERS

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

 

UNIT III: PERFORMANCE, COACHING, AND POSITIVE PSYCHOLOGY

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

 

UNIT IV: Solutions for Complex Trauma

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

 

UNIT V: TREATING BODILY AND MEDICALLY-BASED TRAUMA

 

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

 

UNIT VI: MORE EMDR SOLUTIONS

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

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

 

Using Solutions II

 

 

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

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

Research considerations

 

 

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

 

Case histories

 

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

 

Chapter conventions

 

 

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

 

Attribution

 

 

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

 

REFERENCES

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

 

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

 

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

 

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

Why Book Editing Is Like Doing Psychotherapy

The Book has a title now: EMDR Solutions II, for Depression, Eating Disorders, Performance and More. It has a cover photograph, too. and the photo has a story. (Full disclosure--the photographer is my husband.) See it and read it at http://www.dougplummer.com/archives/ireland2/fall9.html

I'm in full-blown editing mode: going through each chapter, attaching a header, reformatting it, and reading for sense, structure, and grammar. All the writers are talented psychotherapists. Some of them are good writers. Some had lousy English teachers. In an attempt to solve the he/she dilemma, a few of my writers have turned "they" into a singular pronoun. "When I talk to a client, I tell them . . ."  Some, even without using "they" can't keep their subjects and verbs in agreement. Or the verb tense in agreement in one sentence. Some of the sentences are like puzzles. I work hard to understand what the writer means and to make it cogent and "correct". Mostly, I like the process. Sometimes, I whine about it.

Editing seems natural to me because, as a therapist, I listen intently to people. I notice tone, meaning, coherence of narrative, posture, breathing, and monitor my own human reaction to all of it. When I see a discrepancy between, for instance, affect and content, I might intervene. "What do you feel, inside, when you're talking about the bad thing?" Or "I notice you look kind of hunkered down while you're talking about something good that happened. What's going on?" Therapists, the good ones, anyway, sift through a pile of complex information every moment and help bring clarity to murky responses. Through questions and other techniques we help clients create coherent narratives, acknowledge and process affect, and build the neural networks that come only from human response. In the mean time, we see the clients through the eyes of our editors' brains.

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.

The Instinct To Heal

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

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

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

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

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

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

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.

"Dark, Bad Day . . .Go Away!"

Ana M. Gomez has written a lovely book for children or anyone about trauma and EMDR: Dark, Bad Day. . . Go Away! It's simple, and complete, and true. The drawings by Carlos Serrano Acosta are lovely and expressive. And it has a good and true happy ending. There's a "Note for Professionals" in the beginning about how to use the book in introducing EMDR to children. If you do EMDR with Children, buy this book. If you do EMDR with child parts, it could work, too. There are no kids in my practice, and I'm putting it in my waiting room for the adult clients to read. You can get it through EMDR-HAP's store: http://www.emdrhap.org/osCommerce/index.php  It's selling like hotcakes at this week's EMDRIA conference. I know. I saw it happen.

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.

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.