Trauma & Attachment Therapy

Problems with Dear Evan Hansen

Last night, I saw Dear Evan Hansen, the musical about an anxious, shame-filled high school senior. The play deals with broken families, suicide, OCD, social anxiety, and attachment. The music and the singing in this touring production was fantastic. I cried several times, and laughed a few. Still I was distressed with some serious problems:

1. The "therapy", for the boy, which we never saw, was Evan writing a letter to himself, each morning, about how good his day would be. Ineffective CBT, with no dealing with his evident attachment issues (abandoned by dad at 7, and with a completely unavailable (time-wise and attention-wise) mom, nor his obvious social anxiety, PTSD, and OCD.
2. The suicide of a main character, the son of another family, was never fully characterized. We know he used drugs and avoided school, was shame-filled and narcissistically violent, in an attempt to protect from that shame. But we didn't know much else about him.
3. A main character, Jared, was an obviously Jewish stereotype that made me cringe: loud, manipulative, whiny, and somewhat sociopathic. Even though the man who wrote the "book" of the play, is probably Jewish (Levenson), it felt very anti-semetic to me.
4. Evan's own suicide attempt is hinted at, throughout, but never really explained. And he never gets real help. This could have been a great way to show a kid talking to a crisis-line, or in a group, or otherwise getting good care. A lot of teenagers see this musical, and it could have been a great way to show what's available. There were texts, emails, Facebook, and instagram posts in the background of the set, throughout. I wish they would have had Evan or others interacting with https://www.crisistextline.org/ as a way to show where help is available. 
5. There's a homophobic setup at one time. I wish it wasn't there.

Research: CBT FAIL!

Huge study in Sweden finds that CBT often doesn't work on anxiety and depression and can make the problems much worse: 

REVOLUTION IN SWEDISH MENTAL HEALTH PRACTICE: THE COGNITIVE BEHAVIORAL THERAPY MONOPOLY GIVES WAY

Please don't flame me, I'm just reporting the study.

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.

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!

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

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

Here are nearly random gems from 3 hours of notes:

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

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

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

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

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

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

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

Developmental Trauma Disorder

A. Exposure

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

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

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

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

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

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

baseline; not reduced in intensity by conscious awareness.

•Affective

•Somatic (physiological, motoric, medical)

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

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

depersonalization).

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

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

C. Persistently Altered Attributions and Expectancies

•Negative self-attribution

•Distrust protective caretaker

•Loss of expectancy of protection by others

•Loss of trust in social agencies to protect

•Lack of recourse to social justice/retribution

•Inevitability of future victimization

15

D. Functional Impairment

•Educational

•Family

•Peer

•Legal

•Vocational

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Small t traumas cause more pathologies than PTSD.

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

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

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

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

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

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

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

EMDR increases resilency and engenders a new sense of self.

 

 

"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.

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

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

Counting the Walking Wounded

By LAWRENCE M. WEIN in the New York Times

Published: January 25, 2009

Stanford, Calif.

Related

Times Topics: Veterans and Post Traumatic Stress Disorder

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

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

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

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

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

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

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

 

 

Principles of Trauma Therapy, Briere & Scott

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

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

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

KENSPORTAL.COM

Check out this great therapy resource. It has forms, great links, directories, and information about client populations. If you do therapy, you'll find something useful on it. I met Ken Eisenberger a few weeks ago at a workshop and he turned me onto his helpful, free website. Check it out at

http://www.hiddenhillcounseling.com/kensportal/

Procrastination

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

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

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

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

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

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

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

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

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

 

 

 

Depression for Dummies

I'm writing several chapters about depression for the new book, and have been doing an informal survey of books about treating depression. Depression for Dummies (Smith & Elliott, Wiley Publishing, 2003) and How to Heal Depression (Bloomfield & McWilliams, Prelude Press, 1996) are consumer-friendly, step-by-step books for depressed people. They both give bulleted lists of symptoms, medications, and treatment possibilities. Both normalize depression and concurrent bad thoughts. Both are enamoured of CBT, above all and give a nod to "relationship therapy". Both give advice about changing thoughts to change your life. Both endorse exercise and eating well.

Depression for Dummies has at least twice as much information, and is more up to date. It follows the user-friendly "Dummies" format. It's packed with data and exercises. It has pages and pages of ways to talk yourself into action: out of bed; into exercise; out of the house; out of a bad mood, and into therapy. It endorses Cognitive Behavior Therapy (CBT), Behavior Therapy, and Relationship Therapy. According to Smith & Elliott, nothing else works for depression. (Insert sigh here.) Of course, Bessel van der Kolk's 2005 study wasn't out  (published in 2007). In that study 8 EMDR sessions beat out months of Prozac in almost every way, especially in longevity of treatment effects. (EMDR group kept getting better and better, months after treatment. When the Prozac people stopped taking the meds, they went back to very near their original baseline in nearly every measure. I hear that Lilly defunded the study, when they learned the results, but Bessel published it anyway.)

D for Ds mentions trauma as a cause for depression, but gives no good explanation of how it affects the brain and how to change that. It talks about relationship, some, but misses how poor attachment can fail to build the capacity for positive affect in people. And when I thought of my most horribly depressed people, I thought the book might overwhelm them with homework before they barely got into it. (It does say, "Go to therapy if this exercise is overwhelming." or words to that effect.)

I liked the book for what it is and was sorry that it adhered so religiously to CBT. I use CBT with depression. But my thinking about depression starts directly in the body and in attachment. I think about Porges' Polyvagal theory and how we reflexively shut down and how social engagement shifts that shut down. I use EMDR to clear affect about depression (guilt, shame, hopelessness), trauma that triggers it, and to practice all the good CBT, exercise, taking meds/supplements, and socializing behavior that all the books talk about. I use resource installation to help "rebody" people of a time they weren't depressed, and install the heck out of that. I also use EMDR with my "hunkered down folks", by clearing out the poor attachment experiences and bringing in the adult self to connect with with people. Expect chapters on all these topics in at about 18 months. In the mean time, have a great '08!