Trauma & Attachment Therapy

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.

Healing MCS and Graft vs. Host Disease

MULTIPLE CHEMICAL SENSITIVITY CASE

On Friday and Saturday I gave a workshop about combining EMDR and Ego State Therapy. At the workshop, I did a demonstration with an attendee who was 8 months out from a horrible allergic reaction to crab meat. Since then she's had daily hives, breathing issues, and has had a very limited vegan diet.  She reacted to meat and fish,wine, air-borne odors and chemicals, and substances she can't identify.  We used EMDR to clear the first huge horrible reaction from 8 months ago. Then I asked her to imagine the control room of her immune system in her brain, and asked her who was in there running it. "A big burly guy named Bruce." I told her to put on her CEO business suit and persona, march into that control room and tell him to Stand Down, aim the immune system only at bacteria and viruses and stop being so over-protective. She immediately started to feel better. We imagined that if "Bruce" began to over-perform that she could tell him to "Stand Down" again.

The next day, she told the group that she'd felt much better, had had to tell Bruce to calm it down about 4 times and that she was no longer reactive. She'd had a glass of wine for the first time in 8 months. Last night I saw her eat her first fish in months, with no reaction. And she was having none of her life-long allergy to cats, at least not to my cat.

GRAFT VS. HOST DISEASE

About 15 years ago, I invented the above protocol when my friend Elizabeth and I were practicing on each other at a training. Over a year ago Elizabeth contracted a horrible leukemia and spent months in the hospital awaiting a good match for a stem-cell transplant. Finally, the cells arrived from Europe and the transplant was done. Elizabeth then developed Graft vs. Host disease: the new cells attacked her body and started to kill her. (GVHD has a 50% mortality rate.) The doctors gave her steroids and other drugs to knock back the immune response, but they didn't stop it and Elizabeth got sicker and sicker. She called me to the hospital. In two sessions we used the same kind of ego-state work, with nearly continuous bilateral stimulation, that we had done years ago for her MCS.

I asked her to personify her new immune system--it was a scared little boy. "Too bad you don't know what to do with anxious kids," I said to the wonderful mom and amazing child therapist."I'm holding him and telling him he's safe, he's with me, and he doesn't have to attack anything."    After a while she reported he had calmed down.

Me: "Tell him you're going on a tour of the body and you'll show him what's safe and what he needs to protect you from."

And we went through the list of bodily organs and places, while he was safely held." Elizabeth was exhausted after about 30 minutes of processing. When I checked in with her a few days later she had more energy and she said the little boy was chasing butterflies in a field and much happier, and she was much better.

The next week, she called me again. The "attack" was more localized: just to her digestive tract. And there were many boys.When I got to the hospital, I had Elizabeth round up the boys and announced we would take them on a spelunking tour through the entire "cave" of the digestive system. I turned on the tappers, and we "led" the boys through the "cave" from the throat, through the esophagus, to the stomach and all the way through the twisty-turny intestines. I told Elizabeth "tell the boys that they may not attack the walls of the "cave", or the "good" bacteria bugs that were around. These bugs are needed to help digest the food. You can pet them and play with them, but not hurt them. However, the bad bugs, like e-coli and C-Diff, are fine. You can stomp those bugs to death and have fun doing it." She felt even better, though still tired.

After that she had rapid improvement, but got traumatized by one of the doctors. He had been off that floor for a few weeks. When he saw Elizabeth with color in her face, walking the halls with a bit of vigor he was shocked. "You're still here."

"Yes, but they're going to send me home in a few days." 

"No, but I mean, you're still here."

"What do you mean?"

"People don't survive what was happening to you."

When Elizabeth got out of the hospital, I did a home visit and we cleared her response to that distressing conversation.

She's been home for months and is exercising, driving, able to hold her granddaughter (she couldn't before with depressed immune system.) And the "boys" are behaving in their new body, just as they should.  When she's got more energy, we think we'll write a journal article about GVHD and our work with it.

(I wrote a chapter about Multiple Chemical Sensitivities in EMDR Solutions II: for Depression, etc.)

 

 

 

 

Roy Kiessling's Belief Schema Perspective for EMDR

Roy Kiessling, a prolific EMDR trainer and innovator, has come up with a great idea for EMDR. Instead of coming up with a different negative and positive cognition on the fly, right before processing, find the general negative belief or beliefs that underlie the client's life during the first stages of therapy. During the history-taking phase and the preparation phase, when there's no hurry, and you can delve deeply into the clients' perspectives and overarching schemas, you can find a sentence that brings tears to their eyes and sense of being truly understood to their hearts. When it's time to do some processing, you can say, "does 'I'll never get it right" (that core belief) still fit this situation?" Then go to the already configured positive belief and your off and running.

This weekend, during the training, every participant experienced a profound shift when they cleared the core belief/schema during processing. For some of us, the knowledge of the belief was sufficient to make some changes.  

If you're an EMDR professional, you may want to contact Roy and sign up for this training. He's also giving Basic EMDR trainings, that include this focus. If you don't do EMDR, you may want to organize a training in your town. You can find out more about Roy at http://www.emdrconsulting.com/

Why I love EMDR!

A friend of mine was home when her house was broken into last night. She got away, and the cops found the guy and arrested him. She posted the whole story on Facebook this morning. This afternoon, she posted this. I have her permission to repost. Please don't mention her name in the comments.

"Quite a day! I really appreciate everyone's support, it helps so much to feel cared for and connected. Got in a session of EMDR on this morning's incident, which was extremely helpful too. Both to discharge reaction and emotion that hadn't fully hit me yet because i was in "deal with it" mode, and to put the scary parts in context of the whole 'movie' along with "and i wasn't hurt and i'm ok and i handled it well enough, and it's over and extremely unlikely to happen again...". 

To top it off i get to go contra dance tonight. That's going to feel good! After EMDR i am feeling more like i could be ok with sleep tonight, and i would still welcome any prayers, holding in the light, thoughts and intentions for safety, that any of you would like to send my way for the next few nights. Thanks for your caring, friends! Wishing everyone a safe and comfortable evening."

I didn't do this session, but this is why I love EMDR!

Trauma is Curable: My letter to the NYTimes

When I read Mark Epstein's op-ed "The Trauma that Life Brings" in the 8/3/13 New York Times, I had to reply. Epstein, a psychiatrist said that trauma and grief are inevitable and that there's nothing to do about them but wait it out and suffer. I like that he was normalizing both, and I was horrified that he 1. Conflated grief with trauma; 2. said that there was no way to clear trauma; and 3. said both to the many people who see the Times as the "paper of record".

Letters to the Times can have no more than 150 words. To make the words count, I skipped issue #1. Luckily another letter writer picked it up. My letter is the second one in this link  Here's the letter, but you can hit the link to read the others:

"Mark Epstein’s essay does a grave disservice to trauma sufferers when he says people must live with trauma. There are many psychotherapies that heal trauma.

The most effective therapies for trauma that truly clear the shock, fear, flashbacks, bad dreams and emotions include eye movement desensitization and reprocessing, or E.M.D.R.; many somatic therapies, and Brainspotting.

In my work with grieving people, I first help them clear the trauma of the illness, accident or moment of finding out about the death. Then we target the grief. People still move through the grieving process but are no longer stuck in the past. When the grief resolves — and it does resolve — patients still miss the person who died but are no longer stuck in the moment of the death or in active, acute grief.

Trauma runs through everyone’s life. But unending suffering need not.

ROBIN SHAPIRO
Seattle, Aug. 4, 2013

 

The writer, a social worker, is the author of “The Trauma Treatment Handbook: Protocols Across the Spectrum.” "

Installing the Future

Dissociative people often lack coherent narratives of their pasts (Mary Main & Dan Siegel). I'm finding that they often lack coherent visions of their futures. Today I "installed the future" in a formerly dissociative client, who has given me permission to tell this story. 

When "Linda" was 6 weeks old, her mother became gravely ill and was hospitalized for several weeks. Linda was passed around to different relatives, none of them parents, until her mother returned home. After that Linda, was different, sometimes frantic, sometimes shut down. As a teenager, she was in and out of mental hospitals, overdosing on drugs, and acting out in big ways. Later she settled into a long-term relationship with some good earned attachment, became a respected professional and had two kids.  She came to me two years ago, functional, but prone to huge swings in mood, perspective, and ego states: DDNOS in presentation, possibly DID.  

After two years of intensive EMDR, Ego State Work, Brainspotting, and great therapeutic alliance, Linda, in her late 30's, is stable, adult, and integrated. A few months ago, after a violent death in her family, Linda had the normal reaction of fearing for her own mortality. In discussion, she revealed that she couldn't see her future. Her future felt like one second away, even thinking of herself as 90 years old, felt like a momentary blip. Her past, too, felt like a blip. Dissociation had stolen a coherent sense of time.

I stole a piece from Lifespan Integration (Peggy Pace), which leads kid parts up past years, year by year to the present. Instead of doing it in the past, I led Linda through the years from now until her 90's, including the changes in her body, her kids, her partner, her parents, her work life, her age-appropriate world view, and technology. In 20 minutes we visited developmental stages from now until old, old age, while I administered bilateral stimulation.

When we were done, she said something like, "Wow, that was great! You've given me the future. I feel much calmer. For the first time in my life I can imagine what it would be like. It's not just a blank, like my childhood. . . I feel safer and less afraid of dying, since I can imagine living. I know that anything could happen, but I had no alternative in my mind to something happening. Thanks!"

At the end of session, we agreed to go back and use Lifespan and the bilateral stimulation to bring coherence to her life, up until now.

Defining Rape and Sexual Assault

I've been working with survivors of rape and sexual assault since I started in the mental health field. Here are my definitions:

Rape: The sexual use, involving penile, digital (fingers) or objects on a woman's, man's or child's body without that person's consent, with forced consent (threats) or if that person cannot conset due to age, mental disability, state of drunkeness or druggedness, or relative social position to the rapist (employee, slave, patient, lower rank, parishoner, etc.)  

Rape can include penis in vagina, anus, or mouth, or forced masturbation. It can include objects. It can include rubbing genitals on a person with clothes in between. Women can, but rarely do, rape people by forcing them to touch or otherwise sexually interact. People of any age can be raped. People in an otherwise consensual sexual relationship can be raped, if they say "no" or are asleep or passed out, and their partner is sexual with them without their consent. 

Sexual Assault: Unsolicited, unwanted touching, grabbing, or other sexualized physical utilization of another person. All rape is sexual assault. Not all sexual assault is rape.

Molestation: See Sexual Assault. Often used when describing either the Sexual Assault or Rape of children. I wish this word would go away. I'd prefer "Child Rapist" to "Child Molester" since it's the true definition of what happened.

Effects of Rape and Sexual Assault: It depends on what happened, by whom, and to whom.

• Adults who are raped by strangers tend to experience full-blown Post Traumatic Stress Disorder. No matter the circumstance, they tend to feel dirty, culpable, and ashamed. It ruins, at least for a while, their healthy sex lives, their sense of safety and trust in the world, and their image of an autonomous, safe self. If the adults had a history of childhood sexual abuse, the new rape often brings forth the same feelings, ego states, and flashbacks of the earlier time. Sexual situations with beloved partners can bring up flashbacks of the rape. Men who are raped can have a sense of loss of maleness and a whole other level of loss of self.
• Children who are raped by strangers tend to experience all of the above including a pervasive sense of "badness", and without treatment may carry that sense of shame and fear of sexual situations to adulthood
• Date rape: Rape by someone in dating situation, when the victim has said no or cannot show consent, brings another layer of self-blame, lack of trust, questioning of "fault", and social complications. ("I shouldn't have worn a short skirt; drunk so much; gone out with someone I didn't know well; etc.") along with PTSD.
• Rape of a child or teenager by a parent, coach, teacher, older sibling, uncle, step-parent: Kids can't give consent, even if it's "friendly", it's rape. The worst thing I often hear is "It's (being an object of sex) what I'm for." Child rape by a person on whom the child relies for protection creates huge issues of identity, safety, goodness, worth, and sexuality.  Some kids, after chronic sexual abuse/rape, become prostitutes. 75 - 95% or prostitutes were sexually abused as children.  http://www.womenslaw.org/simple.php?sitemap_id=148. Many have flashbacks for the rest of their lives, unless treated. Many are not believed by their families. (The response of the family and/or institution in which the abuse occurred is strongly correlated with healing, or not, after the rape.) Kids who are raped tend to freeze, then go limp during the act. Afterwards, any sexual threat or even solicitation can bring the same passive, obedient response, making further exploitation more likely. Some re-enact their role with sexual acting out, a warped attempt of mastery of the situation. Most, but not all, people involved in sadomasochist "scenes" were sexually abused/raped as children. Child rape by trusted adults is a factor in most serious dissociative and Borderline Personality Disorder diagnoses. 

Complicating factors:

•     Not all rape is violent or actively coercive. When attachment bonds are used to manipulate kids or adults into sexual activity it confuses the issue of desire, identity, and fault.
• People can be physically aroused and even orgasm during a rape -- by the mechanics of the act. It still doesn't mean they wanted it. This is a huge issue in therapy.

Treatment: Many psychotherapies are helpful with rape and sexual assault survivors. My favorites are EMDR, Somatic Therapies, and, with victims of child rape and long-term abuse, Ego State Therapies. With permission, my favorite phone message from a client, after 3 sessions of EMDR for childhood sexual abuse: "Robin, I just called to tell you that I had sex with my husband today and it was great. After 12 years of marriage, this was the first time we made love and my grandfather wasn't in the room! Thank you!" 
 

Politics: Misinformation by the anti-choice people has muddied this issue. Some of them don't want women to have abortions. Some don't want women to be able to get pregnant from rape, necessitating the need for discussion of incest and rape exceptions in laws. Women who are ovulating can get pregnant from rape. It's a fact. "Legitimate Rape" appears to mean a violent rape by a stranger, only one kind of rape. 

A Song: Illegitimate Rape. the only good thing to come out of this political kerfuffle: http://youtu.be/mg_4O6XmKAQ

Traumatic Brain Injury

Traumatic Brain Injury (TBI) is in the news again. Robert Bales murdered 16 civilians in Afghanistan. He has TBI, drinks too much, and just saw a friend lose a leg. Why does TBI matter? 

Traumatic brain injuries are head injuries that can occur from a direct blow to the head, in an accident, sports, or assault (how most civilians get them), or from the shock waves of an explosion (how many military people get them). People who have strokes or brain aneurisms or too many steroids may have the same symptoms. 

Symptoms can include disorientation, memory loss, difficulty learning things, headaches, and confusion. Some people with TBI get right brain damage that makes them lose control of their emotions. They can have outbursts of rage, uncontrollable weeping, major depression that doesn't quit, and even laugh too long and too loudly. When traumatized or provoked, they don't have the normal "off" switch. If you add alcohol to TBI, you add more disinhibiton. If you add trauma, which amps up emotions, you can have the human equivalent of a bomb.  

I don't know Robert Bales, so I can't say more about what turned a nice guy into a mass murderer. However, I have worked with people with TBI. My clients all had memory loss, headaches, and wild emotions. They all had increased startle response, out-of-control anger, low frustration thresholds, and lives that were falling, or had fallen, apart. All these bright people needed help organizing basic things in their lives: finances, schedules, social lives, medical care. All felt dissociative, but weren't: one person when not filled with affect, but like a whole other person when showing emotion. 

With each one, I used EMDR, lots of support, and lots of cognitive work. We always targeted the accident with EMDR. With one person, who had had a tree-limb put a big dent in her skull, we were able to halve the pain, recover a fair amount of memory (2 years of graduate school), and cut back "out-of-her-mind" affect(emotion) in about 10 sessions. With others, it went more slowly, but was still helpful. The EMDR targets for most included the day of the accident, the losses that accrued from the head injury, the daily frustration, and the targets that would bring up much affect. We would imagine emotion rising and cognitively and physiologically calming it down. I taught basic relaxation, refocusing, grounding techniques, and how to deal with others. We brought in family and friends to teach time outs. Either the TBI survivor or the other person could call a timeout and the other one would have to back off, until the injured brain could cool out. I used the future template of EMDR for survivors to image using these techniques when needed. 

I've had a few clients that I didn't know had TBI, until nothing worked with them. After scratching my head, I would finally ask the question: "Have you ever been hit in the head?" In both cases, TBI answered my question, and I knew what to do. When people exhibit TBI symptoms, I always ask this questions at the intake. When people don't exhibit these questions, I try to remember to ask.

Back to military people. I have been hearing that many active duty military and veterans aren't getting proper care for TBI. Why? Poor screening and institutionally not wanting to pay for the cost of extensive, long-term treatment. In my opinion, it's a crime to ignore this devestating injury in the people that are taking the hits for the rest of us. If our country won't pay for the treatment, we will pay for it in traumatized families, increased suicides of military personnel, and more chaos in theaters of war and at home.

An op-ed in the NYTimes: War is Brain-Damaging

TBI Website: http://www.traumaticbraininjury.com/

 

Francine Shapiro in the New York Times on EMDR Research

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

EMDR with Body-Image Issues

An overseas reader asked what I do with body-image issues. I wrote her this:

If it's full-blown dysmorphia, there's a chapter by DaLene Forester, "Image is Everything" in my book, EMDR Solutions 2, but if it's regular "I don't look like Twiggy, so I'm not okay" distress, I start with the 2-Hand Interweave: "In one hand, hold the way that society tells you that you should look. (body fat, shape, skin color, etc.) In the other, hold the body you have." 10 - 20 BLS. "What do you notice?"   

I then target with the EMDR standard protocol the shame, grief, anger, etc. that arises, taking special care with the cognitions. I often go back to the transmission of the messages: family, teasing, media images. "How did that message get into you?"  And go through the stages of grief in accepting the body they have.   Make sure you target shopping for clothes, being around people who have that ideal shape, and anyone who currently shames them for their shape. You may target them being naked (with a lover, at the gym, at the spa) and dealing with any distress that arises.

As a tall woman with no butt and a big belly (like every person on my dad's side), who got teased a lot as a teen,  I've gone through my own acceptance process. And it comes down to clearing the grief, accepting reality, and realizing that I'm lovable, that the person who matters thinks I'm sexy, and that this body is going to continue to deteriorate in the aging process, so I'd better take care of it. 

Psychotherapy for Gay, Bi, Questioning Clients, and People with Gender Issues

Last week, I was contacted by a sincere, heartful, intelligent man who wanted to hire me for EMDR consultation. After a 45 minute conversation, I turned him away because he doing “reparative therapy”, seeking to "help" gay people become straight. He uses EMDR and other methods to target the attachment issues of gay men, so that they heal their same-sex attraction and are able to function in heterosexual relationships. (Here's a link to wikipedia)  This man uses EMDR, and uses one of my EMDR techniques, the Two-Hand Interweave in some of his work, which I find appalling.

Why am I appalled? This man is using an outdated, disproven Freudian lens through which to see his clients. According to him, gay men got that way by having overbearing mothers and distant fathers. He thinks if he clears up the relational issues with EMDR and nurturing, and he'll get a straight man. I think his skill and empathy and the therapeutic relationship push people into the boxes that his religious beliefs say they should fit in. That Freudian paradigm has been soundly disproven. Every year brings more evidence for uterine influences of androgens and other hormones, in the etiology of gender identification and sexual orientation.(Wikepedia post w/ references) (Psych Today: Finger Length) Like Lady Gaga says, we’re all Born That Way: Gay, Straight, Bi, feminine, studly, androgynous (having both high female and male characteristics) and feeling male or female.

I have worked with sexual minority clients for my entire career. I have read extensively about, taken classes on, taught classes on, and written about these clients. In 1981-83, I ran one of the world's first day treatment programs for seriously mentally ill sexual minority clients. Several of our sickest clients (bipolar, borderline, schizoid, etc.) graduated from the program into jobs, school, and weekly individual therapy. Many had thought they couldn't be sane if they were gay, bi, or had gender issues. When they were able to accept themselves, and to know that their sexual or gender feelings weren't crazy, they were able to do the trauma work, attachment work, or medication regimens that allowed them to heal and function in the world.

When I work with someone who is uncomfortable with his or her orientation or gender, we explore it, and look at the contexts in which the discomfort has arisen: family, religious belief, social expectations at work, with friends, etc. We discuss orientation. I never tell someone what they are. I do explain the oft-replicated Kinsey Scale: 0=absolutely no homosexual thoughts, dreams, activity. 6=only homosexual fantasies, dreams, activities. 3=bisexual, can go either way or both ways.  People might move a bit up and down the scale during their lives. But 0's don't become gay. 6's don't become straight. I tell them about the newest research.  I ask clients where they think they fit today on the scale. And I ask them how they feel about it. 

 That feeling may become the focus of therapy. I often see people go through all the stages of grief: NO! ; Oh shit!; Sadness; Growing Acceptance; Joy.  Some people skip quickly through the stages, coming quickly to joy that they don’t have to try anymore to be other than they are. I never tell clients what or who they should be or love. They realize it and tell me.

When people come in with gender issues (Am I a man or a woman? Can I be man and be effeminate, a woman and "butch"?) we discuss the 3 different scales:

1. Orientation: Who attracts you? 
2. Gender: What gender feels right? I've found very few people, including transgender people, to be confused about this question.
3. Society's Gender Expectations: Are you more traditionally "male" or "female". Are you androgynous, with both traditional male and female attributes? Are you "man's man", a "girly girl", a man with traditionally female pursuits and temperament, or a woman who is doesn't fit her traditional gender role? 

Examples across the 3 spectrums:

• My husband is a Kinsey 0. He says that he doesn't understand why anyone would sleep with men, though he's glad that women do. He's happy with his male body. As a slight, sensitive, emotional, artistic, introvert, he has had mostly female friends, was happy playing with dolls and girls as kid, has no interest in team sports (playing or watching), and is uncomfortable with displays of machismo. He’s very male in his single-mindedness, tenacity, and sense of stewardship and responsibility.    
•  
• When I read the new research on prenatal influences of androgen I realized that my male twin that died in utero may have provided me with the androgens that made me how I am: Kinsey 2 ½, in a tall mannish body, with highly androgynous interests:.  In grade school, I had crushes on girls and boys. When the hormones hit, I thought everyone was cute, and still do. I've been in relationships with women and men. I've had this female body a long time, but I'm not that attached to it, or to being male. I think I could be happy either way. Only on camping trips, did I wish I had different plumbing. I'm tall, broad-shouldered, thin-hipped. Because I don't dye my hair, nor wear make-up very often, and can dress androgynously, I get "sirred" often. (Can I help you, sir?) I never had girly interests. I brought home snakes and frogs. I'm bossy, can be aggressive, can be soft and nurturing, can act like a guy around guys,. I've learned to "pass" as more female than I feel, using the gay male idea of "drag": any thing you wear, any way you look is a chosen persona. So I can do girly drag, professional drag, or wear what’s most physically comfortable. I was lucky to have parents who let me be as nerdy and idiosyncratic as I turned out to be, so that I never needed psychotherapy to reconcile my gender, sexuality, and cultural issues.
•  
• A male friend is a Kinsey 6. He says that he has always known he was gay. He thinks women are beautiful, and could not imagine having sex with one. He falls in love with men. He loves his male body. He loves to play through the gender roles, going from black leather macho "drag" to pretty-boy soft fabrics. He goes from nurturing sweet artist to macho man in five seconds. Thirty years ago, he and I did "high drag" together, wearing hyper-feminine drag queen apparel and make-up. We looked like twins of indeterminate gender. 
• A female friend was a sexually abused by nearly every male in her extended family. She thought she was gay by default: women weren’t frightening to her, men were. When she cleared her sexual abuse in years of EMDR therapy, she found out that she was really was a lesbian. Her friends, including me, thought her predilection for highly feminine partners (lipstick lesbians), tomboy sports, and a construction jobs made her an absolutely stereotypical dyke. It turns out she is.
• Her lover is highly feminine, in the arts, loves her femaleness, and as a Kinsey 6, defies all stereotypes.
• A coworker from years ago, was a very feminine boy, who as soon as he left home, took on a female persona when not at work. He hated everything male about his body. It was “not me”. After going to a support group for transgender people and years of therapy, he decided to transition to a female body. Now, she feels at home in her body and is searching for Mr. Right.
• In the early 1980’s, another acquaintance, after decades living as a very butch lesbian, transitioned to a male body, finally coming home to himself. His lover of 25 years, a tiny feminine woman, stayed with her partner throughout the transition. After partner #1 became legally male, they were legally married and shortly thereafter, left the gay community to “pass” out in the suburbs.

 

Therapy Issues

• Don’t project that these clients are coming with issues about their orientation. They may be fine with being gay, bi, or gender variant. They may be coming in with PTSD, anxiety, depression, addiction, or grief.
• Don’t miss the milestones. When I do an intake on gay, bi, or transgender people, I often ask when they first knew, when they first told someone, and when/if they are out in their lives, and what kind of discrimination they experienced. Often there is trauma, grief, or ongoing anxiety. Imagine not knowing how each new person will respond to who you are. Or fearing firing, violence, or death, for being who you are.
• Do notice and acknowledge ongoing stress and fear about being a targeted minority.
• Coming out is differentiation:  “I’m here. I’m queer. Deal with it.”  Differentiation means accepting oneself, even when others don’t.  First coming out to self. Then others. And for many, coming out to everyone. “I’m out” means to anyone who wants to know. 
• Coming out can be dangerous. Never push clients to come out. Always acknowledge clients’ fears of coming out: rejection, judgment, loss of relationships, even violence. I’ve had friends and clients lose their families, experience shunning by their church communities, and lose jobs. I’ve known military people who lost their positions and their health care and their pensions. And this week is the 13^th anniversary of the murder of Matthew Shepard, killed by homophobes in Wyoming.
• Coming out can be exhilarating and empowering. Here’s the subtext: “I’m here. This is me. I care about you enough that I want you to know me. I’m willing to risk our relationship in order to be known.”  And it, in the best of circumstances, coming out becomes mundane: “My husband/wife/partner and I saw a great movie last night.” Or, “Yeah, I look familiar because I used to be Mary and now I’m Marvin.”
• Things are changing, but not fast enough. Don’t Ask, Don’t Tell is gone. Gay marriage is now acceptable to about 50% of Americans. Sitcoms with gay characters are normal and popular. Rosie and Ellen are icons. Chaz Bono is dancing with the Stars. And kids are still being bullied to death, thrown out of families, and fearful of growing up alone and “weird”. Gay people are vilified from many pulpits. “That’s so gay!” isn’t a nice thing to say about anything. One of my favorite referrals is to Dan Savage’s “It Gets Better” campaign. Gay, bi, and straight people giving messages of encouragement to gay kids: “Hang in there. It gets better when you grow up. You’ll find love. I made it. You can too.” There are thousands of videos, some of them musical, all testimonies to the future.
• Community can be powerful. There is no one sexual minority, gay, bi, lesbian, or trans community (except in the minds of certain right wing opposition). There are many groups. And it's a thrill for an isolated person to find "people like me". Back in my day, it was support groups. Now, online communities can be a first step for people looking for support, information, acceptance, and relationships. I warn newly exploring people to watch out for jerks and crazy people. I say, "Just because they share an attribute with you, doesn't mean they aren't out to exploit you. Pay attention! Look for smart, kind, honest people, whether online or in person."
• Steer your clients towards themselves. Be curious. Support. Use your tools towards healing in everyway. I tell my clients of whatever orientation, "When you lay me off, I want you to be as weirdly idiosyncratic as you were always meant to be, and absolutely accepting of all of it." 

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

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

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

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

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

Trauma and Trauma Therapy: Interview on "Public Exposure"

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

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

Tricare Refuses to Pay for CRT & EMDR for Veterans

National Public Radio wrote and spoke about the "Battle Over the Science" of Tricare not paying for cognitive rehabilitation therapy (CRT) for Traumatic Brain Injury (TBI) "despite pressure from Congress and the recommendations of military and civilian experts, the Pentagon’s health plan for troops and many veterans does not to cover” cognitive rehabilitation therapy — a “limitation that could affect…tens of thousands of service members who have suffered brain damage while fighting in Iraq and Afghanistan.” See article in Veterans Today:  http://www.veteranstoday.com/2010/12/21/battle-over-science-money-blocks-widely-recommended-tbi-therapy/ and the NPR story: http://www.npr.org/2010/12/21/132203864/philanthropist-provides-care-that-the-pentagon-wont

It turns out that Tricare hired a research company that it knew (or maybe told to) would find this well-researched therapy to be "not scientific", despite unanimous by 50 clinicians and researchers on a special governmental commission. The reason: It didn't want to pay. CRT is expensive. And necessary. Thousands of military people are returning from Iraq and Afghanistan with TBI's from exposure to roadside bombs. The shock waves from these explosions move through brains, temporarily jellifying the tissue and causing lasting cognitive problems and difficulties with affect regulation. CRT helps people learn to cope and manage despite brain damage. It's necessary therapy.

This is reminding me of Tricare's refusal, until just this week, to pay for EMDR therapy for vets, despite EMDR's acceptance by the VA, the APA, and other entities as an "evidence-based practice". This was more about politics than money. Cognitive behaviorist and exposure people had colonized Tricare's committees, not allowing support for other effective therapies. I'm sorry that our active duty people and veterans have been victimized by the political and financial b.s. at Tricare. They deserve better.

In my experience, many "researchers" quote studies that support their beliefs and not the ones that support the facts. Or else cling to lab-based double-blind studies. Many effective therapies were not hatched or researched in labs. They work despite the lack of studies. Some, even after the "appropriate" research is complete are debunked because of the belief systems of the meta-researchers.  My belief: Do what works for the client in front of you.

 

Is Schizophrenia Caused by a Retro-Virus?

Fascinating article, The Insanity Virus, in the November online Discover magazine describes studies that show that schizophrenia and MS may be from viruses that trigger the Toxoplasmosis and CMV viruses that most of us already carry. It's a long read that got more interesting (for me) on pages 3 and 4.

This article makes personal sense to me because I've been around many people with AIDS whose impaired immune systems allowed the CMV and Toxoplasmosis to flourish and make them psychotic for the rest of their lives. I'm interested to see more about this research trend.

It's also interesting because last month at the EMDRIA conference I just heard Paul W. Miller MD, a Northern Ireland-based Psychiatrist, talk about how he has cured psychotic delusions in schizophrenic clients using psychotherapy that includes EMDR.

Living with the Awareness of Evil

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

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

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

How did I get through it this week?

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

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

Video with Amen brain scans and EMDR treatment of PTSD

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

Trauma Treatment Handbook: Protocols Across the Spectrum

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

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

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

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

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

First Person Account of EMDR

Mary Elizabeth Williams talks about receiving EMDR after a mugging. On Salon's site:

http://www.salon.com/life/feature/2010/07/23/emdr_after_a_mugging/index.html

Narcolepsy and EMDR Processing

A client has given me permission to post about her situation: the effects of Provigil, Prozac, and time on trauma processing:

 

Round 1, 15 years ago: She was bright, effusive, and had the odd habits of jerking her head up to look around and writing down everything I said. We worked for eight months using EMDR to clear the PTSD from the physically and emotionally abusive marriage that she had escaped 17 years before. She seemed dissociative, but in a strange way, staring off, then going to the head jerk. The EMDR worked, the flashbacks stopped, the client, satisfied, went off.

 

Round 2, 10 years ago: After her narcolepsy diagnosis, she started taking Provigil. A few days later, the flashbacks from the abuse began again, and she returned to therapy. We went after the abuse, in greater depth as more details arose. Again, we cleared all we could find, and she left therapy feeling good.

 

Rounds 3 – 5: I saw the client through the illness and death of a sweet boyfriend, and various stressful work situations. Then as she became more constitutionally anxious, then obsessive, which became manageable when she started Prozac.

 

Round 6: last week: Planning her 45^th high school reunion, to which her abusive ex-husband had been invited, brought up the next round of distress over the marital abuse. SUD 10, when she thought of him. She processed through fear and rage, bringing up memories that had not arisen in rounds 1 or 2. She left, after a 60 minute session, feeling safe, calm, and able to ignore him, if he came to her reunion.

 

She and I think that whether or not her narcolepsy was a dissociative response, the Provigil allowed her brain to stay on task with the trauma processing, and that the Prozac with the Provigil keeps even more of her brain online and on task in trauma processing. She and I would love to hear if other people have had similar reactions with these medications affecting the depth of trauma processing.

Is addiction a form of dissociation?

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

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

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

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

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

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

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

Here are nearly random gems from 3 hours of notes:

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

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

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

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

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

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

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

Developmental Trauma Disorder

A. Exposure

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

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

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

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

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

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

baseline; not reduced in intensity by conscious awareness.

•Affective

•Somatic (physiological, motoric, medical)

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

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

depersonalization).

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

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

C. Persistently Altered Attributions and Expectancies

•Negative self-attribution

•Distrust protective caretaker

•Loss of expectancy of protection by others

•Loss of trust in social agencies to protect

•Lack of recourse to social justice/retribution

•Inevitability of future victimization

15

D. Functional Impairment

•Educational

•Family

•Peer

•Legal

•Vocational

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Small t traumas cause more pathologies than PTSD.

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

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

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

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

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

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

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

EMDR increases resilency and engenders a new sense of self.

 

 

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

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

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

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

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

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

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

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

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

Counting the Walking Wounded

By LAWRENCE M. WEIN in the New York Times

Published: January 25, 2009

Stanford, Calif.

Related

Times Topics: Veterans and Post Traumatic Stress Disorder

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

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

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

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

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

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

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

 

 

EMDR for Veterans: Write a Letter

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

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

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

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

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

Phantom Itching Cured With EMDR

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

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

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

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

Procrastination

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

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

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

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

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

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

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

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

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

 

 

 

EMDR and Depression poster

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

Download DepressionPoster-1.pdf

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

Unit I: TREATING Depression

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

2.Trauma-Based Depression, Robin Shapiro

3.Endogenous Depression and Mood Disorders, Robin Shapiro

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

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

UNIT II: TREATING EATING DISORDERS

6.The Why of Eating Disorders, Andrew Seubert

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

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

9.Treating Bulimia Nervosa with EMDR, DaLene Forester

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

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

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

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

UNIT III: PERFORMANCE, COACHING, AND POSITIVE PSYCHOLOGY

14.EMDR and Performance, David Grand

15.EMDR and Positive Psychology, Ann Marie McKelvey

16.EMDR and Coaching, Ann Marie McKelvey

UNIT IV: Solutions for Complex Trauma

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

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

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

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

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

UNIT V: TREATING MEDICALLY-BASED TRAUMA

22.Clearing Medical Trauma, Robin Shapiro

23.Treating Birth Related Post Traumatic Stress, Katherine Davis

24.Treating Multiple Chemical Sensitivities with EMDR, Robin Shapiro 

UNIT VI: MORE EMDR SOLUTIONS

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

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

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

Dear Readers,

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

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

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

Here is the some of the introduction of the book:

 

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

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

 

Unit I: TREATING Depression

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

 

UNIT II: TREATING EATING DISORDERS

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

 

UNIT III: PERFORMANCE, COACHING, AND POSITIVE PSYCHOLOGY

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

 

UNIT IV: Solutions for Complex Trauma

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

 

UNIT V: TREATING BODILY AND MEDICALLY-BASED TRAUMA

 

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

 

UNIT VI: MORE EMDR SOLUTIONS

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

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

 

Using Solutions II

 

 

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

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

Research considerations

 

 

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

 

Case histories

 

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

 

Chapter conventions

 

 

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

 

Attribution

 

 

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

 

REFERENCES

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

 

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

 

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

 

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

Trauma Lecture

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

Register at [email protected] (email your name and phone).

or go to wacoatlition.org for the website

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

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.

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

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.

ISREALITY Video: "Color Red"

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

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

Here's another if that doesn't work:

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

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.

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!

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.

"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.

Multiple Chemical Sensitivities

With my client's permission, here's what I did to clear out Multiple Chemical Sensitivities in 8 sessions:

Client: Late 50's, professional, intelligent, a "highly sensitive person" (Elaine Aron), a good connector, with a supportive husband and a circle of good friends.

Symptoms: Ears would hurt, throat and tongue swell, face turned red, etc., at the slightest whiff of a chemical smell. Couldn't bear the Sharpie pens I use in doing the genograms for my intake. Had been driven out of a house and away from her family (with whom she gets along). Work, socialization, and many activities impacted. Duration, a few years.

Therapies outside our work: spiritual work, some cognitive restructuring, a great cognitive-oriented couples' retreat. Helped her frame the situation and gave her hope, though symptoms continued.

What we did:

1. Thorough intake with special foci on attachment hx (checked out mom), generalized anxiety symptoms (lots), and of course, onset & hx of MCS symptoms. We used Maureen Kitchur's genogram (EMDR Solutions, 2005) intake and had it in front of us during every session.

2. We were a good fit and comfortable with each other. We did safe place, etc. in preparation, and then we were ready for processing. All processing was a mixture of the EMDR standard protocol with some Brainspotting technique thrown it. I set up targets, cognitions, emotions, body sensations, SUD, and then while she held theratappers with continuous stimulation, found the "spot" in her eyes that caused the most blinks, and held the wand there for up to 40 minutes.

3. Two-Hand Interweave: In nearly every session I had asked her to take a moment and tell her immune system to pay attention to its targets. "Put the real enemies, bacteria, viruses, and other bugs in one hand, and hold the benign things your immune system reacts to in the other." (Bilateral stimulation). "Which are the things you need your immune system to fight? . . .What can you chill out around?"

4. Targets: Ala Kitchur, we started with early attachment targets: Looking into mother's eyes as an infant, a toddler, etc. Lots of distress there. Other childhood targets, most of small "t" traumas, of Mom checking out. Some accidents and other incidents. Dad's anger. As a highly sensitive child, she was acutely tuned into her parents and surroundings and more impacted than some kids might have been. She was a great subject. Brainspotting/EMDR were great methods for her. She processed quickly, with great insight. Sometimes we used interweaves of bringing in the adult self to hold different younger parts. Often, that wasn't necessary. We went through her life, clearing relationship issues, and standard events, losses, and distresses of life. Before we ever discussed MCS, her symptoms were about 50% less, in both # of times triggered and intensity.

5. MCS targets: As preparation to do work directly on MCS, we inadvertantly cured it. In our earlier work, the Two-Hand and other suggestions that her immune system relax, it had become personified as an overactive little imp, jumping up and down, wanting to do battle, always "on", hypervigilant.   I used Roy Kiessling's conference room of strengths and positive traits (also in EMDR Solutions) to create "what you will need to solve this problem". We imagined the conference room, we invited, one at a time, whatever traits she thought would help. Strength, wisdom, intuition, sense of humor, and several others walked into the room. What exemplifies each of them? Many of hers were Egyptian gods and goddesses. Each time she named a trait, I had her remember a time that using the trait "worked for you", and installed it with some bilateral stimulation. Then I had her show the hypervigilant immune system imp all of the strong traits, while using bilateral stimulation. I tried to take a break. She said, no. I complied. After a while, about 10 minutes, she said that she was done. She had imagined the "imp" as an Egyptian god that used to get over excited and kill humans. In Egyptian lore, the other gods had gotten together and plied this being with alcohol, making it drunk and happy. It stayed relaxed and stop killing people. She had her conference room of strengths overpower the imp, get him "drunk and happy" and let him quit his job!    We did a few rounds of imagining a real bug attacking her, a cold virus, and her immune system calmly rising to the occaision. And a few rounds with triggers that had bothered her in the past, with no distress. I passed an open Sharpie under her nose. No symptoms.

6. Finishing up: Two more sessions, focusing on family of origin triggers, based on current life situations. No MCS symptoms. We reinforced the earlier work with future pacing running into triggers. We gave each other lots of strokes for our good work. She promised that she would come back if the symptoms reappeared. It's been months. No calls.

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.

A New Two-Hand Interweave Application

Gary Hiam, a senior therapist from Tacoma, has come up with a new way to do the 2-Hand Interweave. The therapist establishes a "resource hand" with the client, where the client feels her strength and power. Therapist touches the hand to anchor the feeling, "Now go inside and feel where you feel it." Therapist taps on the backs of the client's closed hands.

Then the therapist asks the client to notice the hand that holds "the struggle". Touch it. "It's the part that feels weak or is scared. Go inside with that." Tap on both hands while the client feels the struggle for a moment.

Then bring the attention to both hands at once, start tapping, and see what happens.

Remember that in the Two-Hand Interweave, sets are brief. We're not clearing trauma, but connecting different neural nets for comparison or integration.

The Trauma Spectrum, by Robert Scaer

The Trauma Spectrum by Robert Scaer (2005, W.W. Norton). According to Scaer:

A. Trauma is a continuum.

B. What you have to endure during moments of helplessness and hopelessness creates a freeze response. It's the frozen, uncompleted actions that make for PTSD.

C. These moments can start prenatally (fetuses feel). The medical process of birth can create traumatic stress, as can many other medical processes.

D. There are many, many ways, including family-caused, medically-caused, and culturally-accepted stresses that can harm the body/mind.

E. Many medical and pain issues are caused by traumatic stress.

F. Body/Somatic-based therapies such as Peter Levine's Somatic Experiencing, EMDR, EFT, TFT, and others allow people to complete the uncompleted movement and clear out the held/dissociated freeze response and release pain, PTSD, frozenness, and illness.

That's the gist according to the book group. We liked the way he talked about that body/mind are one entity. No Cartesian dualism for us. Some of us liked the stories about how the body reactions create different illnesses, including fibromyalgia, reflex sympathetic dystrophy (RSD), IBS,GERD,Whiplash syndrome, Phantom Limb Pain/Chronic Pain, Multiple Chemical Sensitivities- and other body phenomena, such as stigmata. (I've used EMDR and Brainspotting on Phantom Limb Pain and Multiple Chemical Sensitivities with great results.) The book was readable. One person said that much of it was taken from Peter Levine's Waking the Tiger which was even more readable and clear.

As EMDR clinicians, we wished for more solutions. Trauma Spectrum is not a how-to book and we always want to know how to. As readers we wanted Scaer to stop ranting about the culture, the medical profession, and gender discrimination. We never disagreed with his opinions, but if we want to experience a rant, we'll do our own, thank you.

We wanted more talk about character and resiliency. Some people, who have experienced many of the traumas listed in the book, do not seem as harmed, frozen, or dissociated as Scaer would have them be. One reader thought that in Scaer's model, the entire U.S. population would be dissociated wrecks. Scaer didn't say that, but I could see the reader's point.

I asked, "What EMDR or Brainspotting targets would you go after, using the book as a guide?" Here is our list: prenatal and birth trauma. Any medical trauma, from birth to present. Surgeries. Any harassment for gender, work issues, or difference. (The question: "When did you feel like you didn't fit in?") Any time a person felt helpless or hopeless. Experiences of uncontrollable pain or an unidentified or scary disease. Injuries. Car accidents. Attachment injuries. Work stresses. Cultural stresses. Any injuries or illness that keep flaring up.

If you are interested in the physiology of trauma, this book is good (despite the ranting.) If you want to know what to do about it, learn EMDR, Somatic Experiencing,  Brainspotting, Sensorimotor Psychotherapy or other body/mind therapies.

Next up, The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization by van der Hart et al.

 

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.

EMDR Humanitarian Assistance Program

I'm on the board of the Humanitarian Assistance Program of EMDR. We are a non-profit organization whose goal is to "expand access to effective mental health treatment for traumatized and underserved communities through direct service and training of local caregivers, anywhere in the world."

HAP's current projects include training therapists in Lebanon, the West Bank,India, Indonesia, and the Philippines. Domestically, it has a big project on the Gulf Coast (post-Katrina), and many projects training staff of community mental health centers, rape crisis centers, child treatment agencies, VA's, military counseling staff, and where ever a non-profit group, serving underserved populations asks them to go (given specific criteria, of course). It is often described as "Doctors Without Borders" for mental health. All trainers and facilitators are volunteers. Trainees are encouraged to become facilitators, and then trainers, so as to create a training infrastructure in each area. (This has happened in Israel, and is well on its way in both the West Bank, and India.)

HAP sends volunteer therapists to some disaster scenes. Many HAP volunteers assisted New Yorkers, post-911, and people in the Gulf Coast, post-hurricanes. In my town, Seattle, we've worked with people in the aftermath of a shooting incident, and with some Katrina transplants. HAP in the midst of formalizing our Trauma Recovery Network (TRN) to be able to connect volunteers to people who need them. Volunteers give 5 free stabilization and EMDR sessions to clients, and are not allowed to see the people, for fee, at anytime. If you are a certified EMDR-therapist, you can volunteer for the TRN here. If you'd like to know more about HAP or make a donation, click here. It's a great organization, well-managed, with most of the money going to direct service. For having a tiny staff, it does alot. HAP's goal for next year is to train 1200 people, who would not otherwise have its traumatology or EMDR trainings. I'm proud to be part of it.

Francine Shapiro replies

I had posted on my last thoughts on a private list and got a reply from Francine Shapiro, the founder and steward of EMDR. It was a bit daunting for me. She's smarter, more well-informed, and the inventor of what I do in much of my working hours. She has given me permission to post our discussion. Read the last entry to see what it refers to.

"Regarding a description of VR and EMDR, the actual explanation for the use of exposure therapy is that prolonged exposure is supposed to cause an extinction of the response.  Not a dissociation.  It is based upon animal models and has a long history in behavior therapy. 

Whatever other treatments achieve, I'd be careful about describing shared attributes.  That is, EMDR does not focus on increased affect, but rather the affect generated by the stored memory.  The dual attention is the attention to the manifestations of the elicited memory:image/thoughts/emotions/physical sensations/beliefs---which is an internal focus--and the bilateral stimulation which is external.  The here and now sensations are manifestations of the stored event.  So if that is what the other therapies are focusing on it is not dual attention. 

As we know in EMDR people can process with a primary attention on body OR thoughts Or images.  So none is mandatory as it is in other forms of therapy.  Nor do we coach a client to a coherent narrative as done in other therapies.  It merely evolves as a byproduct of the reprocessing.  As do the changes in affect, body sensation, thoughts, images, sense of self, etc."

My reply: I don't mind you jumping in and I think your comments are absolutely relevant.  I've worked with several people who had had exposure therapy for PTSD, and the experience created dissociation in all of them, not extinction. Of course, they all could have had underlying dissociative processes, before the exposure therapy.
        I went to rat-running behavioral undergrad school: U of Iowa. and cognitive-behavioral graduate school, U Washington. I love how, since then, the neuro-research shows us how it all works. The dampening of affect, with exposure, showing up in the midbrain--I can't remember if it was the amygdala or hippocampus in which the electrical response stops. With EMDR, the integrative process shows up in the left cortex, as more activity in the narrative part of the brain. All the trauma therapies that I like, especially EMDR, which is my "therapy of choice" appear to result in a coherent narrative. I think my language wasn't precise. EMDR brings up "the affect generated by the stored memory." I have witnessed about 20 hours of tapes of Diane Fosha working. I think she does a similar thing. I sat in a 5 day class she did last year. The 6 EMDR therapists who were there, could see the Standard Protocol at work, in what she did. It's all we talked about at lunch. She brings up the old state, the related cognition, the related affect, and the related body sensations. It appeared to us, that the switching of attention back and forth between internal states, related to the trauma, and the connection with the therapist worked much like EMDR. It had the same outcome. Or so it seemed to us.
        I like EMDR, better, because it's easier to teach and easier to keep track of. It's what I do. The Standard Protocol works, and it's not fuzzy. It can be measured. I've taught some not-very-bright therapists the protocol. They were able to do ok, but not stellar, therapy. I don't think they could do AEDP, because it's not as structured.
Thanks for your input, it's always welcome!
Warmly and with great respect, Robin

Her reply:  "It’s hard to know what outcomes really are, or are maintained, without follow up research.  I’d just say  that I’d be careful about the neuro research.  It’s all in it’s infancy.  There are various studies that show various things.  And you can’t link “left cortex” to “more coherent narrative.”  you can say that Broca’s area is off and then activated.  That has to do with language.  But things are a lot more complicated than that.  Exposure therapists claim the same thing (more coherent narrative) for their therapy."

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.

Chronic Pain

John Koewler asked me for more information about EMDR treatment for chronic pain. First an update, then some information.

My heel pain remained at 0-3 on the 11 point pain scale for several weeks. The pain is starting to creep back in, when it shouldn't. There's a particular throbbing that I think is generated in the brain, not the tissues of the foot, so I'm going to do a clean-up session to stop the "kindling" in my brain.

What is chronic pain? It can be ecological, or naturally occuring from damaged tissue and stimulated nerves at the place that it feels like it hurts. Or it can start in the brain or start in some body part, shoot a message to the brain, and feel like it's hurting in some other place. Why would pain start in the brain? Lots of reasons. There are diseases of the brain that telegraph all kinds of wrong information, as if it's happening in the body. Many medications impact the brain and make it "lie" about what's happening in the body. Chronic pain in the body, which sends many pain messages to the brain, may start a reaction, like a reflex, in the brain. There is measurable electrical activity in the brain's representation of amputated limbs, for example, when there is phantom limb pain.

As clinicians, it's our job to turn off the reaction in the brain. How? Lots of ways. Before I knew EMDR, I used a combination of Hypnosis and Guided Meditation (a different kind of hypnosis). I worked with many AIDS patients, many of whom had neuropathy from the action of the HIV virus or a secondary infection or their meds on the brain. Most of the time I made it go away. Here's how: In a cadenced, low voice, with a pause after each phrase, I'd use a combination of Stephen Levine's pain meditations embedded with extra hypnotic suggestions: "Watch what feelings arise as you let your awareness move toward the place of discomfort. Let the pain just be there. Notice if there's any resistance to the pain. Is there fear there? What feelings arise around the pain? Just notice. Wherever we hurt, we tend to tighten around the pain. It's a reflex. We even do it in our sleep. Notice if you've made a fist around that pain. Gradually let the fingers holding that pain soften, soften, and ease open, finger by finger. That's right. That's right, allow that pain to be held softly in your awareness. Notice if it's sharp or dull or constant or intermittent. Most pain changes, moment to moment. Notice the sensations changing, moment to moment, shifting place, shifting in intensity. That's right, just notice. (If it's not ecological pain): Your brain is impacted by HIV/your meds/former pain. Your brain is telling your toes/back/whatever that it's hurting. In fact, a little spark is popping in your brain that's lying to you about pain. Tell your brain that you know that it's lying to you. When you feel that sensation in your toes and fingers it's just that little spark jumping. Tell your brain, that in this regard, you're not going to listen to it any more. Got it, brain? Good. Now notice your toes again. Notice what floats into the sea of your awareness as you attend to your toes." (Oftentimes clients said that they felt a tingle, but it was no longer pain, and they learned to disregard the tingle.)

(If it's "real" pain, from physical damage to the tissue, this pain meditation works, but you don't tell them that their brain is lying.) "Notice the sensation, now that you've allowed the fist around it to soften and open. That's right. As you breathe in and breathe out allow your self to notice another area of sensation. Notice if it has intensity. Notice how it changes, moment to moment. Is there holding in this area? If so, can you loosen the fist around it, too. "(Then the whole body, then the fear that the sensation has caused to arise, etc. Then have them buy Stephen's guided tapes, or make them a tape, tailored to their pain and their situation, yourself.)

Since I learned EMDR, and then learned that it worked with pain, I've been using it. When I learned about the phantom limb pain protocol, I learned it and then "pointed it" at all the chronic pain in all my clients. I like it so much that I had Sandra Wilson and Bob Tinker, a married couple who have both researched and operationalized EMDR for Phantom Limb Pain, write a chapter for my book, EMDR Solutions. The protocol involves a thorough pain and lifestyle post-amputation and pain intake taking at least two hours. In the third session, you target the worst traumatic aspect of the amputation (or the accident or the onset of the pain, if it's not an amputation). You clear all the trauma targets with the EMDR standard protocol. That may take weeks. Then you go back to the pain scale and focus on the worst pain and keep going until the pain goes away. You may have to focus on many aspects of the pain. Sometimes, once you start with the pain onset, you can nail it all in one session. Sometimes the pain is gone after you focus on the onset, and there are no other targets. Sometimes you need to go after all the trauma, all the lifestyle losses, and all the ways it works.

Another way I work with pain is also in EMDR Solutions. Jim Cole's Reenactment Protocol gives another method, that's not exactly EMDR, but I like it so much I had to publish it. Cole will have people do a fantasy reenactment of the accident or pain-causing incident, using the energy of the pain itself to change how the situation went. I witnessed him working with a therapist who had just been in a car accident. A month later, her hip still hurt. When she imagined that her foot was made out of strong, but flexible rubber, and that right before impact she used it to deflect the other car, both her PTSD and her hip pain disappeared. It took about 5 minutes. The great thing about Cole's technique, is that it nearly always ends with the client's delighted giggle.

Mark Grant has published both a manual and guided pain meditation for EMDR with Chronic Pain. Both are excellent. Mark agrees with me that no patient should ever be in agony and that it can be the therapist's job to advocate for clients to get appropriate medical treatment for pain, before it becomes chronic.

In another post, I'll tell you about my "miracle client". But I''ve gone on too long in this one.

Eye Movements

I'm switching sides in the great EMDR bilateral debate. While I diligently taught eye movements in my EMDR basic training, I tended to use theratappers or knee taps with the majority of my clients. In all cases, the traumas cleared, the clients integrated their experiences, and we installed their new awarenesses ("It's over." "I'm safe." "I'm great!" etc.) and their new body feelings (relief, joy, present-time being, etc.) So touch works well for most people. Why not stay with it?

Since I've been doing Brainspotting, which involves helping clients hold focus from one or both eyes on a particular place, I've watched clients go deeper, more quickly, than in any other technique. While assisting at and then consulting for an EMDR basic training, I've been watching the difference between people who got tapped on and people who got waved at. The eye movements worked faster. It was hard not to coach the students into turning their EMDR sessions into Brainspotting classes. Instead, I'll tell them to go to David Grand's class in Seattle in May.

So, for garden variety EMDR, I'm going to suggest using eye movements over any other bilateral modality. After witnessing 18 EMDR sessions in 2 days, I think the "eyes" have it.

In my current practice, I'm doing Brainspotting with 95% of my traumatized patients. Most of them are listening to bilateral music on headsets. A few are holding theratappers, while I find the spots. One is using the "spotting" only, which seems to lessen the "flooding" of emotions and images, while he clears trauma.

If there are any opinions from other people, I'd love to hear them.