Trauma & Attachment Therapy

Grieving the Loss of a Child

A participant in an overseas workshop sent an email request: 

"A patient of mine, a woman in her 80's, lo"st her son at the beginning of the year. She already took antidepressant drugs, but at the moment she no longer does. However, she still feels deeply sad. What are your suggestions?"

This is what I sent her: 

It is absolutely normal for a mother to grieve her dead child for many more than 9 months. Do EMDR with the trauma around the day he died or the worst parts of the dying process, and the wanting to see him/talk to him and he's still gone. If she feels that should have saved him, do EMDR with the cognitions about that. Otherwise sit with her, hold her hand, look in her eyes and let her know that horrible grief is a sign of the good attachment she had with her son. (My mother took a few years after the death of my brother to start to feel okay in her life. We all still miss him, 21 years later, but no more acute grief.) Let her know it will worse on holidays, his birthday, her birthday, and especially bad on the anniversary of his death. She had at least a 50-year attachment to this child. That's an enormous loss!

Here are some tools for both of you from my writing about grief:

"Normalize the grief experience. explain that people move through the stages over and over. It may be in minutes, on seeing someone who looks likes the loved one on the street, then realizing the loss, again, the anger at self for being mistaken, the hopelessness, again, that the loved one is really gone, and re-integration. or the stages may last for months or years. When clients can identify the stages, they feel less out of control, and see a progression to the process. Move on to the Rules of Grief, normalizing the experience and that our society doesn’t have a realistic idea of the depth and length of the grief process. I often paraphrase Stephen Gilligan: “It is the job of life to make every human being feel every possible emotion at every possible intensity. It is the job of human beings to allow every emotion to move through unimpeded.”

Stages of Grief:  (May occur in succession or over and over.)

1. Shock and disbelief
2. Anger and blaming: Self, the one who is gone, doctors, fate, God, et.al.
3. Sadness, depression, hopelessness, yearning
4. Integration, alternating with all of the above.
5. Over the acute grief and still missing your person.

My Rules of Grief:

1. It always hurts more than you think it should. 
2. It always last longer than you (and others) think it ought. 
3. It makes you tired, cranky, stupid or feeling hopeless. 
4. avoid it and it stays terrible, creates depression and/or useless busyness. 
5. Feel it all and it gets better

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.” "

NBC's Awake: Creative Grief Avoidance

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

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

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

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

The Names of Love

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

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

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

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

Connie Sidles Interview: Grief, meaning, presence and bliss

Connie Sidles is a famous Seattle birder. Here is this week's KUOW radio interview with her about why she spends so many hours at the Montlake Fill. Connie gives a cogent discussion of dealing with grief, how to create/have meaning in life, how to get present, and why birding creates bliss in its more conscious adherents. Hear her here: http://kuow.org/program.php?id=17451

And if you want to see my husband's book of photographs of the Montlake Fill, go here: http://issuu.com/dougplummer/docs/at_the_fill . You don't have to buy the book to see the pictures. Click on the book then on the pages below. You can listen to Connie on one Explorer and look at the book on the other. Connie wrote the intro to the book.

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.

 

 

Brainspotting Class

David Grand brought his Brainspotting (BSP) class to Seattle this weekend. He was ably assisted by Lisa Schwarz, who teaches about using BSP with dissociative and other fragile clients. Lisa and I helped with the practica parts of the training.

Brainspotting is a powerful, flexible, client-centered therapy that appears to go more deeply and more quickly into the body/brain than other therapies I work with. Grand says that it works on the "reflex" level of the brain. I don't know how it works, but it's simple and gets into different and deeper levels of material and responses with clients. First you turn on a steady bilateral stimulation, Grand starts his sessions with "Biolateral" cds, coming through stereo headsets. There are two ways "in" after setting up the activated target: "outside window", when the therapist observes the client's response to stimulus, and sets up a focused gaze, or "inside window", during which the client collaborates with the therapist to find the "brain spot" on which to focus. (No, I'm not going to be more specific, because even though the techniques are simple, the therapy isn't.) Then the therapist waits and the client reports. Some clients have no words for their experience and no explicit memories or images. Some clients have a bunch of both. There are specific tracking techniques and good focusing questions to ask. I watched 50 people receive BSP in the practica. Each one experienced a change. One of my buddies saw her lifelong anxiety abate. Another buddy, 2 weeks post-surgery, experienced her shoulder pain disappearing. People moved trauma. People moved affect. People moved ADD!

I was a demonstration subject on the second day, working in front of about 50 people, half of whom were either my EMDR trainees or consultees, or both. I wanted to work on my experience of the thyroid condition and the underlying inflammatory process in my body, that some medical people think is driving a bunch of illnesses in my body (IBS, asthma, frozen shoulder, plantar fascitis, and the thyroid yoyoing). I put the headsets on and listened to different tracks of "biolateral" sounds and music move back and forth through my ears. Grand demonstrated "inside window" technique, having me put a blacked-out lens over my right eye, so that I could see only out of my left eye and focus on the end of the pointer he held still, so that I could gaze through my eye's "spot", as I attended to the thyroidal "buzz" in my chest and a feeling of grief. For the next 80 minutes sensations, affects, and associations roared through my body/brain. First came grief. Old grief. Staying with it, I found myself thinking about my friend and mentor, Thom Negri, who had died of AIDS 12 years ago. Then all the AIDS deaths came. I had lived on Seattle's Capitol Hill in the 80's, the gay neighborhood. I lost many friends, neighbors, colleagues and acquaintances. I founded the Seattle AIDS/Mental Health Network, which did nearly free trainings for any psychotherapist who wanted information. I was power of attorney or executor for people. I did funerals. I had a message on my phone machine. "If someone has died, don't leave it on this phone message," after I couldn't bear to pick up my phone. It all came back. Despite having moved this material with movement work (at the time) and EMDR (since), I sobbed and sobbed and felt many sensations, some quite painful, run through my body. Grand seemingly did very little. He had me focus on bodily things, a few times. He was present and receptive, very "there". Even during the processing, I thought about how client-centered this technique was.

One of the few directive things he did, when I had a huge pain arise in my right (non-frozen) shoulder, was to tell me to be aware of the same spot on the left shoulder. When I focused to the left, the pain on the right abated. Eventually when I focused to the right, the pain was nearly gone. (It disappeared completely by the end of processing.)

Most of the sensations were up and down my core. Some painful, some just feeling. The only affect was grief, then relief. At the end of the processing Grand had me "squeeze the lemon" and try to bring back the grief and then the initial sensations. They're gone now. My head is more clear (also attributable to 4 days of thyroid meds) and the "buzz" is cleared for the first time in several weeks. It will be some time before I know what effect this work will have on the inflammatory process. Grand and Schwarz report using BSP with chronic pain, with fibromyalgia, and other physical ailments, to good avail. What I can tell you today, is that I feel lighter, clear-headed, and pain-free. My nose is dripping less. I'm breathing more easily. And I'm tired.

When it was all done, yesterday, Grand wondered aloud about what kind of an imprint those multiple losses can have on a body. I thought about his work with post-911 firefighters and families of lost firefighters. I thought about anyone who lives in violent Baghdad or Darfur or the Congo or all the African places where AIDS continue to reign.

I recommend Brainspotting. I recommend listening to David Grand. He has been one of the innovators in EMDR for many years. Now, as he teaches BSP, he constantly tells us to make it ours, to do what works, to innovate, and to use phenomenology (seeing what is and acting accordingly--by observation not theory) as our guide. I like it. I still do EMDR. I've done Brainspotting since last fall. I continue to do whatever works for my clients. Brainspotting works.

Grief

Here's excerpts of a letter I wrote to a neighbor whose adult child died in an accidental overdose. I've edited out most of the personal data, but left the general gist.

"I’m deeply sorry for your loss. Losing a child is beyond tragedy. I’ve been with my mother through the loss of my brother (eleven years ago, at 33 years old). Because of his drug involvement we weren’t surprised, but we were shocked, benumbed, and then broken open by grief.

It’s the day after the funeral. You’ve done the ritual things. What now? I want to share a little bit that I’ve learned in my personal and professional life. You may know all of it. If you don’t it might help a little—not that anything can fix this situation. It’s just that sometimes it’s nice to have a map, even through hell. Grief circles through somewhat predictable patterns. You clear one little piece (oh, I’m not going to see him at X holiday) then another piece arises to knock you over.

The pattern goes like this Numb, during which you can plan a funeral and sort of function, then Anger, (which can hold Blame, of your kid, your self, the Universe, God, Fate, and anyone else, including your beloved). Anger can come out at the guy who cuts you off in traffic, the slow clerk, the dog, or anyone. Tell yourself it’s grief, and don’t hit anyone. Sadness is next, and it can cut to Hopelessness and Despair and Depression pretty easily. You need to keep remembering that these are inevitable feelings, not definitions of either yourself or reality. You’ll cycle through all these feelings over and over, as reality keeps punching you, and you, somehow, keep getting it. After way longer than you think, you’ll start to integrate the reality a little at a time. You’ll be able to remember your son more clearly from happier times. You’ll smile more. Then you’ll see some kid who looks just like him, and the wave will knock you down again. After a while the waves get smaller and you get bigger, encompassing more of your life, even liking it again. My mother and other mothers say you never get over it, but it gets easier. My own experience of grief (my brother, my dad, and about 20 friends, including 2 best friends in the AIDS epidemic) is that the acute phase ends after way too long and then you simply miss the person, without feeling punched in the stomach or knocked over, just missing. Here are the 4 rules for grief that I came up with for my clients:

1. Grief always hurts far more than you think it should. 2. It always lasts far longer than you think it should. 3. As a process, grief sucks, and has nothing to recommend it. 4. Slowly, it moves through.

Advice: 1. Use your friends. It’s what they’re for. You’ll figure out the ones who can support you. 2. Remember to eat, hydrate, take vitamins, walk. 3. Try to add an hour or more of sleep to your days. Grieving is physical and it’s exhausting. 4. I have no idea if you drink. This would be a horrible time to start or do more. Alcohol creates depression when mixed with grief. 5. Don’t shame yourself for how you grieve. You don’t get to function the way you’d like to. 6. Use your husband. He wants to do something (probably, being a guy.) Tell him what works. For instance. “Hold me, don’t pat me, and don’t say anything.” If that’s what you want. Be explicit. Most guys, especially engineers, are good at working to specification. Tell him he can’t fix it, but that being with you, when you want to, is actually helpful. Send him to Doug for advice. Between my family, my close friends, dying clients, and the AIDS epidemic, Doug could have an honorary degree in grief counseling. He’s learned to shut up and simply be there. It helps. 7. Have rituals, whatever works for you. Talking to his picture, religion, an altar, whatever. Time to direct to dealing with your son. 8. Support groups of grieving moms can be helpful. You’ll feel normal there, at least. 9. Some people beat themselves up for not being grateful. People who’ve lost a kid don’t get to feel grateful for a long time. 10. You don’t get to hit people who tell you to get over it, or who try to make it o.k., but you can fantasize about it. Tell me, and I’ll hit them for you.

Please accept my condolences. I’m so sorry this has happened.