Trauma & Attachment Therapy

A Highly Sensitive Man

Years ago, when I read Elaine Aron's The Highly Sensitive Person, I could recognize the HSP people around me with the innate ability to sense, revel in, or be overwhelmed by their external and internal worlds. These folks (I'm not one) are the best cooks, among the most creative artists in any field, and make with their ability to track both minute changes in their clients and the corresponding responses in themselves, some of the best therapists. They also can be over-loaded by too many people, too much noise, too much light, too much commotion, and their intense awareness of their own internal states. See Aron's website with her books and other information, here. 

I just read a lovely post by an HSP man, Rick Belden, coming out as Highly Sensitive and exploring issues of maleness as HSP. Every therapist and every HSP and interacter with HSP's (that would be everyone) should read this lovely post.  http://rickbelden.com/blog/2012/11/16/i-am-a-highly-sensitive-man/

Related articles

Are you a highly sensitive person?

The Highly Sensitive Person and Creativity

NYT's Article: Stimulants given to soldiers may increase PTSD.

Dr. Richard Friedman in "Why Are We Drugging Our Soldiers" shows the correlation between Ritalin and Adderall prescriptions and increased PTSD. He cites several studies showing that these drugs enhance the memory of fear-provoking events. Scary and makes all kinds of sense. Read it!

Cultivating identification with the "other", thus love and peace.

A great article about why we have aggression towards "the other" and how to cultivate identification and peace inside and outside of us. The Wolf of Hate by Rick Hanson on mentalhelp.net   

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.

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.

Kathy Steele: Neurobiology of DID, on Science Friday

Kathy Steele, cocreator of the Structural Dissociation Theory, patiently defends the existence of Dissociative Identity Disorder to Ira Flatow and Numan Gharaibeh (a clueless psychiatrist) on NPR's Science Friday. Worth a listen: http://www.sciencefriday.com/program/archives/200911133 

I've run into this blindness before, mostly in analytically trained psychiatrists, despite all evidence.

Spirituality and Neuroscience

There was a great series on National Public Radio this week about the neuroscience of spirituality. I'm going to post links to all 5 days. You can read about it and then play the pieces if you want. They're by Barbara Bradley Haggerty and each is 7 to 9 minutes.

1. Is there a God chemical?                     http://www.npr.org/templates/story/story.php?storyId=104240746

2. Are Spiritual Encounters All in Your Head? http://www.npr.org/templates/story/story.php?storyId=104291534

3. Prayer May Reshape Your Brain, and your Reality: http://www.npr.org/templates/story/story.php?storyId=104310443

4. Can Positive Thoughts Heal Another Person: http://www.npr.org/templates/story/story.php?storyId=104351710

5. Decoding the Mystery of Near Death Experiences: http://www.npr.org/templates/story/story.php?storyId=104397005

UCLA Trauma Conference Synthesis

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

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

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

What are the threads that run through this varied work?

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

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

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

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

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

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

UCLA Trauma Conference Day 2: Dan Siegel, Mindfulness

Daniel Siegel: A System's View of Disintegration & Integration

(He's still cute, he's still brilliant, he speaks in easy-to-remember aphorisms and he's still heartful. What's not to like?)

"Integration is the linking of differentiated parts. The concept is useful for assessment, tx planning and therapy. . .Presence is absent in trauma survivors. Presence begins with us as therapists."

P.A.R.T.T.T.T  
when fully
Present we can
Attune to the client or others and
Resonate with others and develop
Trust which is important because it activates the smart ventral vagus so the social engagement system turns on so that we can
Track what's going on in moment to moment experience which allows the
Truth to come out and creates
Transformation/healing.

We help clients become open systems: self-organized: chaotic moving toward complexity, flexibility and adaptable: energized and coherent. System acheives complexity by linkiing differentiated parts. Coherence comes from integration. (Thank God for systems theory in social work school in 1979! I understand this stuff!) When not integrated we move toward rigidity (avoidance), chaos (flooding) or both.  It's all about the mind regulating the energy and information flow. "The mind is in the whole body and among people: it's embedded socially/relationally and embodied." "What I am is a process of regulating energy and information flow, not limited to our bodies and right now and this relationship. The ripple effects after we leave or die are also who we are." (My woo-woo teacher says the same thing. So does Hillel, sort of.)

Calming exercise: Put one hand on your heart, the other on your abdomen. Hold them there for a while. Try switching hands to see if you prefer one over the other. Most people do.

Your right hemisphere contains the storage of autobiographical information. PTSD is impaired integration. Long story about how a past trauma impeded on the present and how mindfulness allowed him to integrate the past event and stop reacting to the trigger.

"There's a distinction between awareness and mental activity: Awareness is the infinite possibility of neural firings."

In trauma, mental activies get locked into rigidity and chaos and pull humans into limited possibility. With unresolved trauma, rigidity and chaos imprison the person's possibilities. Good therapy transforms the brain of the the client to totally shift their center of attention and stay present to the self and watch self and make sense of it. The labeling of the internal state downregulates the limbic system. The client knows that "this" is not "that". Integration is the capacity to sit with core awareness and sit with anything that comes in. You can use mindfulness practice to help people distinguish between mental activity and true awareness. Ventral integration--being touch with the bodily state: Track it and you transform. Supress it and it screws you up.

"Liberate the innate drive of a complex system to integrate. Interpersonal integration: We are designed to be interdependent and interconnected. There's hope for we as humans to move from chaotic & rigid states to integration, kindness, and peace.

(Thank you, Rebbe Dan.)

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

After Dan, Martha Stark, a child psychiatrist spoke about Optimal vs Traumatic Stress. Traumatic Stress overwhelms and disrupts. Optimal Stress provides the impetus for transformation and growth. Optimal Stress--you need enough to stimulate adaptation and growth but not enough to overwhelm the system. In therapy, challenge when possible and support when necessary. (My brain was full and I took a walk.)

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

The Question and Answer period at the end of the day was worth the price of admission:

Dan Siegel: Txist attunement helps clients widen their ability to be with emotions and curiosity; integrates the experience; brings openess; widens the window of affect tolerance and acceptance and love, and moves away from rigidity and chaos. Be safe but not too safe: push the limits of the window of tolerance.

Francine Shapiro: Schizophrenia is sometimes misdiagnosed. Not all psychosis is genetic. Some is trauma-based, early and not-so-early childhood. If you target the negative experience, set up information processing. If they have positive networks to go to, the trauma will clear. Do processing if the client can stay present during processing (maintaining a dual awareness) and have positive experiences to call on. Otherwise spend as much time as you need to set up those positive networks. Truly schizophrenic people can be traumatized by their disease or by abuse, or disrupted attachment. Go after those targets if the client is resourced enough.

Pat Ogden, to Dan: Too much attention to mindfulness doesn't develop relational capacities. Dan to Pat: If you improve mindfulness, people have the capacity to connect. Capacity for the parent to be with his/her own self and material predicts the kid's secure attachment.  Teach people to harness the social capacity of their brains.

Steve Porges: We've developed to deal with humans, but school teaches/rewards dealing with objects. Psychiatry depersonalizes relationships. We need to teach social interaction: develop exercises. Play tempers mobilization states. We need more exercise that is face-to-face. Treadmill running teaches mobilization, badly. (I disagree.)

Bessel van der Kolk: Med school kills empathy in trainees. (Cited research)

Francine: EMDR and Dreams. Same brain process. (Robert Stickgold) Customize sets by attuning to clients needs. Goal is to take the REM state further than it goes in sleep. Images change in each set as new positive information comes in. . . Early therapeutic intervention for early humiliation would help people immensely. We need to teach parents and educators the impact of humiliation. (Jim Knipe and I wrote chapters about using EMDR on these issues to clear depressionin Solutions II.) The window of tolerance closes because of these childhood negative experiences.

Bessel: EMDR is hypnagogic, like sleep with very rapid associative processing. . . But people need to move, to play. EMDR has no movement. People need to complete the movement. But, research shows that EMDR clears 83% of the trauma. Movement-based treatment doesn't have the same success.

Martha Stark: Did EMDR with an insomniac client over a suicide attempt. In processing she remembered that at the last minute she saved herself, and the meaning about self changed for the better. Her insomnia disappeared and she started to remember her dreams.

Skipping some -- too tired.

Dan: Mindfulness creates secure attachment to the self. It's a way of being. Mindful awareness is brain hygiene, not a religion, should teach it in schools, to doctors, and create empathetic practitioners.

More in the next few days. Steve Porges read this blog and told the other presenters about it. I got some interesting attention today.

 

 

UCLA Trauma Conference 3/7/09 Day2: Porges

Stephen Porges, Demystifying the Mechanisms of Trauma: Maladaptive Consequences of Adapative Bio-Behavioral Reactions to Life Threat 

Stephen Porges knows how to connect. I could listen to him talk all day.  I explain his Poly-vagal theory to every trauma client and every consultee. Today, after he answered a difficult question, in a most kind way, my friend Barbara said, "Now, I'm in love with him."

Here's a post from exactly 2 years ago on Porges and his work. It might help to read it first. http://traumatherapy.typepad.com/trauma_attachment_therapy/2007/03/ucla_attachment.html

Here is the quick and dirty explanation of the Polyvagal (PV) Theory: "Neuroception of danger and safety or life threat trigger 3 neurological circuits." They developed at different evolutionary times. The newest one (Green Traffic light) occurs when we understand that we are in a safe environment. When it's on, we have the capacity to be socially engaged, to think, to hear and understand other humans, eat and to play. The second oldest (Yellow light) is engaged when we perceive danger, but we don't think it will kill us. In this mobilized state, we attend only to cues about danger and safety. We can't connect well, we can't even really hear people. We are scanning for danger and predators. The third state and evolutionarily oldest state (Red light) is immobilization in the face of life threat. We shut down completely, can't connect, feign death, and can't/don't have protective reflexes. (Can you say "dissociation?) 

Today, Porges said that "our nervous system reacts differently to the same stimulus, depending on our psychological state." The Polyvagal theory is about our biological quest for safety. He bemoans that these states aren't better recognized and then explained to clients, medical patients and all trauma survivors. Here are some but not all of the gems from his presentation:

People are different. The same stimuli can create different states in different people depending on a host of factors: genetics, attachment, and history. He talked about voodoo death--when people are literally scared to death, they aren't hyper-mobilized, but immobilized. Their hearts and respiration slow down to nothing and they just die, when cursed or after having broken an "unbreakable rule" and they have no ability to escape, no options, or are being held tightly.

"Immobilization with fear is a missing concept in psychology and psychiatry and medicine."

Vagal Paradox: Slow heart rate is mediated by the vagus. Sometimes too much (see voodoo death.) Heart rate variability (a good thing) is primarily mediated by the vagus and is a protective factor. "If the face is flat, the heart rate is flat. If the face is lit up, there's heart rate variability."

Singing, listening and chanting: when we feel safe and tuned into the tones we hear best, the human voice, we can't hear the low tones, the predator frequency. . . New brain circuits damp or control the old ones. We lose the adaptive urge in immobilization, pain threshholds are raised, we conserve metabolic resources and are prepared to die. (Imagine chronically abused people who live in this state, over and over.)

Yoga students with abuse history get a higherheart rate after mild exercise. No abuse hx, makes for a lower heart rate. Abuse supressed vagal regulation and lowered the threshold to be defensively reactive. Tell clients: "Your threshold to react changes and this is what happens."

Since "social behavior is a regulator of our physiology", use your self to help your clients regulate. Make the office safe. Make it quiet. Muffle the low traffic noises. Have face to face interactions that are safe.

"Face to face is play with reciprocity." What could be aggression without face to face contact becomes play. Puppies and kitties look at each other when playing. So do kids. So do people in consensual sex. People can be in a mobilized state, without fear, in play. They can be in an immobilized state without fear in play or rest. (Baby in mom's arms).

The nervous system continuously evaluates risk. Reactions to life threat is not easily reversed. These reactions can bring up rage if a client misreads the clues. (Think borderline or DID clients.)

Auditory pathways (music, voice, and song) invites proximity. It's the first route in to change the nervous system. Music therapy in the frequency of the human voice and social engagement help traumatized clients regulate themselves. So does Prana Yana breathing, with slow exhalation.

(Stephen, if you care to correct, edit, or add anything, I'd be honored. Links to articles or websites would be great, too.)

More tomorrow.

 

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.

 

 

Babette Rothschild: The Body Remembers

The name of the workshop was "The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment".  The main point was: therapists do too much trauma therapy too early and should do much more preparation before they do the "memory processing" and should often do no trauma processing at all. She talked alot about helping people regulate their physiology by 1. "Talking about recipes or baseball" 2. Tracking their sympathetic and parasympathetic responses 3. Using cognitive techniques to separate past trauma, experienced as flashbacks, from here and now reality  4. Using some simple toning techniques to ground and feel the body. 5. Noticing external and internal resources.   Then she left out "making the experience of trauma go away."  The physiology was old hat: sympathetic and parasympathetic instead of vagal nerve tone, wrong information about the hypothalamus, etc.

I like trainings in which the presenter turns the fire hose of information on me and I have to swallow all that I can. This wasn't one, by design.  Rothschild says that she wants people to get the theory and then extrapolate what to do, out of that. She wants to go slow so that people can take in what she's saying. I agree with her suggestion that clinicians learn at least 3 trauma techniques and then figure out which ones will work with which clients. And I felt that we could have learned what she had to say in about a third the time, so I'm still disappointed. She is in private practice and doesn't take insurance. She seems to do therapy as if there is all the time in the world and that her clients must be ever protected from their distress.

As someone trained in about 10 kinds of trauma processing, I agree with having many techniques. And I think you should have enough technique and interpersonal containment to halp your clients move through the trauma, not just learn to calm down when you have it. Yes, you may need a long preparation phase and you need to have a stable client before you start. And the processing phase is important. Done well, it makes the trauma go away, a good thing.

WALL-E, a Story of Attachment

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

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

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

 

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

A Neuroscientist Explains Her Stroke

Check out this amazing 18 minute video suggested by Kelli Sherine:

http://well.blogs.nytimes.com/2008/03/13/when-a-brain-scientist-suffers-a-stroke/

Dan Siegel's Parenting From the Inside Out

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

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

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

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

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

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

MYSHRINK.COM

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

The Neuroscience of Psychotherapy

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

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

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

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

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

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

The Neuroscience of Photographers' Artistic Process

My husband, Doug Plummer, who is a wonderful professional photographer, interviewed me for a podcast about the neuroscience of "being in the zone" of taking good pictures. Given our interests, it's an ongoing discussion. Here's the podcast. It's about 15 minutes long, boiled down from about an hour. If you'd like to visit Doug's blogs go to http://dougplummer.blogs.com/daily/  to see his picture of the day, taken that day. Go to http://dougplummer.blogs.com/dispatches/ to read his blog about photography, birds, and contradance. (Today's post includes a picture of me holding a brain.)