Trauma & Attachment Therapy

Stalkers: Classification and Treatment

Stephanie Rhys wrote a helpful article about Stalkers on Robert Muller's fantastic Trauma and Attachment Report blog right here: http://trauma.blog.yorku.ca/2012/06/29/in-the-mind-of-a-stalker/?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+trauma-report+%28The+Trauma+and+Attachment+Report%29

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.

Avoidance, AIDS Dementia, and Chosen Families

Last Wednesday I flew down to Fresno, CA, and flew back up with an old friend who, after battling AIDS for 25 years, is losing the fight. R''s brother and a few other friends and I have been managing his care up in Seattle for the last week.

R is one of my favorite flavors of people, a skinny nervous person, smart, funny, charming, talented, and relational. He has also had OCD since I met him in 1980. The OCD, related to a bipolar diagnosis, manifested in several ways, eating disorders, an inability to get out of the house without carrying half his belongings with him (the bag-lady syndrome "what if I need something"), and extreme indecision. The OCD also carried avoidance behaviors. R. avoided conflict, asking for what he wanted, and anti-retrovirals. He would get busy controlling the minutiae of his life while avoiding the big issues. In the last few years, he would worry incessantly about his belongings in storage units, while not chasing down the health care that he needed. Several of his Seattle friends offered to fly down to help him. He couldn't accept their offers because his appearance (another obsession) wasn't up to par, his apartment wasn't clean, and he would have to take care of them (another compulsion.)

Two months ago, R got pneumonia and began to show signs of dementia. His California social worker, Frida, and I talked him through getting on an ambulance to the Emergency Room. We both thought for sure that he would be admitted, but he was cut loose with some heavy-duty antibiotics and sent home. After a few weeks of daily calls by the Seattle support group, he had managed to take his pills daily, but was obviously losing his mind. A month ago his brother flew down and took over. 10 days later his brother's boyfriend drove down to help. R. was emaciated, covered with KS, and had about 2 minutes of short term memory. He didn't know where his own bathroom was. He didn't finish a meal without constant reminders. Last week I flew down and flew up with him. He was hospitalized at the best AIDS hospital in town and will go to Bailey-Boushay, a state of the art AIDS care facility, with loving staff and loving volunteers and really good art.

My feelings are extremely mixed. My lovely, vain friend, has a wasted body and a wasted mind. He's in pain much of the time. I'm grieving. I'm sad. But we have him now, he won't die alone, and he's in the best possible care, so I'm relieved, too. I'm also, clinically, fascinated by the dementia process (when I'm not frustrated by it or laughing.) R. can remember people and activities from 30 years ago. He can charm nearly every nurse and doctor who comes in the room. He remembers, at this point, all the people who love him and whom he loves. His right brain is working pretty well. His left brain doesn't tell him where he is, anything that happened in the last 6 weeks, what day or time of day it is, or the name of the person in front of him whose name he just asked. He is often sweet and charming. The more confused he is the snarkier he gets. He is very sarcastic, especially with his long-suffering brother. R. confabulates what he doesn't know. His brain makes up stories to fill the holes in his memory. Some are quiet elaborate. I haven't seen R in 8 years, nor has he been on a plane in that time, but evidently we've been on several long trips together. His brain told him that he has an apartment in a neighborhood of Seattle, not Fresno, and he wanted me to take him out of the hospital and take him home. Much of the time he thinks he's in Fresno, despite the view of Puget Sound out the window. His friend, Joe, says, "is that Fresno out the window?" and R. replies, "Oh, we're in Seattle." R., the compulsive care-giver, asks for back and foot rubs, tells the doctors that he wants us in the room to supply information that he won't remember, and has allowed us to talk him into many medical procedures. The right brain relational trust is working, even though the left brain thought process is not. His sentences are complete. His syntax is perfect. He knows his social security number. And he doesn't know who visited him or what vile procedure they just did or that his body is wasted or that he has AIDS. The KS constantly suprises him. (Advanced Kaposi's Sarcoma looks like an archipelago of red, mountainous islands everywhere but his feet, hands, and face. Sometimes it hurts like hell, sometimes it itches, sometimes it's hot to touch.) He asks, "Why am I so weak? Why do I hurt?"  "Honey, you have advanced AIDS." "When did that happen?"

Back in the 80's, I lost about a hundred friends, clients, mentors, colleagues, and neighbors to AIDS. I started the AIDS Mental Health Network, which gave free training to therapists about psychosocial issues, safe sex, dying, resources, anything we needed to know. It was before the AIDS agencies arose and we were flailing to find information and the skills we needed to take care of all these dying young men. Back then we created care committees: chosen families of caregivers that ran errands, cleaned houses, did pharmacy runs, took the person to the doctor, and generally hung out. There was no internet, so we communicated by phone, and sometimes by a log at the PWA's (person w/ AIDS) house. R. has an AIDS nursing home to go to, the Lifelong AIDS Alliance, and a group of about 5 people, including his brother, who are the support team. In the 80's, PWA's died within 16 months. R. has lived with AIDS for 25 years, at least, and is in the last stages with good medical and social support.

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.

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