Trauma & Attachment Therapy

Living with the Awareness of Evil

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

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

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

How did I get through it this week?

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

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

New Theory Links Chronic Brain Inflammation to Depression

The more stress and depression, the more inflammation. University of California, San Diego, medical school report from Newswise: http://www.newswise.com/articles/view/569853/

Therapeutic Metaphors from Star Trek and other Popular Culture

Utilization is the idea that therapists should use the culture and the language that their clients already use. If your client has watched Star Trek, they already know how to utilize these great tools. 

• Safe place: "Do you know what a containment field is on Star Trek? Great! So imagine your safe place has a containment field around it. No one can see it, no one can get through it, and it will keep you completely safe from harm."
• 
  
• Sharing between Parts with highly dissociated clients: "We've cleared a lot of the trauma that that part holds. Does the Adult part feel ready to know what happened back then? Good. Then let the child do a Vulcan mind-meld with the adult and share the information about what happened and what it was like for her. Let me know when the transfer of information is complete."
• "So lets bring this to the Holodeck and run through the event so you can control how it turns out this time."
• Practicing: "So lets create this situation on the Holodeck, you can direct the Holodeck to create facsimiles of all the players and you can practice how you want to talk to that person/ those people until you feel that you know exactly how to do it in real life."
• "Now imagine transporting that 5-year-old self out of that bed and out of that time, letting her rematerialize right here and right now. Is she here? Then let her know who you are and where she is and that she's finally safe from that guy."
• Other magic:
• "What would Harry Potter do? What spell would you cast?"
• "Imagine you had Superman's/Wonder Woman's strength? What would you do then?"
• "So could you go back in time with Doctor Who and rescue that child?" (For Brits)

My clients are delighted when I speak their language and use what's already in their brains. If they've spent years with Star Trek or Doctor Who or the mutants in Heroes, their mirror neurons have already had them doing the magical activities, and are ready to take them into a different reality. 

Years ago, a cult-abused DID client cured her insomnia by imagining a Star Trek containment field around her bed, which she turned on before sleep. Later, after years of trauma-clearing and Vulcan mind-melds between related parts, she did a mind-meld between all remaining parts and integrated (mostly) in my office. 

  

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.)

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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.)

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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 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

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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.

 

 

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. 

 

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.

Reading Group: The Neuroscience of Psychotherapy by Cozolino

The next book in the reading group will be The Neuroscience of Psychotherapy, by Louis Cozolino (W.W. Norton, 2003). It's easier to read than you might think, and written by a psychologist, not a medical person, who struggled through the medical/scientific texts in order to bring we clinicians the good news. According to Cozolino, we are "rebuilding the brain."

The group meets on Friday, November 9 from 10-12 at my Seattle home. Contact me for directions. Bring a lunch if you'd like to stay later to socialize.

Obsessive-Compulsive Personality Disorder

We all know what Obsessive-Compulsive Disorder (OCD) looks like: repetitive rituals, obsessive thoughts, and the people who are thinking or doing the compulsive thinking or behavior and know that they're not being rational. Obsessive-Compulsive Personality Order (OCPD) is something else. People with OCPD are detail oriented, to the exclusion of the big picture. They are obsessed by control. They may get involved with organizational details, the minutiae of tasks, or tasks that have very little to do with what most needs to be completed in their jobs, their studies, their homes, and in their lives. Many OCPD folks are prone to angry outbursts when their environments, kids, or coworkers don't go with the program. They may be very nice, but they're not usually capable of intimacy.They are the nightmare managers from hell. They often don't keep or rise very far in employment. though they work half again as many hours as any other employee. And nothing is ever right with anything. Expect depression, anxiety, and either massive pollyannish denial or massive criticism of everything, including you.

Avoidance of anxiety is their not-conscious organizing principal. Here's how it works: If I need to get the big job done, and I feel anxiety when I think about the big job, I'll bring my attention to this little task that's not so scary and I'll do it perfectly, for hours. Working on the little task makes me feel better. (Dan Goleman's book Vital Lies, Simple Truths: the Psychology of Self-Deception descibes the biology of this phenomenom.) When I take my attention away from that which makes me anxious, the pharmacy in my brain gives me really good drugs. This is why procrastination and self-distraction are so popular. If I don't work on the scary task, I'll feel better, instantly. If I keep doing the intricately complex avoidance behavior, my brain keeps giving me good endorphins. If I've been self-medicating since childhood, by focusing on unimportant tasks, instead of anxious or checked-out or angry or controlling or absent mom and my own loneliness, I'm going to build a big neural net of reflexive avoidance/distraction behavior.

In my opinion, here's the etiology: First, there's a mom, who for some reason can't connect well with her child. Non-connecting moms, be they passive or screaming, are frightening to kids. If a kid learns to distract him or herself by focussing on little tasks, she can dissociate/self-medicate away the terror of being all along and taking care of him or herself. What he or she doesn't learn is the non-dissociative self-soothing techniques that arise from the attachment dance of connection, backing off a bit, and reconnection. So the child's only self-regulation comes from distraction/dissociation.

How do you treat these people? Mostly, they don't come to therapy, and you won't get the chance. Good therapy is the opposite of avoidance, the pathology keeps them away. However, once in a while, someone gets "drug in" by their spouse, or employer, or even their own miserableness and the work begins.

They will try to control the session and keep you focused on the unimportant details. Don't let it happen. Get more assertive than you usually are, or you and your client will unhappily spin your wheels for months. Since I start most clients off with Maureen Kitchur's genogram-based intake with its predetermined list of "nosy, snoopy questions", (EMDR Solutions) I'm able to keep the initial sessions on task, and then share what I think much of the therapy will be. Then work on four things:

1. Staying on Task in the sessions: Make and keep a strong alliance. Show your compassion and your grit. When they change the subject to some small distress of the day, say "Oh that's so upsetting when that happens! Let's go back and get the underlying material, so this won't have to be so distressing later on."

2. Work on Affect Tolerance and Self-Soothing: Tell them we'll start with one-pound hand weights and work up to the big feeling. Teach them containerizing of emotions, mindfullness techniques, relaxation, and containing their own inner babies. (April Steele's Imaginal Nurturing is wonderful for this, as are many kinds of ego-state work.)

3. Use EMDR or Brainspotting or whatever you have that works to target the early childhood relationship with the caregivers. "Imagine looking into your mother's eyes when you were an infant. What do you notice in your body right now, as you imagine your mom?" Clear whatever comes up. Go through all the ages until there's no distress.

4. Finally, target the avoided things. I adore Jim Knipe's Level of Urge to Avoid in EMDR Solutions. Knipe would ask these clients, "How good on a scale of 1-10 would it feel to completely avoid that big project by focusing on sorting out your sock drawer?" "Where do you feel that feeling in your body?"  "Stay with it." While applying a bilateral stimulation. Often the "inappropriate positive affect" (the endorphins) go down by itself and the clients are left with the somewhat appropriate feeling of dread about what they've been avoiding. Then target the dread about the project, clear it, and have them imagine doing the damn thing, step by small step. And then imagine what having it finished would feel like. Aahhhhhh.   If the inappropriate affect doesn't go down by itself, I often two-hand it. (Also in Solutions.)  "In one hand, hold how good it will feel to continue avoiding the project. In the other, hold the consequences for not doing it." Apply bilateral stimulation, and your clients are very likely to feel their discomfort and then be directable to clear it.

I won't kid you. These people need a long therapy. They've been reinforcing avoidance in themselves since babyhood and you and they have a lot of neural networks to rewire. And it's possible, with a good alliance and good attachment and affect work to create clients who can choose avoidance (vacations, breaks, movies, Spider Solitaire) and relationships and getting their real work done, over reflexive busy work, blowups, inadequacy, and loneliness.

NYT's Article on Unconscious Cues

Here is a great article about effect of unconscious cues on behavior. We don't consciously run our lives as much as we think. Thanks to Kathy Downing on the ERC-List for finding it.

http://tinyurl.com/yrpu7c