Trauma & Attachment Therapy

Australian Prime Minister Apologizes to Sexual and Ritual Abuse Survivors!

Here is a link to speech by Scott Morrison, the Prime Minister of Australia, from 11/25/2018, apologizing for his society's lack of support for and belief of sexual and ritual and institutional abuse survivors. I would like to see every leader of every country make this speech.

For the video: https://m.youtube.com/watch?v=zp5IgxPhee4

For the transcript: https://www.sbs.com.au/news/i-believe-you-your-country-believes-you-pm-s-apology-to-child-sex-abuse-survivors

Easy Ego State Intervention Workshops

Dear Readers,

Ego state work has been around since before Freud, and in latter years, has been the main stay of many practices. Interventions can range from "How old did you feel when you were yelling at your wife?" to "Let's identify those dissociative states that take over your body." I've been working with this stuff since I became a therapist, 38 years ago, and have read, been taught, taught, and written about it, extensively. It's one of the most versatile tools and lenses through which to see clients that I have.

In January, I expanded my 2-day Ego State training to 3 days and presented it in near London, England. there was time for practice, demonstrations, and some case consultations. Participants raved about the workshop, saying things like "I know MY parts now!" "I know exactly what to do with many of my clients!" "This is the most practical workshop I've taken!" There is special info for EMDR practitioners, but you don't have to know EMDR to take the workshop and get credit. EMDR practitioners get 12 hours for EMDRIA and 12 for their profession. Others get it for their profession.

I'm  giving it several times this year. 

• 4 days in Milan,Italy.  May 10 -13 https://www.international-isc.com/wp-content/uploads/2017/12/brochure-shapiro-ing.pdf
• 3 days in Seattle, WA, June 8 - 10 https://www.eventbrite.com/e/easy-ego-state-interventions-seattle-tickets-44375863402  
• 2 days in Des Moines, Iowa October 20 and 21st, link to follow
• 3 days in Boston November 9-11, link to follow

Here is what I cover:

• Distinguishing Healthy/Flexible and Dissociative Ego States (and map your own)
• Overview of Ego State Interventions
• Identify Vagal States
• Use Embodied Ego State Interventions (includes practice)
• Clearing Trauma (includes practice)
• Theory of Structural Dissociation
• For EMDR practitioners, distinguish when EMDR, when EMDR and when both are the treatments of choice
• Tools to work with sexual abuse, and then bring back healthy current sexuality
• Work with Attachment Issues, including April Steele’s Building a Secure Self (practice)
• Couples Therapy
• Calming Over-Active Immune Systems, Multiple-Chemical Sensitivity (possible demo, if someone has one)
• Pain Protocol
• Shame (practice)
• Suicidal clients
• Resourcing (including installing your own “team”)
• Healing Personality Disorders
• Working with Dissociative Identity Disorder

If you can't get to a workshop, you might read Easy Ego State Interventions or sign up for one of the many good trainings on this subject. It's good stuff to know!

Why I love EMDR!

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

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

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

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

Trauma is Curable: My letter to the NYTimes

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

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

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

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

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

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

ROBIN SHAPIRO
Seattle, Aug. 4, 2013

 

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

Penn State: Was the abuse too horrible to acknowledge?

Here are two similar views of the Penn State child abuse debacle. One from the anonymous humble2humble blog (obviously by a man of faith who understands child abuse): http://humble2humble.blogspot.com/2011_11_01_archive.html. The second is by David Brooks, from yesterday's NYT's: http://www.nytimes.com/2011/11/15/opinion/brooks-lets-all-feel-superior.html

Both speak to the commonality of denial and avoidance. Both are great writing. What do you think?

Vets discharged with PTSD finally allowed benefits.

It took a law suit and it's about time!

http://www.washingtonpost.com/local/dc-politics/2011/08/02/gIQAEm8cqI_story.html?fb_ref=NetworkNews&fb_source=home_multiline

Dissociation Often Caused By Disrupted Attachment

Andrew Leeds' Sonoma Psychotherapy Training Institute posted a great article on its blog: Developmental Pathways to Dissociation. They quote Dutra, Bianchi, Siegel, and Lyons-Ruth saying that ". . . lack of positive maternal affective involvement, maternal flatness of affect, and overall disrupted maternal communication were the strongest predictors of dissociation in young adulthood." Read the whole article here:  http://www.sonomapti.com/sonomaptiblog_files/developmental_pathways_to_dissociation.html

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.

When Encouraging "Self-Care" Feels Like a Brush-Off

Dr. Kathleen Young, writes in her wonderful blog: Treating Trauma in Chicago, about when self-care is interpreted as abandonment. Read the article and the comments, then look at the rest of this great blog: 

http://drkathleenyoung.wordpress.com/2010/11/08/does-self-care-mean-others-dont/

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/

How Trauma Therapy Works, a Video

Here is a 9 minute video of me talking about how trauma therapy works. Expect more pieces of this video in the future. My husband, the videographer and photographer, Doug Plummer made the video.

Why We Do Trauma Therapy

Here is the last paragraph of the Introduction to Trauma Treatments Handbook, Protocols Across the Spectrum. You're seeing it before the publishers do. Before I send it in, do you have anything to add about why we do this work? I'll publish what you write, unless it's spam.

 

As trauma therapists, we are privileged to use all of our selves to help people heal from deep wounds. We connect deeply, from the heart, all day long. We use our detective brains to puzzle out what is happening with our clients and what do about it. We enjoy helping the grateful single-trauma survivors get quickly back to their lives. We dig deep into our skills while slowly and carefully helping our most dissociative clients into their new, healed selves. We continually learn new skills from the innovators in our field and in innovative collaboration with our clients. We hang out with colleagues who love their work and support ours. Throughout each therapy we are delighted to hear, “I finally know it’s over!” “I feel like ‘me’ again!” “It wasn’t my fault, I was a little kid when that happened.” “I’ve got my body back!” “I can have sex again.” “I didn’t have one nightmare all week!” “Thank you for letting me get completely here and now!” “I’ve got my life back!”

 

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.

Self Care for Trauma Therapists

As trauma therapists, we are privileged to watch our clients’ trauma fade from terrible, here-and-now experiences to mere memories; their dissociation shift to integrated presence, and their pain disappear. We are also privy to the gut-wrenching details of rape, accidents, war, and story after story of child abuse, domestic violence, and horrible neglect. The more terrible the abuse and the more dissociated the clients, the more they project the actual emotions of their trauma into us. Some therapists become grim. Some avoid complex trauma clients. Some help their clients avoid expressing affect in the sessions. Some burn out and leave the profession. Here are some ways to keep yourself whole while doing this important work.

1.   Do your own work. If you’re not able to tolerate your own history and your current affect, you won’t be able to tolerate the despair, rage, shame, and grief that move through many trauma survivors.

2.   Learn mindfulness. Meditate, do yoga, do chi gong, do breathing exercises. It will help you “stay in the chair” while witnessing whatever is there to see. Learn to breathe and ground yourself while being with anything.

3.   Know yourself. If you start a session in a state of equilibrium, and you start feeling rage or exhaustion in the session, guess that it may be the client’s rage or dissociation. If you then say “What are you feeling right now? There’s something in the room.” The client is likely to say, “Oh, I’m angry, I guess it’s about X.” or “Oh, I was just spacing out.” When you know where you are, you’ll know when you are being drawn into someone else’s experience and use it for their benefit.

4.   Know the signs of burn out:

a.   You aren’t excited to go to work.

b.   You talk only about work and have no other interests.

c.    You treat everyone on earth like a client.

d.   You dream about clients, all the time.

e.    You’re angry at clients for being the way they are.

f.     You feel shame for your human limitations.

g.   You have vicarious PTSD: flashbacks, anxiety, depression, avoidance around client material.

h.   You want to drink, gamble, or otherwise dissociate after work.

5.   Get support.

a.   Join a supportive consultation group. (Not just about the technique, but about you, too. And no shaming allowed.)

b.   You might get individual consultation for the most troubling cases. As a consultant, I’m going step-by-step with a few consultees with their most fragile, barely tractable cases. It’s good for the therapists and good for the clients.

c.    Increase your therapeutic arsenal. If what you’re doing isn’t working, find something else that does.

d.   Do your own work. Hire a good trauma therapist who can help you clear your vicarious trauma.

6.   Develop other interests that have nothing to do with therapy. Make sure some of them involve unmitigated joy.

7.   Do things that bring you into your body: Run, stretch, work out, dance, do yoga.

8.   If you have any control over your schedule, limit the number of the most complex, dissociated, abused, unstable clients. And don’t put them all on one day.

9.   You will probably learn your tolerance the way most of us do, by exceeding it. Once you know, keep your own boundaries. Follow the Platinum Rule: “Fill your own cup first, then give away what’s left over.” And another rule, “To Thine Own Self Be Nice.” Trauma is compelling, but don’t let it run your entire life.

10.  Watch out for grandiosity. You can’t fix everything. Know your limits.

11.  If you have a spiritual practice, use it to support your work. Ask whatever higher power you have for help when stuck.

 

 

Lessons Learned While Writing A Book for Psychotherapists

I'm 13 chapters into writing Trauma Treatments Handbook, Across the Spectrum. Here's the advice I'd give anyone doing the same thing:

• Get a second screen for your computer. Keep the reference page, internet search materials, etc. open on the second screen. It will save you days of searching for the right open file.
• Start the reference list on the first day of writing. Write the reference first, then refer to it in the text. Do it on a separate page.
• Figure out who you're writing for and address the book to them. I have a range of imaginary readers, from clueless, but bright, grad students to informed therapists. I try to keep it simple enough for the students and entertaining and interesting for the rest.
• Use your own voice and use active voice. It's hard to read academese. Don't try to impress anyone with how much you know. It's not the point. Make it accessible.

• Don't worry about people hating it. Some will. I'm writing a book that will piss off every true believer, by showing the usefulness of every trauma technique that I know about, and by talking about the shortcomings, too.

• Take some time to only write. I just took two weeks off, writing about 5 hours a day. I was able to hold all the chapters in my mind and let the obsession take over me: waking at 3 and 5 a.m. to scribble notes. Up at 6:30 with my brain ready to go, moving things from one chapter to another. I finished 4 chapters, including one very long one. My brain needed time to nail the structure of the book.

• Make a list of acronyms to put at the end of the book. I've wanted every therapy book to have them. Put them on the list the minute they pop up in the text. I'm up to 3 full, double-spaced, pages of acronyms and 9 pages of references, so far.

• Talk over difficulties with anyone who is around. Everytime I began to tell my husband about a quandry, it solved itself before I was done explaining it.

• Use the thesarus on dictionary.com

• Read many sources.

• Share milestones with your friends, virtual or in person. Let your publisher know too. They worry about books not being on time.

• If you don't know something that you want to include, ask everyone. I still don't know where Kluft said, "The first integration, isn't." Do you? Or was it Kluft?

• Enjoy the process of writing. Let the "alter" that writes take over and type. It's easier than torturing yourself over every word.

• Don't fall in love with your words. Reread. Edit. Reread. Edit. Reread. Edit. But don't worry. Your brain knows. Trust it. And trust that there will be mistakes in y our book. Despite you, your professional copy-editor and your friends.

• Back up everything to an external hard drive, every day. Every done chapter, send an email with attachments of all chapters to a few friends who don't live in your town and ask them to put the attachments on their hard drive. If you have gmail, as I do, you can send the attachments to yourself and they'll live in the gmail "cloud" of servers. Losing a book is a terrible thing. BACK IT UP!

• Exercise, get massage, socialize. You live in a body with needs. Take care of yourself.

• A book is a great excuse to neglect your blog. Sorry everyone!

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 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.

 

 

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.

"The Post-Traumatic Stress Disorder Sourcebook"

I'm reading piles of books in preparation for writing a trauma therapy survey book. My friend and colleague, Barbara Hinsz lent me Glenn Schiraldi's The Post-Traumatic Stress Disorder Sourcebook. (McGraw-Hill, 2000) It's a great self-help book, one of the best I've seen. Schiraldi's a good writer. I never wanted to fix his sentences. He's simple without being simplistic. He gives a great description of dissociation. He talks clearly and cleanly about therapy. (Giving CBT, EMDR, Counting, and TFT good "marks", describes many other self-help and therapeutic techniques, and gives the same warnings I do about prolonged exposure.)

If you have a client who wants more information and some good self-help advice as an adjunct to therapy, suggest this good and wise book. And if you have suffered a trauma, and are still feeling the after-effects, read this book. I just bought one for myself.

Waltzing With Bashir

Ari Folman has made a beautiful and devastating movie about trauma, dissociation, and war. As a young Israeli soldier, he was in the 1982 Lebanon war. When a friend came to him with troubling memories of that war, Folman realized that he had no memories about being in Lebanon. A therapist friend told him to ask fellow veterans about what happened and Folman interviewed people until his own memories came back. The movie is animated. It flips between "talking head" interviews with middle-aged men at home, and their younger selves in Lebanon. The animation is amazing; the music, perfect; the characterization of the various soldiers/veterans makes them totally human.

You see the trauma and the men's attempts to cope with it. One man,was considered a genius as a teen. As an adult  he hides on his Dutch farm, constantly stoned.  Some seem untouched. Others still devastated.

As the movie unwinds, you see the event begin to come together--The assassination of Bashir, the Lebanese Christian Falangist leader, led his followers to slaughter men, women, and children in a Palestinian refugee camp. The Israelis, their allies, were supporting the Falangists to "find the terrorists". By the time the Israelis understood what was going on, and the word finally got to the Israeli leadership (slowed down by idiocy and disbelief), it was too late. The last few minutes of the movie are film footage of bodies and wailing women in the camps. There is no other resolution. Nothing to make us feel good.

The movie brilliantly portrays what trauma looks like. Its director also directed the original Israeli In Treatment , which portrays among other things, the therapy of a soldier who inadvertantly bombed an orphanage. I wonder if he was compelled to do In Treatment, before he remembered what he forgot about his own war experience. Here's a link to some "stills" from the movie, and an interview with Folman.  http://lukeford.net/blog/?p=4343 My favorite lines in the interview are, "Having made WALTZ WITH BASHIR from the point of view of a common soldier, I’ve come to one conclusion: war is so useless that it‘s unbelievable. It’s nothing like you’ve seen in American movies. No glam, no glory. Just very young men going nowhere, shooting at no one they know, getting shot by no one they know, then going home and trying to forget. Sometimes they can. Most of the time they cannot."

Evidently the movie brings two distinct responses from some Israelis: "Folman should be shot as a traitor for bringing up the incident."  Or "It's good, he's finally showing the world that it wasn't our fault." My response and the response of the two Israelis with whom I watched the film, was devastation and hopelessness. In the light of our despair over the recent attack on Gaza, we were stunned. We had to walk in the cold wind, swing on swings, and watch children play in order to bring ourselves back to here and now in our safe Seattle neighborhood. Today, I'm back to thinking that the little we do as trauma therapists makes a differences. As Hillel said, "If you save one person, you save the world." I need to keep this always in mind, or I get paralyzed by the trauma we humans create.

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.

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

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

Counting the Walking Wounded

By LAWRENCE M. WEIN in the New York Times

Published: January 25, 2009

Stanford, Calif.

Related

Times Topics: Veterans and Post Traumatic Stress Disorder

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

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

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

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

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

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

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

 

 

Principles of Trauma Therapy, Briere & Scott

I'm doing research for my next book, Trauma Treatments, and just finished John Briere and Catherine Scott's Principles of Trauma Therapy: A guide to symptoms, evaluation and treatment. (Sage Press, 2006). It's a good book, full of common sense and practical advice about trauma survivors. Briere and Scott do a good job explaining the effects of trauma and the way it manifests in different kinds of people. They mention temperment, a subject neglected in much of trauma therapy. Since Briere comes from a psychodynamic background, he emphasizes the importance of the relationship as a component of healing (backed up by Alan Schore and Dan Siegel, my heroes.) And he does a good job of explaining the "therapeutic window" in which trauma treatment occurs: between too little and too much activation of traumatic material. He lays out an amalgam of cognitive and relational therapies called the self-trauma model. He mentions Acute Stress Disorder, the precursor to PTSD. And he has a comprehensive chapter on medications and trauma. It's nice. and it's not enough.

Through-out the treatment section, I kept thinking, "You're missing the body! You're missing affect! Get out of your clients' heads and into their experience!" I wanted to drag Briere out of the book, teach him EMDR and movement work, and let him loose with his magnificent skill set and deep understanding. As he talked about trying to keep people from running out of the room during exposure therapy, I wanted to say, "Tap on them!" When he talked about how people are often traumatized by exposure therapy and often leave therapy before they're healed, I had the same feeling. I used to do exposure, I was trained at a rat-running behavioral undergrad school (U of Iowa) and a CBT-oriented MSW program (U of Wash.) And when I learned EMDR, I finally had a tool that made the trauma go away, quickly enough that people didn't need to run out of the room.

If you are just starting out as a therapist, you might read this book to get the broad view of trauma, it's effects, and good common sense ways to begin treatment. Then go get trained in EMDR, body-centered therapies, and Brainspotting. You'll be ready to do good therapy with traumatized people, hitting all the bases. 

Projection: the Underpinning of Political Polarization

I woke up way too early musing on our polarized election. In Washington State, where I live, there are two close races, for governor and for congress. The negative advertising is relentless and fierce. One gubenatorial candidate is backed by the builders' industry, which is pouring millions of dollars into villifying and lying about his opponent. And you all know the discourse at the presidential level.

I'm appalled, but not surprised. The name-calling of our current candidates is nothing compared to what our founding fathers did. No one is being accused of treason or sedition, or selling out to the enemy. No contemporary candidate is calling for the hanging of his or her opponent.

The psychoanalytic and object relations theorists talk about projection. Wikipedia defines projection as "a defense mechanism in which one attributes one’s own unacceptable or unwanted thoughts or/and emotions to others. Projection reduces anxiety by allowing the expression of the unwanted subconscious impulses/desires without letting the conscious mind recognize them." We, the good Germans/Tutsis/Royalists/Protestants/fill-in-the-blank, are for the common good. Those dirty Jews/Hutus/Seditionists/ Catholics/Black/other football team/different people are the bad ones. Politically, projection appeals to our most basic (and base) natures. We don't have to acknowledge our own aggression, greed, and hatred. They are the bad ones. Not us.

When clients hit the anger phase of healing from a trauma, they are often ashamed and sometimes aghast at the intensity of their hatred. Part of the therapeutic process is explaining that every human on this planet has aggression. It gets us going, it helps us defend ourselves, and it's innate. I explain that the trick is to own our aggression, monitor it, and process through it, like any other emotive state. And then cultivate the parts of us we of which we approve. Can you imagine a political leader saying, "Look, we as a people have been greedy, self-serving, and blind to the good on the other side. Let's talk about what's good over there. Let's talk about where we don't measure up. Let's make this work together."

Personally, I use the meta meditation to connect me with myself and the rest of the planet. As a human, I'm not above polarization, stereotypes, and bad thoughts about the "others". As a human, I've also got a thinking brain and willing heart to try to mend my innate aggression. You do each part, until it really sinks in and you feel connected. Here's the version I use. There are many. It takes me about 10 minutes.

Meta Meditation

May I be well. May I be happy. May I be at peace.

May my loved ones be well. May they be happy. May they be at peace.

May all the people in Seattle be well, happy, and at peace.

May all the people of this hemisphere be well, happy, and at peace.

May all the people of this planet be well, happy and at peace.

Then I bless  specific trouble spots in the world. Then when my heart is really open, I focus wellness, happiness, and peace on some of the people, about whom, in another mood, I have other feelings, mostly specific politicians. It works for me, and for a little while, knocks out the automatic projection of evil onto those "different" people.

There is true evil in the world. I work with people who have been tortured, raped, and sorely used. My step-father was a Holocaust survivor. And I try to work against Evil. Scott Peck says that Evil happens when a human being doesn't see another as human. I'm trying not to cultivate blindness to others' humanity. And I am trying to cultivate the part in me that can see beyond my own knee-jerk projections.

 

Trauma and Temperment

I recently took on several new clients and am on my 3rd session with several new people, I'm struck by how much temperment affects people's experience of trauma. Some people have iron constitutions. It's hard to scare these people. It takes a truly life-threatening trauma for them to experience PTSD symptoms.

Others are traumatized by a harsh look, a trauma once-removed, or an unmet expectation. These folks, often with anxiety diagnoses, need more trauma processing sessions, more containment, and more reassurance than the other kinds. I can take all the factors I know into account: attachment history, prior trauma, culture, etc., and temperment stands out as one of the strongest predictors of posttraumatic symptoms. I wonder why it's so little researched and so rarely discussed. Elaine Aron's The Highly Sensitive Person, speaks to this issue. Is there anything else out there?

If any of my readers know of research or resources about the effect of temperment on the experience of trauma, please leave me a comment. According to the stats there are 100's of you lurking on this site. Please speak up!

New Sybil movie. DID in the media.

CBS aired a new Sybil on Saturday, starring Jessica Lange as the therapist and Tammy Blanchard as Sybil. It was less fantastic and spooky than the original Joanne Woodward/Sally Field movie, and was a realistic depiction of a poly-fragmented DID person. The movie depicted realistic switching behavior, flashbacks, losing time, and amnesia between parts. It showed recurrent triggering that brought out different parts.The therapist was as competent as she could be, with no training, and fiercely attacked by colleagues for "making a multiple". The movie showed the kind of early abuse that creates DID. My husband kept saying, "How can that happen to a child?" And I kept saying, "I hear this at work, nearly every day."

It was worth watching: the acting was great, the depiction realistic, and the state of therapy pretty bad. Unfortunately, CBS isn't making it available for replay on its website, or I'd provide a link.

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

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.

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.

Long-Term Clients

I've been in practice since 1981. During that time, I've seen around 1000 clients and in the last decade consulted to other therapists about at least a thousand more. DSM diagnoses are one way to describe clients. Another way is by the length of time they stay in therapy. (Not counting analysands) Here is a list of clients, by length of time spent in therapy.

• Fly-over: never a "customer", leaves after a few sessions because it wasn't his idea to come, or the therapist isn't a fit (lost one because I wore Birkenstocks in the 80's), or she's too scared to stay.
• Questioner: Needs something normalized. "Am I crazy because. . . I'm grieving/I like to have sex the way I like it/I just moved and I don't immediately have new friends, etc." This client needs information about normal human behavior and reassurance that a trained professional finds her/him sane. (Not to be mistaken for a client with underlying issues who tests you with this kind of question.) One session.
• Three-session wonder: The famous (and extremely rare) well-attached car accident victim who clears the trauma in two sessions and comes back to praise you wildly on the third. I've treated about 20 of these in the 14 years that I've been doing EMDR. For them, therapy is penicillin: Take a good dose, and the symptoms go away.
• The Next Developmental Step Client: She's at the cusp of differentiating from her family of origin/partner/workplace and finding out how to be herself. If she's reasonably well attached and reasonably untraumatized, she'll be around from three to eight months. If more traumatized or with an abusive or alcoholic or otherly dysfunctional family and/or attachment issues, you might be seeing her from months to a few years.
• Big "T" Trauma client. She takes some time. If she was raped more than once or injured badly in the accident, or spent too many months in that war zone or horrible work environment, you have months to a few years of work. Best case, you nail the root trauma early (that molestation by the neighbor) then the rape, then work on integrating it all and dealing with her current, hopefully safe, life. Worst case: despite your thorough intake, you keep finding more and more suprise antecedents and the current life stays unsafe and in flux, and you spend three or four years getting her life in order and trauma moved through.
• Horrible attachment, relatively light trauma: Years of finding the baby parts that go into shut down or cling or fight or flight. Years of helping him own the baby and hold the baby and soothe the baby, instead of reflexively disappearing or pushing you away. He de-hunkers. He connects. He finds someone else with whom to connect. He learns self-regulation. He leaves therapy, after checking 6 times that he can return, if necessary.
• Bad chemistry clients. It depends. If she gets on the meds and "feels like myself again" and the good feeling stays, say goodbye and thank your favorite diety.    If he only gets depressed in the summer. You may see him for a year or so, the first go round, and then every time he goes down. You'll remind him to call his medicator person for a medication adjustment, and help him cope with the affects and effects of the bipolar/major-depressive dx/schizo-affective dx. In every round of therapy, you'll help him clear some more trauma and help him reset his thoughts (there's nothing wrong with Cognitive Behavior Therapy, when you need it.). When he's back on the horse, you review what you both learned, and cut him loose until the next round. If he's more chronic, fighting debilitating chemistry with little respite, or rapid cycling, you become insulin. The attachment relationship is paramount. Attachment to you may be thing that keeps this client around. Each interaction raises hope, reregulates your client, gives them an experience of being witnessed and loved. You won't fix him. You will help him cope. If attachment disruption and trauma created the depression, therapy can, finally, nail it. And it will often take years. If it's 95% "bad brain", you need to hold to your presence as the most healing tool you have. Use all your tools: CBT, EMDR, adoring your client, cheerleading ability, and connectivity. Work with them to try yet another med, keep exercising, keep eating well, get to work. Find them the best psychiatrist in town. And settle in for a long-term relationship.
• Severe dissociation with awful attachment and horrible trauma: Settle in for the long haul. You and the therapy are both penicillin and insulin. It may take months or years to make a good, trusted attachment relationship. It may take just about the same years to stabilize your client. Then you can tackle the trauma with some good penicillin (EMDR, Life Span Integration, Brainspotting, etc.) And tackle more trauma, and more trauma, and more. Then you can help her integrate all the changes. It's 10 years later. She's in a good relationship; has a better job; can have sex; and finally can say, "How do I know if I'm done?" She's making her own insulin. She may come back for another dose of penicillin. Maybe more than once. But you did your job.

As a trauma therapist,I get to see my merely traumatized clients move through material quickly. They may go from debilitated to functioning to joy in a few weeks or a few months. These people connect quickly, don't "slap" me, have appreciation, and leave grateful. If I'm working with someone with poor attachment, thus poor affect tolerance, and, often, poor relationship skills, I have to keep my whole job description in mind: The relationship is paramount, the trauma healing can go forward only when the client is ready. It will happen as it can.

I have a huge box of therapeutic tools. I can and will try every one of them. I can seek more tools. And the relationship is paramount. If I'm attached to the client (which I must be), I'll feel his hopelessness and despair. I must metabolize it, and when it's digested, find a way to hold it, without buying into it. As a consultant, I'm constantly helping consultees metabolize their clients' despair. "Yes, it's a long therapy. And you want to take the pain away. And the client is really hard on you. And that's what this kind of client is like."  I normalize. I empathize. I give examples. We work with the countertranference. And we find where the client and therapy are, developmentally, name it, and surmise what the next steps are. As the therapist holds her client, the consultation holds the therapist, offering insulin so that the therapist can metabolize another month of a long therapy. Then we talk about the client again.

The Trauma Spectrum, by Robert Scaer

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

A. Trauma is a continuum.

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

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

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

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

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

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

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

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

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

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

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

 

EMDR Humanitarian Assistance Program

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

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

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

Soldier with PTSD from War or Rape

PBS's Frontline has a new show about the psychological effects of the Iraq War on soldiers, including the culture of "suck it up" in the service that prohibits many soldiers from getting treatment, go here to read about it or watch it online.

The New York Times Magazine has a cover story about rape and sexual harassement in the military. Go here to read it.

Day II: UCLA Attachment Conference Day 2

John Gottman on Meta-Emotions

John Gottman is the relationship research guru of the world. He’s studied thousands of couples to find out what makes happy and long-lasting relationships and what makes miserable short-lived ones. Today he talked about research he did with Lynn Katz, starting in 1985 on Meta-Emotions: thoughts and feelings about emotions. They identify two kinds of people:

"Coaching" people like to notice emotions, talk about feelings and needs, like to ask questions about emotions, accept and value emotions, and use their emotions as a guide about what to do next.

"Dismissing" people avoid and minimize negative emotion. They are into "the power of positive thoughts". They rarely acknowledge needs. They’re into a "suck it up* philosophy. They hold negative affect (anger, sadness, despair) as dangerous. If their kids have negative feelings, they think either the kids are bad, or else they parented incorrectly. They believe that you can have any emotion you want, through will.

Two "coaching" people, if married, are likely to stay married, with high intimacy and high marital satisfaction. Two "dismissing" in a couple are likely to stay married with low intimacy and high satisfaction. A "mismatch" couple, with one of each, is 85% likely to divorce, without intervention.

On a different topic, Gottman said that in couples who are likely to stay happily married, they say: "Yes". "I agree." "You may be right." And "Good Point", much of the time, in verbal and non-verbal ways. Bids for attention, in these marriages, are accepted 86 % of the time. In a disasterous marriage, the majority of the time, people say: "No." "No Way!" "Ridiculous!" Couples who "turn toward" are likely to stay together. Couples who "turn away" or "turn against" are quite likely to divorce withing 6 years. In a "mismatch" marriage (see above), there is more turning away, more secrets, betrayals, attachment injuries, and eventually, violence. These are low intimacy and low satisfaction marriages.

Gottman’s blue print for what couple’s therapy needs to be:

1. Emotionally Focused.
2. Psychoeducational skills including regulation of negative and positive affect and turning toward bids.
3. Make conflict constructive by managing power, cooperation, accepting influence and partner’s anger and other affects.
4. Build the friendship with sex, affection, shared adventure, fun, play, intimacy, romance, and passion.
5. Create intentional shared meaning: purpose, rituals, goals, values, legacy, holidays, etc.

His Conflict Blueprint:

• Postpone persuasion until each can summarize partners’ stance.
• Each partner must assume similarity. If I question my husband’s motives, I have to question mine. If I think I’m being noble, I have to consider that he is noble, too.
• Validate & listen.
• Speaker: I statements Listener: postpone agenda
• Both sooth selves.
• Compromise.
• Explore the dreams behind the conflict.
• Repair the regrettable interaction.

He said more, but I couldn’t write fast enough. Here’s one thing that stuck with me from the question period: Gay couples, both male and female had more positive affect and humor than straight ones; less power issues; were more fair to each other; could talk more easily about sex; and were generally less defensive.

If you want to know more, read John Gottman’s many books. One of my favorites is 7 Principles For Making Marriage Work.

Sue Johnson: Hold Me Tight, a model of Adult Love

I wrote about Sue’s EFT model in an earlier post. Here are some gems from today’s lecture.

• Couples come into the session in a primal panic. You have to shift them from primal panic to calm safe connection.
• The attachment system is pre-eminent.
• Attachment issues are existential questions: "Do I matter to you?" "Do you see my pain? Do you care?" "Will you be there for me?"
• Clients who haven’t ever experienced "felt security" or who haven’t seen a good relationship still fight for connection and love.
• Intimate relationship is the best source of resilience and growth and hope for the future.
• Fighting is often separation "protest".
• There’s no such thing as overdependency or true self-sufficiency
• The cure for an attachment injury is to know that your partner feels your pain on a body level. Then there is a possibility of forgiveness and connection.

Several of my favorite teachers are at this conference. Diana Fosha, Dan Siegel, Pat Ogden. In my opinion, Sue Johnson would be the most fun to have to dinner. She’s hyper-present, funny, intelligent (they’re all brilliant), and down to earth. When asked why she represented men as more alexithymic (feeling phobic), she said that she grew up in an English pub, and the men all were in touch with their feelings after the second beer, sometimes too much so. Gottman then chimed in that his statistics showed that men were much more avoidant of feelings and intimacy by a vast percent. Then went on to explain it with cultural and sociobiological explainations.

Jude Cassidy, an attachment researcher

• People open to the pain of the past function better in relationship with partners and children, because they’re not so busy ignoring their own pain. If they ignore their pain, they won’t be able to see and respond to others’ pain.
• If you can regulate pain, you can be present with it, and respond to others’ needs, not just your own needs to shut off your feelings.
• People need a secure base from which to explore and a safe haven to return to.
• 3 kinds of secure bases: Important relationships in childhood; adult romantic relationships; and therapeutic relationships.

I’m too tired to go on, and there’s a third day to come. I hope to write more about Jude Cassidy and tell you about Dan Hugh’s amazing attachment work with kids. Maybe tomorrow.

UCLA Attachment Conference, Day One

I’m at the UCLA/Lifespan Learning Institute’s Attachment Conference. This year it’s called The Healing Power of Emotion: Integrating Relationships, Body, and Mind. Today, about 500, tomorrow and Sunday, about 1000 people will sit in a ballroom while a firehose full of information is directed at us. We will try to swallow all that we can. At the end of the day, there is a panel discussion of the participants. They take questions from the audience and from each other. Sometimes it’s very scholarly. Sometimes, it’s almost a brawl. The brawl, of course, is more fun.

Stephen Porges started off the day with a lecture on his research: "Application of Polyvagal Theory to Clinical Treatment". Most of it was in understandable English, because Porges is a U of Illinois professor and knows how to teach. According to the conference bio, "his polyvagal Theory of Emotion led to the discovery of an integrated neural system that regulates social engagement behaviors." His lecture today focused on the need for face-to-face interactions for bonding to occur. When there’s a violation of the interaction—someone doesn’t make eye contact, when a supposed intimate is speaking, the speaker experiences distress: anger/shame/alienation. Safety creates proximity creates contact creates bonding. There might be more bonding in sleeping together than in sex. Porges commented on the dysfunction in the Seinfeld rule, "No sleepovers!" (We know that those people were all attachment disordered!)

I can’t recount the whole lecture, but I can give you tidbits:

• Facial muscles go down to the heart. Talking, listening, and smiling calm us down.
• Two vagal nerve systems. The old one, from lizard days, shuts us down completely. It’s the one from which we can swoon, be literally scared shitless, or become selectively mute, when distressed.
• The new vagus is linked to face and is protective of mobilization systems. It works socially.
• Our nervous system can relax us through the meyelinated vagus, if we are experiencing safety; mobilize us, through the sympathetic and adrenal system, if we sense dangere, or completely immobilize us, through the old, lizard unmeyelinated vagus, if we think our life is in danger, feigning death like a mouse fooling a cat. (Doug, out birding during the day, caught and pet a horned lizard, who didn’t move at all. It was in the immobilization vagal phase.)
• Social behavior enables us to function better.
• Social engagement systems: prosody (tone and music of our voices), gaze, facial expressivity, posture during social engagement, mood, affect, and behavioral state regulation.
• Environment can be interpretted, based on our state.
• Borderline cutters, in a study, lost vagal control of their hearts while watching emotional videos. Controls, did fine.
• Very autistic kids attend to low (more frightening) tones. They stay scared and "mobilized" most of the time and try to soothe by doing weird stuff, not be connecting with others. If you play them music with all the low tones filtered out, over time, they will become socially engaged, like normal kids. I saw the video, it was way cool.

Then there was Dan Siegel, talking, again, about mindfulness. At last year’s conference he was gushing about a meditation retreat, as if he’d invented it. I love Dan Siegel. He’s brilliant, sweet, a great lecturer, a good writer, and a wonderful clinician. But I wasn’t the only one shaking my head at his response to what I’ve been doing/knowing for 25 years. He is compiling research on what meditation actually does. He will be big in making it even more mainstream.

• He spoke about getting clients to become aware of the SIFT, Sensations, Images, Feelings, and Thoughts.
• He teaches mindfulness to clients so that they can change their states.
• Contingency: Person A sends a signal. Person B perceives, decodes and responds in a timely and effective manner. (That’s how you get healthy attachment or a good therapy.)
• Mindfulness training is great for ADHD. (I’m going to send my ADD clients to meditation class when I get home.)
• Mindfulness is: The capacity to be present as an experience is happening; Non-reactivity; Not clinging to judgements; The ability to label & describe one’s internal state; and Self-awareness, awareness of one’s awareness.

Then there was Pat Ogden. She was a student of Peter Levine, who has taken his work farther, by bringing in more of an attachment slant. I’ll write about her in a few months, when we read her book. Her videos, when they worked, were inspiring.

The final speaker was Robert Neborsky. He’s loud, brash, and does the scariest and possibly most effective brand of therapy that I know about, Intensive Short-Term Dynamic Psychotherapy. He showed a video of his work, excerpts from a 15-hours-in-one-week therapy with a hunkered-down guy, a middle-aged abuse survivor. He carefully pushed the guy through every defense against affect, every time. He took no prisoners. He went for the kill. And within hours, he had the client enacting killing his horribly abusive father, and getting over his affect phobia. The therapy looked horribly mean and the client didn't act like he was being abused. He was having breakthroughs all the way through the work. In the break afterward, people had lots of reactions, from admiration, to "Take his license away."

At the panel discussion, an audience member, from a psychoanalytic background, shared his distress about Neborsky’s work. "It left no room for the client. . ." There was scattered applause. Dan Siegel and Bob Neborsky both lauded the questioner for his bravery, then spoke about the efficacy of the technique. (Short Term Dynamic Therapy has been well researched. It works.) Neborsky said that his clients look good, even many years later and reiterated his rule: "Longer therapy is not better therapy." He talked about his "holding" coming from his spot-on interpretations. And that clients love him and love the work.

Neborsky’s ideas about good therapy:

• Strong alliance
• Help clients confront what they avoid
• Revive Hope
• Create a sense of mastery over Past, Present, and Future
• The patient owns the therapy.
• The therapist is a biofeedback loop, and helps the client recognize, feel and structure his anxiety.

Therapy doesn’t work when there’s

• Too much talking and not enough feeling
• Too much defensive feeling and not enough thinking
• A failure to help the client regulate anxiety
• A failure to generate anxiety
• A collusion with the client’s defense.
• Giving too much (over-involvement)
• Giving too little (under involvement)

The most fun question of the panel discussion: A man described how Pat Ogden was able to express her dismay over her video breaking down, take care of the audience, take care of herself, switch to another hard drive and seamlessly use an unedited video for the presentation. He asked Pat how she handled the situation with such grace, then asked Dan Siegel how Pat handled the situation with such grace. Siegel’s answer: "Mindfulness."

Francine Shapiro replies

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

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

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

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

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

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

"Virtual Reality" in tx of PTSD

Check out these links for looking at "Virtual Reality" videos for treatment of war-caused PTSD in soldiers.

http://www.msnbc.msn.com/id/14048170?GT1=8307

http://www.defense-update.com/products/v/VR-PTSD.htm

Virtual Reality? It sounds like old fashioned exposure therapy that teaches dissociation, not healed presence.  There are non-EMDR treatments that work for trauma and don't promote dissociation. All of them, that I know about, share EMDR's focus on increased affect, body awareness, dual attention, and a more coherent narrative. In most of the others (AEDP, somatic experiencing, STDP) the "dual attention" is either the tracking of here-and-now body sensation and/or the intense connection/containment by the therapist.

More "Healing Trauma"

Our book group has just finished Solomon & Siegel's Healing Trauma: attachment, mind, body, and brain. It is one of the most difficult books I've read, and quite rewarding. The first four chapters by Dan Siegel, Hesse/Main et. al, Allan Schore and Bessel van der Kolk speak to research about the interactive nature of attachment/brain growth, and the necessity for those interactions for we humans to learn to regulate affect, connect to others, grow empathy, and more. We just finished the last four chapters, which describe four different approaches to therapeutically moving the "small-t" traumas that created the disordered attachment. See January 14 & 28 posts for more detail.

Francine Shapiro writes about EMDR and its Adaptive Information Processing Model. She is the founder/discoverer of EMDR. Her rigor in pursuing research and holding EMDR therapists to researched interventions has given EMDR iron-clad credentials in the therapy world including acceptance by the APA, DOD, VA, and many other credentialling bodies and insurance companies. In her chapter Shapiro describes how EMDR works: "The goal of EMDR therapy is to forge new connections between the unprocessed memory  and more adaptive information that is contained in other memory networks." (p. 199) and ". . . EMDR catalyzes a learning process and metabolizes the experiential contributors to clinical problems. (206) She presents a case of a "large t" trauma, resulting in Post Traumatic Stress Disorder, in an earthquake survivor, and the trauma's ties to childhood themes of lack of safety and chaos. Then she tells of an amazing case, a 14-year-old guy with a "classic attachment disorder" who avoided eye contact, touch, and social contact. "EMDR was used to target the anger he felt toward his parents. During the session, he remembered. . . being dropped off at a day care center at 3 years old. There, he became terrified that his parents were never coming back. The experience of that day was locked into his system, and he kept people at a distance. Processing was rapid because Todd had a loving home and many other positive expereriences in multiple memory networks. As the negative experience was integrated, associative links were made to these other memories, and Todd became a loving and affectionate child." (210) If Todd had been neglected and abused for years, treatment would have taken much longer. After 13 years of practicing EMDR, I've cleared hundreds of attachment-related injuries in clients. I've seen people lose their "Axis II" diagnoses, and become able to connect, self-regulate, have boundaries, and come to positive affect (happiness), when they didn't have it before.

Diane Fosha's chapter is "Dyadic Regulation and Experiential Work with Emotion and Relatedness in Trauma and Disorganized Attachment". Fosha, a scary-good clinician developed accelerated experiential-dynamic psychotherapy (AEDP) marrying attachment/relational sensibility/techniques to Davanloo's short-term dynamic psychotherapy. AEDP includes intentional use of the therapist and the therapist's affect to move the client along, direct attack on defenses, and absolute containment at all times. I'll talk about it more next month, when our group reads Fosha's book, The Transforming Power of Affect. Let me give you the headings in her case example: Setting Up the Focus of the Work; Identification and Clarification of Defenses Against Affective Experience; Experiential Work to Deepen the Visceral Experience of the Categroical Emotion of Anger: The Emergence of Fear; The Breakthrough of Fear; Corrective Experience: Affirming the Patient and Taking Off the Pressure. (That's one session!) In the next session: The Subsiding of the the Fear, the Operation of the Reflective Self Function, and Accessing of Emotional Resources; The Undoing of Dissociation: Adaptive Access to Anger; then Outcome. So Fosha helps clients go from Defense to Core Affect to Core State, masterfully. More next monthabout her.

Robert Neborsky's chapter is A Clinical Model for the Comprehensive Treatment of Trauma Using an Affect Experiencing-Attachment Approach. He speaks of the difference between a recently traumatized person with good attachment, (distressed, but metabolizes the experience and moves on) and a person with poor attachment, in whom old defenses and old emotions are activated, and not regulated nor cleared. Neborsky, another student of Davaloo's, states that short-term dynamic therapists believe that "the patient must experience his or her genuine feelings from the past in the present." (292) He adds his own component that "a patient leaves the intitial interview with a coherent narrative of the origin of his or her psychopathology." (293) He explains the STDP model, his additions and presents an edited transcript of 6 hours of therapy with insecure attachment. His full-bore attack on the client's defenses was amazing, as was the connectedness he kept, throughout.

After reading Fosha's and Neborsky's chapters, I noticed that I was confronting my (non-DID) clients' dissociative responses more directly and more clearly ferreting out the affect that underlied the dissociation. It worked wonderfully with four different people. (I wish I could say more on a public blog!) I noticed that Fosha and Neborsky get to the same place as EMDR does with their therapies. They go for the cognitions, the affect, the body feeling, and make people talk about it. I think that the "dual attention" in their work is the therapeutic relationship. EMDR ought to take place in the context of a good therapy relationship. It works better if it does. And I know a few people, intense relational holders, who sometimes drop the bilateral stimulation, they can "fosha" a client with their connection, and lead them through to what Francine Shapiro calls : "The basic goal of treatment, to acheive the most comprehensive effects possible, in the shortest period of time, while maintaining stability, within a balanced system. This goal is achieved when the distressing memories are processed and integrated withing adaptive memory networks, and when all past, present, and future aspects are addressed." (202) It's nice that there are many paths to the river, all using affect, connectedness, and here-and-now orientation to get there.

EMDR with Veterans

Like a Ghost: Using EMDR to revive a traumatized vet's marriage by Nancy Errebo is a wonderful article in the recent Psychotherapy Networker. Click here to read it.

The Psychotherapy Networker is my favorite therapy magazine. It's readable, easy to look at, open to many modalities, and full of useful information. I always find at least one piece of information I can use in each issue. It's written for clinicians, though lay people would be able to follow many of the article. Since it comes every two months, I'm not overwhelmed with issues. (Unlike the weekly New Yorker! Fall behind one issue and you're a goner!) If you subscribe to only one publication, get this one.

"Dehunkering"

I've been using a new diagnostic category, though I haven't seen it in the DSM-IV-R: Hunkered-downedness. Hunkered-down clients are a few inches shorter than their natural heights. They often look younger than their natural age. They can be appeasing. They can be hyper-vigilant. On the other hand, they can be somewhat dissociated. All of them have been a little depressed, some more than others. Their complaints may include procrastination, inability to make decisions, and general confusion. They have all been nice people, easy to be around. They are rarely assertive.

I do an intake with a genogram, paying special attention to attachment issues. All of these people had rigid or highly critical moms. When I explain, often at the end of the first session, that due to the history and current issues and presentation of the client that he or she has the "hunkered-down" diagnosis, they usually relax and agree. One person said, "You see me."

What to do? I usually ask them to think of a current interpersonal situation in which they are in this state, and then "float back" to the earliest time they ever felt that way. It's usually sometime between 2 and 4 years old. It's Mom, saying, "I'm ashamed of you." or "Stop it!" or similar words. The feeling is caved in, shame, inhibition. The cognitions are about being unworthy or unlovable or damaged goods.  If they can't remember, I'll guide them: imagine that you're 2 years old. You're exuberently dumping clothes out of drawer or banging pots. Mom shows up. Look at her face. Hear her voice. That gets them right there.

I use a combination of EMDR clearing with some Brainspotting thrown in, to clear the event. I've done up to six sessions on this event, alone, before it clears. During the last session of processing the "hunker", I watch the client's body change. The neck becomes vertical, instead of horizontal. The shoulders come back while the chest sticks out. The chin comes forward. Today I saw a man stop looking like a boy. In a way, it was like the incredible Hulk, coming out of a little man's body, except it was an incredible man. He felt it. I saw it. We install: I'm worthy, I'm lovable, I'm acceptable.

Then we finish the processing, by doing a body scan, and noticing the difference in this body. Then come back to a current "hunkering" kind of situation, and use the future template: dealing with the situation with the new body and new brain.

The next time, the clients come back and brag about their weeks. They're different in many spheres: assertiveness, stick-to-it-iveness, decision-making. It's very cool work.

Healing Trauma, reading group report

The reading group had its first meeting. We discussed the first four chapters of Healing Trauma: attachment,mind, body, and brain edited by Marion Solomon and Daniel Siegel.(W.W. Norton & Co. 2003) It's a difficult book. Several chapters speak about brain physiology. Several are in "academic speak" in which all sentences must have at least 10 clauses and must be in passive voice. And the content has necessary (though not perfectly written) bases for understanding what is happening in the minds and brains of poorly attached and/or traumatized people and what to do with them.

Dan Siegel's first chapter is An Interpersonal Neurobiology of Psychotherapy: The Developing Mind and the Resolution of Trauma. Siegel uses complexity theory to define Mental Health as the maximal complexity that the brain and mind can have: maximally stable, adaptive, and flexible. Not too rigid, not too chaotic. Some of his main points are that

• Experience changes brain structure. A connecting, congruent, responsive parent allows a baby to develop the hardware for self-regulation (including affect tolerance), meaning, and communication on overlapping circuits. Other kinds of parents can get kids to develop blind spots, dissociative responses, or chaotic or ultra-rigid circuitry.
• Communication inside an attachment relationship is the main experience that regulates and organizes and develps the circuits of the brain that mediate self-regulation and social relatedness. . .We connect by sharing emotional states.
• Therapy works by letting the therapist be an attachment figure in an interactive relationship the enables the coregulation of internal states. Later the clients (like growing children) can regulate their own emotional states.
• (p.38) To create a secure attachment you need 1. Contingent (responsive/understanding) communication 2. Reflective dialog on the contensts of mind (feelings, thoughts, memories, beliefs, etc.) 3. Repair (when there's a rift or miscommunication, it's acknowledged and the parties make attempts to move forward and reconnect.) 4. Emotional communication that creates an experience of empathy and compassion (positive emotions are amplified, negative ones are soothed) 5. Coherent narratives (when we can speak about something with coherence while feeling, but not being overwhelmed or shut down by emotion, we're doing o.k. with it.
• Coherent narratives. See above. An incoherent narrative about childhood events (even in an otherwise articulate parent) predicts disorganized attachment in the person's children. I've known about this work for years, it's explained in detail in this chapter and in the next.
• Clinical applications. (p.45) "Patient should be given the sense of safety in which traumatic states are re-experienced, communicated and altered in more adaptive patterns" resulting in better integration of information and energy flow. (p. 47) "Effective therapy is an emotionally engaging and transformative experience that enables . . .integration to occur. He says in bigger words that the normal human emotional response is therapeutic. Staying sane and staying connected to your clients while they work through hard experiences is good therapy.

There was much more in that chapter. It made me think of Dan Siegel's comment, at the 2004 Attachment Conference. He'd been asked, in front of a thousand of us, what he thought about EMDR. He said that EMDR was a bilateral brain therapy, but not because of the hand waving or other bilateral stimulus. When we set up the protocol, we first stimulate the amygdala and hippocampus, by bringing up the trauma. Then we connect in the left frontal brain, by asking about cognitions, go into the right brain to bring in awareness of feelings, hop to the left brain to name the feelings then back to the right brain to bring up the body map, then to the left brain again to name the place.       

One more Siegel thing. He wrote a lovely book, with Mary Hartzell, for parents: Parenting from the Inside Out. It explains his brain integration ideas, almost in English, and gives clear instructions in using what is known about attachment to do better parenting. (And better psychotherapy, too.)

Eric Hesse, Mary Main, Kelley Yost Abrams, and Anne Rifkin cowrote Unresolved States Regarding Loss or Abuse Can Have "Second Generation" Effects: Disorganization, Role Inversion, and Frightening Ideation in the Offspring of Traumatized, Non-Maltreating Parents. A title and a synopsis all in one! If you can't figure out why your client, who has pretty nice parents, turned is so dissociative, borderline, full of scary thoughts/anxieties, or incredibly codependent, look to their parent's histories. If a parent had unresolved grief or trauma that leaked out in little dissociative lapses or sad/scared looks when nothing particularly sad or scary was going on, the kids could have learned to space out, take care of the parent, or become unable to self-regulate. They have a good description of disorganized attachment (beyond the scope of this article!) and how the kids got that way. They back it up with concrete research. It explains a lot of the people I see. They don't say much about clinical implications. Here are my suggestions for any poorly attached clients:

  Building Attachment Functions

a.      Sit close.

b.      Mirror affect and attention.

i.         Tone

ii.       Intensity

iii.      Backing off, when they do

iv.     Engaging when they do.

c.      Model positive affect: excitement, humor, happiness

d.      Create opportunities of intersubjectivity: knowing that you are in synch, experiencing the same feeling at the same time.

e.      Be a constant object. Be consistent, session-to-session in limits, attention, etc.

f.        Let yourself feel your client inside of you—experience their somatic experience.

g.      Use resource installation (RI) of any past experience of attachment, feeling connected, cared for, loved, and/or understood.

Utilization language Kitchur (99/00)—from M.Erickson:  Use the clients’ metaphors, belief systems, and experience when explaining, encouraging, etc. 

I'll write more later.