Trauma & Attachment Therapy

Gottman & Navarra: Couple Recovery Development Approach Workshop

John Gottman and Bob Navarra gave a useful workshop about working with couples in recovery from addiction, in Seattle yesterday. Here are some of the take-aways:

• "Mastery, Not Perfection" A wonderful thing to say to anyone learning a new skill ,is the "perfect" thing to say to recovering addicts, who are likely to be perfectionists. (I often remind them that "the ideal is the enemy of the real.")
• Recovery destabilizes the family system, and can replace alcohol as the "organizer" in the relationship. Couples and families need to discuss what happened when the partner was using, how things are different now, what everyone feels about it, and what both partners need now. New recovery is a perfect time to break up the alcoholic "Don't Ask, Don't Tell, Don't Feel" rules and and replace them with open, differentiated expression and mutual support. (This was frowned upon in the bad old days of recovery work, leading to this joke I heard 25 years ago: "What's a 'slip' in Al-Anon? . . .A moment of compassion.") 
• Gottman and Navarra's approach looks at 3 recoveries: the addict, the spouse, and the relationship. It emphasizes the centrality of the relationship, not just the addict staying clean. It looks at current and historical Family of Origin influences on the individuals and their relationship. It helps each partner learn to care for self and the other in "co-existing recoveries." 
• Couples learn to "create shared meaning; help each other to make life dreams come true; manage conflict; take a positive perspective; turn towards each other; share fondness and admiration; and build Love Maps." (Love Maps is a Gottman tool for couples that have them know each other, from favorite colors to worst traumas.)
• Gottman ran through his "4 Horsemen of the Apocalypse", the actions that predict divorce: Criticism (he teaches whining rather than blaming--"I'm unhappy" vs. "You're a jerk".) Defensiveness, Contempt, and Stonewalling. I had forgotten that he sees Stonewalling as a response to a Dorsal Vagal shut down reaction: flooding. He teaches people to self-soothe so that their physiology can handle the conflict.
• If trust is the number one predictor of marital happiness, how do you build it? Teach attunement. Let the answer to "Are you there for me?" be "Absolutely" and be able to show it by listening, comforting, and showing up, even during conflict. 
• Great acronym: ATTUNE: Awareness, Turning toward, Tolerance, Understanding, Non-Defensive Responding, Empathy. Gottman says that "Bonding created by turning toward any negative affect and fully processing conflict and failures to connect . . .has the power to create trust."
• Never avoid conflict: process it and it's gone. Avoid it and it sticks around forever.
• Gottman showed us part of his "Recovery Kit" for post-fight or post "regrettable incident". It's swell. For $2, you could have a great tool for helping your clients out of fights, and to send home with them, when they understand the simple but effective steps. (it's Gottman's, so it's impeccably researched). Here's the order form from Gottman: http://www.gottman.com/57329/579672/Books-DVDs-and-Workshops/Recovery-Kit.html.
• Navarra spoke about breathing exercises for self-soothing, and how couples can talk about recovery with each other. They both spoke about the importance of positive affect: Gottman, about using humor; Navarra, about bringing up what's working, what's good, and what each person likes. He spoke about the couples' needs to note their shifting identities as couples, and as a result of recovery; shifting boundaries and being choiceful about what they are, and importance of discussing new rituals of connection, old family scripts, and what they want now.
• A nice workshop (despite some A/V and organizational issues).
• John Gottman is the godfather of couple research and couple therapy. You can find out about his great books, DVD's, handouts, and workshops at his Relationship Research Institute: www.rrinstitute.org  My husband and I read a Gottman book to each other on our honeymoon.
• Bob Navarra's research about couples, addiction, and recovery is lovely, and a great antidote to the idea that the addict has a separate recovery from his or her family system. His website is www.robertnavarra.net  He's got a Gottman blog and a recovering couples' blog on his site.

It Gets Better

The outpouring of support after the spate LGBT suicides has been amazing. The latest and most moving part is a song by young Broadway performers "It Gets Better".

My homeboy, Dan Savage started the project with videos of gay and lesbian adults talking about how they survived harassment and worse and how life got better in the It Gets Better Project. (Many cool videos from all kinds of people)

President Obama recorded a video for the project, though the most moving one I've seen, besides the song, is a long video by a member of the Ft. Worth city council, Joel Burns, where he talks about bullying and a suicide attempt before it got better for him.

I started my career in 1981 working at Seattle Counseling Services for Sexual Minorities. If these resources had been around then (the internet, U-Tube, celebrities supporting gay teenagers to stay alive) I would have spent less time consoling grieving parents and friends and dealing with clients' failed suicide attempts. Back then, kids were routinely kicked out of their families for coming out. It still happens, but Oprah, Ellen, Rosie, and the increasing acceptance of gay people as human beings, legally and socially, has made this country a much healthier place to grow up gay, bi, or trans. Thank God.

Ethics and Technology Workshop

I attended Lisa Erickson's Professional Ethics & Technology workshop today, sponsored by Cascadia Training. Here's what I came away with:

SKYPE

Skype, the computer phone and video-phone service, is encrypted and hard to break into. If Skype's employees wanted to listen in, they could. But why would they?

The picture can freeze, fragment, or lag. You can't do eye contact. And it's still often better than the phone because you can see each other.

If you are "skyping" or emailing a session, have a back-up plan in place (like the phone) in case the technology fails.

Many of us in the workshop wouldn't use Skype for regular sessions, but would use it for sessions if the client or therapist was out of town. Some do and many would use it for consultation or supervision.

You can only legally do long distance psychotherapy if the client resides in a state in which the therapist is licensed.

Informed Consent

Add a new section to your consent form stating your rules about technology. For instance:

• I never "friend" anyone who is or has been a client of mine.
• Email is not 100% secure. Email security can be breached. My email policy is this: Either: "I don't do it with clients." OR "You may email me only for changes of appointment." OR "You may send me emails to update me on your status, but I don't return them." OR "I will try to respond within 24 hours, but if I don't, please call me on the phone, because I may not have gotten the email." And/OR "I will charge $2 per minute for reading and responding to any email longer than one brief paragraph." (With some clients who seem to want to move the therapy to email, I stop accepting emails except for appointment changes.)
• "Please do not send me emails, or Skype me from any place that is not secure and private, including the library, an internet cafe, your job, or any public network or place. I don't want your confidentiality breached."
• "If you want to show me something on Facebook or your blog or any other social media, you can show me during our session from your account or print it out for me. I want to be sure to protect your privacy, even from me."
• "I don't google my clients, so if you want me to know something, tell me."
• "Since we live in different areas and do therapy through the computer, I will provide you with a list of emergency services available in your area."
• Conversations by cell phone or cordless phones may be picked up by people in the area. The only completely safe phone call is from one old-fashioned corded phone to another. When we have a phone call, be sure that you can't be overheard.

Other random issues

• Online or phone sessions are not covered in 39 states. Telemedicine is covered in the other 11, and it's unclear if therapy is "medicine" in all of them.
• On your website, provide links to relevant state licensing boards to protect your clients' rights.
• Make sure you do online work with people who have the equipment, technical savvy,  access, and ego strength to do it well.

Resources

(a few of the many that Lisa Erickson gave us)

M. Maheu has a great technology/therapy blog: http://telehealth.net/blog/ 

Mahue, Pulier, Wilhelm, McMenamin, & Brown-Connolly (2005) The Mental Health Professional and the New Technologies

metanayoia.org: Safeguarding Patient Confidentiality in email.

 

 

KENSPORTAL.COM

Check out this great therapy resource. It has forms, great links, directories, and information about client populations. If you do therapy, you'll find something useful on it. I met Ken Eisenberger a few weeks ago at a workshop and he turned me onto his helpful, free website. Check it out at

http://www.hiddenhillcounseling.com/kensportal/

EMDR and Depression poster

I applied to the EMDR International Conference to lead a 3-hour workshop on Treating Depression with EMDR. I wrote four chapters about it in the new book, EMDR Solutions II, for Depression, Eating Disorders, Performance, & More. Instead of a workshop, I was invited to do a poster. I know how to write. I know how to talk. I never had to put four chapters in an understandable form that fills an 8 foot X 4 foot poster and can be seen at 5 yards away. It took about 20 hours, including half-learning a new program (Power Point), formatting nightmares (why did the text size keep changing?), and pruning all my case examples, wit, and nuance from the basic information. It’s still too crowded, but understandable. If you want to see the content of the poster on EMDR and Trauma-Based Depression, Mood-Disorders, and Attachment-Based Depression go here:

Download DepressionPoster-1.pdf

Here are the other chapters. They’re in to Norton, the last laggards have sent in the “artwork” for their charts. And Norton’s copy editor is ready to find 1,000 errors that I missed in 3 edits, and still won’t find them all.

Unit I: TREATING Depression

1.Introduction to Assessment and Treatment of Depression, Robin Shapiro

2.Trauma-Based Depression, Robin Shapiro

3.Endogenous Depression and Mood Disorders, Robin Shapiro

4.“Shame is my Safe Place”: Adaptive Information Processing methods of resolving chronic shame-based depression, Jim Knipe

5.Attachment-Based Depression: Healing the “Hunkered-Down”, Robin Shapiro

UNIT II: TREATING EATING DISORDERS

6.The Why of Eating Disorders, Andrew Seubert

7.Integrating Eating Disorders Treatment into the Early Phases of the EMDR Protocol, Janis Scholom

8.The Neurobiology of Eating Disorders, Affect Regulation Skills, and EMDR in the Treatment of Eating Disorders, Linda J. Cooke & Celia Grand

9.Treating Bulimia Nervosa with EMDR, DaLene Forester

10.Image is Everything: The EMDR Protocol in the Treatment of Body Dysmorphia and Poor Body Image, DaLene Forester

11.Addressing Retraumatization and Relapse When Using EMDR with Eating Disorder Patients, Janet McGee

12.Desensitizing Desire: Non-Verbal Memory and Body Sensations In the EMDR Treatment of Eating Disorders, Catherine Lidov

13.The Case of Mistaken Identity: Ego States and Eating Disorders, Andrew Seubert & Judy Lightstone

UNIT III: PERFORMANCE, COACHING, AND POSITIVE PSYCHOLOGY

14.EMDR and Performance, David Grand

15.EMDR and Positive Psychology, Ann Marie McKelvey

16.EMDR and Coaching, Ann Marie McKelvey

UNIT IV: Solutions for Complex Trauma

17.EMDR Friendly Preparation Methods for Adults and Children, Katie O’Shea

18.The EMDR Early Trauma Protocol, Katie O’Shea

19.Towards an Embodied Self: Integrating EMDR with Somatic and Ego State Interventions, Sandra Paulsen & Ulrich Lanius

20.Direct Targeting of Intrusive Images: A Tale of Three Soldiers, Elizabeth Massiah

21.Attachment, Affect Tolerance, and Avoidance Targets in Obsessive Compulsive Personality Disorder, Robin Shapiro

UNIT V: TREATING MEDICALLY-BASED TRAUMA

22.Clearing Medical Trauma, Robin Shapiro

23.Treating Birth Related Post Traumatic Stress, Katherine Davis

24.Treating Multiple Chemical Sensitivities with EMDR, Robin Shapiro 

UNIT VI: MORE EMDR SOLUTIONS

25.EMDR With Sex Offenders in Treatment, Ronald J. Ricci & Cheryl Clayton

26.Using EMDR with Religious and Spiritually Attuned clients, Martha S. Jacobi

"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.

Visual Aids

Here are the visual aids that I use with my clients and consultees. Each of them is hand-printed in magic marker on a 2 by 3 foot piece of drawing paper. I often pull one out for a client, propped up behind me and say nothing about it. Sometimes, I will pick up a page and go through it step by step with a client. Two modalities can be more useful than one.

For the Anxiety Disorder types:

STAGES of GRIEF:
SHOCK/UNREALITY
ANGER/REGRET
HOPELESS/SAD
INTEGRATING
INTEGRATED
"READY FOR MORE PUNISHMENT" (after a breakup, according to Matt Groening)

RULES OF GRIEF

1.Grief always hurts more than you think it should.
2. It always hurts for far longer than you think it should.
3. Grief sucks and has nothing good to recommend it. 
It makes you tired: Sleep more.
It makes you cranky. Be mindful of the people you're around.
It makes you stupid. It's not permanent.
It can make you think that you suck or the world sucks. It's lying.
4. After a while, the acute phase passes and you merely miss the person.

STAGES OF HEALING AFTER TRAUMA:

SCARED/ASHAMED
ANGRY
SAD
MAKING SENSE OF IT
INTEGRATED 

SYMPTOMS OF PTSD:

ANXIETY
NIGHTMARES
JITTERS
CRANKY
HAIR-TRIGGER
AVOIDANT OF ANYTHING THAT REMINDS YOU
WEEPY
LACK OF TRUST
INTRUSIVE THOUGHTS, SENSATIONS and/or IMAGES

I also have a drawing of Onno van der Hart's chart about Sommatoform Dissociation, but I can't figure out how to show it to you. I'll explain it to you when I review his new book, The Haunted Self,in a few months.

If you have words or images that you find useful, please share them here. Comments are welcome.