Transcript EMDR Therapy - Trauma Made Simple

2-DAY TRAUMA INFORMED
TREATMENT CONFERENCE
DAY 2: PROCESSING TRAUMA &
POST-TRAUMATIC GROWTH
Jamie Marich, Ph.D., LPCC-S, LICDC-CS
Founder & Director, Mindful Ohio & The Institute for Creative Mindfulness
ABOUT YOUR PRESENTER
• Licensed Supervising Professional Clinical Counselor
• Licensed Independent Chemical Dependency Counselor
• 14 years of experience working in social services and counseling; includes three
years in civilian humanitarian (Bosnia-Hercegovina)
• Specialist in addictions, trauma, EMDR, dissociation, performance enhancement,
grief/loss, mindfulness, and pastoral counseling
• Author of EMDR Made Simple, Trauma and the Twelve Steps, and Trauma Made
Simple (forthcoming)
• Creator of the Dancing Mindfulness practice
OBJECTIVES
• To define processing within the context of the adaptive information processing (AIP) model
• To effectively explain the impact of trauma on the human experience and how processing
trauma can help a client in terms relatable to an average client
• To discuss the available categories of therapy available to help clients process trauma,
highlighting the advantages and disadvantages of each for types of clients
• To evaluate treatment planning options for a presenting client ready for trauma processing
• To define reintegration, post-traumatic growth, and resilience, and explain the relevance of
each to overall trauma treatment
• To explain how self-care amongst clinicians working with trauma is a quality of care issue
and (if desired) to discuss strategies for making oneself a more effective trauma therapist
through cultivating skills in self-awareness
GENERAL CONSENSUS MODEL OF TRAUMA
TREATMENT (ISTSS TASK FORCE, 2012)
•PHASE I: Stabilization
•PHASE II: Processing of Trauma
•PHASE III: Reintegration
WHAT DOES IT MEAN TO
PROCESS SOMETHING???
THE ADAPTIVE INFORMATION PROCESSING
MODEL (SHAPIRO, 2001/2015)
• The neurobiological information processing system is intrinsic, physical,
and adaptive
• This system is geared to integrate internal and external experiences
• Memories are stored in associative memory networks and are the
basis of perception, attitude and behavior
• Experiences are translated into physically stored memories
THE ADAPTIVE INFORMATION PROCESSING
MODEL (SHAPIRO, 2001/2015)
• Stored memory experiences are contributors to pathology and to
health
• Trauma causes a disruption of normal adaptive information processing
which results in unprocessed information being dysfunctionally held in
memory networks.
• Trauma can include DSM-5® Criterion A events and/or the experience
of neglect or abuse that undermines an individual’s sense of self
worth, safety, ability to assume appropriate responsibility for self or
other, or limits one’s sense of control or choices
THE ADAPTIVE INFORMATION PROCESSING
MODEL (SHAPIRO, 2001/2015)
• New experiences link into previously stored memories which are the basis of
interpretations, feelings, and behaviors
• If high levels of disturbance accompany experiences, they may be stored in the
implicit/non-declarative memory system.
• These memory networks contain the perspectives, affects, and sensations of the
disturbing event and are stored in a way that does not allow them to connect with
adaptive information networks
• When similar experiences occur (internally or externally), they link into the
unprocessed memory networks and the negative perspective, affect, and/or
sensations arise
• This expanding network reinforces the previous experiences. Adaptive (positive)
information, resources, and memories are also stored in memory networks
THE ADAPTIVE INFORMATION PROCESSING
MODEL (SHAPIRO, 2001/2015)
• Direct processing of the unprocessed information facilitates
linkage to the adaptive memory networks and a
transformation of all aspects of the memory
• Nonadaptive perceptions, affects, and sensations are
discarded
• As processing occurs, there is a posited shift from
implicit/nondeclarative memory to explicit/declarative
memory and from episodic to semantic memory systems
• Processing of the memory causes an adaptive shift in all
components of the memory, including sense of time and
age, symptoms, reactive behaviors, and sense of self
A CLIENT’S PERSPECTIVE:
FROM MARICH (2010)
Fadalia (pseudonym), a recovering heroin addict with complex trauma reflected on
where she was at before receiving the integrated treatment that led to her longest
sobriety to date (3 years):
“Before [treatment], my feelings, thoughts and
experiences were all tangled like a ball of yarn. I
needed something to untangle them.”

FROM JAYCEE DUGARD (2011)
“This book might be confusing to some. But keep in mind throughout my book
that this was a very confusing world I lived in. I think to truly begin to understand
what it was like, you would have had to be there, and since I wish that on no
one, this book is my attempt to convey the overwhelming confusion I felt during
those years and to begin to unravel the damage that was done to me and my
family.
FROM JAYCEE DUGARD (2011)
You might be suddenly reading about a character that was never
introduced , but that’s how it was for me. It didn’t feel like a
sequence of events. Even after I was freed, moments are
fragmented and jumbled. With some help, I have come to realize
that my perspective is unique to abduction. I don’t want to lose that
voice, and therefore I have written the book how it came to me
naturally. I’m not the average storyteller…I’m me…and my
experience is very uncommon. Yes, I jump around with tangents, but
that’s somehow the way my mind works. If you want a less
confusing story, come back to me in ten years from now when I sort
it all out!” (p. viii).
FACTORS TO CONSIDER BEFORE GOING FARTHER
•
•
•
•
Does the client have a reasonable amount of coping skills to access?
Is there a sufficient amount of positive material in the client’s life?
What is the nature of the living situation (safety)?
Have you looked at the picture with drug/alcohol use, including psychotropic
medication?
• Is the client willing (and ready) to look at past issues?
• Have you assessed for secondary gains and other related issues?
• Have you considered number of sessions available?
PROCESSING MADE SIMPLE
•I am not good enough 
•I am good enough
BISSON & ANDREW (2007)
• Meta-analysis of over 30 studies about PTSD over an 8 year
period (1996-2004)
• Past-oriented PTSD treatments were far superior to coping skill
only PTSD treatments
• Past-oriented or trauma-oriented treatments can include pastoriented cognitive behavioral therapy, exposure therapy,
hypnosis, or EMDR
WORLD HEALTH ORGANIZATION
(2013)
• Primary health care staff are also warned against certain popular
treatments. For example, benzodiazepines, which are anti-anxiety drugs,
should not be offered to reduce acute traumatic stress symptoms or sleep
problems in the first month after a potentially traumatic event.
• Types of support offered can include psychological first aid, stress
management and helping affected people to identify and strengthen
positive coping methods and social supports.
• CBT and EMDR listed as two primary treatments of choice for referral
following the psychological “first aid” stage
BENISH, IMEL, & WAMPOLD (2008)
• A meta-analysis examining all studies on bona fide treatments for
PTSD (e.g., desensitization, hypnotherapy, PD, TTP, EMDR, Stress
Inoculation, Exposure, Cognitive, CBT, Present Centered,
Prolonged exposure, TFT, Imaginal exposure) conducted between
1989-2007 found no statistical significance amongst the treatments
(Benish, Impel, & Wampold, 2008).
• The only factor leading to any statistically significant impact was
therapist allegiance.
THE COMMON FACTORS
• Client and extratherapeutic factors
• Models and techniques that work to engage and inspire the participants
• The therapeutic relationship/alliance
• Therapist factors
Source: Duncan, B.L., Miller, S.D., Wampold, B.E., Hubble, M.E. (2009). The heart and soul of change:
Delivering what works in psychotherapy. (2nd ed.) Washington, D.C.: American Psychological
Association.
FROM THE BODY KEEPS THE SCORE
(VAN DER KOLK, 2014)
• Does not endorse any one modality
• “For real change to take place, the body needs to
learn that the danger has passed and to live in the
reality of the present” (p.21).
FROM THE BODY KEEPS THE SCORE
(VAN DER KOLK, 2014)
Ways for helping survivors feel alive in the present and move on with their lives:
• Top down methods: talking, connecting with others, self-knowledge
• Technology: medications to shut down inappropriate alarm reactions; other therapies/technologies that
change the way the brain organizes information
• Bottom up methods: allowing the body to have experiences that deeply and viscerally contradict the
helplessness, rage, and collapse that result from the trauma
Usually, a combination of the three is needed.
OPTIONS FOR PROCESSING
Accelerated Experiential Dynamic Psychotherapy
Acceptance and Commitment Therapy
Art Therapy
Dialectical Behavioral Therapy
The Developmental Needs Meeting Strategy
Emotional Freedom Technique
EMDR
Energy Psychology
Equine-Assisted/Pet Therapy
Exposure Therapy
Focusing
Gestalt Therapy
Hakomi
Hypnosis & Hypnotherapy
Internal Family Systems Therapy
Interpersonal Neurobiology
Life Span Integration Therapy
Mindfulness Based Cognitive Therapy
Narrative Therapy
Neurofeedback
Neurolinguistic Programming
Neuroemotional Technique ®
Play Therapy
Psychodrama/Drama Therapy
Psychodynamic therapy
Sensorimotor Psychology ®
Somatic Experiencing ®
Stress Innoculation
Systematic Desensitization
Trauma-Focused Cognitive Behavioral Therapy
Traumatic Incident Reduction (TIR)
Yoga Therapy
Visit the SAMHSA Registry at
http://www.nrepp.samhsa.gov/
OPTIONS FOR PROCESSING BY GROUPINGS
• Cognitive-behavioral therapies
• New wave cognitive therapies
• Exposure therapies and visualization
•
•
•
•
•
EMDR Therapy and related interventions
Somatic and movement therapies
Creative arts approaches
Gestalt approaches
Energy therapies
Please Return by 1:00pm
PARADIGM COMPARISON
Cognitive
• Irrational thoughts are the basis of pathology
• Cognitions are changed through reframing, self-monitoring, and homework
exercises
Behavioral
• Cannot see within the “black box” (the brain)
• Learned behavior is changed through conditioning, exposure, modeling,
etc. (learning processes)
PARADIGM COMPARISON
New Wave CBT
• Suffering is inevitable
• Change is through acceptance, commitment, and mindfulness exercises
Psychodynamic
• Explores the impact of the family of origin, object relations
• Change is created by insight or working through
• Goal is to make the subconscious conscious
PARADIGM COMPARISON
Family Therapy
• Problems and solutions are interactional
• Exploration and evaluation of family dynamics
• Change through education and role realignment
Experiential
• Facilitates client self-healing
• Affect and body are central
• Uses relationship, “two chair,” “meaning bridges”
EMDR THERAPY (W.H.O., 2013)
• Negative thoughts, feelings and behaviors are the result of unprocessed
memories
• The treatment involves standardized procedures that include focusing
simultaneously on:
(a) spontaneous associations of traumatic images, thoughts, emotions and bodily
sensations
(b) bilateral stimulation that is most commonly in the form of repeated eye
movements.
EMDR Therapy Demonstration
RESILIENCE & REINTEGRATION
• What does resilience mean to you?
• What do protective factors mean to you?
THE 14-ITEM RESILIENCE SCALE (RS14)
• I usually manage one way or another.
• I feel proud that I have accomplished things in my life
• I usually take things in stride.
• I am friends with myself.
• I feel that I can handle many things at a time.
• I am determined.
• I can get through difficult times because I’ve experienced difficulty before.
THE 14-ITEM RESILIENCE SCALE (RS14)
• I have self-discipline.
• I keep interested in things.
• I can usually find something to laugh about.
• My belief in myself gets me through hard times.
• In an emergency, I’m someone people can generally rely on.
• My life has meaning.
• When I’m in a difficult situation, I can usually find my way out of it.
THE 14-ITEM RESILIENCE SCALE (RS14)
Health Questions
• Feelings of depression in last two weeks
• General rating of health
• Ideal body weight
• Exercise 30 or more minutes most days
• Eat a healthy diet most days (5 fruits/vegetables)
• Use of tobacco products
• Use of alcoholic beverages
TAKE THE FULL TEST ONLINE
www.resiliencescale.com
VICTIM-SURVIVOR-THRIVER TABLE
Barbara Whitfield (2003)
FINAL DISCUSSION:
EFFICACY AS A TRAUMA THERAPIST
QUALITIES OF A GOOD TRAUMA THERAPIST
PARNELL (2007)
•
•
•
•
•
•
Good clinical skills
Ability to develop rapport with clients
Comfort with trauma and intense affect
Well-grounded
Spacious
Attuned to clients
THE CASE OF ANNA: QUALITIES OF A
GOOD THERAPIST (MARICH, 2014)
• To know and understand a client’s diagnosis.
• To get to know you, where you're at (are you externally and internally
safe???), where you've come from (historical context; triggers, traumas, what
to be aware of), and where you want to go (short- and long-term goals).
• To be a person who believes in TEAMWORK. Both the professional and the
client do work, lots of it. There is not an aggressor in the equation,
ever. When/if it happens, stop.
THE CASE OF ANNA: QUALITIES OF A
GOOD THERAPIST (MARICH, 2014)
• To have compassion and empathy—NOT PITY, ever. I have seen
pathological psychiatrists who don't like humans. Pity is just destructive to
what is supposed to be happening: growth and healing. Pity is never a
foundation for that.
• To have a sense of connectedness. For people without a diagnosis, when
they're going through a hard time, the baseline is to find someone you
connect with.
• To never, never, never put their own moral thing (e.g., Christianity) above the
code of treatment. Ever!!!!! No dogma at all should be in the way of the
client finding her way.
THE CASE OF ANNA: QUALITIES OF A GOOD
THERAPIST (MARICH, 2014)
“Bad therapy is worse than no therapy. I have learned this
experientially.”
QUALITIES OF A GOOD EMDR/TRAUMA THERAPIST
MARICH (2012)
caring
trustworthy
intuitive
natural
connected
comfortable with trauma work
skilled
accommodating
magical
wonderful
good common sense
smart
consoling
validating
gentle
nurturing
facilitating
QUALITIES OF AN INEFFECTIVE TRAUMA/EMDR
THERAPIST (MARICH, 2012)
•
•
•
•
•
•
rigid
scripted
detached
anxious
unclear
uncomfortable with trauma
BEUTLER, ET AL. (2005)
ON THE CONNECTION BETWEEN THERAPIST TRAITS & CLIENT
OUTCOMES
• Effective therapists are interested in people as individuals
• Have insight into their own personality characteristics
• Have concern for others
• Intelligent
• Sensitive to the complexities of human motivation
• Tolerant
• Able to establish warm and effective relationships with others
CHARMAN (2005)
•
•
•
•
•
•
•
•
•
•
•
•
mindful
not having an agenda
having concern for others
intelligent
flexible in personality
intuitive
self-aware
knows own issues
able to take care of self
open
patient
creative
INTENSE AFFECT & ABREACTION
• “The therapeutic process of bringing forgotten or inhibited material (i.e.,
experiences, memories) from the unconscious into consciousness, with
concurrent emotional release and discharge of tension and anxiety.”
APA Dictionary of Psychology (2007)
MINDFULNESS & SELF CARE
• Promoting mindfulness in psychotherapists-in-training could positively
influence the therapeutic course and treatment results in patients
(randomized, double-blind controlled study; Grepmair, Mitterlehner, Loew, et
al, 2007)
• Health care professionals participating in a mindfulness-based stress
reduction program (MBSR) were able to more fully identify their own themes
of perfectionism, the automaticity of “other focus,” and their tendencies to
always enter “fixer” mode; this recognition led to numerous changes along
personal and professional domains (grounded theory; Irving, Park-Saltzman,
Fitzpatrick, et al., 2014); a similar study that exclusively studied nurses yielded
similar findings (Frisvold, Lindquist, McAlpine, 2012)
MINDFULNESS & SELF CARE
• In an extensive mixed methods research study with working psychotherapists
from a variety of theoretical backgrounds, Keane (2013) concluded that
personal mindfulness practice can enhance key therapist abilities (e.g.,
attention) and qualities (e.g., empathy) that have a positive influence on
therapeutic training.
• Mindfulness practice could provide a useful adjunct to psychotherapy
training and be an important resource in the continuing professional
development of therapists across modalities.
FOR CONTINUED DEVELOPMENT
• How many of the qualities on these lists do I possess?
• How do I handle intense affect and abreaction?
• What are my personal barriers with trauma?
• What factors may inhibit me from being effective with someone struggling with trauma?
• What enhanced training might be most appropriate for me at this time,
considering the other responses?
REFERENCES & READING
• Aiena BJ, Baczwaski BJ, Schulenberg SE, Buchanan E. (2014). Measuring Resilience with the RS-14: A Tale of Two
Samples. Journal of Personality Assessment, DOI: 10.1080/00223891.2014.951445. 1-10.
• Benish, S., Imel, Z., & Wampold, B. (2008). The relative efficacy of bona fide psychotherapies for treating post-traumatic
stress disorder: A meta-analysis of direct comparisons. Clinical Psychology Review, 28(5), 746–758.
• Bisson, J., & Andrew, M. (2007). Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database
Syst Rev, July 18(3), CD003388.
• Dugard, J. (2011). A stolen life: A memoir. New York: Simon & Schuster.
• Duncan, B.L., Miller, S.D., Wampold, B.E., Hubble, M.E. (2009). The heart and soul of change: Delivering what
works in psychotherapy. (2nd ed.) Washington, D.C.: American Psychological Association
• EMDR International Association. (2015). EMDR Training Requirements- Updates on the Adaptive Information Processing
Model. Austin, TX.
• Grepmair, L., Mitterlehner, F., Loew, T., Bachler, E., Rother, W., & Nickel, M. (2007). Promoting mindfulness in
psychotherapists in training influences the treatment results of their patients: A randomized, double-blind controlled
study. Psychotherapy and Psychosomatics, 76, 332-338.
• Irving, J.A., Park-Saltzman, J., Fitzpatrick, M., Dobkin, P.L., Chen, A., & Hutchinson, T. (2014). Experiences of health care
professionals enrolled in mindfulness-based medical practice: A grounded theory model. Mindfulness, 5, 60-71.
• ISTSS Task Force: Cloitre, M., Courtois, C. A., Ford, J. D., Green, B. L., Alexander, P., Briere, J., … van der Hart, O. (2012).
The ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults. . Retrieved from
http://www.istss.org/AM/Template.cfm?Section=ISTSS_Complex_PTSD_Treatment_Guidelines&Template=/CM/ContentDi
splay.cfm&ContentID=5185.
• Keane, A. (2013). The influence of therapist mindfulness practice on psychotherapeutic work: A mixedmethods study. Mindfulness. DOI: 10.1007/s12671-013-0223-9.
REFERENCES & READING
• Marich, J. (2010). EMDR in addiction continuing care: A phenomenological study of women in early
recovery. Psychology of Addictive Behaviors, 24(3), 498–507.
• Marich, J. (2012). What makes a good EMDR therapist?: Exploratory clients from clientcentered inquiry. Journal of Humanistic Psychology, 52(4), 401–422.
• Marich, J. (2014). Trauma made simple: Competencies in assessment, treatment, and working with
survivors. Eau Claire, WI: Premiere Education & Media.
• Parnell, L. (2007). A therapist’s guide to EMDR: Tools and techniques for successful treatment. New
York: W. W. Norton & Company.
• Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing: Basic principles, protocols, and
procedures. (2nd ed.) New York: The Guilford Press.
• Van Der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing
of trauma. New York, Viking.
• World Health Organization. (2013). Assessment and management of conditions specifically related
to stress mhGAP Intervention Guide Module. Geneva, Switzerland: Author. Available at:
http://apps.who.int/iris/bitstream/10665/85623/1/9789241505932_eng.pdf?ua=1
To contact today’s presenter:
Jamie Marich, Ph.D., LPCC-S, LICDC-CS
Mindful Ohio
[email protected]
www.mindfulohio.com
www.jamiemarich.com
www.drjamiemarich.com
www.dancingmindfulness.com
www.TraumaTwelve.com
www.TraumaMadeSimple.com
Phone: 330-881-2944