Trauma Primer

I know, I know….I’ve been slacking off on the blog, but the past month has been really hectic and I put some skills into use.  One thing CBT and DBT both teach is to be more effective when it comes to time so that you don’t overburden yourself or harm relationships by not following through on commitments.  As a result, I had to put the blog on the back burner until I was able to recognize what a normal life looked like again.

Many clients who have experienced negative events in their lives may feel that these events aren’t worth exploring in therapy because, as many would put it …”it’s not like I have flashbacks or anything”.

In order to be diagnosed with PTSD a person has to meet certain criteria, but not meeting criteria doesn’t mean that traumatic experiences don’t have an impact on a person’s life.  Trauma is broken down into two categories, the first (“Big T”) includes experiences that meet the formal definition of trauma outlined in the DSM (rape, natural disaster, sexual abuse, war) and the second (Small T) includes events like neglect, job loss, emotionally abusive relationships or historical events that elicited strong feelings of shame or embarrassment.

Folks who experience Big T traumas are more likely to develop symptoms of PTSD, but most people who experience Big T traumas do not develop PTSD.  There are certain factors that may make someone more vulnerable to developing PTSD, including:

-Family History of Mental Health Issues or Addiction
-Presence of a Mental Health Issue or Addiction
-Exposure to traumatic experiences in the past
-High Level of distress experienced during the traumatic event
-Lack of Social Supports available to the person after the traumatic event
-Presence of other stressors during the time of the traumatic event (job loss, divorce etc)
-Gender (females are more likely to develop PTSD)

Although I use PTSD as a formal diagnosis when appropriate, I (and a lot of folks who work with trauma) tend to view trauma reaction on a spectrum with PTSD representing the most severe point on that spectrum.  A person may not meet the full criteria for PTSD, but may experience some of the symptoms within the disorder or may meet criteria for other disorders.

When it comes to Small T traumas, the popular culture tends to mock associations made between historical events and current symptoms with clichés and stereotypes of therapy as being about a problem in search of either more problems or a scapegoat. Many times, these types of trauma related disorders are more difficult to identify and treat because clients do not always associate the trauma with current mental health symptoms or, because of the cultural context, are ashamed to admit that these events are having a significant impact.

The good news is that the symptoms associated with both types of trauma follow similar treatment protocols, and even if associations to the traumatic event are not identified early on in treatment, most modalities have a way of teasing out these connections and determining validity.  Using CBT as an example, I typically work in an exercise around source credibility when identifying core beliefs which involves going beyond the core belief and determining the evidence that a client has historically used as a means of coming to the negative conclusion about themselves. Sometimes the less invasive interventions used in CBT are enough to attack source credibility and extinguish these negative beliefs, other times more invasive interventions (like EMDR or Exposure Therapy) are needed.

EMDR,The Weird Therapy

Before I get started with this I feel like I have to talk about the “Little Mermaid”.  That’s right.  I have to play it with my daughter every night. I’m either Sebastian or her father.  I try to be Sebastian as much as I can because that whole relationship with her father is a set-up.

Thanks Disney.

We have Ariel in doll form at every stage of her life (they make a baby Ariel now) and I’ve watched the movie at least three times this year- I watched for the third time last night.

Am I the only person in the world that finds the idea of a half human-half fish mutation repulsive?   The smell alone must be unbearable.  I cannot understand how this whole thing is still sustaining any kind of success.

Alright, so enough of that.

More than a few clients who would and eventually do benefit from EMDR are initially turned off by its “weirdness” and a lot of that usually has to do with their focus on bi-lateral stimulation (BLS)- the whole freaky eye movement thing.

EMDR stands for Eye Movement Desensitization and Reprocessing, it is a form of therapy that is primarily used to treat distress related to a traumatic event.  Given the wealth of research that demonstrates its efficacy and the media attention it received at one point, the questions that many people still hold about EMDR is surprising to me.

Part of the issue is what I believe to be the strange debates around BLS that pop up when someone does a search on EMDR and efficacy.  BLS (right to left/left to right stimulation that is feature of EMDR; takes the form of eye movements, tapping or sound )is  one thing that separates EMDR from other modalities, it’s not the only thing, nor is it the most important. There is no evidence to prove that BLS  works the way the EMDR folks say it does (behind closed doors) but that doesn’t mean EMDR is ineffective or that BLS is not useful. I use BLS because I think it takes the edge off the distress – it can act as a slight and almost soothing distraction for clients during processing. Another reason I use it has to do with the relationship between fidelity to the model and efficacy. This may be surprising to hear since EMDR began with its’ founder (Shapiro) using it as the basis for the model but that bears little relevance to the argument one way or the other.

Saying:

“EMDR works because of BLS and I know this is true because that is how it all started.”

Is as silly as saying:

“EMDR does not work because we have no evidence that BLS is what makes it work.”

When the research suggests EMDR does in fact work but BLS does not appear to be the reason why.

The other aspect that might freak some people out is the floatback which pulls from psychodynamic theory and speaks to the belief within the model that historical events influence current day thinking and reactions.  A significant minority of folks who walk through my the door requesting EMDR confuse it with Recovered Memory Therapy (although they don’t refer to it by name) which is one of many embarrassing chapters in the history of mental health treatment.

The floatback does not seek to recover lost memories, it seeks to work with the memories the client reports while he or she is fully conscious.  If the client struggles with an incomplete memory that drives the distress to the point where EMDR is indicated then EMDR can be used to desensitize the person to the partial memory/thought but it does not  seek to explore its validity or create new memories.

So this brings me to the other criticism of EMDR so succinctly stated by Richard McNally;

What is effective in EMDR is not new, and what is new is not effective. (link)

He is from Harvard, or as they say it – Hawvahd – so he must be right. Right?

Calling EMDR a re-hash of old therapies is like calling DBT a re-hash of CBT. I’ve received formal training in CBT and although DBT pulls from CBT and my understanding of CBT helps me to understand and use DBT skills, I would never call myself a DBT therapist until I was formally trained in it. There are differences that exist in their philosophies, the packaging of the interventions and the language/thinking that is used in applying the interventions.

EMDR is a collection of interventions pulled from several established forms of treatment; its different because it is both eclectic and structured. Its uniqueness and effectiveness probably has more to do with how EMDR understands trauma and its application of these interventions. It demonstrates the same efficacy as CBT and Exposure therapy in treating trauma related distress without the homework and it is more effective than psychoanalysis, psychodynamic therapy or supportive therapy.

Differences, however, don’t just exist in the application of EMDR. One topic that really gets missed in the discussion is the theoretical contribution Shapiro made to the field of trauma work;

All humans are understood to have a physiologically-based information processing system. This can be compared to other body systems, such as digestion in which the body extracts nutrients for health and survival. The information processing system processes the multiple elements of our experiences and stores memories in an accessible and useful form. Memories are linked in networks that contain related thoughts, images, emotions, and sensations. Learning occurs when new associations are forged with material already stored in memory.

When a traumatic or very negative event occurs, information processing may be incomplete, perhaps because strong negative feelings or dissociation interfere with information processing. This prevents the forging of connections with more adaptive information that is held in other memory networks. For example, a rape survivor may “know” that rapists are responsible for their crimes, but this information does not connect with her feeling that she is to blame for the attack. The memory is then dysfunctionally stored without appropriate associative connections and with many elements still unprocessed. When the individual thinks about the trauma, or when the memory is triggered by similar situations, the person may feel like she is reliving it, or may experience strong emotions and physical sensations. A prime example is the intrusive thoughts, emotional disturbance, and negative self-referencing beliefs of posttraumatic stress disorder (PTSD).

It is not only major traumatic events, or “large-T Traumas” that can cause psychological disturbance. Sometimes a relatively minor event from childhood, such as being teased by one’s peers or disparaged by one’s parent, may not be adequately processed. Such “small-t traumas” can result in personality problems and become the basis of current dysfunctional reactions.

Shapiro proposes that EMDR can assist to successfully alleviate clinical complaints by processing the components of the contributing distressing memories. These can be memories of either small-t or large-T traumas. Information processing is thought to occur when the targeted memory is linked with other more adaptive information. Learning then takes place, and the experience is stored with appropriate emotions, able to appropriately guide the person in the future. (link)

As a culture I understand we have walked away from using theory as a credible argument for legitimacy (which has become problematic but material for another time); yet the theory is a match to the model and the model works.

Like other treatment modalities, EMDR pulls from other schools of thought in its thinking and application. Like other modalities there are pieces of it that we know work and parts of it we think might work but cannot yet reasonably demonstrate whether they really do work, how they work and/or why they work. We do know that, as a whole, EMDR is highly effective in treating complicated trauma and as a result of the research conducted on its efficacy, groups like the APA and VA have thrown strong support behind its use as one of three preferred methods of treating it. EMDR is also safe; the initial stages of EMDR seek to assess the appropriateness of the intervention for clients (both in terms of potential vulnerability and responsiveness); has formal protocols in place for grounding and de-escalation and contains the active work around the trauma to the session. This does not mean EMDR is right for everyone (some folks don’t respond and others respond poorly); like I said, this fact is formally acknowledged in the protocol which seeks to identify candidacy issues before any processing taking place.

So stop calling it weird.

wpid-20131221_095917.jpg

You’re making it feel bad.

Okay…what I just did there was weird.

But that makes me weird (which you probably already guessed was true), not EMDR.

Trauma and Forgiveness

Seated Statue at US Supreme Court While forgiveness may be an important part of the work with a trauma survivor, the idea that it must happen is something that really doesn’t jive with my experience as a therapist. Many of the survivors I’ve worked with have been able to achieve symptom reduction and acceptance with very little time spent on forgiveness at all.  That may be surprising given that over the years forgiveness has become such a prominent fixture in therapy and highly associated with work involving trauma and loss.

The three most effective modalities in relation to PTSD, as an example, are  –

Cognitive Behavioral Therapy

Exposure Therapy

Eye movement desensitization and reprocessing

None of these are predicated on the idea that forgiveness is necessary. All three are open to it, have ways of addressing it but avoid being directive about its inclusion or outcome. Forgiving the perpetrator does not magically make the distress in relation to the event disappear. Being able to think about the event without feeling distress does not always mean that the survivor has forgiven the perpetrator.  It can mean these things sometimes. 

Not forgiving can be as valid, considered and reasonable as forgiving.

One can argue that a lot depends on how we define “forgiveness” – this is true and another reason it has the potential to become problematic if not handled carefully.

From the Forgiveness Therapy folks-

Forgiveness does not necessarily mean reconciliation with the person that hurt you, or condoning of their action. What you are after is to find peace. Forgiveness can be defined as the “peace and understanding that come from blaming that which has hurt you less, taking the life experience less personally, and changing your grievance story. (Luskin, F. M. (2003) Forgive for Good: A Proven Prescription for Health and Happiness. Harper Collins: San Francisco.) – emphasis added

This definition appears most consistent with a Buddhist or Hindu take on the subject but it also describes the outcomes most clinicians who engage in the three modalities mentioned previously, seek to achieve. Using the term “forgiveness” as a label or grouping for these components is a subjective call.

This isn’t to say that helping folks negotiate their definition of forgiveness to something more adaptive isn’t important or meaningful; but it’s equally important for therapists to remember that forgiveness is not solely defined by psychology – theology, philosophy, family of origin etc, – all have a part to play.  Our understanding is a relatively new spin on a term that may have different and deep rooted meanings for survivors, depending on the theological or philosophical framework they operate from.

Catholicism-

Forgiveness goes beyond those three virtues, but without negating any of them. Justice, clemency, and mercy provide the very foundation that allows forgiveness to be a possibility. Forgiveness goes beyond mercy and treats the offense as if it never happened. It wipes the slate clean, as it were, and gives the transgressor a fresh start.  (Forgiveness, Donald DeMarco, Catholic Education Resource Center, 2002)

Judaism-

The offended person is prohibited from being cruel in not offering mechila, for this is not the way of the seed of Israel. Rather, if the offender has [resolved all material claims and has] asked and begged for forgiveness once, even twice, and if the offended person knows that the other has done repentance for sin and feels remorse for what was done, the offended person should offer the sinner mechila (Rabbi David R. Blumenthal quoting Maimonides link )

Aristotle-

 The man who is angry at the right things and with the right people, and further, as he ought, when he ought, and as long as he ought, is praised. (Nicomachean Ethics)

Objectivism-

Learn to distinguish the difference between errors of knowledge and breaches of morality. An error of knowledge is not a moral flaw, provided you are willing to correct it; only a mystic would judge human beings by the standard of an impossible, automatic omniscience. But a breach of morality is the conscious choice of an action you know to be evil, or a willful evasion of knowledge, a suspension of sight and of thought. That which you do not know, is not a moral charge against you; but that which you refuse to know, is an account of infamy growing in your soul. Make every allowance for errors of knowledge; do not forgive or accept any break of morality. (Ayn Rand, Atlas Shrugged)

Voltron-

From days of long ago, from uncharted regions of the universe, comes a legend; the legend of Voltron, Defender of the Universe, a mighty robot, loved by good, feared by evil. As Voltron’s legend grew, peace settled across the galaxy. On Planet Earth, a Galaxy Alliance was formed. Together with the good planets of the solar system, they maintained peace throughout the universe, until a new horrible menace threatened the galaxy. Voltron was needed once more. This is the story of the super force of space explorers, specially trained and sent by the Alliance to bring back Voltron, Defender of the Universe!

The last one had nothing to do with forgiveness but I don’t think I ever worked in a Voltron quote. It just needed to get done.

Pursuing forgiveness as a treatment goal prematurely and/or without invitation on the part of the survivor can create an unnecessary and even counter productive dynamic that challenges some deep seated beliefs which may or may not bear any relevance to the issue.  Even if the clinician is right in their thinking, getting it wrong on timing may have a negative impact on the success of the intervention and the overall work.

If forgiveness does come up, it is important for therapists to identify and operate from an understanding of forgiveness that makes sense for the survivor and their world view.  Although the work is harder on the clinician,  doing so creates a greater potential for authenticity and is more protective of a survivor’s self determination.

Time and Attention

Chance Agrella-freerangestock.com The past or future can be hot spots for people who are in treatment as a result of a loss (death, career, marriage, identity) or trauma.  In the grief and loss groups I facilitate, I spend a few sessions on the subject because attention away from the present can be a barrier to adaptive grieving.

Living in the past, or rather, replaying it over and over again, typically leads to sadness, anger and regret.  Focusing exclusively on the future typically leads to anxiety and fear. The former has to do with guilt and inadequacy while the latter centers on safety and predictability. To be clear, there is a difference between reminiscing (past), planning (future) and ruminating on the two.

While we encourage remembering in our work with clients; not all remembering is good- it depends on how you go about it.  “Remembering”, to assign responsibility or “undo” the event in our thinking is generally harmful because it can create a series of movies that act as evidence to our “mistakes”.  While reasonable and focused planning is necessary, constantly being on guard against future losses or harm is the product of or can lead to hypervigilance; we prioritize safety in a way that disproportionately affects other parts of our lives.

Folks who struggle with loss and trauma sometimes play the “what if” game. Having behaved differently before or in response to the loss or trauma may or may not have produced a different result.  Even if the result were different it may not have been more desirable. Survivors of sexual trauma may struggle with having  “given up” during the trauma – feeling ashamed and inadequate about the fact that they did not fight long enough. In reality, not fighting after being overpowered may be a reasonable choice a survivor makes during the traumatic event as it represents a shift in strategy from trying to stop the act to surviving the act.

Other survivors may struggle with the position they feel they placed themselves in just before the trauma; feeling “stupid” or responsible for the act. Most acts of sexual trauma (90+%) are committed in environments familiar to the survivor by a person known to the survivor.   To have expected the event would have required more than hypervigilance; like having a sixth sense.  Survivors of trauma who hold on to this expectation in their understanding of the event may be more prone to hypervigilance or re-enactment – placing themselves in unsafe situations as way of gaining mastery over the original trauma.

It’s unreasonable to expect someone to just turn the thinking off in the early stages of treatment . The ability to turn it off is a desirable mid- long term goal; but in the short term objectives may have more to do with shifting attention away from the past and future or thinking about each in ways that do not consume time, impact functioning or trigger unsafe behaviors.

With regard to grief, one strategy involves creating time in your schedule to remember a loss while allowing yourself permission not to think about the loss until your appointment with it. The appointment can include  journaling, art, prayer, looking at photo albums with family members, a church service, a therapy session or support group – anything that is action oriented, time limited and most people would describe as healthy and reasonable. Anticipatory anxiety about the approach and the distress involved with tolerating the activity can be mitigated by engaging in activities such as attentive breathing or exercise before, during and after the activity.

With regard to physical or sexual trauma, “thinking” about it should probably be handled in a context that prioritizes safety with access to expertise or help readily available.  Support groups or therapy  can be the appointment that provides opportunities to work through the trauma. In our practice, work involving trauma occurs within a framework of a highly structured and guided process that seeks to mitigate the risk of unsafe emotional escalation.  It begins with increasing capacity to tolerate memories of the event by learning and reinforcing coping skills then, when a person feels ready, directly addressing the event through some form of exposure therapy.

The “appointment” with the loss or traumatic event allows survivors access to a credible holding ground – it gives them a receptacle they can use to contain the material when it’s not safe or convenient to think about.  Thinking about therapy or any other safe activity in this manner can help increase the credibility clients give to attentional coping skills like mindfulness or “stop’ techniques because we are speaking to their desire to address the events while giving them “permission” to get relief from the material.