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.

Core Beliefs

Spiral Staircase

Automatic thinking is a term that comes up a lot around these parts (parts=this blog) and refers to the self-talk or narrative that folks with depression and anxiety immediately engage in as a response to an activating event or trigger.  Automatic thinking can be the result of a trigger or can act as a trigger for distress.  Many of the clients I work with are often curious about how or why this type of thinking occurs. The primary source of automatic thinking are core beliefs; beliefs that we hold about ourselves, others and/or the world around us.  Individuals who struggle with a mental health issue typically have negative core beliefs that can influence thinking on a variety of events that occur on a day to day basis.

Core beliefs can center around adequacy (“I am worthless”), control (“I cannot be trusted”) or safety (“I cannot protect myself”). Someone who holds the core belief of “I must be perfect” may be prone to polarized thinking (placing events or people in categories of “all good” or “all bad”) which may in turn increase the distress associated with failing and could also influence a reaction to failing that is unhelpful or harmful.

There are many factors that influence core beliefs; one being a biologically based condition like depression.  A person may have a typical family history and childhood  but because of the impact depression has on their mood,  that person may interpret the “stuff” we all go through in ways that are more negative and impactful.  Failing a test or feedback received from a parent may take on a deeper meaning that feeds into the understanding that a  person has about themselves. A child or teen without depression may move on from these events or, perhaps, use these events as motivating factors to improve. A person who struggles with depression or anxiety may view these events as evidence of a fundamental flaw.  This perceived flaw may begin to shape how everything is viewed and can even be predictive.

Another factor involves traumatic events which can range from being embarrassed in front of a classroom by a teacher to events we typically associate with the word trauma like sexual abuse, assault, combat or witnessing the unexpected  death of a loved one.  These events, especially when they are experienced at younger ages, can have a very big influence on core beliefs as survival becomes the driving force in holding onto the belief.  A survivor of sexual abuse may live in a home environment where the belief of “I am not safe” is actually adaptive.  This belief helps to maintain the kind of  vigilance the survivor needs to avoid the trauma.

Once the survivor leaves the home environment the cost-benefit of the belief and the behaviors connected to it shifts. Because of the association the belief has to survival, it may be very difficult for the survivor to consider any other alternative in their thinking.  Imagine living your day to day life in a mine field for the first 12-17 years of your life. Now imagine someone taking you away, placing you in the middle of another field, telling you “there is nothing to worry about now” and even demonstrates this by running through the field carelessly. How easy do you imagine it would be for you to act according to that evidence?

There are several steps to changing core beliefs in therapy, the first one involves actually identifying it.  In CBT, the process to accessing a core belief involves asking a series of repetitive questions around an automatic thought or hypothesis a client has in relation to an activating event or trigger.

T- “So you’re saying that going to the grocery store will probably result in a panic attack.  What would having a panic attack at the store say about you?”

C-“It would be pretty embarrassing.”

T-“So you would feel embarrassed, what would make it embarrassing?”

C-“Everyone would be staring at me….avoiding me.  People who know me might look at me differently.

T-“And what would that say about you?”

C-“That I’m unstable….crazy.”

T-“What would that mean to you?”

C-“That I shouldn’t go to the grocery store.”

T-“And what would that say about you?”

C-“Well… that’s a pretty basic thing…..if I can’t do that then I’m pretty helpless.”

T-“And what would that say about you?”

C-“Just that…I’m helpless.”

T-“So when you think about those three statements “I’m crazy.”, “I’m unstable”, “I’m helpless”, which one makes the most sense to you when you think about having to go shopping?”

This is pretty consistent with how EMDR handles it within its’ protocol; the only difference being that clients are asked to look at the worst image of the event they are working on (usually historical) when coming up with the core belief. If someone is struggling with putting words to the core belief, I’ll provide them with a list that they can either pick from or use as a way to jog their thinking.

Negative core beliefs typically develop during times of high distress when we are less capable of looking at events objectively.  Because they are distressing, we may not revisit them for reasons ranging from discomfort to fear. As a result, the initial understanding or conclusion about the event may not change or be challenged.  Being aware of the core belief(s)  is key to long term sustainable change as it addresses the root cause.  In identifying core beliefs, we become more able to engage in a variety of skills that seek to address the source of the belief in ways that can lead to fundamental shifts in our thinking.

EMDR and Eye Movements

I recently got an email from the EMDR institute linking to an article on Scientific American. The article cites two studies demonstrating the importance of eye movements in EMDR.  The email was timely as I recently wrote an article about EMDR a few weeks ago.

From the article (citing Chris Lee, Murdoch University)

“Our experiments clearly show that negative autobiographical memories are very rich in sensory detail, and by pairing them with eye movements, they lose this sensory richness,” Lee says. “People describe that the memories become less vivid and more distant, that they seem further in the past and harder to focus on. What follows after this distancing is a reduction in the associated emotional levels.” In other words, the traumatic memory stays, but its power has been diminished.”

Although the article is dated, I’m glad I finally got to it…or rather it to me. Granted, the conclusion at the end of the article is not tied to the research highlighted in the article; it is a theory (which is different than a guess) based on other research that seeks to explain why eye movements make a difference.

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.

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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.