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Treating Complex PTSD and Dissociation with Integrative EMDR

Therapy: A Resilience Informed Approach to Trauma Treatment

Arielle Schwartz, PhD

PTSD,ChronicPTSD,C-PTSD• AcuteTraumaticStress:Normalresponseafterexposuretoatraumaticeventthatincludespanic,grief,andsomaticsymptoms.

• PostTraumaticStress(Disorder):Symptomscontinuetointerferewithindividual’slifebeyond4weeksafteratraumaticincident(crime,accident,naturaldisaster)

• ComplexPTSD(C-PTSD):Symptomsarerelatedtorepeated,prolongedexposuretotraumaticeventsthatoftenhaveachildhoodonsetandareofteninterpersonal(domesticviolence,childhoodabuseorneglect).

SymptomsofC-PTSD• IntrusiveMemories• AvoidanceSymptoms• EmotionalDysregulation• InterpersonalProblems• CognitiveDistortions(Inaccuratebeliefs)

• HealthProblems(ACE)andChronicPain

• Dissociation

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SymptomsofDissociation:Arangeofsymptoms:• Disconnectedfrombody,thoughts,oremotions

• Feelingfuzzy• Havingahardtimeverbalizingtheirexperience• Feelingdizzy• “Lossofcontrol”• Disoriented• Lackofdistinctionbetweenpastandpresent.• Lapsesofmemoryor“losttime”• Multiplepartsorsub-personalities.

Dissociation:DisorderofPerceptionChallengeinrecognizingthat:• Thetraumaticeventhappened• Thatthetraumaticevent

happenedto“me”• Thetraumaticeventisover• Iamhereandnow(notthenand

there)• Mybodyispartofme• Themeofthenispartoftheme

now• Myactionsinthepresentbelong

tome

DefensesMaintainDissociation• Repression:“IfIdon’ttalkaboutoracknowledgemypainfulpastitdoesn’texist.”

• Denial:“Yeah,Iwasabusedbutitwasn’tabigdeal”

• Avoidance:“IfIjuststayinbedandsleepIdon’thavetofacereality”

• Fantasy:“IfIjustactlikeeverythingisokaythenitwillbeokay.”

• Self-Blame/Idealization:“IfonlyIhadn’tbeensobadIwouldn’thavebeenabused”

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PhobiasMaintainDissociation

Phobiaof:• Traumaticmemories• Partsofselfthatcarryshame

• Attachment,relationship,andloss

• Innerexperience(arousalstate,affect,bodysensations)

WorkingwithC-PTSD:Evokesfeelingsof:• Helplessness• Hopelessness/Despair• Isolation/Loneliness• Injustice/Unfairness• Suffering• Rage• Evil• Meaning/Purposeputinquestion

PersonalInquiry

• Whatresourceshelpyoustaypresentwithyourclientsastheyexperiencehelplessness,despair,suffering,uncertainty,disappointment,andloss?

• Whatmeaningmaking,spiritualperspectives,orself-carepracticeshelpyouattendtotheweightofthiswork?

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TreatingC-PTSD

• Increaseyourclient’scapacitytostaypresentwithandeffectivelyrespondto(regulate):– Statesofmind– Emotions– Sensations– Interpersonalexchanges

DevelopToleranceFor:• Uncertainty• Ambiguity• Disappointmentandloss• ConflictandCompromise

• Difference• Competingneedsanddesires

• Conflictingideasandemotions

GoalsofTreatmentTheclientisabletosay:• Thetraumahappenedtome• Iamawareofmypastandhowitaffectsmeinthepresent

• Thepastisdifferentiatedfromthepresent(Itisovernow)

• Icanbemindfulofthepresentmoment• Icansenseandfeelmybodynow• Ihavechoicesnowaboutmythoughts,emotions,andbehaviors.

• Icanorienttowardthefuture

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EMDRTherapy• NotanIntervention—ATheoreticalOrientation• DualAttentionState(DAS)– BilateralStimulation

• ResourceDevelopmentInstallation– Safeplace,Containment,Grounding,Allies

• BodyBasedandPresentCentered– Nervoussystemregulation,Pendulation

• EmphasisonRelationship– Rapport,Transferenceandcountertransference,Contactstatements,RelationalInterweaves

8PhasesofEMDRTherapy• Phase1 HistoryTaking:Developcaseconceptualizationofclientwithincontextoflife,identifytraumahistory.

• Phase2Preparation:Establishtherapeuticrelationship,Stabilizeandbuildskills,ResourceDevelopmentInstallation(RDI)

• Phase3 Assessment:Targetdevelopment,“lightup”thetraumaticeventwiththedisturbingimage,emotions,beliefs,andbodysensations

• Phase4 Desensitization:UsesDAStoprocessthedisturbingmaterialrelatedtotraumatargetuntiltheclientreportsnodisturbance(SUDS)

• Phase5Installation:Strengthenspositivebeliefsthatariseafterthesuccessfulcompletionofdesensitization.

• Phase6 BodyScan:Releaselingeringtension• Phase7Closure:Ensuresclientisresourcedpriortoendingthesession,Containment

• Phase8Re-evaluation:Reviewofefficacyoftreatmentfromprevioussession.

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IntegrativeEMDRTherapyforC-PTSD

Effectivetraumatreatmentinvolvesabalancebetweenthe

regulatingfunctionoftop-downprocessingandtheaccessingfunction

ofbottom-upprocessing(vanderKolk,2003)

Top-DownorBottom-UpInterventionsTop-DownInterventions:• Engagesupperbraincentersintheneocortextoprovide regulating,conscious,thought-basedtoolsforaddressingtraumasymptoms.

• Pressingonthebrakes-slowsdownprocessing

Bottom-upInterventions:• Engagesthelowerbraincentersinthelimbicsystemandbrainstemtohelptheclientaccessemotionalandsensorycomponentsoftraumaticmaterial.

• Pressingonthegas-speedsupprocessing

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Top-DownInterventions• Psychoeducation(e.g.teachsomaticvocabulary)• Mindfulness• Cognitiveinterventionssuchasidentifyingnegativeandpositivebeliefsorchallengingthinkingerrors

• Resourcinginterventions(grounding,establishingsafety,developingcontainment)

• Talkingabouttraumaticevents• ConsciousBreathing

Bottom-UpInterventions• Focusonbodysensations(e.g.bodyscan)• Sequenceordischargetensionoutofbody• Invitemovementtofacilitatesomaticrelease• Followmovementimpulses• Titration:experiencingsmallamountsofdistresswiththegoalofdischargingphysicaltension

• Pendulation:anoscillationbetweenfeelingdistressandfeelingsafeorcalminthepresentmoment

• ConsciousBreathing

SomaticPsychology• EmbodiedSelfAwareness:Attentiontobodysensationsandbreath

• Grounding:5senses(hearing,seeing,smelling,tasting,touching)anchorclientinhereandnow

• RegulationModel:PhysiologicalregulationwiththeWindowofTolerance

• Sequencing:Movementoftensionoutfromthecoreofyourbodythroughperipheryofbody.

• Pendulation andTitration: Alternatingbetweenresourceanddistress

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Somatictherapiesarenotjustasetofinterventionsfortheclient,theyare

thefoundationfortheattunedpresenceofthetherapist.

WorkingwithintheWindowofTolerance

• WindowofTolerance:anoptimalzoneofnervoussystemarousalwhereclientsareabletorespondeffectivelytotheiremotionsandsensations(Siegel,1999)

• AbovetheWindow:Feelinganxious,overwhelmed,orpanickedisasignthattheclientishyper- orover-aroused.

• BelowtheWindow:Feelingshutdown,numb,ordisconnectedisasignthatyouarehypo- orunder-aroused.

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IntegrativeEMDRTherapyforC-PTSD

Mind-BodyTherapies:• ComplementaryandAlternativeMedicine(CAM)

• Nutrition• Massage• Acupuncture• TraumaSensitiveYoga• TaiChi,Qigong

PreverbalandNonverbalMemories• Earliestattachmentmemoriesarestoredasrepresentationsofmotorpatternsandsensations

• Traumaticstresscanimpairthebrainstructuresinvolvedwithexplicitmemory(vanderKolk,2015)inwhichmemoriesarestoredasfragmentsofdisconnectedsensoryandbodilyexperiences.

EgoStatesandPartsWork• Assessmentofandtreatmentofdissociation:Lookfor

subtlesignsaswellasovertsymptoms• Observecuesofparts:– Voicetone– Bodyposture– Changesineyecontact– Repetitivemovements,suchashairtwirling,skinpicking,ornailbiting

– Changesinbreathingpatternssuchasholdingthebreath– Bodysymptomssuchastheonsetofaheadache,nausea,dizziness,orpain

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PartsWork

ApparentlyNormalSelf(ANP):persona,superego

Defenses:perfectionism,control,idealism,addictions

ExiledPart(EP):emotions,sensations,ormemories

MutualRegulationandRelationalWork

• Yourtaskistoacceptwhattheclientcannotandtofacilitategreaterintegrationatapacethattheclientcantolerate

• Exploretransferenceandcountertransference• Re-enactmentsareinevitable• Rupturesandrepairprovideopportunitiesfornewlearning

EmbodimentinMutualRegulation• Therapistandclientmutuallyinfluenceeachotherthroughouttherapy.

• Whentherapistsattunetotheirownembodiedawarenessduringsessions,theycansensesubtlechangesthatmayprovideinsightintotheexperienceoftheclient.

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EmphasisonSelf-Care• PreventionofStressandBurnout• ClinicianprovidesExternalRegulation• Ownembodimentandmindfulnesspractice

• Ownsupervisionand/ortherapy

ResilienceInformedTherapy• Biopsychosocial:Notamedicalmodel(Doctor/Patient),PartnershipandCollaborative

• StrengthBased:Whatisalreadyworking?• Resilience:Resilienceisadaptingwellinthefaceofadversity-bouncingbackfromdifficultevents

• PostTraumaticGrowth:Improvedself-perception,enhancedrelationships,andastrengthenedlifephilosophythatoccurafterexposuretoatraumaticevent.“I’mstrongerasaresult”

TraumaRecoveryandtheBellCurve

PTSD Resilience PTG

(MartinSeligman,PositivePsychology)

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QuestionsofResiliency

• Whydosomepeoplerespondbettertotraumaticexperiencesthanothers?

• Whatcopingstrategiesandbehaviorsareassociatedwiththegreatestadaptation totraumaticlifeevents?

• Whatarethemosteffectivemeansofintegratingthesestrategiesintoourlives?

• Challenge:Believingthatgrowthandwisdomaregainedfromdifficultorchallengingexperiences.

• Control:Ratherthanlapseintopassivityandpowerlessness;thebeliefthatwitheffortyoucaninfluencethecourseofeventsinyourlife

• Commitment:Theabilitytostayinvolved;stayingengagedinongoingeventsratherthanisolating.

(Salvidore Maddi,TheHardinessInstitute)

FactorsofResilienceandPTG

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ResilienceInformedTherapy• SupportSystems:ResilienceFactors(SocialConnection,Self-Care,Exercise,etc.)

• HealthandWellness: BuildaCollaborativeTreatmentTeam

• TraumaTreatment:SingleIncident,ChronicPTSD,ComplexPTSD,ACEFactors

• FamilyHistory:UnderstandingSymptomsinContext:ChildhoodDevelopment,Familyhistory,TransgenerationalStory,Culture

www.drarielleschwartz.comTrainings

Consultation&SupervisionPsychotherapy