OEI: O bserved & E xperiential I ntegration for Trauma: A New Trauma Therapy

Rick Bradshaw, PhD, RPsych Trinity Western University [email protected]

Laurie Detwiler, M.A., C.C.C.

Kwantlen Polytechnic University ( [email protected]

) CCPA Annual Conference Ottawa, ON May 18, 2011

Polyvagal Theory & Co-Activation of Sympathetic & Parasympathetic

•

Stephen Porges (2001, 2007) Polyvagal Theory

– – –

Social Connection

– Ventral Vagal Complex (VVC) – Brake = On

Fight or Flight

– Sympathetic Nervous System – VVC Brake = Off

Freeze

– Dorsal Vagal Complex

•

OEI – Neuro-Activation & Micro-Attunement together

–

Mirror Neurons, Embodied Simulation, Intentional Attunement

•

OEI – Switching for Titration, Glitch Massaging, Transference

–

Extraocular muscles, Intraocular muscles, and Proprioception

•

OEI – Switching for Artifacts, Release Points, Sweeping

–

Feigned Death (Freeze) responses – Chest, Airway, Stomach

Observed & Experiential Integration

(OEI): What is it?

• • • • • •

SWITCH

– Alternately covering & uncovering the eyes

SWEEP

– Covering one eye, guiding other eye across

TRACK

– Guiding one or both eyes, watching for glitches

GLITCH MASSAGE

– Guiding eye(s) over/out of glitches

GLITCH HOLD

– Bilaterally stimulating, holding in glitches

RELEASE POINTS

– Places to guide eyes for release of: * Hyperventilation & temporary cessation of breathing * Chest compression & throat constriction (LR & Abducens) * Nausea, queasiness, abdominal cramping (SO & Trochlear) * Jaw tension and tooth grinding

OEI: What is it used for?

• Rapid de-escalation of affective & somatic intensity • Assessment & treatment of negative transference • Avoidance of, and relief from, panic attacks • Overcoming addictions, including self-harm • Dissolving barriers to performance

The Self-Trauma Model: Briere • • •

Flashbacks constitute natural attempts of the human brain to desensitize traumatic material, but… In those with severe, prolonged childhood trauma there is often a developed capacity to dissociate when overwhelmed (Lanius) This leads to cycles of abreaction and dissociation (PTSD, CPTSD, DDs)

OEI & the Abreaction-Dissociation Cycle

Dissociation

…Therapeutic Window Staying within the…

Abreaction

Once upon a time….

Two psychotherapists in Vancouver Canada (Audrey Cook & Rick Bradshaw) • • Working with abuse, neglect and other trauma Finding ‘talk therapies’ ineffective for PTSD, Complex PTSD, and Dissociative Disorders likely because… • Psychological trauma affects different areas of the brain than speaking and listening….

1994 & ‘95 Audrey Cook found that:

EMDR wasn’t working with some CPTSD/DD clients: – Those with ‘lazy eyes’ couldn’t track their therapist’s fingers with both eyes at the same time – Some clients were too dissociated & disconnected – Some clients were overwhelmed by intense abreactions • Thought : “I wonder if it would work one eye at a time” - Led to OEI ‘Switching’ (alt covering eyes) SWITCHING VIDEO DEMO

OEI and EMDR: Differences

EMDR

Doesn’t address negative transference between therapist & patient No acknowledgement of tiny halts or hesitations in eye movements No recognition of “side effects” of trauma processing on additional aspects of the past

OEI

Includes transference checks & clearances for individuals & groups Involves identification and resolution of tiny halts or hesitations-eye movement Techniques for resolving “artifacts” like headaches, dizziness/drowsiness, and visual distortions

OEI and EMDR: Differences

EMDR

Mechanism = eye saccades and rhythmic sounds or taps (PGO region of the brain)

OEI

Mechanism =

different than

eye saccades and rhythmic sounds / taps; Can involve simple covering of eyes Cognitions are essential in protocol – Negative Cognition, Positive Cognition, SUDS, VoC Cognitions not in protocol. Numbers optional rather than required. Observe Intensity & Conflict Markers

OEI and EMDR: Differences

EMDR OEI

Requires use of both eyes simultaneously One eye at a time

or

eyes two Vision

not required

. Can use sound or touch to stimulate the brain mechanism Requires vision to sense light & track movement across both visual fields

Does not acknowledge

address nausea, hyperventilation & or cessation of breathing, chest tightening, or jaw clamping Includes “release points” for nausea, hyperventilation & cessation of breathing, chest tightening, and jaw clamping

OEI and EMDR: Similarities

Can be performed using both eyes. Procedures in both therapies involve the tracking of a moving object (therapist finger, wand, etc.) Involves focusing on trauma in multi-sensory fashion to expose individual to the intensity of past experiences Involves arousal of fight-or-flight response and/or freeze response via midbrain & forebrain.

Speech Area: Speech Production

Listening Area – Understanding Speech

Limbic & Paralimbic Structures •

The parts of the brain most involved in producing intense symptoms, like:

•

Panic, flashbacks, startle response, nausea, and throat or chest constriction

•

Are

not

directly affected by

talking

or

listening

Limbic System: Midbrain

Anterior Cingulate Gyrus

Eye & Brain Connections •

Both eyes have connections to both halves of the brain

•

Half of each visual field in each eye is associated with half of the brain, and the other half of each visual field is associated with the other side of the brain. Integration can occur with one eye at a time or both eyes

An Overview of OEI Procedures

with

Treatment Targets

by

Dr. Rick Bradshaw

5 Building Blocks of OEI

Level I Techniques

Switch Sweep Release Points

Level II Techniques

Glitch Hold Glitch Massage

OBSERVATIONS & DISCOVERIES 1

Core Trauma Symptoms:

• • • • Encountered during processing of traumatic material In the center or ‘core’ of the body. Symptoms include: • • • • • Hyperventilation temporary cessation of breathing chest compression throat constriction nausea OEI switching reduce & glitch work dissipates intensity Intensity, type of emotion, & location of body sensation usually differs, depending on which eye is covered

Core Trauma vs Artifacts

p. 30

OBSERVATIONS & DISCOVERIES 2

• • • • •

Dissociative Artifacts:

In response to intensity of trauma processing Outside (peripheral to) the core of the body Symptoms include: • • • • • visual blurring & occlusions headaches & pressures tingling & numbness (hands, face, feet) Dizziness, lightheadedness, loss of balance drowsiness Usually dissipated quickly with switching & sweeping Balance boards to assess & minimize dissociation

OBSERVATIONS & DISCOVERIES 3

• • • • •

Shock: “Can you believe it….?”

Incongruence: Severity of incident not accompanied by expected emotional & physical intensity markers Process seems blocked by

shock

Switching and asking the questions: • • • • “Can you believe __(

name

)__ did that to you?” “Can you believe ___(

name

)___ was killed?” “Can you believe you

can’t believe

it?” “Can you believe any man would do that to anyone?” Shifts clients out of disconnected states Not unusual for clients to be connected to the reality of an event with one eye open but not with the other open

OBSERVATIONS & DISCOVERIES 5

Eye Dom. & Affective/Somatic Differences

• • • • Dominance check:

The Dominance Factor

(Carla Hannaford) Majority of clients = more fear & anxiety w dominant eye = sadness & despair w non-dominant If much early onset abandonment/abuse, less predictable Often ‘sad & mad’ or ‘sad & afraid’ Difficulty holding gaze: shame or fear of disapproval

OBSERVATIONS & DISCOVERIES 4

Transference Checking & Clearing

• • • • During switching for core trauma symptoms and dissociative artifacts, clients disclose differences in perceptions of therapists, depending on which eye is covered, including differences in: • Perceived proximity of person (close, distant) • • • • Color (green or gray to red or yellow) Perceived age or facial expression (angry, caring) Perceived proportions of head & body Perceived attitude or mood of therapist Switching dissolves these perceptual distortions Sometimes add glitch work for resistant distortions Extended to: • • • • Mirror work - body/facial dysmorphic disorder Body image perceptions – eating disorders Families & groups (couples/parenting/attachment) Substitutions (photos, videos, symbols & objects)

OBSERVATIONS & DISCOVERIES 6

Release Points:

P. 27

• Glitches =

most

intense place in

most

intense eye • Release =

least

intense place in

least

intense eye • • • Respiratory system: cover Dom eye, lowest rib, ND side Gastrointestinal: cover Dom eye, lowest rib, Dom side Jaw Tension: alt cover eyes, level of lips, 180 º to 90º VIDEO OF RELEASE POINTS

Release Points

P. 27

Technique

Release Points

Application

Respiratory (Chest) Gastrointestinal (Throat) (Stomach) Jaw

Target Breathing Compression Constriction Nausea Tension

Key External Events 1

1999:

Audrey has discovered use of both

objective subjective

applications for glitch resolution and EMDR International Association Conference, Las Vegas: First Clinician Manual, First Video* Audrey demonstrating subjective glitch track & hold w bilateral audio stimulation in Las Vegas (video)

2002:

2nd ed. of OEI Clinician Manual: Hi’s, Lo’s, I/O, H/V/D

2003:

OEI Training DVD, first OEI RCT (delayed C)

Key External Events 2

2004: Combine OEI with body therapies (massage) Start arc patterns to reduce lens refocusing 2005-6: Comparative experimental RCT (18-mo RCT) Titrate with therapist body & face, postures 2007-8: 20+ conference papers, OEI Client Handbook Glitch massage: proximal-distal movements

Technique

Switch

Application

Transference Titration Clearing

Target Partners Mirrors Intensity Artifact

Technique

Sweep

Application Target

Clearing

Artifact

New Applications & Combinations

• • • • • • • Process & chemical addictions, eating disorders (urges) Inner voices, self-loathing, and self-harming behaviours Peak performance (focus on goals, target interferences) Dissociative disorders & attachment difficulties (states) Somatic symptoms (fibromyalgia, MS, PNES, chronic pain) Combined w language acquisition & accent reduction Combined w systematic desensitization & psychodrama

Cross-cultural applications

• • •

Indonesia:

GAM vs Military conflict & Tsunami expatriates vs locals “Massage your brain using your eyes to lift your heavy heart” Gender differences (vulnerable vs guarded emotions) • • •

Korea:

‘Expert’ professionals ‘fix’ problems Somatic symptoms = less loss of face Medical procedures to treat symptoms • • •

1st Nations:

Family members & community share Attending to quality of relationships Healing broken attachments (RHAP)

Glitch Tracking & Massaging

Saw note (EMDR listserve): skips/halts in eye movement • • • Resolution of intensity & dissociation with ‘massage’ Patterns were associated with different targets/events ‘Glitches’ seem to clear after massaging ‘stuck points’ • Thought : “I wonder if continued work will bring healing?” Led to OEI Tracking & Glitch Work/Massage TRACKING & GLITCH MASSAGE VIDEO DEMO

Technique

Glitch Massage

Application

Transference Titration Clearing

Target Partners Mirrors Intensity Artifact

Technique

Glitch Hold with Bilateral Stimulation

Application

Restoration Titration Clearing

Target Visual Splitting Intensity Artifact

The Future of OEI - Part I

Unique Contributions of OEI:

•

Easily & quickly integrated with other therapies

•

Reduces interference with cognition & speech (top down)

•

Psychological “Emergency Room” procedures

•

Self-help procedures facilitate affect regulation

•

Increases midbrain-to-prefrontal integration (bottom up)

•

Reduces addictive & self-harming urges

Complex PTSD Symptoms & OEI

(CPTSD was defined by Herman, elaborated by Curtois)

• • • • • • •

There are OEI techniques that address these: Affect Dysregulation Dissociation/Numbing Negative Self-Perceptions Internalized Perpetrator Beliefs Difficulties in Relationships with Others Somatic Symptoms See one-page handout for details – Abuse-Specific, Other Despair & Shattered Assumptions of Hope

Observed

: Therapist watches for glitches while tracking Therapist watches for conflict & intensity markers Therapist watches for visual splitting/dilation

Experienced

: Client cues therapist during tracking (Track-to-Target) Client notices & reports all artifacts Client notices & reports level of intensity

Equalization:

intensity, colour, light, body tension

Combination:

emotions (mad & sad) blend or dissolve

Joining: Sensory: Dissolution: Resolution:

alters (infant, child, teen, adult) merge double vision clears, pains resolve visual distortions clear objects that were invisible materialize

First Study of OEI with PTSD •

Mixed Traumas (witnessing suicides, MVAs, assaults, accidental deaths) and mixed gender

•

Random Assignment to OEI or delayed treatment control group, only switching

•

Script-driven symptom provocation, C = +2 Exp

•

CAPS and IES-R

Treatment vs Control: CAPS

Clinician-Administered PTSD Scale (CAPS) scores from Time 1 to Time 2 for control group (

n

= 5) and treatment group (

n

= 5). The dashed horizontal line reflects a threshold for clinically significant levels of PTSD symptoms (Orr, 1997).

IES-R Avoidance/Numbing

Impact of Event Scale-Revised (IES-R) Avoidance & Numbing subscale scores, Time 1 to Time 2 for control group (

N

= 5) and treatment group (

N

= 5).

Presentation by Laurie Detwiler, Faculty Member,

The Place of Trauma Therapy in the Process of Recovery from PTSD

CCPA Annual Conference May 18, 2011

Research Questions •

What

critical incident

helped or hindered your process of recovery from PTSD?

•

What

event or experience

helped or hindered your process of recovery from PTSD?

•

Follow up questions fit well with the method.

Validity Reliability

• • • Careful definition of the purpose of the research Qualified observers Final follow up • Independent judge sorted 25 incidents into helping and hindering categories • Interpreter reliability: 92% inter-rater agreement between judge and primary rater

Interpret and Report

• 8 people, 6 women and 2 men, aged 28 to 54 yrs (average = 45 yrs) • 6 Caucasian, 2 Caucasian & First Nations • Diagnosed with PTSD in 2003 during a trauma therapy study • Traumatic incidents ranged from sexual assault, emotional abuse, witnessing a death and car accidents • Range of events & time since traumatic event

Categorical Descriptions

(helping) 1.

Awareness of Recovery Coming From Involvement in Trauma Therapy Study 2.

Resources, including Spirituality, Marital/Family, Financial, & Physical 3.

Coping Strategies 4.

Developing New & Positive Relationship With Self

Categorical Descriptions

(helping)

5.

6.

7.

8.

Growth From Trauma Understanding Your Own Life Experience The Importance of Being Listened to, Cared For, Validated and Accepted For Who You Are by a Professional Helper Making Personal Choices to Lead a Healthy Life

Categorical Descriptions

(helping)

9.

Unexpected Positive Circumstances

10.

Knowing That You Are Not Alone

11.

Talking Today Was Impactful

12.

Forgiveness

Categorical Descriptions

(hindering)

1.

2.

3.

4.

Limitations in Resources ICBC Is An Unhelpful System When Boundaries Fall Difficulty Coping

Categorical Descriptions

(hindering)

5.

6.

7.

8.

Fear Magnification The Physical Pain Cycle Harmful Healers Being In Situations Similar to the Original Trauma

Categorical Descriptions

(hindering)

9.

Unexpected Negative Circumstances

10.

Can Not Forgive Self

11.

Sexual Difficulties

Follow Up Themes

1.

Recovery is a process which includes

more than

therapy, and

all

categories are important 2.

However, OEI was

very important

in recovery for all 8 (two said 10/10, average score = 8/10) 3.

Lack of Social Support as a theme was big, in particular Brewin’s (2003) “Other as Betraying” 4.

Also: “Other as Abandoning” Brewin (2003)

Latest Sexual Assault & PTSD Study •

Comparative Experimental Treatment Outcome

•

1 year to recruit 137 women, screened to 33, 18 Months from Start to Finish, Participants

•

Quantitative, Qualitative & Psychophysiological Measures in cross-over design

Visual Overview of Study

OEI B.R.A.I.N

.

CPT-R qEEG & SDSP CPT-R OEI Interviews OEI

Research Design I •

Selected Trauma of Interest: 20% of women sexually assaulted in lifetimes and almost 50% of those develop PTSD

•

Script-Driven Symptom Provocation: 50 second audiotape of most intense portion of trauma played on 4 occasions + TMI-PS

•

Cross-Over Design: CPT-R in phase I gets OEI in phase II, OEI in phase I to CPT-R

• Research Design II

Controls: Random (Wave) Assignment to Groups and Therapists within Groups

• • • •

Assessors Blind to Group Assignments All Participants Receive Control Condition (B.R.A.I.N.) and Active Therapy Participants Receive 3 sessions of OEI or CPT plus 4 hours of Psychoed (sessions & groups videotaped) Credibility Checks for all Interventions (COTQ) Manualized Treatments

Results - CAPS

80 70 60 50 40 30 20 GROUP Control Cognitive Processing One Eye Integration Pretreatment Posttreatment

Time of Assessment

3 - Month Follow up

Time:

F(2,21) = 49.62, p = .04, η2 = .83

Time*Group:

F(4,42) = 2.96, p = .03, η2 = .22

Group:

F(2,22) = 1.32, p = . .29, η2 = .11

Results – IES-R Numb/Avoid

2.50

2.00

1.50

1.00

0.50

1 2

Time

3 ▲ Control Group ↑ Cognitive Processing Therapy * One Eye Integration

Qualitative Interview Findings • •

Randomly selected cases from OEI & CPTSD groups, interviewed

at 3-month follow up

: – OEI: More profound reduction of PTSD symptoms – CPT-R: Improved ‘coping’ & self-referencing beliefs When participants interviewed

after cross-over:

– Majority of participants (~ 75%) chose OEI as ‘most beneficial’ of the two therapies after having both – Therapy preference: Interesting trend by MBTI Thinkers to prefer CPT R (“makes sense”, “logical”)

Limitations • • • • • •

Small N & significant screening process Females, mainly Caucasian, sexual assault Manualization may have affected bond – OEI Script-driven symptom provocation – 1 trauma Small treatment doses (3 hrs. individual plus 4 hours group per therapy, along with exposure & psychoeducation components) Extended periods with no active treatment: (3 months + 3 months), additional traumas

The Future of OEI - Part II (You)

Diffusion of Innovation Theory

Diffusion of Innovations

5th ed. (Rogers, 2003) Lovejoy, Demireva, Grayson, & McNamara (2009) • • • • • Relative Advantage : better job performance & $’s Compatibility: congruence with existing frames Complexity: difficulty in learning, comprehending Trialability: pilot testability on small scale Observability: visibility of positive outcomes

Acknowledgements

Fahs-Beck Foundation for Experimental Research New York Community Trust Dr. Marvin McDonald, Dr. Paul Swingle, Dr. Jose Domene, Kristelle Heinrichs, Dave Grice, Marie Amos, Karen Williams, Kiloko Ndunda, Jessica Houghton, Jake Khym, Becky Stewart, Jen McInnes, Darlene Allard, Tanya Bedford, Heather Bowden, Gillian Drader, Brenda DeVries, Danielle Duplassie, Sandra Dykstra, Ida Fan, Esther Graham, Maren Heldberg, Nadia Larsen, Michael Mariano, Beverly Ogden, Steivan Pinoesch, Mandana Sharifi, Nidhi Sharma, Chris Tse, Dana Vanderwiel, Dawne Visbeek, Melissa Warren, Linda Gibson, Andrea Busby, Melissa Ducklow, Kwantlen nurses, TWU UG Psych students.