Transcript Advanced Techniques in the Use of EMDR to Treat Complex Trauma

Advanced Techniques
in the Use of
EMDR
to Treat
Complex Trauma
Barry Litt, MFT
Concord, NH
Barrylittmft.com
Consciousness
• Neocortex
• Narrative
(semantic)
Memory
EMDR
• Episodic Memory
• Stored in Limbic System and Brain Stem
• Re-lived vs. Remembered
Trauma
• Dissociated from Narrative Memory
memory
• Aspects of Trauma Dissociated from each other
(B.A.S.K.)
Why Ego States Matter…
Consciousness
• Fear/avoidance
• Negative
Transference
• Distraction
• Emotional Numbing
• Blocking Beliefs
EMDR
• Affect Phobia
Trauma
memory
• Amnesia
• Interpersonal Defenses
Object Relations Theory:
Fairbairn’s Structural Model of the Self
Libidinal Ego
Central
Ego
Antilibidinal Ego
Splitting
the Self:Seeking
6 – 18 mos.
Self asofObject
Object Relations Theory:
Fairbairn’s Structural Model of the Self
Libidinal Ego
Central
Ego
Antilibidinal Ego
Borderline Personality Disorder (Kernberg)
Object Relations Theory:
General Model of Introjected Family Members and
Their Relationships
Ego
ID
Superego
Introjects serve as template for relating to others
Object Relations Theory:
General Model of Introjected Family Members and
Their Relationships
Introjected Relational Configurations
Yield
Relational Attitudes
Ego State Theory of Watkins & Watkins
All manner of introjects, including ego cathected roles
Pathogenic Family Dynamics
• Co-Dependency; Collusive Denial
• Undifferentiated family ego mass (Bowen)
• Pseudomutuality (Wynne, 1965)
• Bilateral transference
(Warkentin & Whitaker,1966)
• Trading of Dissociations (Wynne, 1965)
Summary
• Pathogenic family dynamics (relational
configurations) are internalized as ego state
conflicts
• The resulting ego state system is a structured
complementation of the loyalty system
• The subjective sense of Self (and corresponding
relational attitude) is adaptive to the original,
formative context
Phase 2:
Preparation
1. Safety Assessment
• Self-Harm vs. Stability
(Intrusive Experiences, Dissociation)
Phase 2:
Preparation
1. Safety Assessment
• Self-Harm: risk factors
a)
History of Suicidal Ideation
b)
History of Suicidal Gestures
c)
History of Suicidal Attempts
d)
History of Psychiatric Hospitalizations
e)
History or Current Reliance of Self-Harm Behaviors
Phase 2:
Preparation
1. Safety Assessment
• Self-Harm Interventions
a)
Safety Contract
b)
Psycho education
c)
DBT Group?
d)
RDI, Affect Management Skills Training (AMST)
e)
Safe Place
Phase 2:
Preparation
2. Stability Assessment
• Intrusive experiences, including:
a)
Fugue, lost time
b)
Regression
c)
Amnesia
d)
Acting-out (e.g., cutting, substance abuse, risk-taking
behavior)
e)
Panic Attacks; freeze responses
f)
Insomnia
Phase 2:
Preparation
2. Stability Assessment
• Interventions:
a)
Grounding exercises
b)
Mindfulness practice
c)
Journaling
d)
Present-time orientation
e)
Safe-Place work
f)
Medication
g)
Constructive Avoidance (Forgash)
h)
Ego State Work: Daily living team (Twombly)
The Overall Structure of Therapy
Three Intertwining Tracks:
Cognitive
1. Cognitive Scaffolding
Affective Transformation
Insight/Psychoeducation
2. Affective Transformation (EMDR)
Relational Repair
3. Relational Repair ; Rejunctive
Action; Earning Entitlement
Target Selection
Kitchur’s Strategic Developmental Model:
Genogram-Based Target Selection and Sequence
• Parents’
Relationship
• Mother
• Father
• Sibling Dynamics
• Nodal Events
EMDR Target Selection,
continued
• Pathogenic family processes (from genogram)




Double binds
Split loyalties
Intersubjective fusion
Dissociated affect from others
• Affect bridge (floatback) from recent event
All likely to surface covert ego states and ego
state conflict
A. Working with Domains
of the Self
Being vs.
Nothingness
Merit
Safety
Domains of the Self,
continued Being vs. Nothing
•Self-Other Dialectic
•Depersonalization
Being vs.
Nothingness
Merit
•Neurosis
Merit
Safety
Safety
•Hypervigilance
Cognitive Correlates to Domains of the Self
Being vs. Nothing
•I don’t exist’
•I’m invisible
•I don’t matter
Merit
•I’m not good
enough
Being vs.
Nothingness
•I don’t measure up
•I’m a failure
•I’m bad
Merit
Safety
•I’m gonna die
Safety
•I’m not safe
•I’m trapped
1. Features of the “Being” Domain
• Behavior: Acting-out
(Better to be bad than to not be at all)
 Relational conflict and ego state conflict
may be “trading up” from not being
 Cutting; substance abuse; O-C D; etc.

• Affect: anxiety, panic, fear
• Sensation: numbing
• Knowledge (NC): I’m alone, invisible…
Working Through the Being
Domain
The Importance of Sensation:
I think, therefore I am
-Descartes
I notice that I feel, therefore I am
-(Damasio/Litt)
Working Through the Being Domain
• Event Targets
-Rejection
-Abandonment, separation, loss
-Associations
• Dynamic Targets:
-Narcissistic partner
-Partner avoids/withdraws
-”As-if” relating
Working Through the Being Domain
• NC: I don’t exist; I’m invisible;
I’m alone; I don’t matter
• PC: I am; I have myself; I exist even if…
Working Through the Being Domain
• Body awareness must be maintained


EMDR augmented with somatic techniques
Sensory integrity necessary for processing
• Successful processing may “trade up”
from numbing to shame/guilt
3. Features of the “Safety”
Domain
• Behavior: avoidance, hypervigilance
• Affect: anxiety, panic, fear
• Sensation: autonomic hypoarousal
• Knowledge (NC): I’m gonna die, I’m not
safe…
Working through the Safety Domain
• Therapist and client work together to maintain
some control over fight/flight response
• Controlled and organized activation of fight/flight
motor behavior during desensitization phase
• Client attention to present condition of body
while remembering threat event
B. Zone of Optimal Arousal for Processing
absorption
depersonalized
Avoiding/relaxed
abreaction
panic
presence
Parasympathetic
Sympathetic
Techniques :
absorption
depersonalized
abreaction
•Distraction
•Somatic Cueing
•Present-time Orientation
•Somatic interweaves
Avoiding/relaxed
•Node isolation
techniques
panic
presence
Parasympathetic
•Olfactory Cueing
Sympathetic
Techniques:
absorption
depersonalized
abreaction
•Closed eyes
•Push the NC
•Node isolation techniques
•Choosing new target
Avoiding/relaxed
panic
presence
Parasympathetic
Sympathetic
Techniques:
absorption
depersonalized
abreaction
•Breath Control
•Shift visual perspective
(3rd person)
•Node isolation
•Distraction
•Self-soothing techniques
•“Pushing arms” interweave
•Present-time orientation
presence
•Olfactory
stimulation
Avoiding/relaxed
•Safety Interweave
Parasympathetic
panic
Sympathetic
Techniques:
absorption
depersonalized
abreaction
• Self-soothing techniques
or, increase absorption
• Node isolation
• Silent Breath control
cueing
Avoiding/relaxed
panic
presence
Parasympathetic
Sympathetic
C. EMDR with Ego
States
Complications in phase Four (Desensitization):
• Looping
• Blocking (amnesia; avoidance)
• Pseudoprocessing
• “revolving door” ego states
• Confusion, “overwhelm,” or undifferentiated
experience
• Abreaction (Iatragenic)
Phase 3 - 4 Techniques for E.S. Conflict
Change of visual perspective
Pushing the NC
Efficiency
Node isolation techniques
Schiffer Glasses
Somatic Techniques
Affect bridge (floatback)
Targeted elicitation of ego state
Intervention of the Adult Self
Open-ended elicitation of ego state system
(e.g., conference room)
Demand Characteristic