Transcript EMDR in Trauma: Effectiveness and Clinical Implications

EMDR IN CHILDREN
EFFECTIVENESS AND CLINICAL IMPLICATIONS
DR. DEEPAK GUPTA
MD (Psychiatry), DNB (Psychiatry)
Diploma Child & Adolescent Psychiatry (London, UK)
Consultant Child & Adolescent Psychiatrist
Sir Ganga Ram Hospital
Founder, Centre for Child and Adolescent Wellbeing (CCAW)
New Delhi
19.01.2011
ANCIPS 2011, New Delhi
EMDR……..
“I turned my feelings into a Ping-Pong
ball and smashed them out the window…”
EMDR as a Therapeutic Modality
It doesn’t matter how long the memories have been stored and
for how long they have been exerting a negative effect on the
child.
Children reprocess their traumas more quickly in EMDR than in
other therapies and becomes desensitized to the painful
memories and images.
The EMDR procedures results in:
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Decreasing the vividness of disturbing memory, images and related affect.
Facilitating access to more adaptive information.
Forging new associations within and between memory networks.
Efficacy in children
Researcher
and Year
Aim
Result
Jaberghaderi
et al 2004
Randomized
controlled
study with 14
Iranian girls
Comparison between CBT and
EMDR when used with sexually
abused 12-13 year-old
children
Both Cognitive Behavior Therapy
(CBT) and EMDR to be quite
effective. EMDR proved to be more
efficient, as it required fewer
sessions and improvement in related
behavioral problems.
Ahmad et al
2007
RCT
Effectiveness of EMDR Vs WLC EMDR was found to be an effective
in 6-16-year-old children with treatment in children with PTSD from
a DSM-IV diagnosis of PTSD
various sources
Frank &
Wagner
2006
CBT Vs EMDR
Meta Analysis
Trauma-focused CBT and EMDR tend
to be equally efficacious
EMDR is effective in children with:
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Crime victims (Solomon 1995, 1998; McNally & Solomon, 1999 )
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Child with excessive grief due to the loss of loved ones (Solomon
1994, 1995, 1998)
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Trauma due to assault or natural disaster (Lovett 1999; Wilson &
Tinker 2000)
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Sexual assault victims (Edmond, Rubin, & Wambach, 1999)
Accident, surgery and burn victims who were once emotionally
or physically debilitated (Solomon & Kaufman, 1994; Blore, 1997)
Complex PTSD (Manfield, 1998)
Phases of EMDR treatment
EMDR involves 8 phases:
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Phase 1: History and treatment planning
Phase 2: Preparation
Phase 3: Assessment
Phase 4: Desensitization
Phase 5: Installation
Phase 6: Body Scan
Phase 7: Closure
Phase 8: Reevaluation
Phase 1: History and treatment planning
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Sufficient information including dysfunctional
behavior and symptoms can be obtained from
parents, counselors/foster care/case workers
Ask the Child: “what’s the worst thing?” and other
details….
The treatment plan is made keeping in mind the
targeting sequence and the needed skills and
education…..use judgment…..one which is
disturbing him currently
Consent from parents
Phase 2: Preparation
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Developmental appropriate explanation of process
Relaxation techniques along with guided
visualization are used to deal with the distress if
caused
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Eye movements
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Tactile/Tones
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Safe place: real or imagined - to make him/her
feel comfortable and secure- draw a safe place
Phase 3: Assessment
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Memory identified, an image representative of it - can be
made as drawings on paper….puppets and toys can be
used.
Negative cognition (NC) associated with it…….“I am bad”
and a Positive cognition (PC) ….“ I am happy”….that
would be later used to replace the negative thought –
should be developmentally appropriate (drawings on flash
cards)
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VoC Measurement/VAS……..1 to 7…can use hand
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Emotions….may have to teach about emotions
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A 10 point Subject Units of Disturbance (SUD) scale or
blocks is used to measure the level of disturbance caused to
the client ….number blocks/hands
If any physical sensations present, location also identified.
Phase 4: Desensitization
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Reprocessing using bilateral stimulation:
This stage is the toughest but should be continued, irrespective
of the increasing or decreasing internal distress caused.
Verbatim/Storytelling/drawings to report
Emotional response – usually not much during session but more
between sessions
Parents in sessions
Phase 5/6: Installation & Body Scan
Installation
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Positive cognitions only once on the SUD scale the child’s
reaches a 0 value…..Developmentally appropriate….
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Bilateral stimulation the positive thoughts replace the
negative cognitions.
Body scan
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When the positive cognitions have been successfully placed,
the child is checked for any residual tension that he/she
might be still experiencing in any part of his/her
body…..children are somatic…..
Phase 7/8: Closure & Reevaluation
Closure
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At the end of each session, it is important that the child
attains emotional equilibrium…..playing with
them…drawings….
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Child is encouraged and appreciated for his efforts.
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Closure statement….
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Talk to parents.
Re-evaluation
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At the beginning of every new session, it is important to reevaluate in order to be able to determine if the treatment
effects have been maintained or not. These can be noted by
changes in behavior or thoughts – cross checked by parents.
Skills with children
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More active
Creative
Innovative
Tactile works well with smaller children
Don’t probe too much especially with smaller
children
Involve parents
Working with EMDR
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Over the last one year, at our centre, we have
worked with children (7-18 yrs) with a spectrum of
trauma related psychological problems; and varied
Phobias including school phobias with whom EMDR
was found beneficial.
In most of the cases, the average number of sessions
required was 2-4, and they continue to show
improvement, even after EMDR was stopped.
Case Example….TRAUMA
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A 8 yr old male came to us in April 2009, with features
suggestive of anxiety disorder.
In November 2008, he developed fever and had his first
emotional breakdown. These symptoms developed when his
father went out of station on 11th Nov. He would start to cry
and complain that why do people who love me always go
away.
The child’s paternal grandfather passed away in 2006.
After which his paternal grandmother expired in Jan 2007,
and then a month later his maternal grandfather also passed
away and in August 2008 his close friend expired in road
accident.
According to the parents since the episode in Nov 2008, the
child has been restless, clinging, crying, complaining of
headaches and pains, nightmares, missing school.
Case Example
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We decided to help the child using EMDR after the
informed consent from parents.
We started individual sessions with the child from
28th March 2009.
The child responded well to the sessions.
He was able to identify his negative and positive
cognitions, and rate them on the SUD and VOC scales.
The intervention technique mainly used with the child
was drawings.
We did three sessions of EMDR with the child, after
which he was better in all domains.
Case Example…Phobia
A 9 year old intelligent young boy, extended
family, parents doctors, presented with:
- fear of thunderstorm and rains from few months -- increased from last few weeks during rainy season
- associated with school reluctance, clinging
behaviour and separation anxiety
- no academic decline or other psychopathology
3 sessions of weekly EMDR in July-August
2010…..total resolution of fears….doing well……
Working with EMDR
in group setting
We have worked with children living in foster
care (7-18 yrs of age) with history of varied
trauma with whom EMDR was found beneficial
as reported by children subjectively.
Advantages of Using EMDR with
Children (Tinker et al., 1999):
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Children respond very well to EMDR
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Reprocessing often more rapid with children
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Since the changes occur automatically, and in
a non volitional manner, it makes it
comparatively easier to use with children.
Children have less complex memory
networks.
Advantages of Using EMDR with
Children (Tinker et al., 1999):
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Standard EMDR protocol may be used with
developmentally appropriate modifications.
Even parent(s) can participate in the sessions, as it
is generally of a non threatening nature to the
parent(s), as well as, the child.
At times when the child is not able to handle the
intense emotions that can come up during the
sessions, soothing and self soothing approaches,
and other therapeutic techniques can be used.
Challenges:
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Co-morbidites especially dissociation
Selecting a case
Lack of parental support
Psychosocial adversities – Chronic stressor
Conclusion
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The maintenance of treatment effects, even after 15
months of administering EMDR have been recorded.
A note of caution is that it is important that
professionals be trained to use it before they put it to
practice.
EMDR has a huge potential, but along with it comes
the clinician’s responsibility to use it wisely as one of
the promising psychotherapeutic tools with children
with trauma related and other psychological
disorders.
Finally…..
Trauma…
a drop in water but ripples over years…….
& EMDR….
….I’m in my safe place………….
THANK YOU