Transcript First Responders and EMDR Roger M. Solomon, Ph.D. S Know the Culture First responders S Takes a lot for them to seek help and little.

First Responders and
EMDR
Roger M. Solomon, Ph.D.
S
Know the Culture
First responders
S Takes a lot for them to seek help and little to turn them off
S
Action oriented people, hate confinement
S Comfortable giving and taking orders
S Decisive, assertive, willing to do the job in front of others
S Value conformity, tradition, structure and predictability - things
that keep them safe
S Responsibility absorbers
Therapists
S Non-directive and contemplative
S Careful not to impose views on others or give advice
S Work behind closed doors
S Value individuality, spontaneity, and emotional expression
First responder culture
S Make jokes about therapists (sit around, hold hands, sing
“Kumbaya”)
S Spend effort controlling feelings and hiding stress reactions
S Work is about control of self and others; No one wants to
see a first responder break down on scene.
S Compartmentalization/suppression of emotion important
to deal with the stressors of the job
First responder culture
S They see a lot of gory things, be prepared
S They need to talk about what they have experienced with
someone who can understand and contain their own
reactions
S You don’t have to be stonefaced, , but respond calmly and
empathically, e.g. “That must have been tough”.
Characteristics of first responders
S Resilient - hardy, resilient individuals on the healthier end of
the mental health continuum. Undergo psychological
screening, rigorous training, and a probation period
S Ability to deal with conflicting roles - fight a “bad guy” one
minute, comfort a child the next
S Always ready for danger/changing circumstances
Characteristics of first responders
S Occupational suspiciousness
S Clannish nature – trust only fellow workers
S Distrust bureaucracy and administration - have to exercise
discretion and good judgment, and many find it stressful
coping with a bureaucracy that has strict policy and
guidelines.
S Cynical - see the worst society has to offer
Critical incidents
S A critical incident is a term used to describe a potentially
traumatizing event that occurs in the performance of one’s
duty, and that potentially overwhelms the responder’s sense
of vulnerability and control
S Can be direct or vicarious involvement
S What is traumatizing for one may not be for another
Phases of critical incident
aftermath
The situation explodes:
S Physical mobilization
S Mental mobilization
perceptual distortions (time, visual, auditory)
2) SHOCK/DISRUPTION
S the person may initially be dazed, inattentive, confused - this may
last for a few minutes-or a few days
S Stress comedown reactions:
crying lightheaded
rapid pulse
chills
tremors/shakes
hyperventilation nausea
sweats
[These are stress reactions-not signs of weakness]
confusion
Shock/Disruption
S Denial/Dissociation:
S
Feeling of disbelief
Numbness, with occasional anxiety breakthrough
S Running on “auto-pilot”
Shock/Disruption
S Difficulty remembering details of the event
S Difficulty comprehending significance of what
happened
or
S Emotional arousal
Upset, emotional,
Mad/Sad/Scared
Shock/Disruption
S May feel elated for having survived a critical encounter
S Hyper, agitated, irritable, overactive
S Feeling of Isolation - "No one really cares
or understands”
Shock/Disruption
S Heightened sensitivity to the reactions of others
S Preoccupation with event "Its all I can think
about"
Stress Symptoms
Difficulty sleeping
Anxiety
Irritable
Depression Difficulty concentrating Fatigue
Stomach aches
Diarrhea
Muscle aches
Indigestion
Constipation Change in sex drive
(* indicates need for medical evaluation)
Dizziness* High blood pressure*
3) Emotional Impact
(Reaction Phase)
S
Usually hits within a couple of days. It may continue
several weeks or longer depending on the situation,
coping skills, and the presence of support
Normal reactions to abnormal
situations
1.
HEIGHTENED SENSE OF DANGER.....................58%
2.
ANGER/BLAMING................................................49
3.
NIGHTMARES.......................................................34
4.
ISOLATION/WITHDRAWAL................................45
5.
FEAR/ANXIETY...................................................40
6.
SLEEP DIFFICULTIES..........................................46
7.
FLASHBACKS/INTRUSIVE THOUGHTS.............44
8.
EMOTIONAL NUMBING......................................43
Normal Reactions to Abnormal
Situations
.
DEPRESSION....................................................42
10.
ALIENATION..................................................40
11.
GUILT/SORROW/REMORSE.........................37
12.
MARK OF CAIN.............................................28
13.
FAMILY ROBLEMS.........................................27
14.
FEELINGS OF INSANITY/
9
LOSS OF CONTROL…………………………….23
15.
SEXUAL DIFFICULTIES..................................18
16.
ALCOHOL/DRUG ABUSE................................14
4) Coping (Repair Phase)
S
Facing, understanding, working through and coming to grips with the
emotional the emotional impact of the incident.
S
Reactions become more manageable
S
Renewed interest in life
S
Make plans for the future
Coping
SOUL SEARCHING...
S WHAT IF?
S
S
IF ONLY?
WHY ME?
S
WHAT ABOUT NEXT TIME?
S
CAN I DEAL WITH IT
AGAIN?
Coping
S Is the person ready to face the incident and deal with it - in
which case person is ready for intervention
OR
S Does the person need to withdrawal/avoid reminders and
stimulation for awhile?
5) Adaptation (Reorientation)
S The incident happened, I was part of it, and that's reality.
S I am vulnerable, and that's part of the human condition -
but I'm not helpless.
S I can't control everything, but I can control my response to
an incident.
S I did the best I could at the time.
Adaptation
S Fear is a normal reaction to the perception of danger and
can be utilized constructively.
S By facing and actively processing my emotional reactions, I
will come out stronger.
Adaptation
I CAN RE-EVALUATE MY VALUES, GOALS AND LIFE
PRIORITIES:
S
I now realize what is important in life.
S
I can stop and "smell the roses".
S
I can spend more time with people I care about.
S
Things that used to upset me just aren't that important anymore.
S
After coming to grips with my own vulnerability I can emerge
stronger and utilize this strength when facing life's other challenges
6) Learning to live with it
S EXPERIENCING A CRITICAL INCIDENT IS LIKE
CROSSING A FENCE......
AND LOSING ONE'S NAIVETE....WITH NO
POSSIBILITY OF JUMPING BACK.
Learning to live with it
S SIMILAR FUTURE INCIDENTS MAY BRING BACK
EMOTIONAL REACTIONS
S SIMILAR EXPERIENCES OTHERS HAVE MAY
TRIGGER MEMORIES
S ANNIVERSARY REACTIONS ARE COMMON
Learning to live with it
WE ARE VULNERABLE!
WE HAVE TO ACCEPT IT AND LEARN TO LIVE WITH
IT
AND USE THIS VULNERABILITY
IN POSITIVE, MEANINGFUL, PRODUCTIVE WAYS
FOR OURSELVES AND OTHERS
EMDR Therapy: Phase 1
History
S Talk about what brought client in to see you
S If critical incident, get a narrative of what happened
S As about how the incident is impacting the responder
S Ask about previous incidents - current clinical picture may
be the result of cumulative stress
Phase 1: History
S First responders may be reluctant to talk about feelings
S Be supportive of the officer and the role and duties of a
police officer (don’t say, “why didn’t you shoot the gun out
of his hand?”)
S Not for the squeamish therapist
Phase 1: History
S Childhood/family of origin issues - may be initial
reluctance to talk about these , not understand relevance,
wants to focus on here and now (current pain) – May be
more productive to elaborate on current situation first, then
move into past history if needed.
Phase 2 Preparation
S “You are not going crazy”
S Normal reactions to intense situations
S
Explanation of EMDR and what to expect
S First responder does not have to believe that EMDR works and
may think it is silly - WORKS ANYWAY if person is willing to
cooperate with the process
S Coping strategies (safe/calm place, resources, stress reduction
strategies)
Stress reduction strategies
S
Talk it out
S
Write it out
S
Work it out (exercise)
S
Relaxation skills
S
Hobbies/recreation
S
Social engagement
S
Eat healthy meals, avoid excessive alcohol/caffeine
S
Engage in life
Phase 2
For a critical incident
S Narrative (individual or with co-workers using structured
format) to identify salient points - Frame by Frame
S A detailed narrative may not be necessary but experience
has shown it may be containing, preventing other memories
from opening up, provides focus, and may make treatment
more efficient
EMDR therapy protocols
S Recent event protocol (Shapiro, F.) or Recent Traumatic Event
Protocol (Shapiro, E. and Laub, B.)
S Emergency Room Procedure (Quinn, G.)
S Standard protocol
S How soon? When the emotional impact has hit, the client can
verbalize what happened and stay present with the affect, and has
the ability to reflect on it – ALONG WITH THE USUAL EMDR
CRITERIA FOR READINESS
Phase 3: Negative and positive
cognitions
Responsibility:
S First responders are responsibility absorbers who need to
feel in control
S “It’s my fault” (I should have been able to do more/had
more control”) / I did the best I could
Negative and positive cognitions
Safety
S I’m in danger……I’m going to die
S I’m safe today….I survived
Control
S I’m powerless….I’m helpless….I’m not in control
S I have some control….I did the best I could (What I could do, I
did do), beyond my control (not my fault)
Made a mistake?
S EMDR therapy seems to lead to the person taking responsibility
for what happened, realizing what factors may have influenced the
decisions and actions resulting in the
mistake/miscalculation/misperception, and learning from it.
S EMDR therapy will not take away appropriate emotions or
appropriate responsibility
S NC: “I’s bad/defective…” PC I’m okay, the incident does not
define me/ I can learn from this/I can go on
Phase 4-7 Useful cognitive
interweaves (if looping)
S Responsibility (looping on “Its my fault”) -Who was in
control?” or “What other options were there, realistically?” or,
“There was a reason you did what you did at that moment. What
was going on in your mind?”
S Safety (reliving moments of vulnerability)- “What happened
next?” or, “When did you realize the event was over….that you
survived?”
Useful cognitive interweaves
Control (looping on helplessness)S
What happened next?” may help the responder realize forthcoming
actions and decisions where control was exercised.
S
“Given the circumstances (or your perception of circumstances at
the time), could anybody have done more?” can help the responder
realize that, “There is a boundary where being a human stops and God
begins,” which is a useful interweave in itself.
Client is stuck
S Float back/affect scan
S Childhood issues
S Explore world view (e.g. “not supposed to happen to me”, “I’m
always in control”, “bad things don’t happen to good people”)
S If processing gets stuck, or client’s symptoms are not abating, it is
important move into past (attachment) issues and distressing
memories
Future template
S Responder may have to face situation again
S Future incident reoccurring is a tragedy and unpleasant -
not necessarily traumatic
S Build in response contingencies
S Skill building
Phase 8 Reevaluation
Follow-up
S Different issues arise over time
S Returning to duty (job looks different)
S First similar incident
S Anniversary reactions
Dynamics of Fear
S Here comes Trouble – the situation escalates.
S Oh Shit! -- The moment of vulnerability awareness...we
may feel weak, vulnerable, or not in control.
S "I've got to do something" -- we must act to survive or gain
control over the situation. We acknowledge the reality of the
danger. We make the transition from an internal focus on
vulnerability to an external focus on the danger.
S Survival -- We focus on the danger in terms of our ability to
respond to it. We Consciously or instinctively come up with a
plan. We start to react. We feel more balanced and in control.
S "Here Goes"-- the moment of commitment - with our resolve to
act, whether
instinctual or planned, we mobilize tremendous
strength. Our frame of mind is focused; characterized by strength,
control over this strength, clarity of mind, and increased
awareness: the survival resource.
S Response -- We go for it, our response fueled by the survival
resource.
DEALING WITH FEAR
S If we focus solely on the danger, we tend to feel weak,
vulnerable and out of control. If we focus on our ability
and capability to respond to the situation, we feel more
balanced and in control. That's why it's important not to
dwell just on the danger, but to focus on our ability to
respond.
DEALING WITH FEAR
S While it is important to face feelings of vulnerability, we
must also give ourselves credit for what we did to respond.
S Acknowledging what we did in the "survival", "here goes"
and "response" stages balances out the moments of
vulnerability -- we aren't helpless!
DEALING WITH FEAR
S Mental rehearsal of critical incident situation will help you
learn your tactics; get them to the point where they are
instinctual, reflexive, and second nature; and prepare for
future encounters.
S WE ARE VULNERABLE AND CAN'T ALWAYS CONTROL A
SITUATION, BUT WE ARE NOT HELPLESS. WE CAN
CONTROL OUR RESPONSE TO A SITUATION, WITH OUR
ABILITY TO RESPOND FUELED BY THE RESOURCE FRAME
OF MIND.
Dealing with Responsibility
Guilt
S Frame of mind # 1: perception occurring before or during
incident
S Frame of mind # 2: frame of mind one has when the
situation is over, and all the previously unknown facts and
consequences are known
S Self- Second Guessing/Responsibility Guilt - being in
Frame of Mind $2, negatively judging yourself, without
taking into account Frame of Mind #1
Responsibility Guilt
S
To change this, get back in touch with Frame of Mind #1 then go through the
situation FRAME BY FRAME.
S
Knowing what was going on in your mind at the time will help you:
understand why you did what you did
differentiate what was and WHAT WASN'T under you control, and
differentiate what you knew at the time from what was impossible to know.
Responsibility Guilt
S Given your perceptions of the incident, the information you
had at the time, your level of experience, available
equipment, and so on..... You either did
S The right thing (ALL RIGHT!)
S The wrong thing (LEARN FROM IT!)
S You did the best you could (WHAT MORE COULD
ANYBODY ASK?)
Why did this happen to me?
S It happened because of your role, not because of who you
are.
S A better question than "Why did this happen to me?" is "How
did this happen to me?" We can't always answer why, we can
answer how.
Peer Support
S An important buffer for trauma
S Peers have more credibility than mental health professionals
S Peers can aid in initial contact, referral, follow-up, and
education