Advanced Techniques in the Use of EMDR to Treat Complex Trauma

1. Advanced Techniques in the Use of EMDR to Treat Complex Trauma Barry Litt, MFT Concord, NH Barrylittmft.com

2. EMDR Trauma memory • Consciousness • Neocortex • Narrative (semantic) • Memory • Episodic Memory • Stored in Limbic System and Brain Stem • Re-lived vs. Remembered • Dissociated from Narrative Memory • Aspects of Trauma Dissociated from each other • (B.A.S.K.)

3. EMDR Trauma memory Why Ego States Matter… • Consciousness • Fear/avoidance • Negative Transference • Distraction • Emotional Numbing • Blocking Beliefs • Affect Phobia • Amnesia • Interpersonal Defenses

4. Object Relations Theory: Fairbairn’s Structural Model of the Self Libidinal Ego Central Ego Antilibidinal Ego Self as Object Seeking Splitting of the Self: 6 – 18 mos.

5. Object Relations Theory: Fairbairn’s Structural Model of the Self LibidinalEgo Antilibidinal Ego Central Ego Borderline Personality Disorder (Kernberg)

6. Object Relations Theory: General Model of Introjected Family Members and Their Relationships Superego ID Ego Introjects serve as template for relating to others

7. Object Relations Theory: General Model of Introjected Family Members and Their Relationships Introjected Relational Configurations Yield Relational Attitudes

8. Ego State Theory of Watkins & Watkins All manner of introjects, including ego cathected roles

9. 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)

10. 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

11. Phase 2:Preparation • Safety Assessment • Self-Harm vs. Stability • (Intrusive Experiences, Dissociation)

12. Phase 2:Preparation • Safety Assessment • Self-Harm: risk factors • History of Suicidal Ideation • History of Suicidal Gestures • History of Suicidal Attempts • History of Psychiatric Hospitalizations • History or Current Reliance of Self-Harm Behaviors

13. Phase 2:Preparation • Safety Assessment • Self-Harm Interventions • Safety Contract • Psycho education • DBT Group? • RDI, Affect Management Skills Training (AMST) • Safe Place

14. Phase 2:Preparation 2. Stability Assessment • Intrusive experiences, including: • Fugue, lost time • Regression • Amnesia • Acting-out (e.g., cutting, substance abuse, risk-taking behavior) • Panic Attacks; freeze responses • Insomnia

15. Phase 2:Preparation 2. Stability Assessment • Interventions: • Grounding exercises • Mindfulness practice • Journaling • Present-time orientation • Safe-Place work • Medication • Constructive Avoidance (Forgash) • Ego State Work: Daily living team (Twombly)

16. Cognitive Affective Transformation Relational Repair The Overall Structure of Therapy Three Intertwining Tracks: • Cognitive Scaffolding Insight/Psychoeducation 2. Affective Transformation (EMDR) • Relational Repair ; Rejunctive Action; Earning Entitlement

17. Kitchur’s Strategic Developmental Model: Genogram-Based Target Selection and Sequence Target Selection • Parents’ Relationship • Mother • Father • Sibling Dynamics • Nodal Events

18. 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

19. A. Working with Domains of the Self Being vs. Nothingness Merit Safety

20. Being vs. Nothing • Self-Other Dialectic • Depersonalization • Merit • Neurosis • Safety • Hypervigilance Domains of the Self, continued Being vs. Nothingness Merit Safety

21. Being vs. Nothing • I don’t exist’ • I’m invisible • I don’t matter • Merit • I’m not good enough • I don’t measure up • I’m a failure • I’m bad • Safety • I’m gonna die • I’m not safe • I’m trapped Cognitive Correlates to Domains of the Self Being vs. Nothingness Merit Safety

22. 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…

23. Working Through the Being Domain • I think, therefore I am -Descartes • I notice that I feel, therefore I am -(Damasio/Litt) The Importance of Sensation:

24. Working Through the Being Domain • Event Targets • -Rejection • -Abandonment, separation, loss • -Associations • Dynamic Targets: • -Narcissistic partner • -Partner avoids/withdraws • -”As-if” relating

25. 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…

26. 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

27. 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…

28. 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

29. B. Zone of Optimal Arousal for Processing absorption presence depersonalized abreaction Avoiding/relaxed panic Parasympathetic Sympathetic

30. Parasympathetic Sympathetic • Techniques : • Distraction • Somatic Cueing • Present-time Orientation • Somatic interweaves • Node isolation techniques • Olfactory Cueing depersonalized abreaction absorption Avoiding/relaxed panic presence

31. Parasympathetic Sympathetic • Techniques: • Closed eyes • Push the NC • Node isolation techniques • Choosing new target depersonalized abreaction absorption Avoiding/relaxed panic presence

32. Parasympathetic Sympathetic • Techniques: • Breath Control • Shift visual perspective • (3rd person) • Node isolation • Distraction • Self-soothing techniques • “Pushing arms” interweave • Present-time orientation • Olfactory stimulation • Safety Interweave depersonalized abreaction absorption Avoiding/relaxed panic presence

33. Parasympathetic Sympathetic • Techniques: • Self-soothing techniques • or, increase absorption • Node isolation • Silent Breath control cueing depersonalized abreaction absorption Avoiding/relaxed panic presence

34. C. EMDR with Ego States • Looping • Blocking (amnesia; avoidance) • Pseudoprocessing Complications in phase Four (Desensitization): • “revolving door” ego states • Confusion, “overwhelm,” or undifferentiated experience • Abreaction (Iatragenic)

35. Phase 3 - 4 Techniques for E.S. Conflict Change of visual perspective Pushing the NC Node isolation techniques Schiffer Glasses Efficiency 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