Dr Rachel Worthington Alpha Hospitals, Bury and University of Central Lancashire (UCLan)

1. Fight, Flight or Freeze – I’m fighting! The application of EMDR in a group based violence reduction treatment programme Dr Rachel Worthington Alpha Hospitals, Bury and University of Central Lancashire (UCLan)

2. Content Theories of Violence and Aggression Effects of Trauma Trauma and Aggression Current Treatment Approaches The future – EMDR and Aggression

3. Aggression - Definition • According to Siever (2008) “Aggression may be classified in a number of ways, for example,by the target of aggression (e.g., self-directed or other-directed),mode of aggression (e.g., physical or verbal, direct or indirect),or cause of aggression (e.g., medical). The most widely utilizedand perhaps most heuristically valuable classification of aggressionis that of premeditated versus impulsive aggression” (pp429).

4. Theories of Aggression – the early years… Initial theories of aggression focussed less on violence and more on theories of anti-social behaviour Also focused more on the nature of aggression rather than the individual motive Focussed on proactive and reactive definitions Frustration-aggression theories(Gustafson, 1989) Social Learning (Baron et al.,2006)

5. Current Theories of Aggression General Aggression Model (GAM) This asserts that aggression may be attributed to two main factors: the current situation and person factors, influencing human aggression (Baron et al., 2006) Situational and individual differences can cause interpersonal aggression Situation factors include - frustrations, insults from environment and other people, discomfort, and other environmental problems (heat, cold, etc) Individual factors include - irritability traits, physical arousal, affective states, cognitive appraisals, beliefs about other‘s intentions, and developmental skills related to aggression

6. Information Processing Huesmann (1998) developed the ‘Unified model of Information Processing’ This attended to the role of: Scripts Cognitive processing as a simultaneous process Parallel processing Placed all of the above within the context of emotion

7. Advantages of the GAM Takes into account ‘mixed-motive’ aggression Recognises the way in which aggression can adapt Addresses information processing models of aggression Includes focus on peace research and positive psychology Recognises the importance of focussing on client strength for change

8. Aggression and Information Processing According to Huesmann (1988), the conditions ‘‘most conducive to the learning of aggression seem to be those in which the child has many opportunities to observe aggression, in which the child is reinforced for his or her own aggression, and in which the child is the object of aggression’’ (p. 14). • Linder et al(2010) suggest that the processing of social information occurs in an automatic, unconscious and implicit manner. • Todorov and Bargh (2002) suggested that individuals who are exposed to aggression related stimuli develop hostile attributions which influence their social information processing. Furthermore, Linder et al. (2010) suggest that this processing is out of a person’s conscious control and can result in biases in information processing which result in an individual producing hostile attributions. • Furthermore, Zelli et al(1995) found that aggressive individuals only made unconscious hostile attributions when asked to give automatic and spontaneous responses as opposed to controlled responses. • Therefore, it would seem that when a person is exposed to trauma, aggression inputs and hostile attributions may develop at a less conscious level and hence, this may have implications for treatment

9. Information Processing and Trauma • In terms of trauma experiences, there is evidence that those who have been exposed to traumatic experiences remain in a hyper-aroused state, overly attending to environmental stimulus, that they experienced reduced levels of trust and their experience of negative emotions is intensified (Solomon and Heide, 2005) • In addition, it has also been noted that in those exposed to trauma, rehearsal may take the form of both nightmares and flashbacks of the experience (Duke et al., 2008) as well as fear which Jarymowicz and Bar-Tal (2006, p. 367) suggest could lead the individual to store both conscious and unconscious memories which can lead to ‘‘pre-emptive aggression’’. • Furthermore, Siever (2008) found that exposure to repeated acts of aggression can leave individuals with a neurobiological susceptibility to aggression as a result of an imbalance between the prefrontal cortex and the amygdala. The authors argued that this affects the ‘‘top down’’ circuitry and reduces the person’s ability to modulate aggression

10. Trauma and Aggression • Therefore, this would seem to suggest that exposure to aggression and trauma can result in both conscious, unconscious and neurobiological changes which could increase a person’s potential to use pre-emptive aggression as a means of managing fear as well as a reduced capacity for modulating aggression

11. Links between trauma and aggression • There is a growing body of research into the prevalence and impact of prior psychologically traumatic experiences on psychological functioning, impulsive externalizing and violent behaviour (Ford et al., 2007). Within forensic samples rates can be as high as 90% • More aggressive individuals report higher rates than non-aggressive individuals (Sarchiapone, Carli, Cuomo, Marchetti, & Roy, 2009). • Experiencing childhood abuse has also been associated with increased risk of later child abuse perpetration (Milner et al., 2010), often using similar forms of abusive behaviour on their victims that they were exposed to as children (e.g. Felson & Lane, 2009).

12. Trauma and Aggression cont • Studies also find exposure to childhood trauma is related to subsequent perpetration of intimate partner violence (Merrill, Hervig, & Milner, 1996; Reitzel-Jaffe & Wolfe, 2001; Schumacher,Feldbau-Kohn, Slep, & Heyman, 2001), • homicidal ideation, person offenses, and problem behaviours (Clark, Reiland, Thorne & Cropsey, 2014) • physically and/or sexually violent behaviours in adulthood (Jakupcak & Tull, 2005). • It is related to violence in populations with psychosis (Sarkar et al., 2005; Spidel et al., 2010). • It is also related to instability of employment (Sansone et al., 2012) and relationships (Colman & Widom, 2004).

13. Trauma and Dual Aggression • Substance use may also lead to greater trauma exposure, for example Afful, Strickland, Cottler, and Bierut (2010) found higher rates of interpersonal violence, in particular rape or sexual assault in women (58% vs. 33%) in treatment vs. community samples. • The common pathway theory suggests that both trauma and drug use are symptoms of the same underlying factors, such as a low distress tolerance and a tendency to use avoidant coping to manage negative emotional states, such as dissociation or risk-taking—phenomena common to substance abuse and reactions to trauma (e.g., Najavits & Walsh, 2012; Otto, Safren, & Pollack, 2004). These explanations could also be used to explain the relationship between trauma and violence (Clark et al., 2014).

14. Trauma and PTSD • Exposure to interpersonal violence is more likely than non-violent trauma to precipitate PTSD with such individuals reporting problems with attention and emotion regulation (van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005) • too much and toolittle autonomic activity (Corrigan, Fisher, & Nutt, 2011), and either too little or too much arousal is known to have a negative impact cognition (DePierro, D’Andrea, & Pole, 2013).

15. Trauma and Cognitive Changes • Models of anxiety and PTSD suggest that conditioning may be central to understanding an individual’s response to trauma cues. • Mower’s two-factor model of anxiety has been applied to PTSD and suggests that classical conditioning explains the initial fear response to the trauma cue, whereas operant conditioning explains the continuation of this fear response in terms of a reinforcing reduction in negative affect.

16. Trauma and PTS • Research suggests that individuals who are exposed to potentially traumatic childhood experiences (e.g. family violence or natural disasters) are vulnerable to symptoms of post-traumatic stress (PTS). • PTS manifests in three broad clusters of symptoms: • avoidance • re-experiencing • hypervigilance .

17. Trauma – Biological changes • Heide and Solomon (2006) also proposed that trauma experienced in childhood through neglect and/or abuse leads to ‘‘biological changes involving the nervous and endocrine systems’’ (p. 221). They further argue that these changes impact upon ‘‘physiological, emotional, cognitive and social function, including the ability to regulate, affect, relate to other people, and develop empathy’’ (p. 221). However, it is important to note that at all victims of trauma may experience negative biological responses and aggression, therefore, consideration should be given to the potential of genetic predisposition to trauma, the type of trauma and the role of individual differences

18. Nature of Trauma • Emerging evidence suggests that the nature of the trauma may explain the diverse symptomology. It is hypothesised that the separate clusters of symptoms of post-traumatic distress arise from two distinct dimensions of • harm–life threat = Life threat is predicted to lead to symptoms of anxiety, hyper-arousal, hostility, anger and aggression • social betrayal = lead to symptoms of dissociation, emotional numbness, depression and constricted or abusive relationships. • Both = post-traumatic stress disorder where individuals may show symptoms from all clusters.

19. Types of Trauma Therefore, in order to consider the complexities of the nature and degree of trauma Solomon and Heide (1999) suggested that trauma could be differentiated into three types, the most extreme being type III which is regarded as ‘‘severe abuse and/or neglect particularly during early childhood’’ (p. 221) and ‘‘trauma characterised by multiple traumatic experiences that typically begin at an early age may be perceived as life threatening’’ (p. 221).

20. Trauma and logical thinking Heide and Solomon (2005) argue that type III trauma survivors have difficulties engaging in logical thinking and decision making because their responses are more automatically driven. Furthermore, they argue that long term childhood maltreatment can result in chronic physiological ‘‘hyper-arousal’’ and ‘‘survival mode’’ which when exposed to triggers associated with trauma can result in a ‘‘fight or flight’’ response. In addition, they argue that in an attempt to dampen this arousal, trauma survivors may seek to dissociate from their experiences by using alcohol and drugs which may ‘‘impair judgement and reduce inhibition, making violent acting out even more likely’’ (p. 222).

21. GAM and trauma • Following the model of GAM, the ‘‘inputs’’ that a person may bring as a consequence of childhood were also explored by Schore (2003) who suggested that childhood traumatic stress interferes with the development of neural circuits in the brain which connect emotional, psychological and social development. • Heide and Solomon (2006, p. 223) suggest that stress associated with child abuse and neglect ‘‘compromises right brain development’’ resulting in specific impairments of the orbitofrontal cortex which is involved in social adjustment and the control of mood, drive and responsibility and regulating emotions (Rolls, 1999). • Heide and Solomon (2006) also suggest that as a result of these changes situations in which a person who has been exposed to trauma is required to engage in relationships with others may also be impaired

22. Trauma and Criminality • Best et al. (2002) also found that abnormal development of the neural circuits in the brain and the orbitofrontal cortex was associated with reduced inhibition of rage and is associated with ‘‘sociopathy” • Blake et al. (1995) to concluded that severe physical abuse may interact with neurological brain dysfunction and contribute to violent behaviour

23. Implications of Trauma on Interventions • Berkowitz (1993) postulated that aversive and unpleasant experiences directly activate aggression-related motor programs, without the need for actively mindful cognitive processing. In terms of cognitions, in the case of trauma, both the ability to recall memories and the ability to generate cognitions associated with aggression may be impaired. • Parnell (2007) suggested that psychological trauma is believed to cause disassociation of hemispheric processing. That is, the left hemisphere (which is responsible for verbal and motor control, the manipulation of words and symbols, and the sequential processing of information) is locked out thus leaving the encoding of memory as implicit memory in the right hemisphere.

24. Continued.... • Parnell (2007) proposed that fear blocks the hippocampus so that information will not go into explicit memory. Moreover, some argue (Parnell, 2007) that early abusive experiences are stored in the right hemisphere of the brain which is separate from the language centre of the left brain causing synaptic pruning in the orbital frontal cortex resulting in hyper arousal, the misreading of external cues and difficulty with self-soothing or calming. • This results in trauma freezing the integrative processes with the memory and the memory remaining as implicit stored in the limbic system which is responsible for fleeing, fighting, feeding and reproduction

25. Trauma, Memory and arousal • Heide and Solomon (2004) also argued that episodic memories of traumatic experiences ‘‘may be stored in the right limbic system indefinitely’’ (p. 226) because of the restricted ability to process information into the left cerebral cortex where it would be filed away for retrieval when required. The authors proposed that as a result memories of the trauma (including thoughts, feelings, body sensations, sounds and smells) are not processed into semantic memories but instead result in heightened arousal, emotional looping, anxiety and an inability to learn from experiences.

26. The Bridge..

27. Trauma, arousal and processing • Rauch et al. (2000) suggest that this inability to process episodic memories to the left cerebral cortex results in the emotions associated with the trauma being stored in the amygdala and the right limbic system. • Rauch et al. (2000) propose that as a result when any stimulus is triggered which is associated with the trauma this results in an exaggerated response from the amygdala and responses are generated by the limbic system. • Heide and Solomon (2004) suggest that as a result the person responds in an emotional rather than a rational way. Therefore, this would seem to suggest that focusing on the rational cognitive aspects of aggression alone would not take into account the inability of the individual to process information into the left cerebral cortex

28. Trauma, recall and language • In the case of trauma, early abusive experiences are stored in the right hemisphere of the brain which is separate from the language centre of the left brain causing synaptic pruning in the orbital frontal cortex resulting in hyper arousal, the misreading of external cues and difficulty with self-soothing or calming. • Teicher et al. (2004) also noted how the trauma may impact on the capacity of the corpus callosum resulting in reduced neural activity between the logical and reasoned left side of the brain with the emotional right side of the brain. • There is some evidence that the ability of the individual to recall the function of aggression in the context of both the emotional right hemisphere with the logical and reasoned linguistic left hemisphere may be compromised

29. One brain or two? How many brains do you have - one or two? Actually, this is quite easy to answer...you have only one brain. However, the cerebral hemispheres are divided right down the middle into a right hemisphere and a left hemisphere. Each hemisphere appears to be specialized for some behaviours. The hemispheres communicate with each other through a thick band of 200-250 million nerve fibers called the corpus callosum. (A smaller band of nerve fibers called the anterior commissure also connects parts of the cerebral hemispheres.)

30. The Brain

31. So what does this mean? • Information Processing influences aggression • Information Processing is also influenced by trauma • Trauma experiences impact on brain development • Trauma experiences impact on general cognitive functioning So how do we treat this all together?

32. Historical treatment approaches – Anger Management Novaco (1994) developed Anger Management techniques Regarded Anger as an emotional state that leads to aggression and developed a 3 stage approach to the treatment of aggression Phase 1 – Cognitive Preparation Phase 2 – Skills Acquisition Phase 3 – Application Training BUT – only attended to the emotion of anger

33. Current Approaches to the Treatment of Aggression Attend to the SORC – that is directly establish the function of the behaviour(s) as part of the intervention Attend to the role of physiology – ‘stress’ Identify the role of scripts and cognitive biases Directly address the role of emotion management rather than anger per se Utilise methods to induce the emotion experienced and rehearse new ways of managing the emotion Explore the negative reinforcers and maintaining factors for aggression so that these can be explored, challenged and replaced by more pro-social aspects Attends to relapse prevention

34. Current Aggression Interventions continued • According to Ireland et al. (2009) treatment aimed to reduce aggression expression should focus on the four areas identified in the Unified Model of Information processing proposed by Huesmann (1998). Specifically, this noted: 1. social scripts; 2. normative beliefs; 3. emotions and the impact of these on processing; and 4. perception errors

35. Aggression interventions • Aggression Replacement Training • Controlling Anger and Learning to Manage it (CALM) • Cognitive Self-Change programme (CSCP) now Self Change Programme • Healthy Relationships Programme (HRP) • Integrated Domestic Abuse Programme • Community Domestic Violence Programme • Chromis • Life Minus Violence (LMV) • Violence Reduction Programme (VRP)

36. Examples of Treatment Approaches in practice – LMV The LMV treatment modules form part of an intensive high-dosage psychological treatment programme. The LMV programme is cognitive behavioural in basis and uses a range of techniques to convey learning points including: The modules include; • Motivation; • Stress and coping; • How I got here (development of aggression) • Emotional regulation • Information processing and aggression • Consequences • Empathy, emotional intelligence and theory of mind • Interpersonal skills • Working towards the future – Relapse prevention

37. Constraints of current approaches • Do not account for emotional memories • Do not account for the impact of trauma on brain development • Do not account for the impact of trauma on cognitive functioning • Are highly cognitive • Are verbal/language based • Underestimates the ‘state’ of the client

38. Problems…. Stories of delivering standard groups • High drop out • Poor uptake • Arousal in sessions • Lack of recall (from one session to another) • Lack of recall regarding violent behaviours • Dissociation • Accusatory/Unsupportive • Everything took twice as long! • Lack of resources for dealing with Life History

39. Problems – patient experiences “I was terrified going to the group, I didn’t want to go to it but felt I had no choice. I dreaded every session and most of us missed quite a few. For those of us that stayed it did get better but there are days when I would have done anything not to be there” • Secondary trauma • Time for a change……

40. Something has to change.. The FUTURE?

41. Neurosequential Model of Therapeutics (NMT) • takes account of the developmental stage of the brain. • the brain develops hierarchically with four anatomically distinct but interconnected regions: • brainstem, • diencephalon, • limbic system, • cortex. • The brainstem is the least complex and develops first, then it develops in increasing level of complexity through to the cortex

42. Application of NMT to adult brains • therapeutic techniques to be timed to be more effectively in harmony with brain development • therapeutic interventions should also match the order of brain development. This is for interventions aimed at the cortex level to be maximised by improvements feeding it to it from the lower parts of the brain. This is because Perry (2008) stated “the organisation of higher parts of the brain depends upon input from the lower parts of the brain” (p242).

43. Order of treatment using NMT • In relation to the brain stem, patterned repetitive activity is recognised to shape and influence the brain stem and diencephalon (Perry and Hambrick, 2008) • positive patterned repetitive actions include positive interactions with trustworthy peers/ caregivers. Other examples that offer the brain patterned neural activation necessary for reactivation include, sensory motor activities such as music, movement, yoga (breathing), balancing, drumming and therapeutic m)assage (Perry & Hambrick, 2008

44. Eye Movement Desensitization and Reprocessing (EMDR) • EMDR seeks to activate client’s information processing systems by focusing on a target related to a trauma in an attempt to stimulate the memory network where the trauma is stored. Once this is done, alternating eye movements or bilateral stimuli (BLS) is added in order to stimulate accelerated information processing. • According to Parnell (2007) EMDR transforms psychological memory to objective memory, that is, ‘‘memory that feels emotionally charged, alive and self referential into functional and devoid of emotional charge memory’’ (p. 7).

45. EMDR – effects on physiology • Research investigating the neurological effects of eye movements has assisted with this. For example, it has been demonstrated that saccadic eye movements create changes in brain activation that enhance memory processing (Christman et al., 2003, 2004, 2006). • There is also evidence that eye movements produce physiological de-arousal (Sondergaard and Elofsson, 2008). • Schubert et al. (2010) suggest that EMDR may be particularly suitable for patients who cannot tolerate the high-stress associated with standard therapies such as exposure therapies which expose the client to stimulus which triggers emotions

46. Benefits of EMDR • Greenwald (2002) proposed that EMDR has the benefit of being adapted for clients who may not be comfortable providing in depth memories of trauma and/or for those who may have difficulty articulating in depth details of trauma, and for those who may become frustrated and impatient in being asked to provide in depth details. • Farkas et al. (2010) also agree that EMDR has the advantage because homework is not required and because the client is not required to verbalise insight into their experiences nor is there an expectation of any level of cognitive functioning (Seubert, 2005). • Hence, there would seem to be evidence that EMDR may be able to assist clients to reduce the associated effects of trauma and that this may have benefits over other interventions because of the way in which the client is not required to disclose in depth verbal accounts of the trauma, nor are they required to complete homework.

47. Group Treatment using EMDR Cochrane review (Bisson & Andrew; 2009) found the following • Individual TFCBT, EMDR, stress management and group TFCBT are effective in the treatment of PTSD. • Other non-trauma focused psychological treatments did not reduce PTSD symptoms as significantly. • There was some evidence that individual TFCBT and EMDR are superior to stress management in the treatment of PTSD at between 2 and 5 months following treatment • TFCBT (both individual and group), EMDR and stress management were more effective than other therapies

48. Features of effective groups • Group therapy is a well-proven form of treatment for traumatized children and adolescents (Cemalovic, 1997; Kristal-Andersson, 2000; Meichenbaum, 1994; Samec, 2001). • Key features that build a therapeutic, safe, and respectful environment. These features include: - group membership determined by shared type of trauma - disclosure and validation of the traumatic experience; - normalization of trauma-related responses - validation of behaviours required for survival during the time of the trauma - challenge to the idea that the non-traumatized therapist cannot be helpful through the presence of fellow survivors in the group

49. Group EMDR? • Current literature provides consistent evidence that group therapy, is associated with favourable outcomes across a number of symptoms. PTSD and depression are the most commonly targeted, but efficacy has also been demonstrated for a range other symptoms, including global distress, dissociation, self-esteem, and fear. • However, as was noted in the Cochrane Review, EMDR was also noted to be an effective treatment for PTSD. • How EMDR can be used in a group setting and whether this as a treatment maintains efficacy in the treatment of PTSD when used in a group.

50. Group EMDR for trauma • The EMDR-Integrative group Treatment protocol (EMDR-IGTP) was developed by members of AMAMECRISIS due to the extensive need for mental health services after Hurricane Pauline on the western coast of Mexico in 1997. • Combines the Standard EMDR Treatment Phases 1 through 8 (Shapiro, 1995, 2001) with a Group Therapy model (Artigas, Jarero, Mauer, López Cano, & Alcalá, 1999; Jarero, Artigas, Mauer, López Cano, & Alcalá, 2000). • Benefits - offers more extensive reach than individual EMDR applications and that the treatment may produce a more effective outcome than expected from traditional group therapy (Jarero et al., 2008). • EMDR-IGTP has also been found suitable for group work with adults (Jarero, & Artigas, 2010).