EMDR: A MISSING PIECE IN ACCOUNTABILITY COURT TREATMENT

1. EMDR: A MISSING PIECE IN ACCOUNTABILITY COURT TREATMENT TROUP COUNTY ADULT DRUG COURT KELLY J. VEAL, MS, LPC, CCAADC, NCC

2. SAMHSA’S Strategic InitiativeTrauma and Justice • Reduce the pervasive, harmful, and costly health impact of violence and trauma by integrating trauma-informed approaches. • Address the behavioral health needs of people involved in or at risk of involvement in the criminal justice system. • Provide needed treatment and recovery services, intended to reduce the health and social costs of substance abuse and dependence to the public, and increase the safety of America's citizens by reducing substance abuse related crime and violence. (www. samhsa.gov)

3. EMDR could help to achieve the Goals of the Trauma and Justice Initiative • Goal 2.1: Develop a comprehensive public health approach to trauma • Goal 2.3: Reduce the impact of trauma and violence on children, youth and families • Goal 2.4: Address the needs of people with mental disorders, substance use disorders, co-occurring disorders, or a history of trauma in the criminal and juvenile justice systems. (www.samhsa.gov)

4. Rationale for EMDR and Accountability CourtsGilman and Brown (2007) • Gilman and Brown Study (2007) in the Thurston County Drug Court demonstrated EMDR’s positive impact on treatment completion. • Clients who met the criteria for PTSD who opted for an integrated treatment program Gilman and Brown designed that combined EMDR and Lisa Najivits’ Seeking Safety Program Marich, J. (2010). Eye movement desensitization and reprocessing in addiction continuing care: A phenomenological study of women in recovery. Psychology of Addictive Behaviors, 24 (3), 498-507.doi:10.1037/a0018574

5. Rationale for EMDR and Accountability CourtsGilman and Brown (2007) • The clients that participated in this combined treatment program graduated from the drug court program at a rate of 90% whereas those who declined EMDR and completed only Seeking Safety groups graduated at a rate of 62%. Marich, J. (2010). Eye movement desensitization and reprocessing in addiction continuing care: A phenomenological study of women in recovery. Psychology of Addictive Behaviors, 24 (3), 498-507.doi:10.1037/a0018574

6. Eye Movement Desensitization and Reprocessing (EMDR) • Currently, EMDR is rated in the highest category of effectiveness and research support in the PTSD practice guidelines of both the American Psychiatric Association (2004) and the U.S. Department of Veterans Affairs and Department of Defense (2004) (Maxfield, 2007). • Included in SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP) (www.samhsa.gov) • Several studies have been conducted using EMDR with Substance Abuse populations that have yielded significant results (Marich, 2007)

7. Eye Movement Desensitization and Reprocessing (EMDR) Clip • Video Clip of EMDR in the news • KAALtv.com - Innovative Therapy Helps Minnesotans Recover from Trauma

8. EMDR and the MOL Study (2005) • There is recent research that indicates that general life events can cause even more PTSD symptoms than major trauma. • Aim of the Mol Study is to find out whether life events (e.g. divorce, job loss) generate as many symptoms of PTSD as traumatic events (e.g. abuse) • N=832 respondents • Filled out a PTSD symptom checklist while keeping their worst event in their mind • The PTSD scores were higher after life events (t) than after traumatic events (T). • Studies are finding that disturbing life events (t), or the nature of the event, appears to have little indication of the traumatizing effect it may have ( Shora et al, 2009).

9. Eye Movement Desensitization and Reprocessing (EMDR) • Developed by Dr. Francine Shapiro • Basic premise of EMDR is that most psychopathologies are rooted in past trauma (Cox & Howard, 2007). • A comprehensive, integrative psychotherapy approach • Complements other theoretical orientations • Based on the adaptive information processing model

10. Eye Movement Desensitization and Reprocessing (EMDR) • 8 Phases and specific protocols used to address presenting complaints (Shapiro, 1995). • Works by using a dual-attention stimulus (tones, tactile or eye movements) • EMDR treatment results in neurobiological changes in the brain (Maxfield, 2007).

11. Eye Movement Desensitization and Reprocessing (EMDR) has been used to treat: • Personality disorders, • Eating disorders, • Panic attacks, • Performance anxiety, • Complicated grief, • Stress reduction, • Dissociative disorders, • Disturbing memories, • Addictions, phobias, • Pain disorders, • Sexual and/or physical abuse and • Body dysmorphic disorders

12. Adaptive Information Processing Model • The Adaptive Information Processing Model is consistent with Freud's (1919/1955) and Pavlov's (1927) early understanding of what is now referred to as information processing. • The model posits that information is stored in functional ways in brain. The information that is useful is stored in a specific state, while the information that is not as important is essentially pruned by the brain. • This is what occurs when we a normally assimilating information in our brain that is not traumatic in nature.

13. Adaptive Information Processing Model • When a traumatic event occurs it may cause an imbalance in the nervous system which causes the information processing system to be unable to function, and the information acquired at that time, including images, sounds, affect and physical sensations, is maintained neurologically in its disturbing state (Shapiro, 2001).

14. Adaptive Information Processing Model • The hypothesis is that the memory will be encoded in excitatory, distressing, state-specific form, and the original perceptions can continue to be triggered by a variety of internal and external stimuli, resulting in inappropriate emotional, cognitive, and behavioral reactions as well as overt symptoms (e.g. high anxiety, nightmares, intrusive thoughts) (Solomon et al, 2008). • Example: I want you to think of __________________

15. 8 Phase of EMDR • Phase One: Client History and Treatment Planning • Phase Two: Preparation- Coping Strategies Example: Light Stream Technique • Phase Three: Assessment • Phase Four: Desensitization • Phase Five: Installation • Phase Six: Body Scan • Phase Seven: Closure • Phase Eight: Reevaluation

16. The Desensitization of Triggers and Urge Reprocessing (DETUR) Protocol • The DETUR protocol (Popky, 2005) was developed to help clients reinforce positive coping skills by focusing on both treatment goals and relapse triggers (O’Brien and Abel, 2011). • The Focus on a positive treatment goal is what it would look like without the substance which is enhanced through bilateral stimulation. • Then the therapist desensitizes each trigger the client has listed until the Level of Urge (LOU) is reduced. You begin with the lowest LOU and move toward the highest.

17. The Desensitization of Triggers and Urge Reprocessing (DETUR) Protocol • Clients are taught how to use BLS on their own if urges occur and it works!! • Using DETUR it is possible to work with addicts early in treatment (Popky, 2010). • By reprocessing triggers early in recovery client will have a greater chance of engaging with recovery and maintaining sobriety! • Client’s Feedback from DETUR Session in Drug Court- a journal entry

18. The Efficacy of EMDR and PTSD • More than 20 scientifically controlled studies of EMDR have proven its effectiveness in the treatment of traumatic or other disturbing life experiences (Shapiro, 2012). • Better than exposure therapy which requires homework and does not work on guilt. If it does not work on guilt it will not work on the Drug Court population (Zweben and Yeary, 2006).

19. PTSD and Substance Abuse • Many clinicians view PTSD as a major factor influencing addiction treatment outcomes. Traditional models of addiction recovery and relapse prevention fail to appropriately consider the role that unresolved trauma plays in an addicted individual’s attempt at recovery (Zweben & Yeary, 2006). • Developing more effective interventions for this conditions, therefore becomes the key to improvement. Symptoms of PTSD affect the ability to get clean and sober, stay that way, and create a satisfying life without the use of alcohol and other drugs (Zweben & Yeary, 2006). • Clinicians have also noted that even sub-threshold symptoms that do not meet criteria for PTSD can nonetheless interfere with mastering recovery tasks. The Case of Judy

20. PTSD and Substance Abuse • Co-occurring Posttraumatic Stress Disorder (PTSD) and substance use disorders are a major public health concern in the U.S. due to negative physical and mental health consequences and poor treatment outcomes (Hein et al, 2010). • PTSD severity reductions were associated with substance use disorder improvement, with minimal evidence of substance use reduction improving PTSD symptoms (Hein et al, 2010).

21. PTSD and Substance Abuse • Epidemiological and clinical studies have established that the majority of women in substance abuse treatment have been exposed to interpersonal trauma in their lifetimes (Dansky, Saladin,Brady, Kilpatrick, & Resnick, 1995; Lincoln, Liebschutz, Chernoff,Nguyen, & Amaro, 2006; Mills, Lynskey, Teesson, Ross, &Dark, 2005) • Women commonly meet diagnosis for co-occurring posttraumatic stress disorder (Brady, 2001; Najavits, Weiss, & Shaw, 1997). • Clinicians have discovered that in order to properly treat sexual addiction, they must deal with the underlying trauma (Carnes, 1989; Carnes & Adams, 2002; Carnes, Delmonico, & Griffin, 2001).

22. The Solution? Integration of EMDR and Seeking Safety in Accountability Court Treatment

23. Research Studies on EMDR and Substance Abuse

24. Eye Movement Desensitization andReprocessing in Addiction Continuing Care: A Phenomenological Study of Women in Recovery • Marich Study (2010) • 10 women alumnae of an extended care facility that were treated with EMDR • All 10 women called EMDR a crucial component of their addiction continuing care process especially in helping with emotional core access and a shift in their perspective in life! • Helped the women address emotional issues they had suppressed for a long time. • Most of the participants directly credited EMDR as the reason they are sober today!

25. EMDR in the Addiction Continuing Care Process • Marich Study (2009) • Case Study of a cross-addicted female • Prior to this course of treatment, the participant was treated 12 times with traditional approaches but was unable to achieve more than 4 months of sobriety at any given time. • Following EMDR, the participant reported 18 months of sobriety and important changes in functional life domains.

26. Studies on EMDR and Substance Abuse • Hase, Shallmayer, & Sack Study (2008) • 34 patients with chronic alcohol dependency randomly assigned to one of two treatment conditions (TAU) or (TAU+2 EMDR Sessions) • TAU+EMDR showed a significant reduction in craving posttreatment and 1 month after treatment, whereas TAU did not • Fewer patients receiving EMDR relapsed • EMDR treatment was associated with a significant decrease in depressive symptoms, while patients showed no improvement in this area

27. Studies on EMDR and Substance Abuse • Amundsen and Karstad (2006) • 20 individuals with substance abuse showed substantial benefits from EMDR treatment

28. Studies on EMDR and Sexual Addiction • Cox & Howard (2007) • In order to properly treat sexual addiction, they must deal with the underlying trauma and shame • Case Study of 21 year old male with a history of childhood physical, sexual and emotional abuse. • Current sexual addiction-Most distressing memory was sexual abuse incident with brother • NC: I am completely worthless…I don’t deserve to be loved • PC: I am a good person, deserving of real love • VOC: 2 • Emotions: • Subjective Units of Distress Scale (SUD) 9

29. Study on EMDR and Sexual Addiction • Phase Four: Began using BLS and other memories began to resurface along with intense feelings of guilt and shame • Phase Five: Installation Phase to accentuate and increase the strength of the positive cognition PC: “I am a good person…deserving or real love” • Phase Six: Body Scan-visualize the traumatic memory and perform a mental scan of the body identifying any unusual sensation • Phase Seven: Closure • Phase Eight: Reevaluation at the beginning of the next session • Conclusion: He made substantial progress with his addiction, while it also helped in relapse prevention.

30. Treatment Planning Ideas Phase I- Relationship Building, Support Building, Stabilization of the client (possibly DETUR) Phase II- 8 Sessions using DETUR Protocol to reprocess triggers Phase III- 8-12 sessions using the normal EMDR treatment protocol focusing on dysfunctional belief systems stemming from earlier trauma Think of the Stages of Change Model

31. Treatment Planning Considerations • Highly dissociative clients would need more sessions, and a special treatment protocol. • Clients who are absolutely unwilling to participate should not be forced. Always obtain informed consent for EMDR. However, when clients hear about the treatment almost all of them want to participate.

32. Funding Sources • State of Georgia Accountability Court Funding Program. There is supplemental funding for treatment • FY 2013 - Grants to expand substance abuse treatment in adult, juvenile, and family drug courts. • Priority of funding was given to addressing gaps in the continuum of treatment for those individuals in these courts who have Substance Abuse and Co-occurring treatment needs (e.g. trauma)

33. EMDR Humanitarian Assistance Program (HAP) Eligibility Requirements for HAP • Employment with a non-profit or public sector organization • EMDR Training is available to clinicians who work thirty (30) or more hours per week for non-profit or public sector organizations in a clinical mental health capacity. Clinicians may work for more than one non-profit to reach the 30 hour per week requirement. • EMDR training is also available to full time students enrolled in a Master’s or Doctorate level program in the mental health field (Social Work, Counseling, Marriage Family Therapy, Psychology, Psychiatry, Psychiatric Nursing). Students are not required to work 30 or more hours in a non profit or public sector agency, but will be asked to submit a Supervisor’s approval form. • Most clinicians attend a training event hosted by the agency where they are employed, but individual clinicians working in the non-profit or public sector can attend any event posted on the HAP training schedule that offers open seats • Training participants will be asked to provide verification of employment with a non-profit or public sector organization.

34. EMDR Humanitarian Assistance Program (HAP) Clinical requirementsAll participants in the Training must be licensed or on a licensure track. • Licensed clinicians • Must be in good standing in the jurisdiction in which they practice • Must be licensed in a clinical mental health field • Not yet licensed: • Must be working towards licensure • Must be working under the supervision of a licensed clinician • Master’s Degree or Ph.D. students: • Degree must be in a mental health field that will lead to licensure after graduation • Must be in clinical portion of training (first year students are not eligible) • Must be working under the supervision of a licensed clinician

35. EMDR (HAP) Training in Atlanta • HAP has offered to conduct a EMDR (HAP) Training in Atlanta, GA for Drug Court Professionals. • EMDR Basic Training consists of a Part I and Part II Training Event.  Each part is three days of didactic and supervised practice. Typically, the Part I and the Part II are scheduled three to five months apart. You also are required to do 10 consultation hours during this time. • Cost $395.00 for each weekend training • Total Cost = $790.00 • We need at least 18 participants to have the training

36. EMDR Resources • www.emdrhap.org • www.emdr.org • www.emdria.org

37. Contact Information Counseling Services of LaGrange, Inc Kelly J. Veal, MS, LPC, CCAADC, NCC 610 Ridley Avenue LaGrange, GA 30240 (706) 884-5050 (Office) (706) 594-8148 (Mobile) (706) 884-5056 (Fax) KJV0003@tigermail.auburn.edu

38. References Cox, R., & Howard, M. (2007). Utilization of EMDR in the Treatment of Sexual Addiction: A Case Study. Sexual Addiction and Compulsivity, 14, 1-20. doi:10.1080/10720160601011299 Hase, M., Schallmayer, S., Sack, M. (2008). EMDR Reprocessing of the addiction memory: pretreatment, posttreatment, and 1-month follow-up. Journal of EMDR Practice and Research, 2, 170-179. doi:10.1891/1933-3196.2.3.170. Hein, D., Jiang, H., Campbell, A., Chen Hu, M., Miele, G., Cohen, L., Brigham, G., Capstick, C., Kulaga, A., Robinson, J., Suarez-Morales, L., Nunes, E. (2010). Do treatment improvements in PTSD severity affect substance use outcomes? A secondary analysis from a randomized clinical trial in NIDA’s clinical trial network. American Journal of Psychiatry, 167(1),95-101. doi: 10.1176/appi.ajp.2009.09091261. Korn, D., & Leeds, A. (2002). Preliminary evidence of efficacy for EMDR resource development and installation in the stabilization phase of treatment of complex posttraumatic stress disorder. Journal of Clinical Psychology,58(12),1465-1487.doi: 10.1002/jclp.10099. Luber, M. (2010). EMDR Scripted Protocols. New York: Springer Publishing Company, LLC Marich, J. (2010). Eye movement desensitization and reprocessing in addiction continuing care: A phenomenological study of women in recovery. Psychology of Addictive Behaviors, 24 (3), 498-507.doi:10.1037/a0018574

39. References Marich, J. (2009). EMDR in the Addiction Continuing Care Process. Journal of EMDR Practice and Research, 3 (2), 98-106. doi:10.1891/1933-3196.3.2.98 Maxfield, L. (2007). Current status and future directions for EMDR research. Journal of EMDR Practice and Research,1,6-14.doi:10.1891/1933-3196.1.1.6 Mol S.L., Arntz, A., Job, F.M., Mestemakers, Dinant, G.J., Vilters-Van Montfort, A.Pl, Knottner, J. A., Arnound A., J. (2005). Symptoms of post-traumatic stress disorder after non-traumatic events: evidence from an open population study, The British Journal of Psychiatry, 186, 494-499. doi:10.1192/bjp.186.6.494. Shapiro, F. (2012). Getting Past Your Past(need to finish citation Solomon, R., & Shapiro, F. (2008). EMDR and the adaptive information processing model. Journal of of EMDR Practice and Research, 2(4),315-325.doi: 10.1891/1933-3196.2.4.315. Stickgold, R. (2002). EMDR: A putative neurobiological mechanism of action. Journal of Clinical Psychology, 58(1), 61-75. Zweben, J., & Yeary, J. (2006): EMDR in the treatment of addiction, journal of chemical dependency treatment, 8:2, 115-127 doi.org/10.1300/J034v08n02_06