Trauma & Attachment Therapy

Is life more fun without children?

Is life more fun without children? Read this lovely, heart-breaking story from Jennifer Lawler, a mother writing about her experience with her severely brain-damaged child:  http://jenniferlawler.com/wordpress/?p=747&cpage=9#comment-1554 . I think her answer is, "It doesn't matter."

"Anxiety" on To The Best of Our Knowledge

A great hour of interviews about anxiety on one of best radio shows around. This one includes Patricia Pearson, author of A Brief History of Anxiety, Yours and Mine, and her own experience with anxiety medications and learning to self-soothe; Ethan Waters, talking about the globalization of American psychiatric diagnoses and pharmaceutical cures; Dr. Daniel Carlat, a psychiatrist talking about the problem with psychiatry, especially in regards to medications and drug companies; and a cool discussion about anxiety-provoking sounds in Kafka's writing. Lots of good links on their website. Check out the anxiety podcast at the top of the links page here.

Chillout song from ZeFrank

Here is a sweet short song about being okay, "just fine" and breathing. Good for anyone.

Chillout song from zefrank

EMDR-Humanitarian Assistance Program and Doctors Without Borders

I spent yesterday afternoon at a fundraiser for EMDR-HAP's Haiti project and last night at "Living in Emergency", the new Doctors Without Borders/MSF film, followed by a live discussion with MSF staff/volunteers. I'm left with two feelings: overwhelmed that there is so much untreated physical and emotional trauma in the world and gratitude and hope that volunteers have taken on the task of doing what they can to heal it.

(Full disclosure: I'm on the board of EMDR-HAP.)

The EMDR Humanitarian Assistance Program started 15 years ago as a sub-program of the EMDR Institute, to address the psychological trauma of disasters. HAP's first big project was sending therapists to work with first responders after the Oklahoma City bombing. After volunteers used EMDR to clear the trauma for medics, fire-fighters, police, and others, some stayed to train therapists to work with the rest of the population. HAP started out responding to disasters and now has a new mandate: building capacity to serve underserved traumatized communities. While they still respond to specific disasters like Katrina, the Turkish earthquake, the tsunami in Indonesia, etc., they are building capacity by training therapists to do EMDR in those places, and in underserved communities in the U.S. and around the world. HAP has done trainings for community mental health centers, rape crisis centers, children's agencies and military services in the U.S. Its volunteers have trained therapist who work in Israel, the Palestinean territories, Iraq, Egypt, India, Bosnia, Indonesia, Kenya, Mexico, Columbia, and many other countries. Therapists or agencies may pay the expense of the trainings (dirt cheap, since all trainers and facilitators work for free) or grants may underwrite the entire expense. HAP, under its wonderful director, Dr. Robert Gelbach, has turned to "building capacity". Its goal is for each country or region to eventually grow its own training capacity, so that we can bow out and send our volunteers to other places.

HAP is also promoting Trauma Recovery Networks, regionally-based mostly autonomous groups that train themselves to work with disasters or underserved populations. I'm in the beginning of starting such a group in the Seattle area.

Doctors Without Borders (Medecins Sans Frontieres/MSF) was started in 1971. It sends medical personnel to over 60 countries to deal with victims of war and other disasters. Volunteers sign on for a 6-month or more hitch and deal with the medical issues of extremely underserved people. Most of the medical people come from developed countries and most do their stints in places with inadequate supplies, electricity, and communications. In "Living in Emergency", I saw the doctors deal with the deaths of patients they would have been able to save in more modern settings. I saw them dealing without the basics of sanitary surgery and doing amazing work (as far as I can tell). Many doctors smoked. All drank. Many used sex to affirm life while surrounded by death. The stress was amazing. About half do a second stint. Some sign on indefinitely.

I noticed the difference between HAP and MSF. Most HAP volunteers fly away for 3 or 4 days or a few weeks, at most. HAP, being a mental health-based agency, pays attention to the stress of its volunteers. MSF, according to the movie and to the discussion, believes that volunteers are responsible for themselves and should deal with their own problems. There is debriefing, but no formal mechanism for support. It made me wonder about a HAP-MSF connection. Could we at HAP have our EMDR therapists available to assist traumatized MSF personnel?

Go see "Living in Emergency". If you want to learn more about Doctors Without Borders/ MSF go to http://www.doctorswithoutborders.org/ . If you want to learn more about EMDR-HAP go to www.emdrhap.org . Feel free to leave a donation at the websites. These folks are doing great, life-giving work.

 

 

 

Washington State Parity Law for Psychotherapy Sessions

On July 1, 2010, insurance companies in Washington state will have to provide unlimited sessions for psychotherapy clients in most categories. After fruitlessly spending more than 10 hours trying to get Regence Blue Shield to flip an inpatient benefit into outpatient sessions, I remembered the new law. I then called up another part of the company and a nice man explained to me that the client will have unlimited sessions starting July 1.

Don't assume it with every client. Check with the company if you're not sure.I'm sure this means that we Washingtonians will have to be even more scrupulous in record-keeping and diagnoses to prove "medical necessity". Otherwise, Hallelujah!

This came about by the tireless efforts of the Washington State Coalition of Mental Health Professionals and Consumers http://www.wacoalition.org/ and especially the great work by Laura Groshong our amazing lobbyist. Thank you WS Coalition!  If you are a therapist in Washington State, go to the website and join now. It's a wonderful organization.

 

 

Insurance Company Scam

If you get a phone call from Multiplan asking you to lower your fee with an insurance company in order to get "expedited payment", turn them down. This happened to me and to a colleague of mine. First your insurance company doesn't pay you for sessions that you did. Then Multiplan calls you and says that if you lower your fee it will help your client. They wanted me to lower my fee $30. After intensive questioning, the agent told me that it would lower the client's copay by $5. Guess who gets the other $25? That's right! It's the insurance company. Given that the companies make massive profits and the executives get millions in bonuses, I'm not willing to further subsidize them. And neither should you.

And what's with withholding pay and offering "expedited payment." WTF?

Andrew Leeds Positive Affect Training

Susan Kravitz and Katy Murray, the wonderfully effective stewards of the Southwest Washington Regional meeting, organized a training for EMDR therapists in Olympia, at which they played an audiotape of Andrew Leeds teaching about enhancing positive affect. (2007, Learning to Feel Good About Positive Emotions, from the 2007 EMDRIA conference worshop on the Positive Affect Tolerance Protocol) This is what I came away with:

People who were poorly attached to their parents, who didn't get appropriate mirroring of their joy and excitement, may grow up to be unable to tolerate the positive affects of happiness, joy, and excitement. They may have been punished for showing too much exuberance (a depressed child is a quiet child). Or there may have been so much abuse and/or mayhem around them that they learned that "if it's good now, it will turn bad soon."

When you do regular EMDR processing with these folks, you may clear the distressing events, but the relief that we see with other kinds of clients ends up distressing these dismissive attachment folks. If you try to do Resource Installation, having them remember a good or strong time, they fall apart, avoid it, or dissociate, because they don't have the neural hardware to tolerate and assimilate the joyful feeling. They have trouble taking in the good feeling of a compliment. (I've noticed that compliments are ego-dystonic for my complex trauma clients who live in deep shame.)

Leeds and his colleagues came up with a few ways to start building in the appropriate hardware. One is available to any kind of therapist, or anyone reading this blog:

1. When you receive a compliment, maintain eye contact with the give and take a deep breath into your chest and diaphragm.
2. Breathe the compliment into the area around your heart.
3. Continuing the eye contact say, "Thank you. I appreciate you saying that."

Practice this in the session. Have the client give you a compliment, twice, warning him or her that you will turn it down the first time, then accept it. Then give them a compliment and have them take it in say the words. Assign responding to compliments for the next week, (or the rest of their lives) and reporting to you about it.

The next part is for EMDR therapists:

Target moments of positive affect, using a slightly modified Standard Protocol: the Positive Affect and Integration Protocol.

Ask the client for "a recent moment of poorly tolerated shared positive feeling".

There are a few changes in the protocol:

1. The target is a 'feeling state' from a recent experience (not an old memory).
2. It's the discrete behavioral state shared positive emotion, not the event itself.
3. You're going for a small change, only lowering the SUD 2-3 levels, and not for a 0 SUD, so only 3 to 5 sets of eye movements are used.
4. If the client comes up with a positive cognition, and no negative cognition: good! Then skip the negative cognition. Again, you're only going for a small change in the VoC, the validity of cognition.
5. You might want to change the SUD scale to a negative/positive scale.  Completely Distressed is negative 10, completely joyful is positive 10.
6. If distressing memories arise, acknowledge them for future processing, but don't work them: go back to the original target of shared positive affect.
7. The closure phase may be longer and may use your entire toolbox of calming and containing exercises, until the client is "tucked in" and ready to go out into the world.

Of course, it was much more complicated, with descriptions of how people develop dismissing insecure attachment, case histories, and some practica. Leeds said that he saw big changes in his clients' ability to tolerate their positive affect in five or six sessions. I'm looking forward to trying it with my complex trauma clients.

Other ways to build positive affect tolerance, laughing with clients. Sharing their good feelings in obvious ways: mirror smiling and eye contact. Show delight in their delight and talk about it (ala Diana Fosha): "What was it like for you when we laughed together?"  "What was it like for you when you noticed that I noticed your happiness today?"

 

A Meditation for Clients Who Have Complex Trauma

This meditation was generously shared by someone else's client who was neglected and abused as a child. She does it as part of breathing practice: breathing in each true line. In it she speaks to different parts of self and all parts of self, counteracting distressing and untrue beliefs and orienting parts to the present. The changes in type, underlining, etc. are as I received them.

To the writer: I don't know you, but I thank you on behalf of all the therapists who are going to borrow this for their clients who need to learn the same things that you are already learning. Thank you!

Breathing Meditation

1.  I am here now, in my body,

2.  quiet and calm.

 

3.  It’s OK to know.

4.  It was not my fault, ever;

5.  I had no choice and did nothing wrong.

6.  I was not a bad girl;

7.  I was good.

8.  I am good.

9.  It’s OK to know.

10. It was not her fault, ever;

  [multiple “hers”]

11. she had no choice

  and did nothing wrong.

12. She was not a bad girl;

13. She was good.

14. I am good.

15. It’s OK to know.

16. It is not your fault, ever;

17. you have no choice

  and are doing nothing wrong.

18. You are not bad,

  even though it sometimes feels good.

19. You are good,

  even when it feels good.

20. You are good

  even when it’s confusing

  and you think maybe you like it.

21. You are good

  even when you’re sure you’re bad.

22. You are always good.

23. I am good.

24. There has never been anyone there to help you.

25. You have been so lonely.

26. I see you now.

27. You are not alone anymore.

28. I can help you now.

29. It is OK for both of us to know.

30. It is OK for all of us to know.

31. It is OK for all of you to be known.

32. It is OK for me to know all of you.

33. We did nothing wrong.

34. Bad, confusing things were done to us.

35. I have compassion and tenderness

  for all of myself.

Ethics and Technology Workshop

I attended Lisa Erickson's Professional Ethics & Technology workshop today, sponsored by Cascadia Training. Here's what I came away with:

SKYPE

Skype, the computer phone and video-phone service, is encrypted and hard to break into. If Skype's employees wanted to listen in, they could. But why would they?

The picture can freeze, fragment, or lag. You can't do eye contact. And it's still often better than the phone because you can see each other.

If you are "skyping" or emailing a session, have a back-up plan in place (like the phone) in case the technology fails.

Many of us in the workshop wouldn't use Skype for regular sessions, but would use it for sessions if the client or therapist was out of town. Some do and many would use it for consultation or supervision.

You can only legally do long distance psychotherapy if the client resides in a state in which the therapist is licensed.

Informed Consent

Add a new section to your consent form stating your rules about technology. For instance:

• I never "friend" anyone who is or has been a client of mine.
• Email is not 100% secure. Email security can be breached. My email policy is this: Either: "I don't do it with clients." OR "You may email me only for changes of appointment." OR "You may send me emails to update me on your status, but I don't return them." OR "I will try to respond within 24 hours, but if I don't, please call me on the phone, because I may not have gotten the email." And/OR "I will charge $2 per minute for reading and responding to any email longer than one brief paragraph." (With some clients who seem to want to move the therapy to email, I stop accepting emails except for appointment changes.)
• "Please do not send me emails, or Skype me from any place that is not secure and private, including the library, an internet cafe, your job, or any public network or place. I don't want your confidentiality breached."
• "If you want to show me something on Facebook or your blog or any other social media, you can show me during our session from your account or print it out for me. I want to be sure to protect your privacy, even from me."
• "I don't google my clients, so if you want me to know something, tell me."
• "Since we live in different areas and do therapy through the computer, I will provide you with a list of emergency services available in your area."
• Conversations by cell phone or cordless phones may be picked up by people in the area. The only completely safe phone call is from one old-fashioned corded phone to another. When we have a phone call, be sure that you can't be overheard.

Other random issues

• Online or phone sessions are not covered in 39 states. Telemedicine is covered in the other 11, and it's unclear if therapy is "medicine" in all of them.
• On your website, provide links to relevant state licensing boards to protect your clients' rights.
• Make sure you do online work with people who have the equipment, technical savvy,  access, and ego strength to do it well.

Resources

(a few of the many that Lisa Erickson gave us)

M. Maheu has a great technology/therapy blog: http://telehealth.net/blog/ 

Mahue, Pulier, Wilhelm, McMenamin, & Brown-Connolly (2005) The Mental Health Professional and the New Technologies

metanayoia.org: Safeguarding Patient Confidentiality in email.

 

 

Episode 27 - Dr. Charles Figley: Veterans and PTSD: Time for a New Paradigm? (Living Proof Podcast Series of the University at Buffalo)

Episode 27 - Dr. Charles Figley: Veterans and PTSD: Time for a New Paradigm? (Living Proof Podcast Series of the University at Buffalo)

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How Trauma Therapy Works, a Video

Here is a 9 minute video of me talking about how trauma therapy works. Expect more pieces of this video in the future. My husband, the videographer and photographer, Doug Plummer made the video.

Surviving An IRS Audit

Here's how we prepared, what we did right, and how it went:

Our returns were "flagged" by the IRS because my husband, Doug Plummer, has a home office and $20,000 of travel expenses, and because I never gave 1099's to my three consultants, and because of our two rentals (one of which is my office.)

We did several things right:

1. We immediately called our great accountant, Christina Anderson, who told us how to prepare, held our hands through the process, and represented us at the actual audit.
2. We already had good records, easily pulling 2007 files out of storage.
3. We had separate bank accounts and Quicken accounts for each financial entity: one for the rentals, one each for the businesses (my psychotherapy business and Doug's photography business) and we each have personal accounts. So if you are running your business account out of your personal checking account, get yourself another checking account, this minute. If you don't have Quicken or something similar, get yourself a computer-based accounts manager. We printed multiple reports while preparing and even ran some that the auditor requested while he was here.
4. The auditor sends you a list of what he or she wants. We pored over the list, compiling receipts, making Quicken and Excel reports with receipts attached, for everything that the auditor asked for. We put each requested thing in its own clearly marked file, since auditors may work for hours without the tax-payer in the room.
5. We were welcoming and friendly to the auditor, as a guest in our home. He couldn't accept food or coffee, but we provided water, showed him the way to the bathroom, and made sure he had a comfortable chair and an expanded dining room table to work on. We worked collaboratively with the auditor to get him the information that he needed to do his job. Later, our accountant told us that some people start out hostile or defensive with auditors and get the same back. Our auditor agreed. If people are hostile, he assumes they are hiding something. We had a pleasant time, considering the circumstances. It didn't hurt that he was half our ages and baby-faced cute. (No, I didn't pinch his cheeks.)
6. We didn't give the auditor more information than he asked for. We admitted when we didn't know something or had no documentation.
7. Doug, who travels for a living, has written a detailed blog post about how to document travel expenses: http://dougplummer.blogs.com/dispatches/2010/01/how-to-auditproof-your-travel.html  
8. He wrote another post about the audit day: http://dougplummer.blogs.com/dispatches/2010/01/irs-audit-day.html

What I did wrong:

 I had no idea that we are supposed to issue 1099's to other professionals we pay. I had a few thousand dollars of expenses, split between 3 consultants, and I should have issued 1099's to each of them, and 1096 forms to the IRS about them. And, no, you can't declare your personal psychotherapy to be consultation. And it's only for people you paid more than $600 in one year. If you pay rent for your office, you must issue a 1099 to your landlord. It's supposed to go in by Jan 31 of the next year. I'm working on the 2009 1099's right now. 

My 25 consultees and 4 office tenants have never given me 1099's. It doesn't effect me, but it will get them dinged in an audit. I'm paying the not so horrible penalty of $50 for every 1099 I didn't issue in 2007 and 2008, about $300.

Total cost:

We paid our accountant about $900 for helping us prep and then being with us for some of the audit. We lost two days of work each, for the audit. And about 40 hours each in preparation. And I owe about $300 in penalties. It could have been worse.

So, keep good records, issue 1099's, have Quicken or the equivalent, have separate accounts for personal and business, and don't throw anything out. Hire an accountant, we couldn't have done it without one. And I hope all my readers can avoid audits forever.

 

By measuring magnetic fields in brain, researchers identify post-traumatic stress disorder biomarker

By measuring magnetic fields in brain, researchers identify post-traumatic stress disorder biomarker. Article in today's Science Daily, referred to me by Louise Maxfield

Eating Disorders, Not Otherwise Specified: EDNOS Article in the NYTimes.

Abby Ellin writes "Narrowing an Eating Disorder" in today's New York Times, describing her own eating issue, the too-broad EDNOS diagnosis, and the need for medically and insurance company recognized diagnoses for eating disorders.

Brain Connections in Generalized Anxiety Disorder

Research shows that anxious people have different wiring than non-anxious people:

http://psychcentral.com/news/2009/12/08/abnormal-brain-connections-linked-with-anxiety-disorder/10043.html

Why We Do Trauma Therapy

Here is the last paragraph of the Introduction to Trauma Treatments Handbook, Protocols Across the Spectrum. You're seeing it before the publishers do. Before I send it in, do you have anything to add about why we do this work? I'll publish what you write, unless it's spam.

 

As trauma therapists, we are privileged to use all of our selves to help people heal from deep wounds. We connect deeply, from the heart, all day long. We use our detective brains to puzzle out what is happening with our clients and what do about it. We enjoy helping the grateful single-trauma survivors get quickly back to their lives. We dig deep into our skills while slowly and carefully helping our most dissociative clients into their new, healed selves. We continually learn new skills from the innovators in our field and in innovative collaboration with our clients. We hang out with colleagues who love their work and support ours. Throughout each therapy we are delighted to hear, “I finally know it’s over!” “I feel like ‘me’ again!” “It wasn’t my fault, I was a little kid when that happened.” “I’ve got my body back!” “I can have sex again.” “I didn’t have one nightmare all week!” “Thank you for letting me get completely here and now!” “I’ve got my life back!”

 

Kathy Steele: Neurobiology of DID, on Science Friday

Kathy Steele, cocreator of the Structural Dissociation Theory, patiently defends the existence of Dissociative Identity Disorder to Ira Flatow and Numan Gharaibeh (a clueless psychiatrist) on NPR's Science Friday. Worth a listen: http://www.sciencefriday.com/program/archives/200911133 

I've run into this blindness before, mostly in analytically trained psychiatrists, despite all evidence.

NYT's article and video about military women with PTSD.

Video of military woman with PTSD: Video

Article about military women with PTSD: Article

Check out Damien Cave's article in today's New York Times. Women are less likely to be granted disability on the grounds that they weren't in combat, even though they are seeing plenty of action in Iraq. Unrecognized, they feel shame about having the flashbacks and aggression that characterized PTSD and are even less likely to seek treatment than male soldiers.

 

Self Care for Trauma Therapists

As trauma therapists, we are privileged to watch our clients’ trauma fade from terrible, here-and-now experiences to mere memories; their dissociation shift to integrated presence, and their pain disappear. We are also privy to the gut-wrenching details of rape, accidents, war, and story after story of child abuse, domestic violence, and horrible neglect. The more terrible the abuse and the more dissociated the clients, the more they project the actual emotions of their trauma into us. Some therapists become grim. Some avoid complex trauma clients. Some help their clients avoid expressing affect in the sessions. Some burn out and leave the profession. Here are some ways to keep yourself whole while doing this important work.

1.   Do your own work. If you’re not able to tolerate your own history and your current affect, you won’t be able to tolerate the despair, rage, shame, and grief that move through many trauma survivors.

2.   Learn mindfulness. Meditate, do yoga, do chi gong, do breathing exercises. It will help you “stay in the chair” while witnessing whatever is there to see. Learn to breathe and ground yourself while being with anything.

3.   Know yourself. If you start a session in a state of equilibrium, and you start feeling rage or exhaustion in the session, guess that it may be the client’s rage or dissociation. If you then say “What are you feeling right now? There’s something in the room.” The client is likely to say, “Oh, I’m angry, I guess it’s about X.” or “Oh, I was just spacing out.” When you know where you are, you’ll know when you are being drawn into someone else’s experience and use it for their benefit.

4.   Know the signs of burn out:

a.   You aren’t excited to go to work.

b.   You talk only about work and have no other interests.

c.    You treat everyone on earth like a client.

d.   You dream about clients, all the time.

e.    You’re angry at clients for being the way they are.

f.     You feel shame for your human limitations.

g.   You have vicarious PTSD: flashbacks, anxiety, depression, avoidance around client material.

h.   You want to drink, gamble, or otherwise dissociate after work.

5.   Get support.

a.   Join a supportive consultation group. (Not just about the technique, but about you, too. And no shaming allowed.)

b.   You might get individual consultation for the most troubling cases. As a consultant, I’m going step-by-step with a few consultees with their most fragile, barely tractable cases. It’s good for the therapists and good for the clients.

c.    Increase your therapeutic arsenal. If what you’re doing isn’t working, find something else that does.

d.   Do your own work. Hire a good trauma therapist who can help you clear your vicarious trauma.

6.   Develop other interests that have nothing to do with therapy. Make sure some of them involve unmitigated joy.

7.   Do things that bring you into your body: Run, stretch, work out, dance, do yoga.

8.   If you have any control over your schedule, limit the number of the most complex, dissociated, abused, unstable clients. And don’t put them all on one day.

9.   You will probably learn your tolerance the way most of us do, by exceeding it. Once you know, keep your own boundaries. Follow the Platinum Rule: “Fill your own cup first, then give away what’s left over.” And another rule, “To Thine Own Self Be Nice.” Trauma is compelling, but don’t let it run your entire life.

10.  Watch out for grandiosity. You can’t fix everything. Know your limits.

11.  If you have a spiritual practice, use it to support your work. Ask whatever higher power you have for help when stuck.

 

 

Update on Health Care Reform from a Mental Health Lobbyist

From Laura W. Groshong, LICSW, Director, Government Relations, Clinical Social Work Association:

I have just returned from three days of lobbying in Washington DC for the Clinical Social Work Association and have some new ideas of what the President and Congress (the five committees and one informal "Group of Six") are doing to develop a health care reform plan.
 
I think the President is trying to pull together at least four major political groups in Congress (Democratic progressives, 'Blue Dog' conservative Democrats, Republican conservatives, Republican moderates), which are being influenced primarily by PHarma, the AMA/other clinical groups, insurers, hospitals, and AARP/other consumer groups. Any of the political groups could theoretically sink health care reform.  Mental health groups/associations (57) are working well together in the Mental Health Liaison Group, but don't have the kind of influence that the AMA does.  We are working with the AMA on several issues where we have common cause, e.g., stop the proposed 21% Medicare cut to providers scheduled to go into effect in 2010, keep the "evidence based practice" provisions from taking clinical decisions out of our hands (even though this concept started in medicine, and has increasingly become the de facto way that insurers operate), expansion of care to include the uninsured, etc.
As a clinician and lobbyist, I think there is rarely a time when you can accomplish everything you want, in working with patients or in legislation, no matter how strongly you feel.  I think President Obama, Speaker Pelosi, and Majority Leader Reid are trying to deal with the reality that the conflicting interests here will not allow wholesale reform of the health care delivery system or expansion of the kind that would be most humane.
 
Most successful legislation in my 12 years of experience is incremental and works pretty well because most issues do not arouse the conflicting passions that health care is right now.  I think it has become the lightening rod for other sources of anger and anxiety, not the least of which is job loss and income reduction in general. This is unfortunate because it could stop our getting some improvements in health care delivery and coverage altogether.
 
Much as some legislators and interest groups have framed this as an all or nothing situation, it does not have to be.  The HELP draft bill, HR 3200 in the House and the Baucus/Group of Six bill draft all contain several pilot projects which would give us a chance to see what works best in containing costs, the driving force behind any health care reform. 
 
The legislator working the hardest to make sure that any bill has a strong mental health and substance abuse benefit is Rep. Patrick Kennedy (D-RI), with some help from  Rep. Barney Frank (D-MA).  Neither House wants to determine what the basic benefits package should look like at this time.  A new Federal oversight body may be created to do this, the Department of Health and Human Services could be charged with developing the package, or Congress could eventually decide to do it themselves.
 
Here's the time frame as I see it.  Things are on hold until the Baucus bill comes out on Tuesday or Wednesday.  After amendments are considered by the Finance Committee (the 'mark up'), the bill will be passed by the Finance Committee. Then the full Senate will consider the HELP bill and the Finance Committee bill and reconcile them.  This will influence the bill, HR 3200, which has been passed out of three committees in the House, but has not passed the whole House of Representatives.  The Majority Leader intends to pass a bill by mid-October; the President has asked for a bill to sign before Thanksgiving, so the two bills which emerge would have to go to conference committee as soon as possible to be integrated.  Again, the Baucus bill is seen as the most likely framework for a bill that could be passed by both Houses.  

A word about the "public option", or a government health plan to cover the uninsured who cannot find insurance that they can afford.  Though this is a popular concept for liberal representatives in particular, and some clinical groups, keep in mind that the way it is being developed is to tie payment to Medicare rates, possibly plus 5-10%.  That could be a reimbursement decrease for some mental health clinicians.  It appears that the public option will not be part of the final bill but I wanted you to be aware of the financial piece which is not widely known.
 
I hope this is helpful in understanding the incredibly complex process taking place in Congress which will affect all mental health and medical clinicians, in some way.  Please let me know if you have any questions.
 
 
Laura W. Groshong, LICSW, Director, Government Relations
Clinical Social Work Association

Lessons Learned While Writing A Book for Psychotherapists

I'm 13 chapters into writing Trauma Treatments Handbook, Across the Spectrum. Here's the advice I'd give anyone doing the same thing:

• Get a second screen for your computer. Keep the reference page, internet search materials, etc. open on the second screen. It will save you days of searching for the right open file.
• Start the reference list on the first day of writing. Write the reference first, then refer to it in the text. Do it on a separate page.
• Figure out who you're writing for and address the book to them. I have a range of imaginary readers, from clueless, but bright, grad students to informed therapists. I try to keep it simple enough for the students and entertaining and interesting for the rest.
• Use your own voice and use active voice. It's hard to read academese. Don't try to impress anyone with how much you know. It's not the point. Make it accessible.

• Don't worry about people hating it. Some will. I'm writing a book that will piss off every true believer, by showing the usefulness of every trauma technique that I know about, and by talking about the shortcomings, too.

• Take some time to only write. I just took two weeks off, writing about 5 hours a day. I was able to hold all the chapters in my mind and let the obsession take over me: waking at 3 and 5 a.m. to scribble notes. Up at 6:30 with my brain ready to go, moving things from one chapter to another. I finished 4 chapters, including one very long one. My brain needed time to nail the structure of the book.

• Make a list of acronyms to put at the end of the book. I've wanted every therapy book to have them. Put them on the list the minute they pop up in the text. I'm up to 3 full, double-spaced, pages of acronyms and 9 pages of references, so far.

• Talk over difficulties with anyone who is around. Everytime I began to tell my husband about a quandry, it solved itself before I was done explaining it.

• Use the thesarus on dictionary.com

• Read many sources.

• Share milestones with your friends, virtual or in person. Let your publisher know too. They worry about books not being on time.

• If you don't know something that you want to include, ask everyone. I still don't know where Kluft said, "The first integration, isn't." Do you? Or was it Kluft?

• Enjoy the process of writing. Let the "alter" that writes take over and type. It's easier than torturing yourself over every word.

• Don't fall in love with your words. Reread. Edit. Reread. Edit. Reread. Edit. But don't worry. Your brain knows. Trust it. And trust that there will be mistakes in y our book. Despite you, your professional copy-editor and your friends.

• Back up everything to an external hard drive, every day. Every done chapter, send an email with attachments of all chapters to a few friends who don't live in your town and ask them to put the attachments on their hard drive. If you have gmail, as I do, you can send the attachments to yourself and they'll live in the gmail "cloud" of servers. Losing a book is a terrible thing. BACK IT UP!

• Exercise, get massage, socialize. You live in a body with needs. Take care of yourself.

• A book is a great excuse to neglect your blog. Sorry everyone!

Mentally Ill Offenders Strain Juvenile Justice System

This distressing article, http://www.nytimes.com/2009/08/10/us/10juvenile.html?_r=1&pagewanted=all by Solomon Moore in today's New York Times shows us how the mental health system in most of the country is failing teenagers. Kids who need medication, psychotherapy, and structure act out until they end up in detention, often physically and sexually abused by both fellow inmates and staff, with little or no treatment. I worked with one of these guys in a day treatment program. The PTSD was the worst part of his disorder. With what little we knew about trauma at the time, we got him through it, and out of the system. 

In 1983, I saw Ronald's Reagan's gutting of the community mental health system gut treatment for mentally ill adults. I ran a day treatment program that actually worked. We got most of our clients, except the most psychotic, main-streamed into jobs and schools. When Reagan cut the funding medicaid funding, our program closed, and many of our clients who had been maintained on 3 hours of group, 3 times a week, had no where to go. Some lost their housing. Some lost their lives.

If we truly get health care for all and it includes mental health care for all, this may change. I hope so for the lives of all the sick and mentally ill people in our still wealthy country.

Narcolepsy and EMDR Processing

A client has given me permission to post about her situation: the effects of Provigil, Prozac, and time on trauma processing:

 

Round 1, 15 years ago: She was bright, effusive, and had the odd habits of jerking her head up to look around and writing down everything I said. We worked for eight months using EMDR to clear the PTSD from the physically and emotionally abusive marriage that she had escaped 17 years before. She seemed dissociative, but in a strange way, staring off, then going to the head jerk. The EMDR worked, the flashbacks stopped, the client, satisfied, went off.

 

Round 2, 10 years ago: After her narcolepsy diagnosis, she started taking Provigil. A few days later, the flashbacks from the abuse began again, and she returned to therapy. We went after the abuse, in greater depth as more details arose. Again, we cleared all we could find, and she left therapy feeling good.

 

Rounds 3 – 5: I saw the client through the illness and death of a sweet boyfriend, and various stressful work situations. Then as she became more constitutionally anxious, then obsessive, which became manageable when she started Prozac.

 

Round 6: last week: Planning her 45^th high school reunion, to which her abusive ex-husband had been invited, brought up the next round of distress over the marital abuse. SUD 10, when she thought of him. She processed through fear and rage, bringing up memories that had not arisen in rounds 1 or 2. She left, after a 60 minute session, feeling safe, calm, and able to ignore him, if he came to her reunion.

 

She and I think that whether or not her narcolepsy was a dissociative response, the Provigil allowed her brain to stay on task with the trauma processing, and that the Prozac with the Provigil keeps even more of her brain online and on task in trauma processing. She and I would love to hear if other people have had similar reactions with these medications affecting the depth of trauma processing.

Avoidance, AIDS Dementia, and Chosen Families

Last Wednesday I flew down to Fresno, CA, and flew back up with an old friend who, after battling AIDS for 25 years, is losing the fight. R''s brother and a few other friends and I have been managing his care up in Seattle for the last week.

R is one of my favorite flavors of people, a skinny nervous person, smart, funny, charming, talented, and relational. He has also had OCD since I met him in 1980. The OCD, related to a bipolar diagnosis, manifested in several ways, eating disorders, an inability to get out of the house without carrying half his belongings with him (the bag-lady syndrome "what if I need something"), and extreme indecision. The OCD also carried avoidance behaviors. R. avoided conflict, asking for what he wanted, and anti-retrovirals. He would get busy controlling the minutiae of his life while avoiding the big issues. In the last few years, he would worry incessantly about his belongings in storage units, while not chasing down the health care that he needed. Several of his Seattle friends offered to fly down to help him. He couldn't accept their offers because his appearance (another obsession) wasn't up to par, his apartment wasn't clean, and he would have to take care of them (another compulsion.)

Two months ago, R got pneumonia and began to show signs of dementia. His California social worker, Frida, and I talked him through getting on an ambulance to the Emergency Room. We both thought for sure that he would be admitted, but he was cut loose with some heavy-duty antibiotics and sent home. After a few weeks of daily calls by the Seattle support group, he had managed to take his pills daily, but was obviously losing his mind. A month ago his brother flew down and took over. 10 days later his brother's boyfriend drove down to help. R. was emaciated, covered with KS, and had about 2 minutes of short term memory. He didn't know where his own bathroom was. He didn't finish a meal without constant reminders. Last week I flew down and flew up with him. He was hospitalized at the best AIDS hospital in town and will go to Bailey-Boushay, a state of the art AIDS care facility, with loving staff and loving volunteers and really good art.

My feelings are extremely mixed. My lovely, vain friend, has a wasted body and a wasted mind. He's in pain much of the time. I'm grieving. I'm sad. But we have him now, he won't die alone, and he's in the best possible care, so I'm relieved, too. I'm also, clinically, fascinated by the dementia process (when I'm not frustrated by it or laughing.) R. can remember people and activities from 30 years ago. He can charm nearly every nurse and doctor who comes in the room. He remembers, at this point, all the people who love him and whom he loves. His right brain is working pretty well. His left brain doesn't tell him where he is, anything that happened in the last 6 weeks, what day or time of day it is, or the name of the person in front of him whose name he just asked. He is often sweet and charming. The more confused he is the snarkier he gets. He is very sarcastic, especially with his long-suffering brother. R. confabulates what he doesn't know. His brain makes up stories to fill the holes in his memory. Some are quiet elaborate. I haven't seen R in 8 years, nor has he been on a plane in that time, but evidently we've been on several long trips together. His brain told him that he has an apartment in a neighborhood of Seattle, not Fresno, and he wanted me to take him out of the hospital and take him home. Much of the time he thinks he's in Fresno, despite the view of Puget Sound out the window. His friend, Joe, says, "is that Fresno out the window?" and R. replies, "Oh, we're in Seattle." R., the compulsive care-giver, asks for back and foot rubs, tells the doctors that he wants us in the room to supply information that he won't remember, and has allowed us to talk him into many medical procedures. The right brain relational trust is working, even though the left brain thought process is not. His sentences are complete. His syntax is perfect. He knows his social security number. And he doesn't know who visited him or what vile procedure they just did or that his body is wasted or that he has AIDS. The KS constantly suprises him. (Advanced Kaposi's Sarcoma looks like an archipelago of red, mountainous islands everywhere but his feet, hands, and face. Sometimes it hurts like hell, sometimes it itches, sometimes it's hot to touch.) He asks, "Why am I so weak? Why do I hurt?"  "Honey, you have advanced AIDS." "When did that happen?"

Back in the 80's, I lost about a hundred friends, clients, mentors, colleagues, and neighbors to AIDS. I started the AIDS Mental Health Network, which gave free training to therapists about psychosocial issues, safe sex, dying, resources, anything we needed to know. It was before the AIDS agencies arose and we were flailing to find information and the skills we needed to take care of all these dying young men. Back then we created care committees: chosen families of caregivers that ran errands, cleaned houses, did pharmacy runs, took the person to the doctor, and generally hung out. There was no internet, so we communicated by phone, and sometimes by a log at the PWA's (person w/ AIDS) house. R. has an AIDS nursing home to go to, the Lifelong AIDS Alliance, and a group of about 5 people, including his brother, who are the support team. In the 80's, PWA's died within 16 months. R. has lived with AIDS for 25 years, at least, and is in the last stages with good medical and social support.

Schizophrenia May Be Linked To Immune System

Jon Hamilton reports on NPR about three research studies showing that schizophrenia, while having a definite genetic component may need a viral kicker to turn on the appropiate genes in utero. An old Danish twin study that I read about 25 years ago, and can't cite, shows a link between birth trauma, in genetically susceptible people, and schizophrenia. I guess you have to have the genes, then have something else needs to happen.

Here's the link: http://www.npr.org/templates/story/story.php?storyId=106151437

Social Anxiety Treatment

(Dear readers, I'm deep into writing Trauma Treatment Handbook and have been neglecting my blog. Here's an email exchange that the correspondent has graciously given me permission to post.)

From the asker: I just came across your site while researching heart rate coherence.  I have Servan Shreiber's book(s) and actually had forgotten about heart rate coherence until it recently came up again while doing research for my father's heart disease/stress.

I was hoping you might be able to help me navigate in terms of finding the right tools to help myself with what seems to be social phobia (as it's outer manifestation anyway). I have come to realize that I avoid going out and being around others and have managed to avoid talking on the phone although it is a source of stress for me.  If you met me, you probably wouldn't know this(well maybe YOU would) most people don't but I sense people do notice my discomfort when  I have it.  I feel as if I'm never in my own skin and i don't really feel truly in the moment very often.  When I look back...i believe this has been the case for decades but I just wasn't conscious of it.  I don't feel joy very often and I have a hard time remembering things from the past....as if I wasn't even there.

If I have given you the impression that I am suicidal or depressed i assure you I am not:)  I have really been taking care of myself in many ways and I'm trying not to make this into a "problem".  I eat well, I recently gave up smoking...again.  I go to acupuncture, I excersise every day as always and take my supplements(incuding the 7:1 epa:dha which is new).  It's as if the more conscious I am of the issues, the better i am taking care of myself but the worse I feel.  Maybe this is just part of the process.  But still, the anxiety/fear gives me constant problems in my every day life and I'm concerned that they will not be resolved .  Case in point-my boyfreind of 7 years just mentioned his brother and nephew want to come for a visit again(they were here recently).  I found myself making all of these excuses as to why it wouldn't work right now but the truth is It takes my all to pull it off even when it's my own family.  I put a great game face on but it's as if it's a performance and it sucks every last bit of life from me and I feel like I can't keep it up the way I used to.  Bottome line.....I'm tired of feeling like this!

 I keep wondering if there's something internal that isn't being dealt with.   I'm not sure I believe therapy is what is best for me.  I was in therapy on and off for years and iscovered I had a better understanding of how I felt but in the end I still felt like crap. I am, however, intrigued by what I read about EMDR in Servan Shreiber's book.  My fear is it won't be helpful to me and I will humiliate myself in the process........I tend to freeze/go blank when the focus is on me which becomes yet another source of anxiety.

Any ideas on what I may be able to try by myself .  Do you think the heart rate coherence is enough based on your experience.   Any thoughts about the EMDR or any other therapy I might consider?  I'm in a fairly rural area but I'm near a large town and discovered that there are 5 or 6 therapist trained in EMDR.  I know it's near impossible to give any suggestions for someone you've never met.

I have never done this before but you struck me as the right person to ask.  I would be most grateful for anything you may have to offer.  Thanks for your time Robin!!

My Reply: In my opinion and in other people's research there are a clan of people who feel anxiety more strongly. Research shows that social anxiety can be predicted by a 3-week-old baby's reaction to a puff of air in their face. The bad news is, you're anxious.  The good news is, even though your body may be more aware of its anxiety response than some other people's bodies are, there's a lot you can do to manage it.
 
EMDR can be a great way to clear out the trauma part of your sensitivity and give you internal practice at dealing with social situations. And do exercise, take O 3's and D's and learn how to calm your body.
 
Read: Elaine Aron's The Highly Sensitive Person. If it's a fit for you, it's like a care and feeding manual for anxious people.
 
I'm married to an HSP, who used to have social anxiety. He's still high strung, but he no longer lets it stop him from doing anything. Through therapy he's learned to ask for what he wants, say no when he needs to, and accept that he's never going to love crowded places. He's even doing some public talks, now and then. Years ago, he wouldn't knock on neighbors' doors to talk to them about the block party. He doesn't think twice about it now, in fact he's been the Block Captain. And he's still very sensitive to his anxiety, still predicts the worst outcome for everything (he's the designated worrier in the marriage and I'm the designated pooh-pooher), still thinks that we'll be late, and there will be a disaster. (Then we're not late and he has a better time than I do.)
 
Get therapy. Get EMDR from the best person in town. If you don't like them, try someone else. Tell them to read my chapter about anxiety if they haven't done it. And if you had some deficits in your childhood and are not an HSP, they can nail it completely and clear the anxiety, unlike my genetically nervous husband.

Asker: You're a sweet heart!  I don't feel like a freak after reading this.  I think my judgement of what I'm experiencing makes it much worse.
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Bainbridge Book-Signing Party

Book Signing Party!

On Beautiful Bainbridge Island

June 14, 2-5PM

 

Sandra Paulsen, Ph.D & Robin Shapiro, MSW, LCSW will be there to sign and read excerpts of their 2009 books. We may have a special guest reader, Yaak Panksepp.
Bring your checkbook if you want to buy a book. Save shipping costs!

Location: 9054 Battle Point Dr. NE, Bainbridge, Island, WA 98110
At the log house in the woods of Sandra Paulsen, Ph. D and Tim Iistowanohpataakiiwa, MA. Weather permitting, there will be a campfire in the pasture with the horses.

From Seattle: Take the Bainbridge Ferry to wy 305, turn left at the third light--Sportsman's Road--and an immediate right on New Brooklyn. The next light is Miller Road, turn right, go two blocks, then left on Battle Point Drive. Follow the S curve to the very top of the hill. Turn tight at the big cedar mailbox at 9065 Battle Point Dr., and veer right at the fork in the driveway. If you pass Bainbridge Gardens on the left you have gone too far.

From Poulsbo: Take Hwy 305 across Agate Pass Bridge to the first light. Turn right on Miller Road and veer left. Go straight for several miles. Turn right just past Bainbridge Gardens, onto Battle Point Drive. Follow the S curve to the very top of the hill. Turn tight at the big cedar mailbox at 9065 Battle Point Dr., and veer right at the fork in the driveway.

Presented by Sandra Paulsen, Ph. D. and the Bainbridge Institute for Integrative Psychology.

For more information:
206-855-1133
sandra@paulsenphd.com
www.bainbridgepsychology.com

"Mental" Is Terrible

There's a new fantasy show on Fox: Mental. It's supposed to take place in an inpatient psych unit.

So, first, the new head of psychiatry strips down in a room full of clients to connect with a psychotic guy who has pulled his clothes off. Later, he breaks into a woman's house in order to check out his hunch that her schizophrenic brother is an artist. And he thinks it's a good idea for his patients to go cold turkey off their antipsychotic medications. And he doesn't lose his contract, immediately.

All the psychiatrists are cute. All the patients are reasonable. The families just don't understand. And the residents and other psychiatrists have endless time to spend with their clients. Oh, and they invented a radical new idea: intensive outpatient day treatment.

I saw bad treatment, silly ideas, and a romanticization of extreme mental illness. I saw nearly every 1960's cliche possible. It's really bad. Except that all the psychiatrists are cute. And the new head of psychiatry looks to be about 32. That would happen, too.

 

Spirituality and Neuroscience

There was a great series on National Public Radio this week about the neuroscience of spirituality. I'm going to post links to all 5 days. You can read about it and then play the pieces if you want. They're by Barbara Bradley Haggerty and each is 7 to 9 minutes.

1. Is there a God chemical?                     http://www.npr.org/templates/story/story.php?storyId=104240746

2. Are Spiritual Encounters All in Your Head? http://www.npr.org/templates/story/story.php?storyId=104291534

3. Prayer May Reshape Your Brain, and your Reality: http://www.npr.org/templates/story/story.php?storyId=104310443

4. Can Positive Thoughts Heal Another Person: http://www.npr.org/templates/story/story.php?storyId=104351710

5. Decoding the Mystery of Near Death Experiences: http://www.npr.org/templates/story/story.php?storyId=104397005

Daphne Merkin on Her Chronic Depression

Daphne Merkin, a New York Times writer, articulately recounts her history and hospitalization for Depression:

http://www.nytimes.com/2009/05/10/magazine/10Depression-t.html?pagewanted=all

Connie Sidles Interview: Grief, meaning, presence and bliss

Connie Sidles is a famous Seattle birder. Here is this week's KUOW radio interview with her about why she spends so many hours at the Montlake Fill. Connie gives a cogent discussion of dealing with grief, how to create/have meaning in life, how to get present, and why birding creates bliss in its more conscious adherents. Hear her here: http://kuow.org/program.php?id=17451

And if you want to see my husband's book of photographs of the Montlake Fill, go here: http://issuu.com/dougplummer/docs/at_the_fill . You don't have to buy the book to see the pictures. Click on the book then on the pages below. You can listen to Connie on one Explorer and look at the book on the other. Connie wrote the intro to the book.

Addiction, a form of dissociation, II

Ulrich Lanius, a clincial psychologist, researcher, therapist, and writer in Vancouver sent me this:

"The connection between dissocation, depression and addiction is a fascinating one and more likely than not  related to attachment. An article written by Bessel van der Kolk some insight into this:

http://www.cirp.org/library/psych/vanderkolk/

For more intensive reading, Alan Schore describes the effect between attachment and infant trauma and how they lead to traumatic stress syndromes:

http://www.trauma-pages.com/a/schore-2001b.php

There is little doubt that dissociation is in part mediated by an excessive release of endogenous opiates/endorphins. Animal studies that mimic neglect also suggest that animals that have experienced lack of caregiving have fewer opiate receptors. This likely  leads to lack of pleasure and sometimes intolerance of positive emotions, a common phenomenon in human beings that have experienced attachment trauma and who suffer from depression.

Addictions can be seen as an attempt by the addict to make up for impaired functioning of their own opiate system. Except that the pleasure derived is short lasting and commonly leads to negative outcomes in the long run, health or otherwise.

Another exciting development in the research on opiates are the effects of opiate antagonists on immmune system disorders but also potentially positive effects on depression. A review paper can be found here:

www.ldn4cancer.com/techpapers/ldn_for_disease_prevention_quality_of_life.pdf  "

Thanks Ulrich!

Mindfulness Through Pleasure

Mindfulness is a major goal of psychotherapy. We want our clients to be able to savor the moment free of intrusive memories or worries about the future: Right Now. There are many ways to bring a client to the present moment: teaching mindfulness meditation, body awareness, or playing what do you notice? ("Name 3 things in the room that are red, 3 things you hear, 3 sensations.")

Some of my more anxious clients find that their obsessiveness scuttles attempts to meditate ("Am I doing it right? This is stupid? What am I supposed to be focusing on? I can't do it!). Body awareness reminds them of what could go wrong with their bodies. ("What if I stop breathing?!) I'm teaching these folks to make state changes through noticing pleasure. Here's how it works:

"Look around the office. Look out the window. Notice what catches your eye. Notice what's fun to look at or that you enjoy seeing. Stay with whatever it is, as long as it's interesting or pleasurable. (Usually they start to smile and to relax at this point.) When you're ready, and only when you're ready, look around for something else that pleases you. Stay with that object or view until you feel like moving on. Stay with it as long as you like. Great!" (We usually do 3 objects or views. I say that my eye can be pleased by looking at the angles on a molding, or 3 planes coming together in the corner of the room. I only have art that I like and little objects scattered about to look at. I tell them how much I like to look at the big tree across the street. This kind of pleasure can be a new experience for some, and quite profound. For others, it's not new, but consciously using it for mindfulness or self-soothing might be new.) "Now notice how you're sitting on the couch. Could you do anything to make that more comfortable? Try sinking into those cushions. How's that? Try sitting straighter or sticking this pillow behind your back. What feels the best? What fabric feels the best under your fingers? How about your hair on your hand? Do you like that texture?" (Crew cuts win this one!) Hang with what feels the best. Can you imagine the next time you take a shower, totally feeling that hot water, and enjoying it? Can you imagine being worried about something that you don't have power over, and finding something pleasing to look at or feel or smell or do? Think of something that might happen at work, and soothing yourself with something you enjoy. Think of something that happens at home, and coming back to yourself and this moment with something pleasing. If you commute, think of the irritating drivers and the waiting, and how you can shift your body in the car for your best comfort, and look at something interesting, a cool car, the view, a cloud, a bumper sticker, and while still paying attention to driving, have a little pleasure vacation."

People do this homework. And it works, even with the most anxious. And it doesn't feel like work. And they learn both mindfulness and painless state change. It doesn't clear underlying trauma. It doesn't take away an anxiety disorder. But it's a nice, easy habit to take on.

Is addiction a form of dissociation?

I read an article about how naltrexone, an opiate suppressant, curbs the urge to engage in kleptomania. I've had dissociative clients who have successfully used naloxone and naltraxone to vanquish their endogenous (internal) opiates, in order to be able to stay present and process traumatic events, instead of switching or spacing out completely. (See EMDR Processing w/ Dissociative Clients: Adjunctive Use of Opioid Antagonists by Ulrich Lanius, in EMDR Solutions: Pathways to Healing, 2005). I've also had success using ego state work with addicts, alcoholics, and people with compulsive/addictive behaviors. Here's my theory: Opiate Antagonists work on dissociation because much of dissociation is run by endogenous opiates. When addicts think of their drug or behavior of choice, they begin to enjoy their endogenous opiates. When they engage in their drug or behavior it gives them an even better high. The neural pathways to the repetitive addictive behavior become wide and strong, until they become ego states. When people in recovery talk about "my addict", they refer to this strong ego state. Integrate the ego state and help heal the addiction.

So how does this work? Have clients bring up the last time they were frantic to use, or the last time they did use. "Where do you feel that inside? What's the feeling? Float back to the first time you had that feeling. How old is that? What was happening then? Can you bring your adult back to that time/that kid? What do you need to tell that child? You're with her. You can fly her up to the present time. She's with you all the time, now, and you're with her. Can you tell her that now, as a competent adult, you can tolerate those enormous feelings? Can you show her how you have learned to soothe yourself without that drug/behavior? How's that kid doing now? (Do whatever it takes to calm her down.) And are you ready to hug her into you now and forever?"

There is usually a frantic little child and often an angry/protective teenage part. Sometimes there are several "parts" involved in different pieces of the addiction. It has worked on several clients.

A.J. Popky and Jim Knipe have protocols that seem to fit my opiate theory. Popky developed the Level of Urge to Use. Knipe spun off the Level of Urge to Avoid. In both of these you have the person imagine whatever triggers them to use a drug or to avoid a task and to feel how good it would feel to use or avoid. Then you do eye movements and watch the good feeling start to fade away. (DeTUR, an Urge Reduction Protocol for Addictions and Dysfunctional Behaviors by Popky, and Targeting Positive Affect to Clear the Pain of Unrequited Love, Codependence, Avoidance, and Procrastination-- both in EMDR Solutions: Pathways to Healing, 2005, Norton.) You target inappropriate positive affect in both cases. When the positive affect (the good endogenous drugs) fade, you target the distressing affect underneath, and the trigger stops being a trigger. I've done this many times, for many addicts. It works amazingly well.

I've watched clients and people in my private life turn into unrecognizable demons, sociopaths, and screaming or pleading children while in thrall to their addictions. The dissociation/opiate theory explains these behavioral shifts. Please comment and give me your opinion about this theory.

Book Signing Parties!

 

 

Book Parties

EMDR Solutions II for Depression, Eating Disorders,

Performance & More

Robin Shapiro, Editor

&

Looking Through the Eyes of Trauma and Dissociation:

An Illustrated Guide for EMDR Clinicians and Clients

by Sandra Paulsen

Meet both authors at each party.

 2: 00, April 19th, 2009

at 6203 28th Ave NE, Seattle, WA

&

2:00 June 14

at Sandra's log house on Bainbridge Island

Readings, Signing, Snacks, Socializing.

If you are a therapist or friend who wants to celebrate with us, please attend. Bring your books for signing or buy them from us, or just show up for the party.

Please RSVP, if possible, or get more information,

for the Seattle party: Robin 

or the Bainbridge party: Sandra

 

 

More Therapy During Troubling Times

In the face of overwhelming recession-based stress, therapy works again. With permission from my client, I'll tell you her story:

Several people were laid off at her job, a small business, which is a recession-vulnerable business. The newspapers are full of bad news. Other people she knows are out of work. Boeing, a major employer around here, is threatening massive layoffs. And she hasn't slept well for two weeks.

Knowing that she is a well-resourced and very sane person, we went right for the distress: "Think about the layoffs, the unemployment statistics, the mortgage problems, and that the papers say it's going to be worse." (She stiffened.) "Where do you feel it in your body?" Chest/Tight. "What color is in there?" Dark/Fear. I handed her the bilateral tappers and found the "brainspot" in her eyes. In about 8 minutes of referring back to her body, she visibly relaxed and yawned.

"Where do you feel strong and safe in your body?" Hips. "Color?" Pink.  We brainspotted that. The pink deepened and rose in her body. She yawned, her face softened. She said "I'm finally going to able to sleep!" We pendulated between bad news and her body's sense of calm and pleasure. She found a feeling of gratitude and we focused on that.  We installed the "AND" exercise: "The economy sucks AND I'm o.k." "There are more layoffs AND I can feel pleasure in my body." "The news is bad AND I can feel my strong, grounded hips." And we discussed the concept of surrender to what is, using my favorite line from the psychologist, Thom Negri: "What makes you think your life is any of your business."

You can read about a context for Therapy During Troubling Times right here.

Dyadic Developmental Psychotherapy

As I've been reading up on trauma therapies, I've been delighted at how attachment research and theory is permeating the new therapies. A few years ago I was delighted with videos of Dan Hughes working with distressed kidsusing his DDP technique. Last week, Arthur Becker-Weidman sent me an article that he and Hughes published in Child & Family Social Work (2008, 13 pp 329-337): Dyadic Developmental Psychotherapy: an evidence-based treatment for children with complex trauma and disorders of attachment. Here's the abstract and then I'll tell you more about it.

"ABSTRACT

Dyadic Developmental Psychotherapy (DDP) is a family therapy treatment based on Attachment Theory. It is an integration of several approaches, methods and techniques that have a strong evidence base. The approach was originally developed to treat children with disorders of attachment and has been shown to be effective. It has since been more broadly used to help families with a variety of difficulties, including complex trauma. This paper outlines the primary principles and components of DDP and the evidence to support the effectiveness of the components and, therefore, of DDP."

From the article: "Dyadic Developmental Psychotherapy (DDP) has as its core, or central therapeutic mechanism for treatment success, the maintenance of a contingent, collaborative, sensitive, reflective and affectively attuned relationship between therapist and child, between caregiver and child, and between therapist and caregiver. DDP focuses on and relies upon the intersubjective sharing and joint development and organization of emotional experience." They speak about intersubjectivity, one of my favorite concepts, where the parent and child experience themselves as having an impact on the experience of the other. "For example, children experience themselves as being delightful, loveable and clever whenever their parents experience them as manifesting those characteristics. In a similar way, the parents experience themselves as being capable and caring whenever their children experience them as manifesting those traits."

DDP basic principles include the importance of parents' and therapists' good attachment capacity and ability to provide good intersubjective experiences for the children. It's all about attunement. It includes good acronyms: PACE, that the therapist sets a healing pace to tx by being playful, accepting, curious, empathetic; and PLACE, that the parent creates a healing environment by being playful, loving, accepting, curious and empathetic. DDP emphasizes repair of misattunements and conflicts, which helps with affect regulation and teaches that conflict doesn't lead to abandonment, or abuse.

Both kids and parents are involved with the process. Both learn to attune, to make repair, to giggle together, and hold the sadness and pain of life. It looks informal with lots of back and forth, co-relating of stories, cocreation of right-now reality. Resistance is handled with curiousity. Trauma is handled together, with the therapist giving words to the old experience. Parents are taught how to touch their kids to provide solace, engagement, and containment. And parents are assessed for attachability.

It's a great therapy for Reactive Attachment, for trauma, and for kids with any attachment disruptions. I think the principles work with adults, too. It's how I try to work, with a mix of other treatment strategies thrown in.

If you'd like to read the whole article, contact Arthur Becker-Weidman at aweidman@aweidman.cnc.net and he'll send you a PDF file of it. It's a good, clear, easy-to-read nine pages.  His website is www.Center4FamilyDevelop.com

 

 

 

 

GPS-Directed Socially-Engaged States

Two years ago. My husband and I drove up the California coast after the Lifespan Learning conference. We did it again after this year’s conference, with a remarkable difference, my skinny-nervous husband was rarely in hypermobilized vagal states on this trip. I blogged about the last trip, here: http://traumatherapy.typepad.com/trauma_attachment_therapy/2007/03/mobilization.html

In 2007, every time we came into a town, he’d get anxious, incapable of social connection, and constantly scanning for danger. He couldn’t problem-solve very well or negotiate with me about restaurants, hotels, etc. (When relaxed, Doug is a well-connected, loving, sweetheart.) This time he could chat, problem-solve, laugh, play, and negotiate. What’s the difference? We have a GPS device.

Doug has been navigating foreign terrain with his GPS for over a year. (He travels a lot for his photography work.) "Emily" tells him where to go and how to get there. She locates food and shelter. She usually keeps him on the path. Her calm British voice directed us through our five-day trip. Yesterday, she got us around San Francisco, where the traffic can be mobilizing for anyone. Today, she will again.

Because of Emily, I don’t need to back way up to allow Doug time to reset to a meyelenated ventral vagal state, capable of socializing, thinking, and shooting pictures. He spent less time in shut down, dorsal vagal immobilized states, too. His body didn’t need to shut down to recuperate from the mobilization.

As you can imagine, this trip was more fun. We stayed engaged much more of the time. There were less occasions or need for repair. Doug fell into his birding swoons or photograpy swoons much more easily, both highly engaged states. (104 species before we hit San Francisco. But who’s counting?)

We both talk to Emily. And we allowed her to lead us astray, a few times on purpose. (That’s how we saw the White-Tailed Kite, a beautiful hawk that "treads water", Kestral-like, in mid-air while searching for little rodents and reptiles.) If you are or travel with a "born to be anxious" person, I recommend a GPS system for your car. It took the unfun kind of mobilization out of our trip.

UCLA Trauma Conference Synthesis

I escaped the conference yesterday, and am typing in the dark this morning beside my snoring husband. I can’t see my notes, so let me tell you my impression of the conference:

Trauma impacts the right hemisphere of the brain. Helpful trauma therapy targets the right brain. Left brain cognitions and interpretations don’t have much impact on the right brain. (So said Alan Schore in 500 quotes, yesterday.)

How do we, as therapists, help traumatized people heal? We use our attuned relationship with them to keep them present and socially engaged. If they are socially engaged, now, they’re in a meyelenated ventral vagal state and can’t go dorsal/shut down /immobilized or too ventral/ mobilized/ hypervigilant. Connect. Attune. Not just with your words: "I hear you say that you’re scared." Attune with your body. "I feel your fear in the room." Then help your clients locate that sensation. "Where is it in your body?" Then stay connected with them as they mindfully explore what it’s like to be scared, while connected to you, and tracing the affect through their body. If you’re Pat Ogden, you will have your clients try out the movement that they didn’t get to do when the bad thing happened. (I have a movement tx background and incorporate this in what I do.) If you’re Diana Fosha, you’ll use the power of your connection and your brilliant countertransferential language to do hold the clients in your therapeutic embrace while they move through the trauma. (I use her language all the time – in the moment self-disclosure as containment and dual attention, cool stuff.) If you’re Francine Shapiro, you will make sure that client have a deep, attuned connection with you, while bringing cognitions, affect, and sensations into consciousness, applying periodic eye movements, and deeply connecting during the breaks between, while the clients watch their minds clear the trauma. If you’re Dan Siegel, you’ll teach your clients mindfulness, so that they can get fully present, so that they can socially engage, be present with the trauma, and let it move through with whatever techniques you use. If you’re Bessel van der Kolk, you might do any of the above, and you’ll send them to Yoga class, to become re-embodied.

What are the threads that run through this varied work?

1. Presence. Getting into the here and now experience of body, affect, and thought. That includes clients being inside the Window of Tolerance: not overstimulated, not immobilized (dorsal vagal), not over-mobilized (unmeyelenated ventral vagal). Present and capable of connection so that the work can move through them.

2. Dual Attention: In EMDR, it’s the bilateral stimulation. In Yoga and in Ogden’s work it’s the attention to bodily experience. In Fosha and good relational analytic work it’s the relationship that keeps one mind on the present and the other on the traumatic past.

3. Affect while in relationship: In all of this work, clients have affective experiences while "held" inside the window of tolerance and a therapeutic relationship. It’s not that the affect is "discharged", though it might be. It’s that it is felt; not avoided; witnessed; survived; and transformed into a memory, no longer a developmental catastrophe.

4. Relationship with self and the other: Tolerance for one’s own affect and history. Capacity for relating to others.

You have just read the thesis of my next book, Trauma Therapies. I already had it, and was validated and heartened by what I heard, every moment. The next wave of therapy is Right Brain, Mindful, Affective, Embodied, and Relational.

The husband is up and it's time to go. I'm on vacation for the rest of the week. Imagine me bird and scenery-watching on the California coast, self-regulating with no set schedule. I want to see a Condor, this time.

UCLA Trauma Conference Day 2: Dan Siegel, Mindfulness

Daniel Siegel: A System's View of Disintegration & Integration

(He's still cute, he's still brilliant, he speaks in easy-to-remember aphorisms and he's still heartful. What's not to like?)

"Integration is the linking of differentiated parts. The concept is useful for assessment, tx planning and therapy. . .Presence is absent in trauma survivors. Presence begins with us as therapists."

P.A.R.T.T.T.T  
when fully
Present we can
Attune to the client or others and
Resonate with others and develop
Trust which is important because it activates the smart ventral vagus so the social engagement system turns on so that we can
Track what's going on in moment to moment experience which allows the
Truth to come out and creates
Transformation/healing.

We help clients become open systems: self-organized: chaotic moving toward complexity, flexibility and adaptable: energized and coherent. System acheives complexity by linkiing differentiated parts. Coherence comes from integration. (Thank God for systems theory in social work school in 1979! I understand this stuff!) When not integrated we move toward rigidity (avoidance), chaos (flooding) or both.  It's all about the mind regulating the energy and information flow. "The mind is in the whole body and among people: it's embedded socially/relationally and embodied." "What I am is a process of regulating energy and information flow, not limited to our bodies and right now and this relationship. The ripple effects after we leave or die are also who we are." (My woo-woo teacher says the same thing. So does Hillel, sort of.)

Calming exercise: Put one hand on your heart, the other on your abdomen. Hold them there for a while. Try switching hands to see if you prefer one over the other. Most people do.

Your right hemisphere contains the storage of autobiographical information. PTSD is impaired integration. Long story about how a past trauma impeded on the present and how mindfulness allowed him to integrate the past event and stop reacting to the trigger.

"There's a distinction between awareness and mental activity: Awareness is the infinite possibility of neural firings."

In trauma, mental activies get locked into rigidity and chaos and pull humans into limited possibility. With unresolved trauma, rigidity and chaos imprison the person's possibilities. Good therapy transforms the brain of the the client to totally shift their center of attention and stay present to the self and watch self and make sense of it. The labeling of the internal state downregulates the limbic system. The client knows that "this" is not "that". Integration is the capacity to sit with core awareness and sit with anything that comes in. You can use mindfulness practice to help people distinguish between mental activity and true awareness. Ventral integration--being touch with the bodily state: Track it and you transform. Supress it and it screws you up.

"Liberate the innate drive of a complex system to integrate. Interpersonal integration: We are designed to be interdependent and interconnected. There's hope for we as humans to move from chaotic & rigid states to integration, kindness, and peace.

(Thank you, Rebbe Dan.)

--------------------------------------------------------------------------------------

After Dan, Martha Stark, a child psychiatrist spoke about Optimal vs Traumatic Stress. Traumatic Stress overwhelms and disrupts. Optimal Stress provides the impetus for transformation and growth. Optimal Stress--you need enough to stimulate adaptation and growth but not enough to overwhelm the system. In therapy, challenge when possible and support when necessary. (My brain was full and I took a walk.)

--------------------------------------------------------------------------------------

The Question and Answer period at the end of the day was worth the price of admission:

Dan Siegel: Txist attunement helps clients widen their ability to be with emotions and curiosity; integrates the experience; brings openess; widens the window of affect tolerance and acceptance and love, and moves away from rigidity and chaos. Be safe but not too safe: push the limits of the window of tolerance.

Francine Shapiro: Schizophrenia is sometimes misdiagnosed. Not all psychosis is genetic. Some is trauma-based, early and not-so-early childhood. If you target the negative experience, set up information processing. If they have positive networks to go to, the trauma will clear. Do processing if the client can stay present during processing (maintaining a dual awareness) and have positive experiences to call on. Otherwise spend as much time as you need to set up those positive networks. Truly schizophrenic people can be traumatized by their disease or by abuse, or disrupted attachment. Go after those targets if the client is resourced enough.

Pat Ogden, to Dan: Too much attention to mindfulness doesn't develop relational capacities. Dan to Pat: If you improve mindfulness, people have the capacity to connect. Capacity for the parent to be with his/her own self and material predicts the kid's secure attachment.  Teach people to harness the social capacity of their brains.

Steve Porges: We've developed to deal with humans, but school teaches/rewards dealing with objects. Psychiatry depersonalizes relationships. We need to teach social interaction: develop exercises. Play tempers mobilization states. We need more exercise that is face-to-face. Treadmill running teaches mobilization, badly. (I disagree.)

Bessel van der Kolk: Med school kills empathy in trainees. (Cited research)

Francine: EMDR and Dreams. Same brain process. (Robert Stickgold) Customize sets by attuning to clients needs. Goal is to take the REM state further than it goes in sleep. Images change in each set as new positive information comes in. . . Early therapeutic intervention for early humiliation would help people immensely. We need to teach parents and educators the impact of humiliation. (Jim Knipe and I wrote chapters about using EMDR on these issues to clear depressionin Solutions II.) The window of tolerance closes because of these childhood negative experiences.

Bessel: EMDR is hypnagogic, like sleep with very rapid associative processing. . . But people need to move, to play. EMDR has no movement. People need to complete the movement. But, research shows that EMDR clears 83% of the trauma. Movement-based treatment doesn't have the same success.

Martha Stark: Did EMDR with an insomniac client over a suicide attempt. In processing she remembered that at the last minute she saved herself, and the meaning about self changed for the better. Her insomnia disappeared and she started to remember her dreams.

Skipping some -- too tired.

Dan: Mindfulness creates secure attachment to the self. It's a way of being. Mindful awareness is brain hygiene, not a religion, should teach it in schools, to doctors, and create empathetic practitioners.

More in the next few days. Steve Porges read this blog and told the other presenters about it. I got some interesting attention today.

 

 

UCLA Trauma Conference 3/7/09 Day2: Porges

Stephen Porges, Demystifying the Mechanisms of Trauma: Maladaptive Consequences of Adapative Bio-Behavioral Reactions to Life Threat 

Stephen Porges knows how to connect. I could listen to him talk all day.  I explain his Poly-vagal theory to every trauma client and every consultee. Today, after he answered a difficult question, in a most kind way, my friend Barbara said, "Now, I'm in love with him."

Here's a post from exactly 2 years ago on Porges and his work. It might help to read it first. http://traumatherapy.typepad.com/trauma_attachment_therapy/2007/03/ucla_attachment.html

Here is the quick and dirty explanation of the Polyvagal (PV) Theory: "Neuroception of danger and safety or life threat trigger 3 neurological circuits." They developed at different evolutionary times. The newest one (Green Traffic light) occurs when we understand that we are in a safe environment. When it's on, we have the capacity to be socially engaged, to think, to hear and understand other humans, eat and to play. The second oldest (Yellow light) is engaged when we perceive danger, but we don't think it will kill us. In this mobilized state, we attend only to cues about danger and safety. We can't connect well, we can't even really hear people. We are scanning for danger and predators. The third state and evolutionarily oldest state (Red light) is immobilization in the face of life threat. We shut down completely, can't connect, feign death, and can't/don't have protective reflexes. (Can you say "dissociation?) 

Today, Porges said that "our nervous system reacts differently to the same stimulus, depending on our psychological state." The Polyvagal theory is about our biological quest for safety. He bemoans that these states aren't better recognized and then explained to clients, medical patients and all trauma survivors. Here are some but not all of the gems from his presentation:

People are different. The same stimuli can create different states in different people depending on a host of factors: genetics, attachment, and history. He talked about voodoo death--when people are literally scared to death, they aren't hyper-mobilized, but immobilized. Their hearts and respiration slow down to nothing and they just die, when cursed or after having broken an "unbreakable rule" and they have no ability to escape, no options, or are being held tightly.

"Immobilization with fear is a missing concept in psychology and psychiatry and medicine."

Vagal Paradox: Slow heart rate is mediated by the vagus. Sometimes too much (see voodoo death.) Heart rate variability (a good thing) is primarily mediated by the vagus and is a protective factor. "If the face is flat, the heart rate is flat. If the face is lit up, there's heart rate variability."

Singing, listening and chanting: when we feel safe and tuned into the tones we hear best, the human voice, we can't hear the low tones, the predator frequency. . . New brain circuits damp or control the old ones. We lose the adaptive urge in immobilization, pain threshholds are raised, we conserve metabolic resources and are prepared to die. (Imagine chronically abused people who live in this state, over and over.)

Yoga students with abuse history get a higherheart rate after mild exercise. No abuse hx, makes for a lower heart rate. Abuse supressed vagal regulation and lowered the threshold to be defensively reactive. Tell clients: "Your threshold to react changes and this is what happens."

Since "social behavior is a regulator of our physiology", use your self to help your clients regulate. Make the office safe. Make it quiet. Muffle the low traffic noises. Have face to face interactions that are safe.

"Face to face is play with reciprocity." What could be aggression without face to face contact becomes play. Puppies and kitties look at each other when playing. So do kids. So do people in consensual sex. People can be in a mobilized state, without fear, in play. They can be in an immobilized state without fear in play or rest. (Baby in mom's arms).

The nervous system continuously evaluates risk. Reactions to life threat is not easily reversed. These reactions can bring up rage if a client misreads the clues. (Think borderline or DID clients.)

Auditory pathways (music, voice, and song) invites proximity. It's the first route in to change the nervous system. Music therapy in the frequency of the human voice and social engagement help traumatized clients regulate themselves. So does Prana Yana breathing, with slow exhalation.

(Stephen, if you care to correct, edit, or add anything, I'd be honored. Links to articles or websites would be great, too.)

More tomorrow.

 

UCLA 2009 Trauma Conference Day 1, van der Kolk & Shapiro

Day 1: Bessel van der Kolk is lovely. He's humble, he's funny, and he is the premiere researcher on the neurobiology and/or efficacy of trauma treatments in the world. And cute and brilliant, of course.

Here are nearly random gems from 3 hours of notes:

With trauma, there are no stories, only sensory experience: images, affect, and tactile, olfactory, and auditory experience. Bleure (1920): People can't hold the memory of the trauma--can't tell the story. The solution is taking action against the person who hurt you or telling the story over and over. (Prolonged exposure). Bessel says "No. Telling the story is not enough!" Later: "When people are into their trauma, they cannot talk about it. They become dumbfounded." Because Broca's area in the brain shuts down. "When the left brain shuts down, we must shift to right brain processing."

"Our job as trauma therapists is to bring the frontal lobe on line." (He said that GW Bush showed himself to be a "limbic" president with his "Let's kill them all" speech after 9/11. "A dangerous limbic-run man.")

The body relives and reinstates the initial trauma state, even the stress hormones.

Exposure therapy "blasts people's brains with the trauma and drives them crazy. That's supposed to be good for people?" And said the CBT literature is full of the treatment triggering suicide attempts, substance abuse, and worse symptoms.

He talked about his amazing EMDR vs Prozac study. 80% of adult onset trauma completely cleared PTSD & Depression after 8 weeks of tx. Prozac people felt better until they stopped taking the drugs. EMDR folks got better and better for months after tx and stayed that way. Cool study and he had trouble getting published despite 3X the success of CBT. Politics.) http://www.emdr.dk/artikler/07_kolk.pdf

Bessel and many of the top child psychiatrists and psychologists are lobbying for an new DSM 5 diagnosis: Developmental Trauma Disorder:  http://www.traumacenter.org/products/pdf_files/Preprint_Dev_Trauma_Disorder.pdf 

It's much needed. I have so many clients who need this diagnosis! (gai

Developmental Trauma Disorder

A. Exposure

1. Multiple or chronic exposure to one or more forms of developmentally adverse

interpersonal trauma (abandonment, betrayal, physical assaults, sexual assaults, threats to

bodily integrity, coercive practices, emotional abuse, witnessing violence and death).

2. Subjective Experience (rage, betrayal, fear, resignation, defeat, shame).

B. Triggered pattern of repeated dysregulation in response to trauma cues

Dysregulation (high or low) in presence of cues. Changes persist and do not return to

baseline; not reduced in intensity by conscious awareness.

•Affective

•Somatic (physiological, motoric, medical)

•Behavioral (e.g. re-enactment, cutting)

•Cognitive (thinking that it is happening again, confusion, dissociation,

depersonalization).

•Relational (clinging, oppositional, distrustful, compliant).

• Self-attribution (self-hate and blame).

C. Persistently Altered Attributions and Expectancies

•Negative self-attribution

•Distrust protective caretaker

•Loss of expectancy of protection by others

•Loss of trust in social agencies to protect

•Lack of recourse to social justice/retribution

•Inevitability of future victimization

15

D. Functional Impairment

•Educational

•Family

•Peer

•Legal

•Vocational

---------------------------------------------------------------------------------

Bessel talked about vagal nerves (see Porges--later) and said that you can change the way you feel by changing the state of your body (thus our affinity for alcohol, drugs, and sugar.) Drugs, tai chi, karate, yoga, meditation and exercise manipulate the vagus nerves. Do yoga, etc. to affect the state of your body.

"Emotional Regulation is the most important issue in psychotherapy."

Cloitre 2007: '"If treatment relationship lead to affect regulation, the patient gets better."

In a study with chronically traumatized clients: 8 weeks of Yoga class beet 8 weeks of CBT with 28 hours of homework.

In PTSD, the thalamus goes offline. The thalamus orients you to where and when you are in a autobiographical context. Much of the brain goes offline when immobilized and there are no available receptors for attachment or problem-solving.

"Thinking has no avenues of access to the emotional brain. (You can't talk yourself into loving Dick Cheney, whatever the incentive.) . . . Traumatized people don't have a sense of being deeply present because the anterior singulate is off-line. . . Keep clients oriented to 'now' in themselves: 'How does your body experience that feeling?' . . .Help clients process what's inside of their here and now consciousness."

Trauma survivors see the trauma or the "bad thing" as outside of themselves, not as their own response to something that happened. "Bring attention to the body, to internal landscape: What's the sensation? Where do you feel it? What happens if you try something? Take a deep breath, right now. Do TFT tapping on the collarbone spot. . . Notice what comes up and remember how it will come to an end. How can we give the miserable, alone, frightened part of you some company? . . . Tell her you know how terribly lonely it was."

"You can't do trauma work without people deeply observing their own level of consciousness and then deeply connecting on the outside with you."

"The emotional brain runs the show." Feelings should be guides rather than a source of terror.

Bessel spoke of the importance of EMDR and Somatic therapies in working with trauma and showed a moving video of a formerly DID client who was "organized" by neurofeedback. "EMDR is the opening for understanding trauma. You can't do trauma treatment without EMDR or something else that knits the sensory experiences together."

Part II: Francine Shapiro, the brilliant maven of EMDR, looking well and energetic.

Much of what Francine said was material you can find at emdria.com or the EMDR Institute website: The Adaptive Information Processing model and the steps of EMDR treatment. Today I heard her say some different things: The importance of targeting the "small t" traumas. Much of the trauma that can severely impact a life does not fit the criteria for PTSD. She gave many examples of people who developmentally stopped at some distressing, non-life threatening event, until an EMDR session, years later, released them. (It happens. I've seen it many times.)

"Neurophysiology does not equal destiny." There is neuroplasticity in adult brains. Shrunken hippocampi grow again, after the trauma is resolved. Don't give up! A study: 8 sessions of EMDR, 20% increase in hippocampal growth.

Beliefs are a manifestation of trauma. CBT/Exposure = extinction. EMDR = reconsolidation. In prolonged exposure, the memory of the rape doesn't change, but get a competing new memory. But the clients relapse when around a trigger, because the old memory is still there. EMDR reconsolidates memory changes, so the initial triggers won't work.

"Processing dysfunctional and positive memories are the focus of EMDR treatment. Process the negative and integrate the positive. Every positive attunment or modeling by the therapist links the positive information in. . . You need to have positive adaptive memory networks for tx to work."

Process: Family of origin issues, memories that are encoded; Defenses, i.d. the earliest childhood event that caused that pathway to develop; cognition, process the memories that created the cognition--the cause is the encoded earlier event; Somatic/Emotive, "When's the 1st time you felt that way?"; Developmental, "What events derailed attachment?"

(I'm getting too tired to give you all the rest, so I'll hit a few highlights:)

ADHD: some of it is PTSD, some real ADHD.

Body dysmorphia: usually from childhood humiliation, sometimes just one comment. Clears with a few sessions. (There's a chapter in Solutions II about this.)

Small t traumas cause more pathologies than PTSD.

Axis II (personality dx's) are a constellation of attributes, each rooted in earlier events.

Borderline Personality Dx: Cool stuff-- too much to write. But Axis II is moveable and cureable if you go after the childhood antecedents. (I know because I have ex-borderline clients and ex-narcissists.)

If you are treating kids, treat the parents attachment issues and the kids get better. Include in this: targeting the non-bonding event with the child, then make a story about an easy pregnancy, each trimester, an easy delivery, the first breath, first hours, coming home -- better than real life, and install it.

In family systems, you can treat the family of origin issues in every one, all the behavior. Teach skills after the trauma is gone, when it can sink in.

Depression. Yes, See the first 5 chapters in Solutions II.

Phantom Limb Pain. Yes. See the PLP chapter in Solutions I--Wilson

Grief: "There is more positive recall of the loved one after EMDR (for traumatic grief) than after CBT. (Sprang, 2001)

EMDR increases resilency and engenders a new sense of self.

 

 

EMDR Solutions II, for Depression, Eating Disorders, Performance and More

Yesterday I held my new book in my hands. It's hard for me to make meaning of 14 months of work being encapsulated in a 1 1/2 pound book. As I paged through it, I recalled the process of writing; my appreciation of the content of other people's chapters; editing squabbles; waiting, waiting, waiting for late chapters or late edits to show up in my emails; and my immense relief at each ending. The first ending was when my chapters were complete (EMDR with Depression, with OCPD, with Medical Trauma, with Multiple Chemical Sensitivities.) The next ending was when all the chapters were finally in. The next ending was after the first and second edits, by me then by my writer-mother, when I emailed all the chapters in. And last ending was after the re-editing by writers and then again by me.

One of the perks of editing a compilation is that I get to learn the material, really well. I never read a chapter 4 times before I did these books. There are 7 chapters about eating disorders. I am suddenly well-versed. I knew what to do, and successfully did it, when a fledgling anorexic client walked in the door. I know much more about working with early childhood trauma, performance issues, and targeting intrusive images. And I knew next to nothing about Positive Psychology and Coaching. Now I have a clue!

This book is about 200 pages longer than the last, and has units of related material: 5 chapters on depression, 7 on different aspects of eating disorders from affect tolerance to desensitizing desire, 5 on complex trauma, 3 chapters on Medically Based Trauma, and stand-alone chapters on performance enhancement, coaching, positive psychology, sex offenders, and religion/spiritually attuned clients. It's a better book than Solutions I. More depth, more heft. (Though it's not "bigger", because the pages are thinner.) It's even prettier than #1.

Tomorrow, I'm off to Los Angeles for the UCLA-sponsored Trauma Conference. I want to hear about the cutting edge affect theory heralded in the materials, so that I might jump start my next book: Trauma Treatments Sourcebook. I plan to blog about what I learn at the conference. Stay tuned.

If you're in Seattle mid-April, come to the book signing for book # 2. If you're in Seattle in spring of 2011, come to the signing for #3, if all goes well. I'll let you know the dates, as I know them.

The book comes out at the end of March. It's sold over 800 advance copies. I'm amazed.

Trauma Therapists Need Consultation

I just heard another horror story of humiliation in a consult group from a new consultee. It makes me almost as furious as finding out a therapist has been sexually exploiting a client. Another breach of professional ethics by someone who should know better! Grrr!

So what is consultation supposed to do? In my less than humble opinion a good consultant shoud support clinicians to do this hard work by

• Letting them know when they do something right

• Expanding, when necessary, their view of a particular case, or clinical issue

• Teaching good clinical technique

• Sometimes, exploring their emotional response to a case, from grief to celebration

• Acknowledging when the work is hard or heart-breaking

• Noticing when the emotions they have are the projected emotions of a client: "So you're feeling helplessly stuck with this case. The therapy seems to be moving along. Is that your feeling about it or your client's feeling? The client's. So whenever you feel a different feeling with this person, than the one you came in with, you might wonder if it's the client's feeling, and then figure out your clinical response to it.

• Gently, letting consultees know when they're barking up the wrong tree.

• Supporting innovation and creativity.

• If it's a group or consultation based in a particular technique, point out when that technique is not the "drug of choice" for a particular client and suggest a technique that will work better.

• Support the consultees' confidence as they continue to grow as clinicians.

• Consult to them at or only slightly above the level of skill and knowledge that they have. This will vary from person to person. I try to use language that fits what the person already knows. If, in my EMDR consultation groups, a clinician is object relations trained, I might talk about negative and positive cognitions in term to deal with introjected material. If a consultee has a movement background, I might ask what she sees in the body stance of the person, and tie that into the EMDR lens: the AIP.

• On rare occasion, when a clinican doesn't have the stability or affect tolerance to do good therapy, gently and privately suggest a good therapist for him or her.

• Never humiliate, belittle, embarrass, single out, or triangulate a consultee, especially in a group setting. We're here to cure PTSD, not cause it.

• Make your consultation, whether individual or group, a safe place to be. We're therapists. Technique is necessary. Relationship is the context in which it works.

Trauma Therapists Need Consultation

I just heard another horror story of humiliation in a consult group from a new consultee. It makes me almost as furious as finding out a therapist has been sexually exploiting a client. Another breach of professional ethics by someone who should know better! Grrr!

So what is consultation supposed to do? In my less than humble opinion a good consultant shoud support clinicians to do this hard work by

• Letting them know when they do something right

• Expanding, when necessary, their view of a particular case, or clinical issue

• Teaching good clinical technique

• Sometimes, exploring their emotional response to a case, from grief to celebration

• Acknowledging when the work is hard or heart-breaking

• Noticing when the emotions they have are the projected emotions of a client: "So you're feeling helplessly stuck with this case. The therapy seems to be moving along. Is that your feeling about it or your client's feeling? The client's. So whenever you feel a different feeling with this person, than the one you came in with, you might wonder if it's the client's feeling, and then figure out your clinical response to it.

• Gently, letting consultees know when they're barking up the wrong tree.

• Supporting innovation and creativity.

• If it's a group or consultation based in a particular technique, point out when that technique is not the "drug of choice" for a particular client and suggest a technique that will work better.

• Support the consultees' confidence as they continue to grow as clinicians.

• Consult to them at or only slightly above the level of skill and knowledge that they have. This will vary from person to person. I try to use language that fits what the person already knows. If, in my EMDR consultation groups, a clinician is object relations trained, I might talk about negative and positive cognitions in term to deal with introjected material. If a consultee has a movement background, I might ask what she sees in the body stance of the person, and tie that into the EMDR lens: the AIP.

• On rare occasion, when a clinican doesn't have the stability or affect tolerance to do good therapy, gently and privately suggest a good therapist for him or her.

• Never humiliate, belittle, embarrass, single out, or triangulate a consultee, especially in a group setting. We're here to cure PTSD, not cause it.

• Make your consultation, whether individual or group, a safe place to be. We're therapists. Technique is necessary. Relationship is the context in which it works.

"The Post-Traumatic Stress Disorder Sourcebook"

I'm reading piles of books in preparation for writing a trauma therapy survey book. My friend and colleague, Barbara Hinsz lent me Glenn Schiraldi's The Post-Traumatic Stress Disorder Sourcebook. (McGraw-Hill, 2000) It's a great self-help book, one of the best I've seen. Schiraldi's a good writer. I never wanted to fix his sentences. He's simple without being simplistic. He gives a great description of dissociation. He talks clearly and cleanly about therapy. (Giving CBT, EMDR, Counting, and TFT good "marks", describes many other self-help and therapeutic techniques, and gives the same warnings I do about prolonged exposure.)

If you have a client who wants more information and some good self-help advice as an adjunct to therapy, suggest this good and wise book. And if you have suffered a trauma, and are still feeling the after-effects, read this book. I just bought one for myself.

"Marxist Reflections on a Decadent Capitalist ‘Battle’: the CBT/EMDR War"

I'm sick at home today and was surfing EMDR articles. Here's a hilarious "Marxist" polemic about the war between Cognitive Behavior Therapy and EMDR. It's from a British psychotherapist, whose name is written in Russian, so I can't tell you who it is. If you can read the name, please post a comment for us.

http://www.emdr-practitioner.net/practitioner_articles/xxxx_10_2006.html

The Emotional Stress of Unemployment

Good NPR story of a woman who was doing fine, losing it when she lost her job.

http://www.npr.org/templates/story/story.php?storyId=100600029

Waltzing With Bashir

Ari Folman has made a beautiful and devastating movie about trauma, dissociation, and war. As a young Israeli soldier, he was in the 1982 Lebanon war. When a friend came to him with troubling memories of that war, Folman realized that he had no memories about being in Lebanon. A therapist friend told him to ask fellow veterans about what happened and Folman interviewed people until his own memories came back. The movie is animated. It flips between "talking head" interviews with middle-aged men at home, and their younger selves in Lebanon. The animation is amazing; the music, perfect; the characterization of the various soldiers/veterans makes them totally human.

You see the trauma and the men's attempts to cope with it. One man,was considered a genius as a teen. As an adult  he hides on his Dutch farm, constantly stoned.  Some seem untouched. Others still devastated.

As the movie unwinds, you see the event begin to come together--The assassination of Bashir, the Lebanese Christian Falangist leader, led his followers to slaughter men, women, and children in a Palestinian refugee camp. The Israelis, their allies, were supporting the Falangists to "find the terrorists". By the time the Israelis understood what was going on, and the word finally got to the Israeli leadership (slowed down by idiocy and disbelief), it was too late. The last few minutes of the movie are film footage of bodies and wailing women in the camps. There is no other resolution. Nothing to make us feel good.

The movie brilliantly portrays what trauma looks like. Its director also directed the original Israeli In Treatment , which portrays among other things, the therapy of a soldier who inadvertantly bombed an orphanage. I wonder if he was compelled to do In Treatment, before he remembered what he forgot about his own war experience. Here's a link to some "stills" from the movie, and an interview with Folman.  http://lukeford.net/blog/?p=4343 My favorite lines in the interview are, "Having made WALTZ WITH BASHIR from the point of view of a common soldier, I’ve come to one conclusion: war is so useless that it‘s unbelievable. It’s nothing like you’ve seen in American movies. No glam, no glory. Just very young men going nowhere, shooting at no one they know, getting shot by no one they know, then going home and trying to forget. Sometimes they can. Most of the time they cannot."

Evidently the movie brings two distinct responses from some Israelis: "Folman should be shot as a traitor for bringing up the incident."  Or "It's good, he's finally showing the world that it wasn't our fault." My response and the response of the two Israelis with whom I watched the film, was devastation and hopelessness. In the light of our despair over the recent attack on Gaza, we were stunned. We had to walk in the cold wind, swing on swings, and watch children play in order to bring ourselves back to here and now in our safe Seattle neighborhood. Today, I'm back to thinking that the little we do as trauma therapists makes a differences. As Hillel said, "If you save one person, you save the world." I need to keep this always in mind, or I get paralyzed by the trauma we humans create.

Internet Dating: coaching and therapy

Near the end of many therapies, when the trauma has been cleared, the distressed ego states have been integrated, and the clients are making concrete changes in their lives, many single clients think about finding a mate. They turn to online dating, which brings up piles of therapeutic issues: "Am I lovable, attaractive enough, capable of finding someone who will be good for me, etc." Here is my best dating advice to them:

• Come as yourself. You are looking for someone who wants to live with you, not some made-up projection of who you think you ought to be.
• Think of yourself as an employer, looking for the right employee, for the job of being your mate.

• Your prospective date is an employer, too, looking for the right employee.

• Go ahead and "clean up" before the date, but come as you are. That's who you're selling, not a Barbie doll or G.I. Joe action figure.

• You are not the employee that everyone is looking for. Some people have a specific employee with a specific profile in mind. If you don't fit that profile, you're out. It's not personal.

• Meet as many people, that seem to fit what you're looking for, as you can. (I tell them that I went out with 120 people over 3 years before I met my husband through a magazine ad, 17 years ago. 4 or 5  of them fit my employee criteria: intelligent, progressive, attractive to me, moral, communicative, funny, financially o.k., not addicted, local, etc. But I didn't fit their criteria. It only took one for mutual employment to occur.

• Know your criteria. If you keep dating "the same disasterous person", figure out that profile (and, often, which parent that is) and avoid that person. For me it was anorexic guys with personality disorders. They're still cute to me. And I'm so glad that I've got a sane guy, who eats well, now. Be clear on the most important issues (Including that they have to really be into you) and know in advance what's negotiable. (I've got a bald guy now.)

• Know that you don't have to date the wrong person in order to spare their feelings.

• And know that they don't have to date you.

• You may grieve "the ones that got away", but do your utmost not to take it personally.

• Be methodical in your approach. You're looking for a job. In a job search, you don't stop because you've been turned down. When I was hunting, I answered a minimum of two ads each week. I had a template letter that I modified to fit each ad that I answered, in order to respond. I placed an ad every three months. In internet dating, keep your profile on line. If you're not getting the responses you want, ask your friends to help you update your profile and consider other internet services.

As a therapist, I get to make therapeutic hay out of many dating issues. While clients are dating we may work on self-esteem, self-awareness, assertiveness (just say no!), worthiness, attractiveness, and differentiation. Often, I find that a client's baby ego state is going on the dates, looking for a mommy in the other person. In that case, we turn the baby around until it faces the adult self, and I say, "Look into the eyes of that child. Are you (the adult) willing to be the one that takes care of her, holds her, comforts her, and makes sure she's never alone? Are you going to be her grown-up, 24/7? Does she feel your grown-up presence? Take her on a tour of your adult life: your job, car, apartment, good friends, dog. Let her know that you're the one she needs to turn to. And let her know that you're picking the guys from now on, because she keeps picking the old inadequate mommy/daddy/same boyfriend. . . Are you ready to hug her into you, where she can feel your adult presence holding her all the time? Great. Now when you think about dating, what feels different? Remember, if she pops up and adores someone, that might be your signal to run away as fast as you can."

As you accompany clients through the dating process, keep doing therapy. Look for issues to clear. And sometimes, lending your common sense is adequate. "So which of your criteria does this guy fit?"   "How many of your 'absolute nos' does he fit?" "Is cute enough?" I've seen clients become more assertive, more differentiated, and more sure of themselves in the process of dating. And I've seen many settle down with a "good enough" partner, which brings a whole new set of issues.