I-gaze workshop 02-2018 handout - Barry Littbarrylitt.com/yahoo_site_admin/assets/docs/I-gaze... ·...
Transcript of I-gaze workshop 02-2018 handout - Barry Littbarrylitt.com/yahoo_site_admin/assets/docs/I-gaze... ·...
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The I-Gaze Interweave for Attachment Repair in EMDR Therapy
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TheI–GazeInterweave
forAttachmentRepairinEMDRTherapy
Barry K. Litt, MFT EMDRIA Approved Consultant Human Dynamics Associates Concord, NH Barrylittmft.com
Today’sOutline:
Part1:TheDomainsofSelf
Part2:TheZoneofOptimalProcessing
Part3:SomaticInterweaves
Part4:TheI—GazeInterweave
TheDomainsofSelf
Implicationsfor:
Phase3(setup)
and
Phase4–5(desensitizationandinstallation)
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WorkingwithDomainsoftheSelf
Being vs. Nothingness
Merit
Safety
Litt, 2007b
DomainsoftheSelf,continued
Being vs. Nothingness
Being vs. Nothing • Self-Other Dialectic
• Attachment Trauma
• Depersonalization
Merit
Merit • Neurosis
Safety Safety • Hypervigilance
Litt, 2007b
CognitiveCorrelatestoDomainsoftheSelf
Being vs. Nothingness
Being vs. Nothingness • I don’t exist’ • I’m invisible • I don’t matter
Merit
Safety
Safety • I’m gonna die • I’m not safe • I’m trapped
Merit • I’m not good enough • I don’t measure up • I’m responsible/ • I’m helpless
Litt, 2007b
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ShockorDisbelief(a.k.a.peritraumaticdissociation)
• Sometraumasseemedtobelockedinastateofpsychologicalshock– Suddenonset– Perpetratorbehaviorunexpectedoranomalous
• Eventnotintegratedwithnarrativememory
– Doesnotprocesswell;affectblocked– ANPcannotaccepttheevent
• Typicalclientpresentation:– Iknowithappened,butIcan’tbelieveit
AssessingandTreatingShock/Disbelief*
DuringSetupPhase(Phase3):
1. Have client cover one eye
2. Ask: Give me your gut response––can you believe it?
3. Get a SUD for “Disbelief”
4. Repeat with other eye
*Adapted from Cook & Bradshaw (2002)
AssessingandTreatingShock/Disbelief*
DuringSetupPhase(Phase3):
5. Perform DAS with Lower SUD eye
6. Continue DAS until SUD = 0
• Yes, I really believe it happened
7. Repeat with other eye
8. Repeat with both eyes
9. Resume Setup anew
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KeepitSimple…
Trauma Node
Standard Protocol
Resolution
The Royal Road to Resolution
KeepitSimple…unless
Trauma Node
Resolution Shock/ Disbelief
One-Eye Interweave New Setup
Resume Standard Protocol
TheBeingDomain
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Normalvs.PathologicalAloneness
• ByMyself– Amatteroftemporarynon-membership– Astatus;notamentalconstruct– Pleasantorunpleasant
• Lonely– Bored;noonetoplaywith
• Aloneness– TraumaticStateofexistentialisolation– Acuteterrorand/orshame– Belongingtonooneornogroup
Featuresofthe“Being”Domain
• Behavior:Acting-out– (Bettertobebadthantonotbeatall)– Relationalconflictandegostateconflictmaybe“tradingup”fromnotbeing
• Cutting;substanceabuse;O-CD;etc.
• Affect: shame, anxiety, panic, fear
• Sensation: numbing, tonic immobility
• Knowledge (NC): I’m alone, invisible…
(Nihilism)
TheNaturalProgressionofEmotionalExperience
Ar
ou
sa
l
Time
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ThePathologicalProgressionofEmotionalExperience
Ar
ou
sa
l
Time
Normal Progression is Arrested • Distress Intolerance • Overwhelming Shame • Dissociation:
- Numbing - State Shift - Fugue
SensationandKnowledge
BeauBergdahlInterviewFromSerial,PodcastDecember10,2015
WithpermissionfromThisAmericanLife
WorkingThroughtheBeingDomain
• Ithink,thereforeIam -Descartes
• InoticethatIfeel,thereforeIam -(Damasio,1999)
The Importance of Sensation:
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WorkingThroughtheBeingDomain
• Dynamic Targets:
-Narcissistic partner
-Partner avoids/withdraws
-“As-if” relating
• Event Targets -Rejection
-Abandonment, separation, loss
-Associations
WorkingThroughtheBeingDomain
Cognitions:
• NC:Idon’texist;I’minvisible;I’malone;I
don’tmatter;I’mnotenough/toomuch
• PC: I am; I have myself; I exist even if…
WorkingThroughtheBeingDomain
• Somaticregulationmustbemaintained– Clientsoftenareoutsidethewindowoftolerance
– Sensoryintegritynecessaryforprocessing– EMDRaugmentedwithsomatictechniques
• Ensurethatclientsaremostlyembodiedatclosure
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WorkingThroughtheBeingDomain
• Anxietymaypresentasaphobiaofunderlyingshame
• Successfulprocessingmay“tradeup” fromnumbingorfeartoshame
• ShamereactionscanbemappedbyNathanson’s(1992)CompassofShame
Nathanson’s(1992)CompassofShame
Withdraw
Attack Other Attack Self
Avoid
Self Absorbed Paranoid
TheMalignantShameSpiral
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WorkingThroughtheBeingDomainSpecificprotocolsfordoingattachmenttherapy:
• AffectiveCircuitRestructuring(Paulsen,O’Shea,Lanius,2014)
• Attachment-FocusedEMDR(Parnell,2013)• ImaginalNurturing(Steele,2007)• I–GazeProtocol(Litt,2016)
SuccessfulResolutionoftheBeingDomainEntails:
• Increaseddistresstolerancevisavisinsecureattachmentsignalsfromsignificantothers– EMDRwithTraumaFocus
– Discontinuationofacting-outbehavior• Acceptanceofexistentialaloneness
– Mourning
• Developmentoffearnedsecureattachment(startingwiththetherapist)– Trustbuilding –SelfTrust
• DevelopmentofObjectConstancy(acceptanceoftheSelfObject)– AttachmentfocusedEMDR;egostatenurturing
TheMeritDomain
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WorkingthroughtheMeritDomain
• Mourning work: loss of idealized objects
• Transformation of shame yields compassion for self and others
• Typical NCs are expressions of comparative worth defined by the family, community, culture:
‒ Avoid PCs that reify the same paradigm
‒ PCs should express existential worth:
‒ I’m okay; I am
SuccessfulResolutionoftheMeritDomain
• Resolution entails acceptance of:
- Existential worth: I am
- Shifting from an adjective to a verb
- Existential Powerlessness: I’m powerless (and that’s okay)
• Shame narratives do not gain traction: the trait becomes a state
• Increased distress tolerance = less avoidance
TheTootsiePopPhenomenon
WhenDomainsCollide:Beingvs.Merit
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Merit Domain: • Anxiety, obessions, perfectionism,
• Phobia of the Chewey Chocolatey Center
Being Domain: • Attachment Trauma • Aloneness • Depersonalization
ClinicalPresentationoftheTootsiePop
• Presentingproblemanddominantsymptomsareanxious,obsessive,and/orperfectionistic
• Mayhavestable(ifunsatisfactory)relationships• Catastrophicendpointisbeingalone• Responsepreventionstimulatesdepersonalization(BeingDomainsymptoms)
WorkingwithTootsiePops
• TheBeingDomain—nottheMeritDomain—drivestheanxiety
• Clientmustsetasidetheanxietynarrativeanddropintothefelt-sense*ofaloneness– Thismaybeapreverbalmemory
• *Itisfromthisstatethatattachmentworksproceeds
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TheSafetyDomain
Featuresofthe“Safety”Domain
• Behavior:avoidance,hypervigilance
• Affect: anxiety, panic, fear
• Sensation: autonomic hypoarousal
• Knowledge (NC): I’m gonna die, I’m not
safe…
WorkingthroughtheSafetyDomain
• Therapistandclientworktogethertomaintainsomecontroloverfight/flightresponse
• Controlled and organized activation of fight/flight motor behavior during desensitization phase
• Client attention to present condition of body while remembering threat event: temporal safety
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TemporalSafety
• Vision-TouchSynaesthesia:theRubberHandIllusion(BotvinickandCohen,1998)
• Attentiontoreal-timesensorycuesvs.rememberedoranticipatedstates
• Temporalsafetyasassociativevs.“safeplace”(dissociative)
SuccessfulResolutionoftheSafetyDomain
• Acceptanceofroleofchanceineverydaylife(vs.magicalthinking)
• Attentiontotemporalsafety– PC:I’mokayrightnow
• Resettingautonomicnervoussystemtoincreasedparasympathetictone
Part2
TheZoneofOptimalArousal
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TheZoneofOptimalArousal
StabilityandSafetyinPhase4
Involvesthemanipulationoftwocrucialvariablesforreprocessing:
1. Absorption (or, Dual Attention)
2. Autonomic Arousal
• Fight-Flight
• Freeze/Submit
• Tonic Immobility
http://www.traumahealing.com/somaticexperiencing/index.html
Normal (Non-Traumatic)Variation
Autonomic Dysregulation due to Trauma
traumahealing.com/somaticexperiencing/index.html
Dominant ANS
Social Engagement (ventral vagal) -Parasympathetic
Primitive Parasympathetic
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depersonalized
Submission Tonic Immobility
abreaction
panic presence
absorption
Zone of Optimal Arousal for Processing
Hypoaroused Hyperaroused
Hyposaroused Sympathetic
presence
absorption depersonalized abreaction
panic Submission Tonic Immobility
Techniques to Decrease Absorption • Distraction (e.g., breath cueing aloud) • Present-time Orientation • Variable Rhythm of DAS • Somatic Cueing • Olfactory Cueing • Third Person Visual Perspective
Hypoaroused Sympathetic presence
absorption depersonalized abreaction
panic
Techniques:
• Closed eyes
• Push the NC
• Node isolation techniques
• Choosing new target
Submission Tonic Immobility
Techniques for Increasing Absorption • Closing the Eyes
• Steady Rhythm of DAS
• Pushing the NC
• Silent Breath Cueing
• NC in Native Language
• First Person Perspective
• Postural Cueing
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Part3
SomaticInterweaves
SomaticInterweaves(Phases4—7)Goal:KeeptheClientsafelyembodiedfortraumaprocessing
Objectives:• Organizethemotorresponse
• Regulateautonomicactivation• Regulatebreathing• Maintainsomatosensoryawareness
AlwaysmaintainPresentTimeAwareness
SomaticInterweavesforAutonomicHyperarousal
Statesinclude:
• Panic• Rage• Hyperventilating• DesiretoAct-OutObjective:
• Organizethemotorresponsetopromoteresolution
Methods(duringphase4)
• RageDump• MarchingFeet
• FantasyAggression• Slowmotorimpulse
• Two-ArmPush– With/withoutresistance– Staticordynamicversion
• • States include: panic, rage, hyperventilating, desire to act- out aggression• Objective: organize the motor response so promote resolution• Method (during desensitization):� Rage Dump�
Marching Feet� Fantasy Aggression and slowly moving limbs� Two-Arm Pushing with/without resistance✔ Static version✔ Dynamic version
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• Statesinclude:Freeze,tonicimmobility,depersonalization,submission
• Objective:“reboot”theANS• Method(Duringdesensitization)
Somatic Interweaves for Parasympathetic Hyperarousal
• Kneading Toes • Marching Feet • Isometric Pushing
• Two-Arm Pushing o Without resistance o With resistance
• Cross-Crawl
Part4
TheI-GazeInterweave
Indications
• Triggerisrelatedtoabandonment,aloneness,
estrangement,purposelessness
• TraumabeingprocessedisintheBeing
DomainofSelfExperience(Litt,2008)
• NC’sinclude:I’malone,I’minvisible,I’mnot
enough/toomuch,etc.
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Indications,continued
• Maybeusedforshame––attachmenttrauma
perseornot
• Eye-gazeisincompatiblewithmaintaining
shamestate
Indications,continued
• Phase2considerations:
– Clientmusthavebuy-in
– Clientmusthaveconfidenceintherapist
– ClientmusthaveconfidenceinEMDR
– Clientmustbeabletotoleratecloseproximity
Contraindications
• InadequatePreparation(Phase2)
• Intoleranceforproximityoreye-contact
• Unwillingnesstoexploreattachmenttrauma
(e.g.,insistenceonexternalizing)
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MutualEyeGazeasaResource
• SocialEngagement(Porges,2009)
• Oxytocinlevelsincrease(Nagasawa,etal,2012;Kimetal,2014).
• “Mindsight,”socialcognition,andmirror
neurons(Baron-Cohen,2994;Rilling&Young,
2014)
Threatvs.Resource
• Mutualeye-gazecantriggerthreat(Steuwe,Daniels,Frewen,Densmore,Pannasch,Beblo,Reiss,&Lanius(2014))
• UseofBLS,Networkbalancing(Chamberlin,
2015),
• anddualawareness:interoceptionvs.
exteroception
SetupProcedure
1. Identifythetarget• Recent:abandonment,rejection,aloneness
• Past:childhoodneglect,abusewithabandonment;“still-face”caregiver
• Presentstate:noidentifiablememory,butthefelt-senseofaloneness
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I–GazeProtocol,continued
SetupProcedure:
2. Identifytheeyewithgreatestconnectiontothefelt-senseofaloneness
– Haveclientcovereacheyeseparatelyandreportaffect,sensation,cognition,andSUD
– ChooseeyewithgreatestSUD**Unlessitistoofaroutsidethewindowoftolerance
I–GazeProtocol,continued
SetupProcedure:
3. SitKneetoKneewiththeclient*– *orascloseasclientcantolerate
4. Clientthinksabouttarget,focusesonfelt-sense,andstaresintotherapist’sdominanteye
I–GazeProtocol,continued
SetupProcedure:
5. Doanabsorptionsetwithhorizontaleyemovements
6. Assessreactivityineachofthreezoneswithinthefieldofview
7. Choosetheeye-zoneyouwillstartworkingwith
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WorkingwithEyeZones
Step4.AssessthereactivityforeachZone,includingSUD
Zone 4 Zone 5 Zone 6
SUD = 8 7 4
I–GazeProtocol,continued
Processingprocedure(phase4):1. Taponclient’skneesalternately*
– *orhaveclientdobutterflyhugasneeded
2. Paceclient’sbreathing3. Maintainsteadygaze&thinknurturing,
complimentarythoughts
4. Relaxyourface,letyourattachmentsystemdothework
I–GazeProtocol,continued
Processingprocedure(phase4),continued5. Continueprocedurefor1–2minutes
6. Breakoffandbothbreathedeeply7. Debriefexperiencewithclient8. Compareclient’sreporttoyourown
subjectiveexperience
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I–GazeProtocol,continued
Processingprocedure(phase4),continued9. Assessprogress:ifitisgoingwell,
continue10. Iftheclientisnotprogressingaftertwo
sets,dooneormoreofthefollowinginterweaves:
– Readmyeyeinterweave– Healinglightinterweave– Eye-zonedifferentialinterweave
I–GazeProtocol,continued
TheReadMyEyeInterweave:Asyougazeintomyeye,readthemessagemyeyesendsyou– Twolongishsets,asbefore– Bepreparedthatclientmaynotgetasignal,ormaymisinterpret– Irecommendsetsof1–2minutesor
more– Doatleasttwosetsofthisandassess
I–GazeProtocol,continued
TheHealingLightInterweave:Asyougazeintomyeye,imagineyouseeahealinglightcomefrommyeyeintoyoursandgointoyourcore…
• Longishset,thenassess• Installanypositivefelt-senseandtryonaPC:Ihavemyself,I’mokay
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I–GazeProtocol,continued
TheEye-ZoneDifferentialInterweave:– Askclienttorotatehis/herheadsoasto“peer”attherapist’seyethroughdifferentzones
– Askclienttobecuriousaboutanyperceiveddifferences
– Usethosedifferencestopendulate,titrate,orinstallasappropriate
Client rotates head to move through zones
Working with Eye-Zones
Therapist Client
I–GazeProtocol,continued
Closure(Phase5–8):10. Repeatprocedurewithbotheyesopen
• Clientgazesintotherapist’sdominanteyeasbefore
11. Clientrotatesheadtopeerthrougheachofthethreeeye-zones
12. Therapistlooksintosameeye,blinks,looksintosecondeye
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I–GazeProtocol,continued
Closure(Phase5–8):ImaginalNurturingInterweave
– Haveclientimagineadultselfcomfortingchildself
– Reverseroles:childperspectivecomfortedbyadultself
– Installfelt-sense+PC“Ihavemyself”
I-GazeProtocolandthe
IntersubjectiveSpace
WhereTransferenceandCountertransferenceMerge
I–GazeProtocol:theIntersubjectiveSpace
• Thisinterventiondirectlyaccessestheinternalworkingmodel(IWM)ofattachmentforboththerapistandclient
• Clientreactionswillrevealhis/herIWM
• Transferencedistortionsmayinclude:– Projectionofcontemptorangerontherapist– Inabilitytoreadtherapist’sintention– Visualdistortions– Dissociation:blankingout;numbing
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The I-Gaze Interweave for Attachment Repair in EMDR Therapy
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I–GazeProtocol:theIntersubjectiveSpace
• Therapistmustbeabletoaccesshis/herownSecureIWM– Otherwise,fuggettabottit
• Therapistwillfeelclient’sinsecureIWM:– Therapistgetsdistracted;cannotmaintaingaze
– Therapistseesfear,shame,rageonclient’sface
– ClientmaylookmuchyoungerTrustyourinternalreaction:it’sdiagnostic!
I–GazeProtocol:theIntersubjectiveSpace
• Therapistwillalsofeelflowofsecureattachmentwithclient– Gazingfeelsmorenatural,easy
– Therapistmaysensepulseofwarmth– Clientmayappearmorecalm,confident
• Clientmayreportfeeling“solid,”grounded,calmer
• ClientmayspontaneouslyendorsePC
We’re Done! ThankYou,
AndmaytheForcebewithyou!