Trauma,’EMDR&’Addic1ons:’’ AComplete’Course’for’Clinicians ... · 3/13/15 5...
Transcript of Trauma,’EMDR&’Addic1ons:’’ AComplete’Course’for’Clinicians ... · 3/13/15 5...
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Trauma, EMDR & Addic1ons: A Complete Course for Clinicians
(Part 2) Presented by Jamie Marich, Ph.D., LPCC-‐S, LICDC-‐CS
Owner/Operator, Mindful Ohio Independent Consultant & Instructor
EMDRIA Approved Consultant & CerGfied Therapist
Factors to Consider Before Going Farther:
• Does the client have emoGonal support resources, including, but not limited to, an AA sponsor or other recovery mentor, home group and support network, a church group, access to healthy/friends and family that the client can easily telephone?
• Is the client able to reasonably calm and/or relax herself when distressed?
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Factors to Consider Before Going Farther:
• Is there a sufficient amount of adapGve, healthy material in the client’s life? The absence of this does not necessarily rule out use of EMDR; however, more advanced preparaGons (i.e., resource development) will be needed.
Factors to Consider Before Going Farther: • Can the client maintain a dual awareness between the present and the past?
• If the client is under care for any psychiatric disorders besides PTSD or a substance use disorder, is he under psychiatric care and stable?
• Have you evaluated the nature of the living situaGon? • Have you evaluated your number of sessions available?
• Have you evaluated the quality over the quan1ty of sobriety and the nature of the addicGon/behavior?
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The Stages of Change:
An Addic1on Field Classic
• PrecontemplaGon • ContemplaGon • PreparaGon • AcGon • Maintenance • TerminaGon
SOURCE: Prochaska, Norcross, & DiClemente, 1994
Where a person is “at” in the stages of change is a useful guide for how deeply you can go with the EMDR.
The Great Debate
Could you reasonably begin EMDR with someone who is ac;vely using substances?
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The Great Debate
The perspec;ve of this instructor is that reprocessing cannot be safely commenced if a person is s;ll
engaged in the behavior; however, prepara;on work with BLS is
advantageous.
12 Steps in Sum:
� Trust God � Clean House
� Maintain House � Help Others
Think Critically: How may these activities be especially troubling for an addict with trauma issues? How can EMDR help?
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Case Study: Nancy (Marich, 2009a)
• AZer EMDR, Nancy was able to do the clean house steps for the first Gme aZer 12 years of a]empGng A.A. recovery.
• Nancy described her inability to do these steps during those 12 years:
You can’t put anything in the proper perspec;ve. And you can’t really get a heads up on what really happened because you were so trauma;zed and you had such bad experiences and like in my case, I had the trauma then I had the-‐ I call it the aMer-‐effect of my ex-‐husband-‐ pounding over and over and over and over it for like 14 years aMer that. I took so much responsibility for it. It was almost like I vic;mized myself all over again in my mind.
NANCY (con’t): “ [EMDR] dug deep into my soul or into my mind. And along with the trash came the pain, the shame, the guilt, the remorse, whatever went along with the situa;on. When I faced it, and I dealt with it, and I talked about it, and I analyzed it, and then I was able to release it and forgive myself and others for what had been done to me and what I had done to other people. And then I felt a great sense, I felt freer.”
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• 10 females ranging from age 27-‐54 (mean= 41.7; median= 46.5) • ConGnuous sobriety ranging from 1-‐6 years (mean= 3.75 years; median= 3.625 years) • 5 Caucasians, 4 African Americans, 1 Middle Eastern descent • 2 college graduates, 7 in school (6 college; 1 G.E.D. prep) • 7 parGcipants had children, 3 did not • The majority of the parGcipants idenGfied religious upbringing
as a developmental factor
Marich Disserta1on Project (2009b/2010)
Sample Ques1ons from Interview • Background Ques;ons
-‐How would you describe yourself when you were in acGve addicGon? -‐If you have made a]empts at addicGon recovery in the past, what were some roadblocks that you have encountered in staying clean/sober?
• EMDR Experience -‐What were your iniGal reacGons when your therapist suggested EMDR treatment? -‐To what extent did EMDR help you with the roadblocks to recovery that you have encountered in past a]empts at recovery? -‐What role did the EMDR therapist play in your treatment?
• EMDR and Overall Recovery -‐What other elements besides EMDR helped you to achieve your current level of recovery? -‐To what extent are you feeling confident in your recovery at this point?
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Marich (2009b): Thema1c Category 1
SAFETY Subthemes (ways that safety was fostered):
• The treatment seZng • Quelling ini;al skep;cisms about EMDR • The role of the EMDR therapist • Features of the EMDR approach
Fadalia (Study Par1cipant):
“The people that I worked with here communicated to me somehow that they believed that I could really stay clean. I never really experienced that before.”
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Quali1es of a Good EMDR/Trauma Therapist Marich (2010)
caring trustworthy intuiGve natural good common sense connected smart comfortable with trauma work consoling skilled validaGng accommodaGng gentle magical nurturing wonderful facilitaGng
Cindy & JoElle: Descrip1on of Nega1ve Experience with Their First EMDR Therapist
• rigid • scripted • detached • anxious • unclear • uncomfortable with trauma
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Marich (2009b): Thema1c Category 2
ACCESSING THE EMOTIONAL CORE
Subthemes:
• Recovery roadblocks • The role of EMDR in addressing core emo;ons • Impact on recovery
Sasha (Study Par1cipant):
“I was a chronic relapser. And I think that was because, now that I have some awareness of a lot of that, I think it was because I didn’t get to none of my core issues… AZer I got to the core and knew what to idenGfy with, that really helped me to look at me.”
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Thema1c Category 2
Some Common Recovery Roadblocks: • Inability to feel/desire not to feel anything • Inability to express any feeling but anger • Shame-‐based idenGGes/ “Black sheep” • Ability to make sense of traumas cogniGvely while unable to handle them emoGonally • External financial barriers
Fadalia:
“EMDR was the process that allowed me to untangle my thoughts, feelings, and experiences…before they were all stuck, like a ball of yarn.”
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Marich (2009b): Thema1c Category 3
LIFESTYLE CHANGE Subthemes:
• Characteris;cs of ac;ve addic;on • Perspec;ve shiM • Behavioral/aZtudinal change
Becky (Study Par1cipant):
“Before treatment I was resistant to talk about my mother’s death; I was in denial about my mother’s death for many years, despite being haunted by it. Through EMDR, I realized that her death was not the end of the world, and that I did not have to drink or use because of it. I also saw that my mother is now in a be]er place and did not choose to abandon me.”
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Thema1c Category 3
Alfred Adler viewed the life-style as an “individual’s characteristic way of overcoming or compensating for feelings of inadequacy” (VandenBos, 2007; p. 536.). Adler, who contended that the life-style originated in childhood, described life-style as the pair of glasses through which every individual saw her world (Mozak, 2000).
In Adlerian terms, EMDR was a primary factor in helping the participants acquire a new set of glasses, or at very least, get an adjustment on their prescriptions.
Marich (2009b): Thema1c Category 4
USING A COMBINATION OF FACTORS FOR SUCCESSFUL TREATMENT
Subthemes:
• The treatment program’s groups, classes, and services • 12-step recovery • Self care measures • Motivational factors
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The themaGc conclusions drawn from this study indicate that there is a place for EMDR as part of a comprehensive [addicGon] recovery program when applied properly (Marich, 2009b).
AXer Prepara1on, You Have 3 Major Op1ons:
• Take the “recovery roadblocks,” (barriers to sobriety and/or wellness) through Phases 3-‐6 for reprocessing
• Target the craving or urge using standard protocol or one of the specialty protocols (e.g., DeTUR, LOU)
• Proceed with EMDR as you normally would based on your assessment of client readiness
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My General Recommenda1on
• Proceed with the recovery roadblock or targeGng the craving/urge (depending on the client)
• See what that processing reveals and then move into more standard targeGng of past traumas using the floatback
• Remember Shapiro’s three-‐pronged protocol
Three-‐Pronged Protocol
• Past • Present • Future
With addicts or other individuals where healthy distress tolerance might be a problem, going as far back into the past as possible with a floatback is generally not opGmal. In general, it is wise to start with something that is more present-‐tense, and then let it floatback organically/naturally.
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Marich (2009b) Some Common Recovery Roadblocks: • Inability to feel/desire not to feel anything • Inability to express any feeling but anger • Shame-‐based idenGGes/ “Black sheep” • Ability to make sense of traumas cogniGvely while unable to handle them emoGonally • External financial barriers
Recovery Roadblocks: Common NCs • I cannot show my emoGons. • I cannot trust anyone. • I have to be perfect. • I am not deserving. • I am permanently damaged. • My body is hateful. • I cannot handle it. • I cannot Trust God/Higher Power. • My addicGon is my idenGty. • I cannot cope without (drugs/alcohol/food, etc.)
See handout for more examples
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I Cannot Show My Emo1ons (Marich, 2011)
• The case of Bri]a: 26-‐years of a]empts at sobriety, idenGfied “I’m not good enough” as primary cogniGon to work on.
• AZer preparaGon, Bri]a kept shupng down in processing (Phases 3-‐6).
• Despite trying interweaves and a variety of other adjustments, Marich decided to reset the target to “I cannot show my emoGons” since Bri]a did not seem comfortable with emoGon.
• Processing opened up right away with this simple adjustment.
• The three “unwri^en” rules of the alcoholic home:
ü Don’t talk ü Don’t trust ü Don’t feel
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Also consider what may stand in the way of body awareness: • Abuse issues may play a factor, in addiGon to religious or
societally shaming messages about the body • Whatever the cause, addicts and those engaged in
problemaGc compulsions have been out of touch with their bodies.
• Don’t simply expect someone with addicGon issues to be
able to process somaGcally or answer quesGons like “what’s happening in your body?” without preparaGon in body cuing, or targeGng negaGve cogniGons that may stand in the way.
EMDR Demonstra1on
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Ques1ons/Comments Needs Assessment
Popky (2005)
• Developed an EMDR protocol for targeGng addicGon cravings, urges, or triggers called the DesensiGzaGon of Triggers and Urge Reprocessing (DeTUR)
• Solid theoreGcal components of the AIP with exisGng knowledge about addicGon in the protocol; Popky’s protocol has been disseminated widely into the EMDR community despite lack of formal research validaGon
• For more info on DeTUR, see R. Shapiro (2005)
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De TUR ® Basics
• Posi;ve treatment goal: AbsGnence or controlled using is not a treatment goal, but the aZer product of a successful treatment plan (Popky, 2005)
The posiGve treatment goal is the focal point of the treatment plan. Such posiGve treatment goals should be:
stated in posi;ve terms ;me-‐related (not too distant future)
De TUR ® Basics
• Bring up the picture, along with any words, tastes, smells that go with it
• How strong is the level of urge (LOU) at present, from 0 to 10?
• Where are you feeling that urge in your body? • AMer each bilateral set, ask “what are you geZng now?”
• ConGnue unGl LOU is 0
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De TUR ® Basics • Popky advises that if the client abreacts, keep going with bilateral sGmulaGon unGl it passes
• Advises use of similar supporGve statements or tradiGonal interviews used in standard protocol
• Popky also advises that is core issues open up, follow-‐up it through to compleGon, alternaGng to the more standard protocol if necessary
Hase (2006) Addic1on Memory Protocol
• Incident: relapse (for example) • Image: being in the grocery store ready to pick up the mouthwash
• Level of Urge (LOU): 10 • NegaGve CogniGon: I am stupid. • PosiGve cogniGon: I am making healthy choices • VOC: 4 • EmoGon: shame • Body: core
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Miller (2012): Feeling State Addic1ons Protocol (FSAP)
• The Feeling-‐State AddicGon Protocol (FSAP), based on the feeling-‐state theory of behavioral and substance addicGon, proposes that just as single-‐event traumas can become fixated with negaGve feelings, intensely posiGve events can become fixated with posiGve feelings. This fixated linkage between an event and a feeling is called a feeling-‐state (FS).
Miller (2012): Feeling State Addic1ons Protocol (FSAP)
1. IdenGfy the exact behavior that has the most intense posiGve feeling. 2. IdenGfy the exact feeling that underlies that behavior. 3. A modified form of EMDR is uGlized to break the connecGon between the feeling and behavior. 4. The negaGve beliefs that underlie the compulsive fixaGon are processed.
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Dr. Marich’s Cau1on About
These Protocols From a Tradi1onal Perspec1ve
Common Presen1ng Problem: “I’m just having a hard ;me leZng go of this one…”
• Dr. Marich’s adapGon of Parnell’s modified protocol:
-‐ Think about/bring up whatever it is that you are having a hard Gme lepng
go of. -‐ NoGce where you feel that pull to hold on in your body. -‐ Is there any negaGve belief coming up with that? -‐ Any image (or sound) a]ached to that body feeling? -‐ What emoGons are coming up with that? -‐ OPTIONAL: How intense are those emoGons right now (get a SUDs level if
desired) -‐ DESENSITIZE!
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Let’s Try It!
Needs Assessment/Prac1cum
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Ques1on & Answer Case Conceptualiza1on
Let’s Revisit the Ac1vity
• Recall the brief case synopsis with addicGon or related issues:
ü An actual client (using a pseudonym) ü A composite client ü A “famous” example (presenGng for clinical a]enGon)
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Discussion: Your ReacGons and Experiences
For Con1nued Development
• What are my personal barriers with addicGon and trauma?
• How do I handle intense affect and abreacGon? • What factors may inhibit me from being effecGve with a traumaGzed addict?
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To contact today’s presenter: Jamie Marich, Ph.D., LPCC-‐S, LICDC-‐CS Mindful Ohio [email protected] www.mindfulohio.com www.jamiemarich.com www.drjamiemarich.com www.dancingmindfulness.com www.TraumaTwelve.com Phone: 330-‐881-‐2944