“Memory is not a recording of an ‘image’ or a ‘trace’ but part of the process of knowing and understanding.” —Rosenfield, 1992; p.18

There are polarizing beliefs when it comes to eye movement desensitization and reprocessing (EMDR) therapy. On one end, it is viewed as a+ cure-all treatment for mental health symptoms. On the other, critics see it as a treatment akin to modern-day snake oil.

The protocol for EMDR therapy is comprehensive and detailed. Put simply, the idea is to transform disturbing input—process and decondition it—into an adaptive resolution and a psychologically healthy integration. The model is past-focused, meaning one is going back in time to recall events as opposed to addressing current life stressors (not that the two are mutually exclusive). This includes redefining the event, finding meaning in it, and alleviating self-blame while integrating new skills (Shapiro, 2001). The modality focuses on the core cognitions or self-referential beliefs individuals associate with the disturbing events. These often fall into domains related to personal responsibility, safety, and power or control. “Trauma in each of these domains is reflected by the client’s distorted self-referencing beliefs linked to the effects of unresolved memories” (Nickerson, 2017).

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EMDR is an evidence-based therapy primarily used to treat posttraumatic stress (PTSD), but as it gains momentum in mental health circles, indications for its use are ever-expanding. The question for me is less about EMDR efficacy or benefit. The concern is the theory behind it and my general curiosity regarding its unique properties. There are aspects of the treatment that are altogether strange. Likewise, it contains components that are familiar to popular understanding of memory and a few things that tend to go overlooked or are forgotten.

Strange

EMDR was founded by Francine Shapiro in 1989. The legend is she was walking in a park and thinking about something distressing to her. She noticed that moving her eyes from tear duct and back to her periphery (i.e., side to side) lessened her distress. This was the early evolution of utilizing what is called bilateral stimulation. During the processing stage of EMDR therapy, the practitioner will use their fingers, tactile sensors, and/or auditory sounds that activate from left to right or vice versa. The theory is this process stimulates each hemisphere of the brain. The left hemisphere is primarily focused on language, linguistics, and narratives of our experience as opposed to the experiential aspect of the right hemisphere. In this manner, the person processing the traumatic memory integrates both the story and the felt experience. The bilateral stimulation is said to parallel how memory is consolidated during dream or REM (rapid eye movement) states when we sleep.

Fundamentally speaking, accelerated processing during EMDR splits the attention of the individual. During bilateral stimulation (i.e., finger movements, tones in the ear, or hand sensors), working memory is taxed because one must partially focus on the stimulation. This multitasking softens the emotional blow of recalling disturbing memories.

For those unfamiliar to the processing aspect of EMDR, practitioners are trained to sit close to the person in treatment. During this process, the therapist and person in therapy are cohabiting each other’s personal space, with one knee a couple of inches from the other’s. The direction is for the two people to be seated in an orientation “like two ships crossing in the night.” This unique approach to treatment creates an added level of intimacy and implicit vulnerability. It is strange and often overlooked when considering how the intervention benefits people in therapy. In a garden-variety individual therapy session, the two people are often sitting across the room from each other or at least several feet away.

Another oddity of EMDR is the historical context and initial hypothesis pertaining to trauma. In 1989, Shapiro questioned if trauma was essentially a disruption in the excitatory and inhibitory balance of the brain. This was two years after Prozac was introduced to the United States and a year before the Decade of the Brain. Mental health was beginning to be understood from a chemical or biological perspective. EMDR benefited from hitching the idiosyncratic trauma treatment to the biological wagon of mental health. EMDR’s individualized treatment would offer a correction to this brain imbalance akin to the overly simplistic solution for depression being a deficit of serotonin.

Familiar

Popular understanding of memory is that it is solely a brain function, with stored archives of our moments from the past organized in little synaptic shelves of neurons. This concept of memory as photographic snapshots stored in an album of existence is analogous to social and news media feeds displaying a history of ourselves across set positions on timelines. The click or swipe reveals the exact same image with no distortion. In Israel Rosenfield’s book The Strange, Familiar, and Forgotten: An Anatomy of Consciousness, he notes our false conception of memory based on Freudian ideas of the unconscious: “The problem is that we have tended to think of memories as unconscious items that one brings to consciousness, not as part of consciousness” (1992; p. 12). The false dichotomy of consciousness versus unconsciousness holds this misconception in place.

In Pixar’s animated film Inside Out, the main character’s memory process was portrayed in a similar manner. Her brain would produce marble-like spheres that rolled down a mechanical carousel to produce videos of previous experiences. The film portrays an exact reconstruction of past events as if these histories could be called upon via a brigade of emotional activity. This is not unlike the theory behind EMDR therapy. Disturbed memory channels in the limbic system are said to be clogging or inhibiting the individual from moving past the traumatic event. A subtle distinction is important to note: each time one thinks of a memory, they are essentially reconstructing or imagining what happened. This process creates tiny errors similar to the manner in which one copies a computer file. Over time, these little distortions add up and the factual elements of the memory are changed. The most salient and accurate memories are the ones we only rarely recall (like the original file before it is copied). The misconception of memory processes fits with Western culture’s ego-centric, fixed sense of self; “the conviction that memory is one thing is an illusion” (Eagleman, 2011; p.126).

The idea of having storage units or filing cabinets in the brain holding our past experiences aligns with current cultural frameworks (i.e., email, cloud technology, digital folders) and therapeutic modalities related to trauma and clogged memory channels (i.e., EMDR therapy). Rosenfield (1992) is explicit in drawing attention to this faulty neurology. When one remembers, they are referring to an event/object/person as they are represented based on one’s own subjective experience, “not mechanical reproduction” (p.42). Memory is less of a product of history or biological remnant, but a dynamic ability to integrate knowledge in a relational manner. The timestamp or notarizing of the event occurs within a conceptualization of who it is we think we are as a person.

Memory is rooted in our sense of time and part of the very structure of conscious knowledge. It is not an isolated phenomenon, but rather a manifestation of subjective states created by brain activities (Rosenfield, 1992). Therefore, failure of memory is not due to the loss of specific items “stored” somewhere in the brain, but rather a breakdown of the mechanisms of consciousness; “there are no memories without a sense of self.” As Rosenfield (1992) notes, “Without knowledge of one’s own being, one can have no recollections. How can I remember my parents, my house, if I am not sure I exist?” (p.41).

Forgotten

You need to remember EMDR therapy is an intervention that implies a Western understanding of the self or mind. It turns out the way highly educated, wealthy, democratic minds think is not representative of the entire globe. Most of us in the West do not think of ourselves as a body; we think we “have” a body. There is a notion we are the chariot drivers of our experience or, put another way, there is this little person inside our heads that has all types of likes and dislikes, proclivities, and things we retract from or avoid. This is an ego-centric perspective of the mind.

If you stop and pay attention to the present moment, one’s habitual patterns of cognition start to become clearer. The ego-dominating belief of our existence lying somewhere in the center of our skulls begins to be challenged. This is worth remembering.

By comparison, if you ask a Sri Lankan about themselves, they may describe their interpersonal relationships, family, and roles or responsibilities. This is a socio-centric version of the self with less of a demand on individuality. Watters (2010) articulates this distinction via several cultural specific examples in his book, Crazy Like Us: The Globalization of the American Psyche. He describes the 2004 Indian Ocean tsunami that killed around a quarter million people. Sri Lanka was one of the areas hit especially hard by this tragedy.

Western mental health practitioners rushed into these areas without knowledge of the culture. They did not know how to speak the language or have any awareness of local conceptualizations of trauma. This included benevolent EMDR therapists who assumed there would be an epidemic of PTSD. However, if you asked the Sri Lankans where their trauma resided, they generally did not point to their heads or speak of their minds being broken. For them, the damage was to the community and broken relationships. “Because Western conception of PTSD assumes the problem, the breakage, is primarily in the mind of the individual, it largely overlooks the most salient symptoms for a Sri Lankan, those that exist not in the psychological but in the social realm” (Watters, 2010; p.92).

The Westernized perspective is assumed to be a universal one. When one considers trauma, they must consider the time it happens and the cultural frame it occurs in. The consequence of an ignorant global construct for trauma is we remove the nuanced experience from other cultural narratives and beliefs that might give meaning to how the person suffers (Watters, 2010).

Self-Centered Awareness

David Foster Wallace (2005) hit on the margins of this notion—self-centered awareness—in his commencement address to Kenyon College titled This Is Water. He spoke about the choice of where we place our attention within conscious awareness (as opposed to relying on our “default setting” or autopilot) and how one can cultivate compassion within the banal aspects of daily life:

And the so-called real world will not discourage you from operating on your default settings, because the so-called real world of men and money and power hums merrily along in a pool of fear and anger and frustration and craving and worship of self. Our own present culture has harnessed these forces in ways that have yielded extraordinary wealth and comfort and personal freedom. The freedom to be lords of our tiny skull-sized kingdoms, alone at the center of all creation.

There is an ancient technology available to emancipate us from the constraints of these small, isolative worlds. To notice this ostensible imprisonment, all one need do is sit down in silence and observe where their mind goes. Who is producing this stimulation and is there a navigator of control? What happens when all you do is focus on the inhalation and exhalation of the breath?

Mindfulness and meditation practices will not cure individuals from the impacts of trauma or reoccurring disturbing memories. However, it is a prophylactic to inhibit self-centeredness or personalization of momentary experience (which tends to lead to the anxiety-provoking reoccurrences of mind).

When one has a thought, feeling, or sensation, it is often turned into a belief that becomes self-referential. A simple interaction with a partner or family member illuminates this silly human deficiency. If the person yawns during a conversation (the thought), this can lead to a belief (e.g., the person is bored) which is then internalized (i.e., “I am unlikable” or “unlovable.”). One falls down this self-deprecating rabbit hole all too quickly. The antidote is to just notice what is arising in terms of thoughts and beliefs before assuming a story about yourself.

If you stop and pay attention to the present moment, one’s habitual patterns of cognition start to become clearer. The ego-dominating belief of our existence lying somewhere in the center of our skulls begins to be challenged. This is worth remembering.

References:

1. Eagleman, D. (2011). Incognito: The secret lives of brains (1st American edition). New York: Pantheon Books.
2. Rosenfield, I. (1992). The strange, familiar, and forgotten: An anatomy of consciousness. New York: Knopf.
3. Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures (2nd edition). New York: Guilford Press.
4. Wallace, D.F. (2005). This is water. Transcript retrieved from https://web.ics.purdue.edu/~drkelly/DFWKenyonAddress2005.pdf
5. Watters, E. (2010). Crazy like us: The globalization of the American psyche. New York: Free Press.

Editor’s Note: This article contains description of childhood abuse, which may be triggering for some readers.

“I have an image in my mind I can’t seem to get rid of,” I tell Dr. Erickson. “A snapshot of a memory that’s always there, and I can’t stop looking at it.”

His office is dimly lit. On the wall facing me are two pictures of shamans, medicine men who heal spiritually. I had thought a psychiatrist might decorate with pictures from the masters—Van Gogh, Monet, or maybe a classical artist like Michelangelo. Below the shamans, on an end table, is a Kokopelli statue set in a dish of smooth stones. Next to that are two huge bookcases filled with copies of publications from the American Psychiatric Association. At least he seems well-read.

“Are you sure it’s a memory?” He sits near the opposite wall, filing my evaluation form into a folder. Today he’s wearing a shirt and tie. If it weren’t for his long hair and ponytail he would seem every bit a doctor.

“Yes. It’s something the attorneys brought up during the deposition. Something I haven’t thought about in a long time.”

He stares at me and says nothing. I realize he isn’t going to prod. It seems a strange way to communicate, not asking questions.

[fat_widget_right]“When I was nine I told kids at school that I’d seen my father’s penis,” I tell him, “that I’d touched it. Only I didn’t know to call it that. They stared at me in shock. That’s when I realized there was something wrong with what I was doing. You only know what you’re told when you’re a child. I didn’t know that other kids weren’t touching their fathers that way.” I pause. “They stopped playing with me after that.”

He’s quiet for a moment. “That’s the image in your mind?”

“Yes, swinging on the playground, laughing. I remember the looks on their faces when I admitted what I was doing. It was all so … innocent.”

“How does that make you feel?”

How does it make me feel? The memory is so old, almost thirty years have gone by, but it still seems like yesterday. It’s the kind of memory I store in one of those chests at the bottom of my mind, but now I can’t seem to put it back.

“Ashamed, sad, like I’ve done something wrong.”

“Do you feel that in your body?”

Another strange question. The memory is in my head. My emotions are in my head, glued to that image of swinging happily, chattering with my friends and having no idea of the impact of my words. My emotions are not imprinted in my body. But I think about the question anyway because I have so much anxiety these days, a tightness in my stomach that feels like a descending roller coaster. Even my nightly dose of Seroquel isn’t alleviating it.

“In my stomach,” I say.

“Images come forward in your mind to help you get what you want. Your subconscious wants to heal. This is its way of communicating that to you.”

“There’s something for me to learn from this memory?”

[EMDR] is very effective for trauma and posttraumatic stress. Once you process the memory, the picture goes away, along with the emotions associated with it.

He nods. “There’s something called EMDR—eye movement desensitization and reprocessing. It’s a therapy like hypnosis that can help speed the processing of memories. It’s very effective for trauma and posttraumatic stress. Once you process the memory, the picture goes away, along with the emotions associated with it.”

I’d like to get rid of the snapshot memory, and the sadness and shame it brings with it. It was different before; it was a private memory I could easily tuck away. I could convince myself it was a single incident barely worth my energy to consider. But I had admitted it during the deposition; I had exposed my shame to a team of attorneys who simply stared at me, stoic and apathetic. I had mirrored their apathy, determined not to allow them to see my pain. I can still see their unimpressed expressions.

“How do I do that?” I ask Dr. Erickson.

“I move my hand in front of you and you follow it with your eyes as you think about the memory. Emotions will come to the surface. As you process the emotions, they will be released. The memory will lose its emotional charge.”

“Will the image go away then?”

“It should.”

Is that what the memory wants—to be felt? Have I tucked away so much of my life that it stubbornly refuses to be hidden any longer? Or is this just a byproduct of the deposition, the aftermath of stress?

What I know is that the memory bothers me. I don’t like looking at those faces of my schoolmates staring in shock, and the memory of realizing I did something wrong. I don’t like being made to feel bad when the onus should be on someone else. Maybe that’s been the problem; the guilt belongs to someone else and not me.

“Okay,” I say.

“Okay what?”

“Okay, I want to try that. I want the image to go away.”

He moves our chairs closer together, so his left arm will be next to my left arm. We’re sitting side by side, but facing in opposite directions. He lets me sit close to the door so I don’t feel boxed in. “An escape route,” he says. Then he stands back from the chairs like an artist appreciating his work.

I know his deliberate manner is meant to make me feel more comfortable, but his ceremonial style has the opposite effect. I hesitate and glance at the door. Am I going to need an escape route? Do his patients routinely flee the room and he’s learned to anticipate it? Or is this merely a psychological strategy?

I take my seat, knowing that I would rather feel part of the scene than an observer.

Nothing will happen with me standing in place, and if it’s all been set up by design then I’m failing and the image will remain. Unwilling to leave and uncertain of how to move forward, I take my seat, knowing that I would rather feel part of the scene than an observer.

He gives me a moment before taking the seat next to mine. We’re too close for my comfort. I have pretty strict boundaries; I’ve never been able to allow people to get very close to me physically. It always feels like they’re suffocating me with their proximity, as if they’ve wrapped their arms around me in a crushing embrace.

I can see the ring he wears and the tiny hairs on his arms, and it makes my body tense. He’s sitting only a few inches from me; I can feel his gaze studying me, and I become self-conscious and begin to fidget in the chair.

“Think about the image,” he instructs. “Think about being on the playground with your friends. Hear their laughter. Think about how you feel as you talk to them. You feel ashamed, sad.”

I hate this already. What kind of therapy begins like this?

He moves his left hand horizontally in front of me. I follow it with my eyes, but I don’t see his hand.

The playground is noisy. I’m swinging with my friends. It’s a Catholic school, and we’re all in uniforms: replicas of one another.

“I’ve never seen a boy’s wiener before,” Kathy says. Her voice is filled with laughter.

“I’ve seen my father’s,” I say. “It looks like a bratwurst.”

“You have not!”

“Yes. I touched it.”

“That’s right,” Dr. Erickson says in a soothing voice. He’s reading the emotions that play across my face. “Stay with it. Let the emotions build and then let them go.”

I don’t know how to let go. I don’t know what I’m supposed to learn from this. It’s all old news, pain long past. It doesn’t belong with me. I’m an adult now, a grown woman who’s made her own way in the world and crafted her own successes. I’m a million years from that little girl on the playground, but the pain is so fresh.

The transformation is rapid. The expressions on the girls’ faces morph from playful amusement to confusion, settling on prudence. They’re judging me. They know something I don’t know. For the first time in my memory, I feel like an outsider, a pariah.

Dr. Erickson stops EMDR. I can feel his eyes on me, but I don’t look at him. I stare, without seeing, at the carpet.

“I have a question,” he says gently. “Whose shame is it?” He moves his hand in front of me, and the image switches.

I’m touching one of my sisters, kissing her on the neck. On Wednesday nights we played a game my father made up, where we had to select small pieces of paper from a hat. On each piece of paper was written something we were supposed to do: kiss a butt, lick a breast, touch a crotch. Each of us would then choose one of our siblings and go into a room with them.

“Where are you?” Dr. Erickson asks. He’s stopped his hand movement and is studying me.

“With one of my sisters.”

“On the playground?”

“No.” Pause. “Every Wednesday my mother would go away and my father would have us sit in a circle, naked. He made up this game.” When I finished explaining the bizarre game, I said, “I’m with one of my sisters in a room … kissing her.”

“Go with that,” he instructs, and begins EMDR again.

It’s all giggles and little-girl fun. It doesn’t feel sexual, just playful. We’re both naked because that’s the way our father wanted it.

I don’t like touch. It’s a mantra I say to myself and it has defined my life. I don’t have relationships and I don’t let people near. But some part of my brain is wondering why I’m not afraid with my sister, why I don’t feel apprehension. I say as much to Dr. Erickson.

“You’re judging her as an adult with rights and wrongs. She’s feeling the comfort of her sister.”

“I liked when we were touching.” It’s the only time I can recall liking touch, when caressing was comforting and nurturing. What happened to that feeling? Darkness falls on me as tears well in my eyes. An enormous sadness overwhelms me.

“I like touching my sister, but I don’t like touching other people. Men. What kind of a person does that make me?”

“Human.”

What I hear is “different.”

The memories fade, but they don’t disappear.

I like the softness of my sister’s skin and the sense of freedom, and I like the closeness as if nothing were going to separate us. Sitting in a psychiatrist’s office, trying to come to terms with my life, liking to touch my sister seems wrong.

I’ve never had a sexual relationship with anyone, male or female. I stopped dating a decade ago; I long since gave up trying to let someone get close. And yet there I was at the tender age of nine, exploring my sister’s body. Was that what was wrong with me?

“I want you to think about the healing white light,” Dr. Erickson says softly. “It’s coming from high above and surrounding you. A brilliant white light taking away all the pain.”

The light bathes me with a warm glow. It calms my breathing, eases my tension and, like a drug, dulls the pain the memory created.

“Let those images go. You don’t need them anymore.”

The memories fade, but they don’t disappear. I like the light surrounding me. It takes me far away from my feelings of guilt and shame.

Laureen Peltier is the author of Hungry For Touch: A Journey from Fear to Desire. She focuses on educating others on the possibility of making a full recovery from PTSD, as well as the benefits of healing past trauma. A passionate speaker for RAINN and other organizations, Laureen is sought-after for medical and nursing schools, and has participated in several online and DVD documentaries focusing on PTSD recovery.

Life can be stressful for anyone, but for people dealing with the negative effects of trauma on top of everyday life, elevated stress levels can be much more common. One course of treatment for experiencing a more positive and peaceful life after trauma is eye movement desensitization and reprocessing (EMDR), a methodology originated by Francine Shapiro. It pairs specific protocols with bilateral stimulation—back-and-forth eye movements, alternating tones delivered through headphones, and/or alternating tactile stimulation such as vibrations delivered through hand-held pulsers. Part of the eight-phase EMDR protocol includes teaching the person in therapy a relaxation technique to recall when needed.

One of the most common relaxation techniques for EMDR is known as “safe place,” also referred to as “calm place.” This technique is part of the second phase of EMDR known as “preparation.” Prior to this phase, the person’s history is taken, assessments are performed to determine if EMDR is appropriate, and a treatment plan is prepared. This matters because before a counselor proceeds with EMDR, a person must be assessed for physical health, support system, and any tendency to dissociate. Therefore, it is imperative that all portions of EMDR protocols are performed only by a trained, qualified EMDR clinician.

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“Safe place” may be thought of as an emotional sanctuary where a person can internally go to recover stability when feeling stressed. Once the person has successfully learned to perform “safe place,” it is used in the reprocessing phase or to close a session. It is also useful in one’s everyday life between sessions when a person feels stress or a disturbance rising to a point they need to take out and use a coping tool from their internal toolbox.

‘Safe Place’ Protocol in EMDR

When “safe place” is taught to a person preparing for EMDR, the counselor will guide the person through the following steps shared by Shapiro (2001):

“Safe place” may be thought of as an emotional sanctuary where a person can internally go to recover stability when feeling stressed.

1. The person is asked to picture an image of a place that generates feelings of calm and safety.
2. The person is asked to focus on the physical sensations and emotions that are conjured while imagining the “safe place.”
3. The counselor encourages a sense of security and may add soothing tones, such as ocean waves, to enhance the effect.
4. While the person concentrates on the image, sensations, and emotions, sets of eye movements or other bilateral stimulation may be included to “install,” or strengthen, the “safe place.”
5. The person is asked to think of a word to associate with the “safe place” and add this to the calm, safe image and sensations. Sets of bilateral stimulation are added.
6. The person is asked to self-cue the image and feelings.
7. The person is asked to think of a minor annoyance and its accompanying emotions. The counselor then guides the person through the exercise until the undesired emotions melt away.
8. The person is asked to think of another disturbance and follow the exercise without the counselor’s assistance to ensure the person can perform the exercise unassisted.

The person should be instructed to practice “safe place” daily by retrieving the positive image, emotions, and sensations via the cue word. People can then use “safe place” to relax and reduce stress any time needed. Shapiro believes people preparing to be treated with EMDR can benefit not only the “safe place” visualization but also from listening to guided visualizations such as those included in Letting Go of Stress (Miller, 2014), as these may increase the the effectiveness of “safe place” as a means of self-control.

While “safe place” for EMDR should be taught by a qualified clinician, anyone can access guided meditation/visualization CDs and podcasts to help to manage stress, fall asleep at bedtime, and promote a positive self-image. These materials may be found for little or no cost through public libraries, iTunes, and online resources. Comments below sharing your favorite guided visualization/meditation resources are welcome.

References:

1. Miller, E. (2014). Letting go of stress. San Anselmo, CA: Halpern Inner Peace Music.
2. Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures (2^nd). New York, NY: The Guilford Press.

Fourteen years ago, when I was first trained in EMDR therapy, there was less of an understanding of its benefits, as well as a lot of confusion about what eye movement desensitization and reprocessing actually was. One thing it’s never been is a quick fix. And while I make it a point to educate people about this reality, I have found there is another layer to that common misunderstanding: lack of awareness that the existence of complex trauma, as opposed to single-incident trauma, can make EMDR an even longer-term treatment.

When working with those with single-incident trauma—a survivor of a car accident, for example—the standard eight-phased, three-pronged EMDR protocol has the potential to guide the treatment process in a relatively straightforward manner. Treatment can also be more clear-cut and focused when there are multiple traumas that can be grouped into the same category. Someone who reports being raped at various times in their life would be an example of this. Neurologically, the traumas can travel down a similar “track” when processed.

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However, it is usually the cumulative effect of multiple traumas, of multiple kinds and categories, that brings folks to my office. The majority of those who are engaging in ongoing therapy have symptoms driven by foundational experiences—developmental traumas that impact their worldviews. These experiences affect their ability to feel safe, not only physically but also emotionally. These people are seeking to heal from a history of complex trauma.

Complex trauma is identified by Judith Herman and other leaders in the field of traumatology as “the existence of a complex form of posttraumatic disorder in survivors of prolonged, repeated trauma” (Herman, 1992). An example of a history of complex trauma would be a woman who was adopted at birth, experienced sexual abuse by her brother, experienced ongoing physical abuse by her mother, and perhaps had a series of abusive relationships throughout her teenage and early adult years. She has an extensive history of interpersonal traumas at various ages and developmental stages, and spanning multiple categories.

The majority of those who are engaging in ongoing therapy have symptoms driven by foundational experiences, developmental traumas that impact their worldviews. These experiences affect their ability to feel safe, not only physically but also emotionally. These people are seeking to heal from a history of complex trauma.

As part of our healing journeys, we must pay attention to traumas of both omission and commission; both matter and can impact a person’s mental health. Neglect and abandonment, among others, are traumas of omission. Sexual abuse, physical abuse, and violence are clearly acts of commission. Perhaps a person experienced ongoing parental misattunements, significant attachment losses, a parent’s hospitalization or depression, or witnessed a mother grieving the loss of a sibling. These and myriad other experiences are examples of traumas that, at the time, impacted the person’s sense of emotional and physical safety and, more often than not, included caregivers. If they happened in childhood, they may greatly impact the person’s perceptions of the world today. All of this adds up to complex trauma.

Many leaders in the field of trauma treatment believe the newest diagnostic criteria for posttraumatic stress (PTSD), as outlined in the DSM-5, are not comprehensive enough. Although an improvement over the DSM-IV, the latest guide for mental health practitioners does not account for the full clinical picture when it comes to developmental trauma.

The term “complex trauma” didn’t even make it into the DSM-IV; instead, “DES NOS” (disorders of extreme stress not otherwise specified) was often used in clinical application. In the DSM-5, some of the symptoms of DES NOS, such as re-experiencing, avoidance, negative cognitions and mood, and arousal, were included in the PTSD criteria.

Which brings us back around to EMDR therapy. Yes, it is possible to heal from a history of complex trauma. Doing so just takes a conscious, methodical, and phased approach to treatment. If you are considering EMDR and have a history of complex trauma, I highly recommend ensuring that your therapist has experience in working with both. Make sure, also, that your therapist talks to you about extensive preparation and stabilization; these aspects will be a necessary part of your healing journey.

Reference:

Herman, J. (1992). Trauma and Recovery. New York: HarperCollins.

The feeling-state addiction protocol is a modified form of eye movement desensitization and reprocessing, referred to as EMDR in mental health. EMDR is a trauma treatment modality recognized as one of the main treatments for posttraumatic stress (PTSD) and other forms of trauma.

In EMDR therapy, therapists desensitize a traumatic memory by having the person in therapy use eye movements (or other back-and-forth stimulation) while holding the memory in mind along with the feelings, images, and belief about self in that situation. This causes the brain to process the memory in a way that takes the charge off the memory, so it no longer feels disturbing. In feeling-state addiction protocol, we desensitize the pleasant memory causing the addiction by removing the charge from that memory.

Tom and the Feeling-State Theory of Addictions

The feeling-state theory of addictions assumes that the feeling underlying the behavior, not the apparent object or behavior, is the real goal of unwanted compulsive behavior. In alcohol or drug addiction, the substance creates the [fat_widget_addiction_right]“feeling-state” that causes the compulsive behavior. In behavioral addictions, however, any feeling-state can be linked to any behavior. Feeling-states are state-dependent memories created during an intensely experienced event. With gambling addiction, we look for the positive feeling-state linked to the gambling behavior.

I worked with a person in therapy, who I will call Tom, who came to me because he had “reached bottom with the consequences of his gambling,” as he put it. Tom is a 37-year-old man who started therapy saying that he wanted to overcome two addictions: a very destructive woman and gambling.

The precipitating incident that brought Tom to therapy was having just lost his last $12,000 in a poker game, the final straw that caused him to lose his house. He had recently moved in with his parents, and they insisted he deal with the gambling addiction.

Both of the addictions Tom wished to treat are known as process addictions or behavioral addictions because they are not addictions to a substance. When he first came to see me, Tom was dealing with an intense sadness from losing his relationship and shame from losing his house and moving in with his parents. Tom’s parents agreed to pay for his therapy and insisted he make measured progress, lest they throw him out of the house.

Although addiction to a person and addiction to gambling seem different, like all behavioral addictions, they both involve an addiction to a feeling-state. According to Dr. Robert Miller, who developed the feeling-state addiction protocol in 2011:

“The feeling-state theory of behavioral and substance addictions postulates that addictions are created when positive feelings become rigidly linked with specific objects or behaviors. This linkage between feelings and behaviors is called a feeling-state. When a feeling-state is triggered, the whole psycho-physiological pattern is activated. The activation of the pattern then triggers the out-of-control behavior.”

The first step in eliminating a compulsion, according to Dr. Miller’s feeling-state protocol, is to figure out the feeling-state that drives the compulsion.

Identifying the Real Addictive Behavior

In therapy, we determined that the feeling-state Tom was addicted to with gambling was bonding with his father, which had provided both a sense of belonging and mastery.

Tom had one brother who was five years older. He described his brother as the favorite and the one his dad often Tom was very shy and described himself as someone who had never excelled at anything. He had few friends and participated in few social activities. In fact, the first time he said he felt any positive attention from his father was when he would watch his father’s poker games every week.praised for his intellectual ability and athletic success. Tom was very shy and described himself as someone who had never excelled at anything. He had few friends and participated in few social activities. In fact, the first time he said he felt any positive attention from his father was when he would watch his father’s poker games every week.

By the age of 18, Tom became a good observer and was playing cards with his dad’s poker group. He was skilled and was often the winner. It was this feeling-state of bonding with his father and the feeling of belonging to a group that drove his gambling compulsion.

We processed these strong feeling-states with EMDR, and his craving for gambling started to subside. We then discovered other feeling-states linked to his gambling. They were the feeling-state of freedom and mastery. Once we unlinked or disconnected these feeling-states with gambling, his desire for gambling waned and we could then address the psychological dynamics underlying the “need” for the gambling, such as his relationship with his dad, his feelings of being a “loser,” and the belief he is not smart and can’t succeed at anything.

We also desensitized his attraction to the destructive woman who had recently come back into his life. When he realized how easy it was to remove that attraction for her, it gave his self-esteem a huge boost. This helped him see other dynamics in his life with more clarity and confidence.

I have used this model with many process addictions, including:

• Shopping addiction
• Shoplifting
• Addiction to a person
• Internet addiction

I find it to be effective and relatively easy for the person in therapy because the person largely avoids the pain of going through withdrawal.

References:

1. EMDR International Association. (2014). What is the actual EMDR session like? Retrieved from http://www.emdria.org/?120
2. Miller. R. (2011). The feeling-state theory of behavioral and substance addictions and the feeling-state addiction protocol. Retrieved from http://www.psychinnovations.com/EMDRSD/Miller_Feeling_State_Addiction.pdf

A seizure is a sudden and unexpected loss of control accompanied by abnormal body movements or convulsions, a loss of consciousness, or both. Though epileptic seizures are caused by sudden, rapid, and chaotic electrical discharges in the brain, not all seizures are epileptic.

Psychogenic nonepileptic seizures (PNES) are not caused by abnormal discharge of electrical brain signals, but instead are emotional in nature and usually triggered by stress or anxiety. Although these seizures are rarely discussed, they are not rare. PNES have a prevalence similar to that of multiple sclerosis.

Statistically, one in five people sent to epilepsy centers experience PNES rather than epilepsy. In fact, a team of physicians and psychologists at Johns Hopkins Hospital reported that more than one third of patients admitted to the inpatient epilepsy monitoring unit were experiencing stress-triggered seizures rather than true epileptic seizures.

Diagnosing Psychogenic Nonepileptic Seizures

Because PNES can mimic epileptic attacks, they are often misdiagnosed. At least 80% of patients experiencing PNES are treated with antiepileptic drugs for several years before a correct diagnosis is made.

[fat_widget_right]The source of this dilemma is multifaceted. Most physicians do not have access to electroencephalogram (EEG) video monitoring, and even those who do can easily misread an abnormal EEG without video if they have not been specifically trained in epileptology. A 2005 study of 46 patients published in the Neurology journal revealed that 54% of EEG readouts were misinterpreted as epilepsy.

Epileptic seizures tend to be more serious than PNES. If there is any doubt, a neurologist will usually treat the more serious condition. If medication fails to treat seizures, a patient is then referred to an epileptic center, and it is often there that the diagnosis of PNES is made.

With proper equipment and specialized knowledge, an epileptologist can easily distinguish between epilepsy and PNES. An EEG-video monitoring system monitors a patient for several hours and sometimes days until a seizure occurs, though there are techniques that can be used to trigger a seizure to speed up the monitoring process if necessary or desired. By analyzing the video of the seizure, a diagnosis of PNES can be made with 100% certainty.

Causes and Risk Factors

PNES is a somatoform illness, meaning that emotional stress creates physical illness in the body. These seizures are emotional in nature—induced by stress—and often result from traumatic experiences, some of which may have been repressed or forgotten. Such traumas may include divorce, physical or sexual abuse, death of a loved one, incest, or any other great loss or sudden upheaval in one’s life.

Individuals without developed coping skills may be more susceptible to PNES than those with a high level of resiliency to stress. A team of neuropsychologists and neurologists at Johns Hopkins University School of Medicine found that people with PNES don’t necessarily have a higher frequency of stress and/or trauma than others, but they seem to lack effective coping mechanisms to deal with stress and are thus more affected by it.

Coping with Diagnosis and Stigma

Psychosomatic illnesses like PNES are often misunderstood by family members and even by physicians and other health care professionals. A person may be reluctant to accept the diagnosis and become upset when told the seizures are psychological. Some people completely refuse to accept the diagnosis and continue to take antiepileptic drugs even as symptoms continue. This places responsibility on the physician to stop administering the drugs.

A lack of public knowledge and awareness of PNES only increases the misconceptions, misdiagnoses, and stigmatization of the illness. Somatoform illnesses like PNES are real—resulting from real stressors and traumas—and should be treated as such.

Treatment and Outcomes of PNES

Overall, PNES can be treated if properly diagnosed. The earlier the diagnosis, the better the outcome may be. About 70% of people who receive adequate treatment for PNES eventually experience a complete disappearance in seizures. The recovery time will vary from patient to patient depending on the severity of the traumas and stressors involved, as well as the person’s established coping mechanisms and resiliency to stress.

While a neurologist typically treats epileptic seizures, PNES tends to be treated by a psychologist or other mental health professional. Someone who has been newly diagnosed and has been taking antiepileptic drugs will need to work with a neurologist to gradually come off the drugs rather than stopping use abruptly.

About 70% of people who receive adequate treatment for PNES eventually experience a complete disappearance in seizures.Treatment for PNES typically involves various types of psychotherapy. Cognitive behavioral therapy (CBT) may be used to help people develop adequate coping skills to deal with life stressors. Relaxation techniques and biofeedback are also used to help manage and cope with stress.

For those whose seizures are a manifestation of past trauma, PNES is typically treated as posttraumatic stress. In this case a physical seizure may be the body’s way of expressing what the mind cannot. Some physicians have also found eye movement desensitization and reprocessing (EMDR) to be an effective treatment for PNES.

EMDR is a synthesis of many different therapeutic approaches including CBT, psychodynamic, interpersonal, body-centered, and experiential therapies. This information-processing therapy occurs in eight phases—attending to past traumas that contribute to the pathology being treated; the current situations, beliefs, and sensations that are triggering the dysfunctional emotions; and the positive experiences needed to improve mental health and well-being in the future.

The costs of being treated for misdiagnosed epilepsy are high and should not be ignored. As the incidence of misdiagnosed PNES continues, it is important for neurologists, psychiatrists, and psychologists to work in collaboration to raise public awareness, remove the stigma, and provide proper diagnosis, treatment, and support.

References:

1. Benbadis, S.R. and Heriaud, L. Psychogenic (Non-Epileptic) Seizures: A Guide for Patients and Families. (n.d.). Comprehensive Epilepsy Program: Tampa General Hospital & University of South Florida College of Medicine. Retrieved from: http://hsc.usf.edu/COM/epilepsy/PNESbrochure.pdf
2. Desmon, S. (2012, April 10). Symptoms that Mimic Epilepsy Linked to Stress, Poor Coping Skills: Patients with “Pseudo-Seizures” Often Misdiagnosed. Johns Hopkins Medicine. Retrieved from: http://www.hopkinsmedicine.org/news/media/releases/symptoms_that_mimic_epilepsy_linked_to_stress_poor_coping_skills
3. The Truth about Psychogenic NonEpileptic Seizures. (n.d.). Epilepsy Foundation. Retrieved from: http://www.epilepsy.com/article/2014/3/truth-about-psychogenic-nonepileptic-seizures
4. What is the actual EMDR session like? – EMDR International Association. (n.d.). Retrieved from http://www.emdria.org/?120

Nope, this isn’t a strange riddle where someone is found in the desert in a scuba suit. The answer to the question posed above is actually pretty simple: brain integration.

What is that? Excellent question; I am glad you asked. As you may know, we have two hemispheres of the brain. Neuroscience is a relatively young field, and we are continuing to learn more about the complexity of the brain and its function with time and as research evolves. We do know that there are different roles played by different sides and areas of the brain, and that integrating neural networks appears to be helpful in resolving traumatic memories.

The success of eye movement desensitization and reprocessing (EMDR) in treating trauma and mental health challenges teaches us that alternating right- and left-brain stimulation, via visual, auditory, or tactile experience, helps facilitate emotional processing. Through the simple act of holding something that buzzes between your right and left hand, or listening to something shifting from your right to left ear, a memory that was once charged with emotion can become less distressing. During the process, it is common for relevant associations to arise, for memories of thoughts and body sensations to arise. With support, this process can facilitate lasting and integrated healing.

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Right-left brain stimulation may sound like a scary, science fiction-like process, but I assure you there is no electricity involved in this type of therapy. Your body receives input in the form of sound, touch, or sight, without any added energy.

Along with helping us process emotions, EMDR can help build up positive memories, experience, thoughts, and feelings. We call this resourcing, and use imagined or real resources to cultivate feelings of peace, nurturing, protection, and wisdom. In addition to and as part of processing negative experiences, it is crucial to cultivate the positive, sometimes the opposite of what occurred in the experience of trauma.

Think about your life for a moment and ask yourself: when do I engage in an activity that engages my right and left brain in alternating rhythm? How do I feel before, during, and after the fact? How can I incorporate this information into my healing path?

How do walking, running, and drumming factor in? Think about it for a moment. When you walk, run, or drum, you are using your body in a rhythmic way, alternating the stimulation or use of your right and left brain throughout the activity. Have you ever gone on a hike or run and felt that you were sorting through your thoughts, developing new insights, or becoming less distressed about something? We know that exercise has many benefits; EMDR highlights for us some of the mental and emotional benefits.

There are a million ways to alternate right- and left-brain activation, including dance, yoga, and some tai chi moves. People have naturally gravitated toward right-left movements in many healing rituals across the world. Think of how many sacred rituals involve drums, movement, or voyages on foot. Understanding brain integration, plasticity, and resilience gives us some insight into why these rituals have been effective and why they continue to be passed down through generations.

Think about your life for a moment and ask yourself: when do I engage in an activity that engages my right and left brain in alternating rhythm? How do I feel before, during, and after the fact? How can I incorporate this information into my healing path?

If you are looking to heal from specific traumatic memories, I highly recommend working with a skilled EMDR professional who can provide structure and guide you toward health and resolution. Consider how your own choices outside of therapy can support your process as well. Perhaps you will choose to walk or bike to your therapist’s office this week, or do a little dance after your session. Whatever you choose, may it serve your healing and integration.

We may have experienced various traumatic experiences in childhood, whether it be abuse, neglect, abandonment, or ongoing misattunements from caregivers that impact our ability to feel safe to attach. Even though the events themselves may be behind us, those internal responses to the traumatic experiences—images, sensations, meanings we create, and emotions—can become “stuck” in the nervous system. They continue to have a “charge.” That charge stays in our system, is stored maladapatively, and is part of our inner world.

At the most unexpected times, this material can push through what we would consider our “normal” day-to-day activities—such as parenting, working, relationship building, and self-care—in the “outside world.” As a result, we may find ourselves in a constant balancing act of pushing back at that charge. Our normal everyday selves, if you will, try to show the world that we are fine on the outside, even though there may be a lot of material that pushes through.

For example, perhaps we are in a discussion with a loved one when, all of the sudden, we interpret that we are being abandoned, even while there is no actual evidence of this. Or perhaps while attempting to set a boundary with a child, we feel feelings of guilt because we don’t feel that we “deserve” to set those boundaries. All of these can be intrusions on day-to-day life, all from past hurts.

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Those feelings and interpretations can actually be the experiences of the past clouding the now, stopping us from truly being in the moment. The nervous system is activated and defending itself from a past injustice. Unfortunately, that charge from the past compels your nervous system to act as if the traumatic experience is still happening.

There can then develop a kind of tug-of-war between who we are on the outside and the charges that remain from the past. If the tug-of-war with the traumatic material becomes too much and we become flooded, we may need to go numb in order to be able to still “do” life on the outside. We may shut down. Even if we do, it doesn’t mean that the material on the inside is gone; it just means that we have had to become more unaware of it in order to function on the outside.

One of the most challenging aspects of complex trauma, whether or not pursuing EMDR therapy, is that we must be able to identify and “own” our feelings and experiences. This allows us to then process traumatic experiences from the perspective of being “here and now” and visiting them versus feeling as if one is flooded and still in those experiences. In EMDR language, we look for one’s ability to maintain dual attention. It expands into making sure we stay within a window of tolerance as we visit those memories.

Often, those starting their healing work find themselves in one of two extremes: flooded by feelings all of the time or feeling completely numb.

For some, this may not seem like such a large step, but for the majority of those who are healing from complex trauma, it is in fact very difficult. Often, those starting their healing work find themselves in one of two extremes: flooded by feelings all of the time or feeling completely numb. The numbness often comes because the material in our inside world becomes unmanageable and we become more fearful of that material. We shut down from the outside world because the inside world is so invasive.

We typically learn to dance this dance of “daily life” vs. “inner stuff” at an early age. In infancy, we learn that our attachment to our caregivers is required; we cannot survive without a caregiver or we will die. Period. We also learn that our attachment relationship is dependent upon us being in tune with our caregiver’s reactions—to know what to do, how to act, and how OK it is (or not OK) to have our emotions be expressed and seen in the outside world.

We also determine whether it is dangerous to really identify, own, and be with the feelings of shame, anger, or sadness, even happiness or calm. We then create certain strategies that seem helpful at the time but show up later as distressing symptoms. As outlined in my previous article on blocking beliefs, it is often those cognitive errors that hold us back from fully realizing and being in tune with our past hurts because it was, at the time, too much to fully realize.

In future articles, I will share more about what it means to fully realize and own what was once unrealized, back when we were experiencing past injustices. Similarly, I will share more regarding what it means to own and process feelings we may have deemed unacceptable in order to survive the past.

If you are a therapist and are interested in expanding your knowledge on this topic, especially as it relates to structural dissociation theory, you are encouraged to read The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization (2006) by Onno van der Hart, Ellert R.S. Nijenhuis, and Kathy Steele.

“…Not all psychological impacts can be encompassed by a list of symptoms or disorders.” —From Principles of Trauma Therapy

Make no mistake about it, Principles of Trauma Therapy: A Guide to Symptoms, Evaluation and Treatment is a psychiatric textbook. However, it is a rare breed of psychiatric textbook. It has a soul. To borrow from the dialectic wisdom of Marsha Linehan, the question in mental health treatment is often “What is being left out?” This book fills the void in terms of a comprehensive examination of the causes of trauma. It is not solely focused on the lists of symptoms. There are some areas where the book has “left out” important information, but emphasis on cultivating compassion for trauma survivors makes up for it.

John N. Briere and Catherine Scott describe how challenging behaviors exhibited by people who have gone through traumatic events are normal and within the context of psychological resilience: “Although therapists may interpret these behaviors as ‘resistance,’ such avoidance often represents appropriate protective responses to therapist process errors.” (p. 170). The adaptive functioning—or attempts to “metabolize” the trauma—is often interpreted as sabotaging or therapy interfering, but in reality, it suggests the clinician is in error (e.g., moving too fast in therapy). Unfortunately for the person in therapy, these attempts to lessen the pain can inadvertently prolong their trauma (this is what’s called the “pain paradox”). The unskillful attempts used to extinguish the pain often produces an increase in pain for the individual.

[fat_widget_trauma_ptsd_right]The pervasive message in Principles of Trauma Therapy is that a person’s symptoms due to a trauma can resolve via therapeutic engagement within a safe, therapeutic environment. The treatment approach is eclectic, and it weaves together strategies from various models (e.g., cognitive behavioral therapy, psychodynamic approaches, and mindfulness). People in therapy are given the opportunity to develop a coherent narrative of their past experiences, while learning stress reduction skills and psychoeducation through validation, respect, and supportive encouragement.

At the heart, Principles of Trauma Therapy comes from the theoretical perspective of exposure therapy and much of the content centers around this orientation for treatment. The clinician invites the person in therapy to develop alternative perceptions to their negative beliefs about themselves (oral and written) and the environment where the trauma manifested, while reducing “conditioned emotional responses” (CER).

To simplify, the recollection of the traumatic memory (i.e., exposure) occurs by activating the emotional states and schemas. The “disparity” that occurs is based on the idea that the therapy space is safe, so the person in therapy is counter-conditioned to realize they will not be harmed by experiencing the intense emotions that surround the memories. The integration of memories and emotions through exposure—along with the inability to avoid (i.e., CER) in the moment—creates resolution. The emotions are no longer as powerful. The positive results occur if the clinician is able to finesse the client’s capacity to “regulate and tolerate the associated painful affect” (p. 267). Briere and Scott advocate a titrated exposure to avoid both undershooting the level of exposure and not overwhelming the person in therapy. This person should be emotionally activated to allow processing to take place, but not to the point that their coping resources are overwhelmed, which leads to avoidant behaviors (i.e., to seek safety from the distress).

Exposure therapy techniques are undoubtedly effective and reliably decrease posttraumatic stress. However, the dysregulated elephant in the room during my review of this book was a question of ethics: is exposure therapy humane?

There are a couple of areas that should have been addressed more thoroughly in the text. Exposure therapy techniques are undoubtedly effective and reliably decrease posttraumatic stress. However, the dysregulated elephant in the room during my review of this book was a question of ethics: is exposure therapy humane? This form of therapy elicits pain for the person in therapy, often expressed in the form of panic attacks, dissociation, and intense anxiety through a re-experiencing of the trauma. Is it morally right for clinicians to prescribe this approach? Does the end justify the means? Or, are there other treatment approaches that can be used to relieve the immense amount of suffering experienced by trauma victims?

Principles of Trauma Therapy provides only a brief conceptualization of eye movement desensitization and reprocessing therapy (EMDR). In 2004, the APA acknowledged EMDR as a recommended effective treatment of trauma. According to Shapiro (2001), EMDR is the most empirically studied treatment for posttraumatic stress (PTSD). The philosophy of EMDR treatment does not differ drastically from exposure therapy: deconditioning disturbing input, redefining the event, finding meaning in it, and eliminating self-blame, while integrating new skills (Shapiro, 2001). The stark difference between EMDR and exposure therapy is the method of delivery, as well as the path a person in therapy takes toward healing. Exposure therapy is analytical with a narrative-driven process that involves a significant amount of “homework” assignments for the person in therapy. It also runs a risk of vicarious traumatization (for both the therapist and person in treatment) due to repeatedly describing the often horrific events.

The internal process of EMDR utilizes an approach of holding a negative cognition (e.g., “I am unlovable”) paired with what is often an image of the traumatic event (a pre-established target). The person is instructed to focus on the image, negative thoughts, and body sensations while simultaneously engaging in EMDR processing using sets of bilateral stimulation (e.g., eye movements, auditory stimuli, or tactile sensors). They are witnessing in their mind’s eye what surfaces. The clinician does not hear all of the details of the trauma, nor does he or she provide analysis of the experience. Dialogue is at a minimum. It is provided through repeated, brief check-ins between sets of bilateral stimulation; “What comes up now?” or “What did you notice that time?”

Principles of Trauma Therapy has an agenda in terms of promoting exposure therapy, but it also offers a holistic array of coping strategies—for both the therapist and the person in therapy—to increase one’s awareness of bodily reactions and ways to create a vocabulary for the feelings that arise. This mindful mentality is more than a subtle emphasis. Empirically validated mindfulness interventions are presented (e.g., acceptance & commitment therapy, dialectical behavior therapy, mindfulness-based stress reduction, and mindfulness-based cognitive therapy) as to disillusion the reader from the spiritual, Buddhist connotation. Clinicians are encouraged to maintain an open awareness to their own mental states (e.g., reduction of reactivity) without judgement, in order to mirror this process for people (e.g., attending to the breath, a here-and-now focus). There are also scripts for new clinicians and comprehensive assessment material that is applicable to anyone in therapy.

Principles of Trauma Therapy has a final, comprehensive directory of trauma-centered psychopharmacological interventions with content relative to psychobiology. This is extremely informative, but one has to question some of the research that was referenced. One concluding statement regarding the efficacy of selective serotonin re-uptake inhibitors (SSRIs) as antidepressant medication gave me pause. It was noted that SSRIs “have been found to be equally effective in reducing symptoms and improving quality of life across most clinical trials” for many diagnoses. The example reference was to a 2000 study comparing monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants and some selective serotonin re-uptake inhibitors (SNRIs) for depression. ^[1] The citation did not match the broad sweeping claim as the study itself notes “clinically insignificant” differences in efficacy as well as tolerability between SSRIs. ^[1] Read this section with a grain of salt and consider newer research when determining the efficacy of medication for victims of trauma.

Despite the focus on the individual in this book, the reader is walked through the “victim variables”, “characteristics of the stressor”, and “social response and supports” that affect the outcome for the trauma victim, which forces a cultural vista. Briere and Scott implicitly connect to the fact that our society’s disenfranchised groups of individuals (e.g., people of color and in poverty) are much more susceptible to posttraumatic symptoms.

Trauma is no longer just a micro level problem, but an issue of social justice and equality. The book maps out the generational influences and cyclical effects of trauma. There is an “additive effect” of multiple traumatic events throughout one’s life. For example, a survivor of childhood abuse who has residual effects into adulthood will react with “especially severe, regressed, dissociated, or self-destructive responses to the adult trauma” (p. 22). Earlier treatment interventions are essential to desensitize these reactions to stress.

Briere and Scott provide a stylish blend of the metaphysical and tangible aspects of trauma. They do this with learned experience, academic research, and hope as a means to expose the wide-ranging consequences of trauma. If you are a clinician searching for an in-depth examination of the components, conceptualization, causal mechanisms and treatment of trauma, then Principles of Trauma Therapy is here to the rescue.

References:

1. Mace, S. and Tayler, D. (2000). Selective serotonin reuptake inhibitors: a review of efficacy and tolerability in depression. Expert Opinion on Pharmacotherapy: 1(5). 917-933.
2. Briere, John & Scott, Catherine. Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment (2^nd Edition). SAGE Publications, Inc; Second Edition – DSM-5 Update edition (March 26, 2014).

As a therapist, I’ve used eye movement desensitization and reprocessing (EMDR) therapy to treat many adults with mental health issues resulting from trauma. This method of therapy is also safe and effective for children and adolescents, provided that the therapist is skilled and trained in working with this population and in this modality.

What Is EMDR?

When a painful or upsetting experience happens, the memory of the experience sometimes stays “stuck” in the body and mind. Over time, the occurrence may manifest anew in disturbing and invasive ways.

Dr. Ricky Greenwald, a pioneer in developing EMDR therapy for children and teens, describes EMDR as “a non-drug, non-hypnosis psychotherapy procedure. The therapist guides the client in concentrating on a troubling memory or emotion while moving the eyes rapidly back and forth (by following the therapist’s fingers). This rapid eye movement, which occurs naturally during dreaming, seems to speed the client’s movement through the healing process.”

After experiencing trauma, a child may have recurring nightmares or cope by avoiding things associated with the disturbing experience. For example, a child who experienced a car accident may exhibit defiant behavior when in a vehicle, or protest having to travel in the first place.

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Essentially, EMDR can help the brain “digest” the memory of the traumatic event.

How Does EMDR Help Children?

EMDR is effective and well supported by research evidence for treating children with symptoms accompanying posttraumatic stress (PTSD), attachment issues, dissociation, and self-regulation. It has also been effective in treating symptoms related to guilt, anger, depression, and anxiety, and can be used to boost emotional resources such as confidence and self-esteem.

During the past five years, the World Health Organization and the California Evidence Based-Clearinghouse for Child Welfare recommended two psychotherapies for children, adolescents, and adults with PTSD: trauma-focused cognitive behavioral therapy and EMDR. Of the two modalities, some of the research describes EMDR as “significantly more efficient.” My experience as a therapist echoes these recommendations.

One Therapist’s Experience with EMDR

I have personally witnessed children and teens improve in their overall functioning after being treated with EMDR, sometimes after only a few sessions. These children experienced PTSD symptoms as a result of bullying, psychological abuse, sexual abuse, and invasive medical procedures. Some of these traumas occurred at the hands of someone with malicious intent; others were formed from the child’s perceived intent.

Since our emotional states are a result of how we perceive the world, a child may have stress related to a memory that, to anyone else, would not seem to be a “big deal.” In an effort to help their children “get over it,” parents often tell them things such as, “It’s not that bad,” or, “He wasn’t that mean to you.” But if the experience was traumatic to the child, it was traumatic—period.

Trauma can result from one event, multiple events, or a series of them. These events can cause children to see the world as dangerous and can alter their ability to function. A child may experience anxiety, fear of death, panic, powerlessness, anger, and deep sadness. When the trauma is a result of violence perpetrated by a caregiver they trust, it becomes overwhelming and can cause a child to be in a constant state of worry. This, of course, interferes with the child’s ability to trust or to sustain and maintain relationships.

Therapy can be a scary prospect to a child. When I explain to a child that our brains are amazing things that have the ability to heal themselves, and that I will help their brains do just that, they usually react with curiosity and intrigue and the process becomes much less scary.

What to Look for in an EMDR Therapist

The safety of any treatment modality depends on the practitioner’s aptitude to administer it. A licensed therapist who is fully trained in EMDR is well equipped to help a child or teen. The therapist should have training in how to apply the method to the child’s specific developmental needs and an ability to explain the process to the child in a way he or she will understand. A full history should be obtained from the parents, who should be considered partners in tracking changes in the child as the treatment progresses.

EMDR is often used in combination with other therapeutic modalities, such as art therapy, sand tray therapy, play therapy, yoga therapy, and even animal-assisted therapy. A therapist who offers a multifaceted approach, based on the child’s unique needs and interests, is ideal.

If interested in seeking the help of an EMDR-trained therapist, search GoodTherapy.org’s directory for a therapist near you.

References:

1. California Evidence-Based Clearinghouse for Child Welfare. (2010). Retrieved from http://www.cebc4cw.org
2. Gomez, A. (2008). Beyond PTSD: Treating depression in children and adolescents using EMDR. Paper presented at the annual meeting of the EMDR International Association, Phoenix, AZ.
3. Jaberghaderi, N., Greenwald, R., Rubin, A., Zand, S. O., and Dolatabadi, S. (2004). A comparison of CBT and EMDR for sexually abused Iranian girls. Clinical Psychology and Psychotherapy, 11,358-368.
4. Trauma Institute & Child Trauma Institute. (2015). Eye Movement Desensitization & Reprocessing. Retrieved from http://www.childtrauma.com/treatment/emdr/
5. World Health Organization. (2013). Guidelines for the Management of Conditions Specifically Related to Stress. Geneva, Switzerland. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK159725/