EMDR AND ADDICITON: ESSENTIAL SKILLS BEYOUND BASIC TRAINING/ EMDRIA

Transcription

1 1 EMDR AND ADDICITON: ESSENTIAL SKILLS BEYOUND BASIC TRAINING/ EMDRIA 2014 Julie Miller, MC, LPC, LISAC TR/EMDR HAP Trainer-In-Training EMDR Institute/HAP Facilitator EMDRIA Approved Consultant Certified EMDR Therapist Tucson, Arizona Adaptive Information Processing (AIP) 2! Current emotional and behavioral problems (not caused by organic deficit or physical insults) are conceptualized as the result of incompletely or inappropriately processed memories of disturbing or traumatic experiences. ACE Study 3! Adverse Childhood Experiences Study conducted by the CDC and Kaiser Permanente with 17,000 participants, beginning in 1995.! The study was conducted to assess associations between childhood maltreatment/ trauma and problems later in life with health and well-being

2 4! The ACE study found that as the number of adverse childhood experiences increases, the risk for the health and wellness problems increases in a particularly strong manner..! The ACE study outlines 10 categories of adverse experiences..! Example: ACE score of 5 equates to a 4660% increase risk of IV drug use. CHALLENGES 5! Biggest concern in the addiction field: potential for client relapse in dealing with trauma in early recovery! Challenges to trauma work include: alexithymia, affect phobia, and inability to regulate affect! These challenges must be addressed in the preparation phase to reduce risk of relapse. Standard Protocol 6! Standard protocol is grounded in the premise that addictive behaviors are based on unprocessed experiences from the past! Your road map:! PAST/PRESENT/FUTURE! You are looking for early adverse experiences that fuel the Yuck.

3 STANDARD PROTOCOL TREATMENT PLAN! 1. Presenting issue: drinking, drug use, etc.! 2. Negative cognition when thinking about this issue! 3. Body sensations when thinking about negative cognition! 4. Hold that together, trace that back to the first time you can remember feeling this way (touchstone) 7! 5. When was the worst time you remember feeling this way? 8! 6. What other times have felt this way about yourself? (Past)! 7. What are the present triggers/reminders that make you feel this way about yourself NOW? (Present)! 10. How would you like to feel about yourself/behave in the future? (Future) 9! Use Standard protocol to process first, worst/ other events that underlay the addiction! Process past events, then present trigger and future template! Include using/drinking experiences or consequences as targets as well.

4 Caution: 10! If they go out and use, consider that they can t tolerate the affect that is being stirred up. CRAVEX 11! Sometimes called the Addiction Memory protocol. Developed by Michael Hase.! The Addiction Memory (AM) contains the memory of loss of control or cravings, and/or the memory of use of a specific drug.! The AM outlasts periods of drug deprivation (this is why relapse may occur after years of abstinence).! if I have the experience of using and memory of using, the brain can t differentiate between memory and real. So the goal is to desensitize the memory. 12! Internal or external cues can trigger the AM, resulting in craving and use.! We target memories of relapse or of intense cravings as these are an indication that the AM is activated.! Reprocessing the AM leads to reduced cravings (cravings will increase during reprocessing, but this is temporary)

5 13! No special stabilization is needed, just standard safe place! Even if there was previous trauma; the trauma did not appear to get triggered! Shorter treatment was required, 2 sessions of 60 minutes in the research! Standard eight phase protocol is used, with the exception of the target itself being the AM, not a trauma DeTUR Desensitization of Triggers and Urges Reprocessing.! Developed by A.J. Popky, PhD! Addiction behaviors are maintained by the stress relief associated with using (elimination of negative experiences) 14! Focuses on resourcing and desensitization of triggers in order to reduce the level of urge to use/act out 15

6 ! Identify and install external/internal resources to be used to maintain sobriety using BLS (more on that in a few ) 16! Identify and install a positive goal state (PGS) How I want my life to be, a present statement about desired recovery goal, using BLS! Identify and rate triggers (LOU:0-10)! Process triggers to LOU = 0 (or ecological)! Pair each trigger with a with PGS and strengthen.! During processing of triggers, client s trauma may arise. 17! Example: a young adult female client had a trigger for drinking while being at a party. While processing trigger, client suddenly reported she had been raped at a party, which was previously undisclosed. Rape needed to be reprocessed before the trigger could be desensitized. Positive Feeling State Protocol 18! Developed by Robert Miller PhD.! Addiction is created when positive feeling states become wired to specific behaviors! Abstinence is not the goal; loss of interest in the behavior is the goal!

7 19! After standard preparation, identify specific positive feeling state (PFS) associated with using/compulsion! Identify image and intensity of PFS (0-10)! Identify body sensations! Process until PFS = 0 (using EMD) 20! Then Identify NC associated with PFS! Identify body sensation associated with NC! Use float back to identify 1 st time client felt this way! Process incident with standard protocol 21! See handout quick Reference for suggestions! Cravings will emerge during processing; that s a good thing! Just keep going!! Do not leave the client in the middle of a craving if you have to end the session as incomplete. Make sure you have plenty of time to process through it, or take more time than scheduled as this is very important.

8 ! Re-evaluation is essential for each session. Adjust resources or change protocols as needed 22! Interweave resources and development of new resources as needed, especially if client struggles between sessions or slips with addiction! The therapist is in charge of the pace and level of associations made during processing! Reduce associations or slow pace with restricted processing (EMD, EMDr, slower sets, more frequent returns to target, etc) 23 CLIENT USING DURING TREATMENT 24! Safety first- is a higher level of care appropriate?! No processing will take place when client is acutely under the influence! Utilize FSAP to reduce the client s interest in using! Meet more frequently for longer sessions if possible to get more done and quickly reduce the response to triggers! Try DeTUR and Crave Ex as well to see if use can decrease! If trauma is specifically pushing the relapse, consider inpatient EMDR treatment.

9 CRAVEX or Addiction Memory Protocol (M. Hase)! Premise: activation of the addiction memory leads to drug-taking behavior! Use: with a client struggling with euphoric recall, client denies any history of trauma, client doesn t want to address their trauma history! Target: the memories of intense craving or relapse, or the AM itself (use LOU s in place of SUD s) 25 DeTUR (A. Popky) 26! Premise: addiction behaviors are maintained by the stress relief associated with using/ drinking! Use: with a client struggling with triggers, client denies any history of trauma, client doesn t want to address their trauma history! Target and install resources, then specific triggers, then future template (use LOU s in place of SUD s) Standard Protocol (F. Shapiro) 27! Premise: using/drinking is based on unprocessed adverse experiences from the past! Use: With a well-resourced client to address dysfunctionally stored past experiences that push the current symptoms! Target: Past unresolved experiences, process present triggers and future templates

10 Feeling State Addiction Protocol (R. Miller)! Premise: addiction is created when positive feeling states become wired to specific behaviors! Use: with a client struggling to maintain abstinence or experiencing cravings, and the client is willing to look at old trauma! Target: positive feeling state connected to the substance/behavior, then the underlying adverse experience (use PFS instead of SUD s in initial phase) 28 Developing Affect Tolerance and Regulation! We begin to learn affect tolerance and regulation skills through our early childhood experiences with our caregivers. 29! However adverse childhood experiences will impact the opportunity to learn these important skills! The individual learns to be terrified of the overwhelming emotional experiences for which they have no resources 30! Emotions become terrifying.! This leads to fear of the fear or of shame, anger, sadness, pain, hurt.! The grown adult has the phobic response to the experience of emotion because the emotion is too terrifying to experience, from the infant ego state or memory network; no link between adult memory network and child memory network

11 31!Infant Ego state Adult Ego State ALEXITHYMIA 32! Emotional Blindness! With every feeling, there is a somatic cue. These individuals have difficulty identifying feelings and bodily sensations of emotional arousal.! Difficulty describing feelings to other people! Difficulty using the imagination! THEY CAN T LINK IMAGE, SENSATION, AND EMOTION! Possible solutions: 33! Affective education- help the client learn to identify feelings and the bodily sensations that go with emotional arousal (science daily chart)

12 34! Support group or therapy group with affect expression and tolerance exercises (including DBT)! Explore possible blocking beliefs/experiences when they were taught emotions aren t okay, etc.! Notice in the moment. If you see any shift of affect, draw it to their attention, or they ll let it slide by! Mindfulness- every time the client appears to have a feeling, ask what it is, where they feel it. 35! Exercises in which the individual is asked to describe what they get when describing life experiences; they will come to recognize visual memory with practice and time.! Somatic empathy by the therapist: Mirroring! Instead of saying It seems you are feeling anxious, say there seems to be anxiety in the room. Updating the Affective Circuits (K. O Shea and S. Paulsen) 36! Jaak Panskeep believes that we have a few basic emotions which are hardwired in the brain in affective circuits! Updating the Affective Circuits is a resource exercise developed by Katie O Shea and Sandra Paulsen in which the client clears out the circuit (or desensitizes to the emotion itself)! Finally the emotion is just the emotion, not a terrifying thing that gets triggered with adverse experiences or reminders of past experiences.

13 Safe Place 37! Doing safe place can be diagnostic!! If an individual has no experience of safety, they have no neural network to associate with it.! You may need to find another word.. Peaceful experience ; calm place positive experience Earth, Air, Fire, Water 38! Earth: feel your feet on the floor press your heals against the floor! Air: Take a deep breath (you are creating a state change)! Fire: look around the room for the colors of fire. (get s them focused. Red, orange, yellow, blue, white)! Water: Create spit. Notice it in your mouth! This is hitting the breaks of the sympathetic nervous system Sober Self 39! Ask the client for their goals- how do they want to behave/feel in the future, what do they want to achieve (write this down)! Ask the client to close their eyes and listen as you slowly read back their goals- ask them to see if a vision of their future self arises (use slow, lower intensity BLS only if you are sure of the client s ability to contain negative material)

14 Sober Self (cont.) 40! Give them a moment, say take a breath, what comes up?! Go with whatever comes up that is positive as it strengthens, add a few short slow sets.! Ask what the future self looks like, what they are wearing, make it real. Use BLS until it longer strengthens. Sober Self (cont.) 41! If what comes up is negative, consider that negative material is leaking in, blocking beliefs or feeder memories, and briefly explore this. Choose another resource if this one is associated with negative material! Practice this resource with the client, ask them to practice it between sessions, make sure it has a name ( Sober Susie etc.) Sober Self (cont.) 42! Once the positive sober self is installed, test with cued distress 1 st with something mildly irritating 2 nd with a craving situation

15 Sober self (cont.) 43! This can be used as an interweave if things get stuck.. What would Lovely Linda do/say about this?! Can be used in the beginning or end of session! Remind them to practice!! It can help in relapse prevention 44 ANYTHING positive can be developed and installed as a resource! Any recent positive experience, including a nice conversation, a moment of gratitude, a good meeting, a moment of hope, etc.! This builds affect tolerance and affect regulation skills! Use ANYTHING short slow sets. 45! Listen for the positive, then whip out your EMDR equipment and just ask: Where do you feel that in your body?! Whatever the client say s do a short, show set. Go with that..! If positive response, continue with short slow sets and anchor with cue word! If negative response, just take note and move one.

16 This populations needs a boat load of resources!! Sponsor! Higher Power! The Team! Meetings! Hobbies! Colors! A Fun Time! Their relapse prevention plan 46 Remind them to practice!! This will help with relapse prevention!! 47! Development and installation of resources enhances positive networks, which are necessary for reprocessing and between session stabilization! Use cueing of distress to build positive statechange muscle References! 1. Shapiro, F. (2001) Eye movement desensitization and reprocessing, Basic principles, protocols and procedures (2 nd ed). New York: Guilford! 2. Felitti VJ, Anda, RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks, JS, Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventative Medicine. 1998; 14: ! 3. Siegel, D (1999). The developing mind: toward a neurobiology of interpersonal experience. New York: Guilford.! 4. Paulsen, S. (2012, October). Thirty-one secrets of the embodied self; Hearing baby s story in EMDR for trauma in implicit memory. Presentation at the 17 th EMDR International Association Conference, Arlington. VA! 5. McCullough, L. (2007),. Treating Affect Phobia, New York Guilford 48! 6. Paulsen, S., O Shea, K (2009). When There Are No Words: EMDR for Early Traumand Neglect Held in Implicit Memory Workshop. November 9-10, 2012, La Jolla, California! 7. Paulsen, S. Oshea, K., and Lanius, U., (2014) Alexithymia, affective regulation, and the imaginal: resetting the subcortical affective circuits. In U. Lanius, S. Paulsen and F. Corrigan (EdS). Neurobiology and treatment of traumatic dissociation: toward an embodied self (pp ), New York: Springer

17 References (cont.) 49! 8. Panksepp, J (2009). Brain emotional systems and qualities of mental life; from animal models of affect to implications for psychotherapeutics. In D Fosha,; DJ Siegel, &MF Solomon (EdS). The healing power of emotion (pp. 1-26) New York, Norton! 9. Panksepp, J. (1998) Affective Neuroscience: The Foundations of Human and Animal Emotions. New York: Oxford University Press.! 10. Hase, M. (2009) CravEx: An EMDR approach to treat substance abuse and addiction. In M. Luber (Ed), Eye movement desensitization (EMDR) scripted protocols: Special populations (pp ). New York, NY: Springer Publishing Co.! 11. Hase M., Schallmayer, S., & Sack, M., *2008) EMDR reprocessing of the addiction memory: Pretreatment, post treatment and 1-month follow-up. Journal of EMDR Practice and Research, 2 (3), ! 12. Popky., A.J. (2005) DeTUR, an urge reduction protocol for addictions and dysfunctional behavior. In R. Shapiro (Ed), EMDR solutions: Pathways to healing (pp ). New York: W.W. Norton and Company.! 13. Miller, R., (2012): Treatment of behavioral addictions utilizing the feeling-state addiction protocol: A multiple baseline study: Journal of EMDR Practice and Research, 6(4)