emdr therapy with children with complex trauma: new ... · the use of emdr in treatment of ... v...

Copyright Ana M Gomez, MC, 2007 www.AnaGomez.org www.AgateInstitute.org 1

EMDRTherapywithChildrenwithComplexTrauma:NewFrontiersinTheory,Research

andClinicalPractice

Bellevue,WAAugust26,2017

Presented by: Ana M Gómez, MC,LPCCopyright Ana m Gomez, MC, 2007

ComplexTraumaDefinition____________________________1. Chronictraumatizationoccurringatcriticalperiodsof

development(Ford&Courtois,2009).2. Repeatedandprolongedexposuretotraumaticexperiencesthat

haveapervasiveeffectonneurobiologicaldevelopment,memory,affectregulatingsystem,identityformation.

3. Interpersonalandmayoccurwithinchild’scaregivingsystem.4. Impactsthechild’sintegrativecapacities.5. Exposuretochronicmisattunement(invisiblecomplextrauma)

(Schore,2010).

Copyright Ana m Gomez, MC, 2007

ComplexTraumaticStress

SimpleTraumaticStress

• Studiesshowincreasedlevelsofcortisolthroughoutthedayinchildrenwithearlydeprivationandtrauma(Gunnaretal.,2001).

• EarlyandLongtermstressappeartocausealterationsintheHPAaxis.Childrenwithhistoryofsevereearlyneglect,chronicabuseandtraumashowdissociation,hyperarousalandhigherlevelsofthestresshormonecomparedtonon-traumatizedchildren(DeBellis etal.,2005).

Complex Trauma in Children

Tendencytowardshyper- arousal,Re-experiencing,EmotiondysregulationFailureofprefrontalinhibitionoflimbicregions

Tendencytowardshypo-arousal,Detachment&disengagementfromtheemotionalcontent,Dissociationisaregulatorystrategy(Lanius,Paulsen&Corrigan,2014).

FEELINGTOOMUCH

FEELINGTOOLITTLE

AvoidanceApproach

VERTICALINTEGRATION(Siegel,1999)NeocortexHigherthinkingskills,problem

solving,analysisandsynthesisofinformation

Mammalianbrain

Emotionalprocesses

ReptilianbrainSurvival:Fight

flightRegulation

ArousalZones&Attachmentpatterns(Ogden,Minton&Pain,2006- Schore,2003)

OvertandCovertTargets(Gómez,2009)

OVERTvExplicit,consciousencoding.vClientisabletoverbalizeandacknowledgetheexistenceofsuchevents.

vMechanismsofadaptationsallowfortheconsciousexpressionoftheevent.

COVERTvImplicit,non-consciousencoding.Belowawareness.

vEmotional,non-verbal-sensory.vMechanismsofadaptationoverrideandblockrecollectionorexpressionoftheevent.

EMDRTherapyStudieswithChildren

20studies§ 1metaanalyses:ItfoundEMDRtherapytobeaffectivefortreatingchildrenwhohaveexperiencedtrauma.Rodenburg etal.(2009)

§ 9 RandomizedStudies§ 10Non-RandomizedStudies

TypeIITrauma(Terr,1991)- Moresevere,chronicsymptomscausedbyrepeatedexposuretoextremetraumaticstress.Jarero,I.,Roque-López,S.,&Gomez,J.(2013).TheprovisionofanEMDR-basedmulticomponenttraumatreatmentwithchildvictimsofsevereinterpersonaltrauma.Amultimodaltreatmentwasprovided.

Pre-Treatment Post-Treatment Follow-up

CRTESScores

Jarero,I.,Roque-López,S.,&Gomez,J.(2013).TheprovisionofanEMDR-basedmulticomponenttraumatreatmentwithchildvictimsofsevereinterpersonaltrauma.A

multimodaltreatmentwasprovided.

Pre-Treatment Post-Treatment Follow-up

SPRINT

Jaberghaderi,N.,Greenwald,R.,Rubin,A.,Dolatabadim S.,&Zand,S.O.(2004) agroupof14sexuallyabusedIraniangirlsages12–13yearsreceiving12sessionsofeitherEMDRtherapyorCBT- largeeffectsizeforEMDR

CROPS PROPS RUTTER

MeanChange/Session

EMDR CBT Column1

Figure 2. Mean amount of change per session on each outcome measureCopyright Ana m Gomez, MC, 2007

Wadaa,N.N.,Zaharim,N.M.,&Alqashan,H.F.(2010). TheUseofEMDRInTreatmentofTraumatizedIraqiChildren. DigestofMiddleEastStudies, 19,26-36.______________________________________• Iraqichildren,ages7–12-(68.5%)showedsymptomsofPTSD,and25%ofthemcouldbeclassifiedashavingseveresymptomsofPTSD.

• 12childrenexposedtowar-relatedtraumareceived12sessionsofEMDRtherapyand25childrenwereinthecontrolgroup.

• SignificantdecreaseinPTSDsymptomscomparedtocontrolgroup

Comparison of Eye Movement Desensitization and Reprocessing Therapy, Cognitive Behavioral Writing Therapy, and Wait-list in Pediatric Posttraumatic Stress Disorder Following Single-Incident Trauma: A Multicenter Randomized Clinical Trial (De Roos, et. al. 2017)_______________________________________RCT with three arms (n = 103): EMDR Therapy (n = 43), Cognitive Behavior Writing Therapy (n = 42), and wait-list (n = 18)

v Both yielded significant reductions in a broad range of symptoms after a very limited time spent in treatment sessions, an average of 2 hr and 20 min for EMDR versus 3 hr and 47 min forCBWT

v Remission rates were significantly higher for EMDR than WL based on the child and parentinterviews

v 3 -12 months follow up: Remission rates in the EMDR group improved significantlyfrom 3- to 12-month follow-up

v Standard trauma-focused CBT and EMDR therapy were both efficient. However, components associated with stabilization (e.g. a stabilization phase, coping skills training, or parent-focused interventions) were either excluded or minimally active

v Does not generalize to PTSD tied to multiple traumatic events Copyright Ana m Gomez, MC, 2007

StabilizationVsDirectTraumaProcessing

Stabilization&EmotionRegulation

DirectTraumaProcessing

TreatmentofComplexPTSD:ResultsoftheISTSSExpertClinicianSurveyonBestPractices.Cloitre, Courtois, Charuvastra, Carapezza, Stolbach, Green(2011)___________________________________________

• AnexpertopinionsurveyinitiatedbytheInternationalSocietyforTraumaticStressStudiesComplexTraumaTaskForceregardingbestpracticesforthetreatmentofcomplexposttraumaticstressdisorder(PTSD).

• First-lineinterventionsmatchedtospecificsymptomsincludedemotionregulationstrategies,narrationoftraumamemory,cognitiverestructuring,anxietyandstressmanagement,andinterpersonalskills.

• Trauma-focusedtherapiesandsequencedmulticomponentapproacheswererecommended.Copyright Ana m Gomez, MC, 2007

StabilizationVsDirectTraumaProcessing______________________________________• CriticalanalysisofthecurrenttreatmentguidelinesforcomplexPTSDinadults.DeJongh et.al.(2016). ”theevidencedoesnotcurrentlysupporttherecommendationforastabilizationphasepriortoprovidingtrauma-focusedtreatmentinpersonswithcPTSD,orrelatedsevereorcomplicatedpresentationsofPTSD.”

• “Absenceofwell-designedstudiesdirectlycomparingtrauma-focusedtreatments,withandwithoutaprecedingstabilizationphaseincPTSD”

ADVANCESINTHECLINICALAPPLICATIONSOFEMDRTHERAPYINCHILDRENWITHCOMPLEXTRAUMA

AFFECTTOLERANCE&REGULATION

Preparation&StabilizationPhase

Length Intention

Positive & NegativeAffect Toleranceas a Continuum

“The most significant consequence of early relational trauma is the child’s failure to develop the capacity to self-regulate the intensity and duration of emotional states” (Schore, 2012 ,p.65)

ChangingStateVs

BeingwiththeState

SAD HAPPY

BeingwiththeState

v Canwesitwiththatcolorforafewseconds?

v Canwespendsometimewiththisfeeling?

v Iamrightherewithyouandyourfeeling.

v Physicalizethefeeling.

How much of this feeling can

you sit with?

Can we have a drink or a cup of tea with that

feeling?

Teaching kindness and compassion for our inner ExperiencesHelping children tolerate the intolerable

The Various Levels of Resourcing______________________v Increasing the capacity to change statev Increasing negative affect tolerancev Increasing positive affect tolerancev Meet unmet needsv Restore safety in the present

Regulationisnotjustaboutthereductionofaffectiveintensity,buttheamplificationandintensificationofpositiveemotions.(Schore,2009)

GettingDevelopmentalNeedsMet andTolerance&AmplificationofPositiveAffectiveStates(TAPAS)Protocol(Gómez)2014)

§ Psychoeducationonpositiveaffectand“needs”

§ Childexperiencesthroughthecharacterpositivedyadicstates

§ Positiveaffecttemplatesandnetworksarebuiltandenhanced

§ Thechildmovesthroughvariousstagesuntilchildcantolerateplayful-dyadicsessionswithcaregiver.

Dyadicsessions

Parentmeetingneedsofcharacter-Childastherecipient

Parentmeetingneedsofcharacter-Childasawitness

Parentmeetingneedsofcharacter

Beingtheactiveparticipant

Beingawitness

Charactergettingneedsmet

Manfield (2010)Modified to fit EMDR-SandtrayProtocol with Children(Gómez, 2014)

Gómez, 2013, 2014

• Skin-to-skintouchingbetweenparentsandinfantscontributestoincreasedarousalregulation,lowerheartrate,betterorganizedsleepcycle,longerperiodsofrestfulsleepandoverallcalmness.(Jahromi,Putnam&Stifter,2004,Jones &Mize,2007)

• ….Wearehard-wiredtohaveemotionandmeaningshapedbytheperceptionofeyecontactandfacialexpression(Siegel,1999,p.150)

• Theattunedcaregivernotonlydownregulatesstressfulnegativelychargedarousal,butalsoupregulatespositivearousalnecessaryforexploration(Schore,2012,pp.409)

The Importance of Connection

InstallationofDyadic-RegulatedStates(IDRS)

• Parentandchildengageinplayfulrelationalactivities.

• Playful-dyadicmomentswherethechildappearstobecalm,happyandsafeareinstalled.

RESOURCINGANDEMOTIONLITERACY

Sensory-ModulatingActivitiesResourcingthelowerbrain-Up-regulationand

Down-regulation

vSensoryIntegration(SI),withinthefieldofoccupationaltherapy.

vOccupationaltherapytoolssuchasweightedblankets,piecesofspandex,largecrashpillows,foambuildingblocks.

vTraumasensitiveyoga(Emerson &Hopper,2011).

“Functionalneuroimagingstudiesshowthatmusiccanmodulateactivityinbrainstructuresthatareknowntobecruciallyinvolvedinemotion,suchastheamygdala,hypothalamus,hippocampus,insula,cingulatecortexandorbitofrontalcortex. (Koelsch,2014)

Lowemotionidentificationskill(EIS)predictedincreasesinfearandsadness,decreasesinpositiveaffect,anddecreasesinthequalityandquantityofsocialsupportinboysandgirls.(Ciarrochi etal.,2008)

“Whenyouputfeelingsintowords,you’reactivatingtheprefrontalregionandseeingareducedresponseintheamygdala.Inthesamewayyouhitthebrakewhenyou’redrivingwhenyouseeayellowlight,whenyouputfeelingsintowords,youseemtobehittingthebrakesonyouremotionalresponses.”

Lieberman,professorofpsychologyandco-directorofUCLA’sSocialCognitive Neuroscience (SCN)Laboratory

CognitiveLiteracy

EmotionLiteracy

SomaticLiteracy

DISSOCIATIONSPECIFICPREPARATIONSTRATEGIESMENTALIZATION

“Theheartoftraumaisdissociation”Onno vanderhart

MILDMODERATE

SEVERE

TRAUMARELATED

OvercomingTraumaRelatedPhobiasTherapistasaCo-regulator,Co-organizer&AttunedCompanion

IncreasingAffectTolerance

Titration&Pendulation

WorkingwithParts

• State change• State tolerance

• In & out strategies• CIPOS (Knipe, )• State change installation (Gomez)• This is me then-This is me now (Gomez)

Fear of the Fear (van der Kolk)Phobia of the Trauma (van der Hart)

In&OutStrategies

(Gomez,2009,2013)

ASSESSMENTPHASE

Staging&StrategizingPreparingtheBrainandthe

NervousSystemforProcessing

vCreating the platform needed for processingvAchieving optimal arousal: Nervous system needs to be up or down regulated?vPreparing the body and taking care of basic needs

Staging&Strategizing(Gomez,2009)

PreparingtheBrainandtheNervous

System

vIfthechildneedsmovementandplayfulnesstostayengaged,motivatedandwithinthewindowoftolerance:

üStationsüTheEMDRKitforKidsüTheEMDRteamvIfthechildneedssupport:üHelpersthatprotect,nurtureandplay

üAnimaltotemsüAdvisorsüSpecialpowers

Staging&Strategizing

PreparingtheBrainandtheNervous

System

vIfthechildneedscontainment:üTentsü“Thecushionhouse”“theumbrellahouse”

üThe“shyblanket”vIfthechildneeddistance:üTheEMDR-SandtrayprotocolüTheremotecontrol(Parnell,2007,Gómez,2008,2013)

DESENSITIZATIONPHASE

• “Itisablessingthattheurgeforsocialplay— forjoyousphysicalengagementwithothers— notlefttochancebyevolution,butisbuiltintotheinstinctualactionapparatusofthemammalianbrain”(Panksepp,2009,pp.16).

• Playhelpsustomobilize(sympatheticarousal)withoutlosingourabilitytostaysociallyengaged(ventralvagus)(Porges,2011).

THEEMDR-SANDTRAYPROTOCOLFORCOMPLEXTRAUMA

INTERWEAVES

PlateausofInformation LevelsofInformationProcessing Processing

• Cognitive• Emotional• Somatic-Sensorimotor

Responsibility

Safety

Power&Control

NeocortexHigherthinkingskills,problemsolving,

analysisandsynthesisofinformation

MammalianbrainEmotionalprocesses

ReptilianbrainSurvival:Fightflight,cryforhelp&collapseAutonomicarousal

RegulationCopyright Ana m Gomez, MC, 2007

COGNITIVEPROCESSING

EMOTIONALPROCESSING

SOMATICPROCESSING

Mending theSelf of the Child and the Parent

Systemic-Attachment Informed EMDR Therapy“Approaches and strategies that work with the child and parents’ individual needs AND center their work on the parent-child relationship are most likely to interrupt intergenerational transmission of trauma and disturbances of attachment”Wachs C, Jacobs L. Parent-focused child therapy: attachment, identification and reflective

function. New York: Jason Aronson, Inc.; 2006. pp. 12–14.Copyright Ana m Gomez, MC, 2007

Co-organizerandCo-regulator• Positiveexperienceswithmutualregulationlaysthefoundationforthe developmentof self regulation(Crockenberg &Leerkes &2000)

• Theinfantisdependentupontheparent to recognize his/her owndistressandtomodulateit(Buss&Goldsmith, 1998)

Thechildinitiallydiscovershis/herown internal states by having theparentreflectbackinternalexperiences.

IampowerlessIamabadparent

Dyadically-sharedfear

shameloneliness

IambadIamnotworthyof

love&careIamnotsafe

q SURVIVALq FIGHT/FLIGHTRESPONSESq SELF-PRESERVATIONq FOCUSONSELFRATHERTHAN

MUTUAL-REGULATIONq MISINTERPRETATIONSOFCHILD’S

CUES.PERCEPTIONOFTHECHILDISNEGATIVELYSKEWED

IambadIamunworthyIamnotsafe

IampowerlessIamabad

parent/personMychildisbad&manipulative

•Detachment•Intrusiveness•Abuse•Frighteningresponses.•Misinterpretationsofchild’scues&child’sneeds.•Distortionsintheperceptionofthechild.

Growthinhibitedemotionalandsomatic

states§ Shame§ Anger§ Fear

Fight- flight- dissociativeresponses

Dyadic Moments ofActivation

ANAMGOMEZ,MC,LPCEMDRIACertifiedEMDRTherapist

EMDRIAApprovedConsultantandTrainingProviderEMDRInstituteFacilitatorandSpecialtyPresenterEMDRInstitute,EMDR-IBA&EMDR-HAPTrainerEMDRInstitute,EMDR-IBATrainerofTrainers

Phoenix,AZ(602)803-4601

www.AnaGomez.orgwww.AgateInstitute.orgAnaG@AnaGomez.org

emdr therapy with children with complex trauma: new ... · the use of emdr in treatment of ... v...

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