EMDR Treatment With Juvenile Delinquent Populations

CJC 2004

Jay D. Fellers, LCSW

•EMDR-- Eye Movement Desensitization and Reprocessing is a psychological method for treating emotional difficulties that are caused by disturbing life experiences, ranging from traumatic events such as combat stress, assaults and natural disasters, to upsetting childhood events.

•EMDR is also being used to alleviate performance anxiety and to enhance the functioning of people at work, on the playing field, and in the performing arts.

•EMDR is a complex method that brings together elements from well-established clinical theoretical orientations including psychodynamic, cognitive, behavioral, and client-centered treatments. For many clients, EMDR provides more rapid relief from emotional distress than conventional therapies.

What is EMDR?

EMDR

“Looking Through Hemispheres”

An Introductory Video

Dr. Francine ShapiroDr. Bessel van der Kolk

David Grand, CSW

EMDR: An Accelerated Information Processing Model

• Within everyone is a physiological information processing system, that processes experiences to an adaptive state.

• Under normal circumstances, this information processing may occur during thinking, talking, expressive/artistic activities, and/or dreaming.

• Information is stored in Memory Networks—images, thoughts, feelings, physical sensations.

• Memory Networks are organized around the earliest related event.

EMDR: An Accelerated Information Processing Model

• Traumatization has been described as a disruption of the inherent information processing system that normally leads to integration and adaptive resolution following upsetting experiences (van der Kolk & Fisler, 1995)

• In trauma, however, a malfunction of this natural information processing system occurs such that the experience of the trauma remains “frozen”, manifesting in persistent intrusive thoughts, negative emotions and self-referenced beliefs, and unpleasant body sensations.

TRIGGERS

Components of Traumatic Memory

EMOTIONS

BELIEFSSENSATIONS

PICTURES

TRAUMA

EMDR: An Accelerated Information Processing Model (cont.)

• EMDR specifically targets traumatic material and appears to restart this ‘stalled’ information processing in a focused manner, facilitating the resolution of the traumatic memories through the activation of neurophysiological networks in which appropriate and positive information is stored.

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What Happens during EMDR?

•A traumatic memory and associated cognitions, emotions, and somatic distress are identified.

•The client is engaged in bilateral stimulation while experiencing various aspects of the memory.

•The clinician stops the bilateral stimulation at regular intervals to ensure that the client is processing adequately.

What Happens during EMDR?

•The client processes information about the negative experience, bringing it to an "adaptive resolution."

•The "three-pronged approach" addresses:1) earlier life experience. 2) present-day stressors. 3) desired thoughts and actions for the future.

•EMDR treatment may last from 1-3 sessions to 1 year or longer for complex problems.

Why Do Clients Seem to Respond Well to EMDR?

•EMDR is a client-centered approach that allows the clinician to facilitate the mobilization of a client's own inherent healing mechanism which stimulates an innate information processing system in the brain.

• The EMDR model acknowledges the physiological component in emotional difficulties. The EMDR protocol directly targets these physical sensations, along with negative beliefs, emotional states, and other disturbing symptoms.

Why and how does EMDR work? Hypothesized Mechanisms

• Many hypotheses have been put forth to explain the possible mechanism of change related to EMDR, but a definitive explanation has not been confirmed.

EMDR: Hypothesized Mechanisms

One hypothesis was proposed by Harvard Medical School sleep researcher Robert Stickgold, Ph.D. at the 1998 EMDRIA Annual Conference:

EMDR: Hypothesized Mechanisms

“EMDR facilitates the processing of traumatic memory by activating brain systems normally activated during REM sleep.”

EMDR: Hypothesized Mechanisms

• Bessel van der Kolk, M.D. of Boston University School of Medicine states (Boston Globe, 1998):

“In a recent EMDR study, in collaboration with the New England Deaconess/Beth Israel Neuroimaging Laboratory, brain scans were used to measure how brain activity changes after effective treatment.”

EMDR: SPECT IMAGES—PTSD(Amen, 2003)

• No Treatment-- EMDR & St. John’s Wort• Increased Cingulate, Basil Overall Improved Activity• Ganglia, & Limbic Activity

EMDR: SPECT IMAGES—PTSD(Amen, 2003)

No Treatment-- EMDR & St. John’s WortIncreased Cingulate, Basil Overall Improved ActivityGanglia, & Limbic Activity

What is the Research Indicating the Efficacy of EMDR?

Research Demonstrating the Efficacy of EMDR

• EMDR is an empirically valid treatment for civilian post traumatic stress disorder recognized by the American Psychological Association.

• EMDR received an A/B rating from the International Society for Traumatic Stress Studies (ISTSS).

Research: Efficacy of EMDR for Civilian PTSD

Marcus, Marquis, & Sakai (1997) study:

Results showed Kaiser HMO projected to save $2.8 million annually using EMDR for PTSD.

Research: Efficacy of EMDR for Civilian PTSD

Three of four studies comparing EMDR and CBT showed EMDR to be more efficient (Ironson, Freud, Strauss, & Williams, 2002; Lee, Gavriel, Drummond, Richards, & Greenwald, 2002)

EMDR Research: Panic Disorder & Phobias

•Goldstein & Feske (1994)

•Choking phobias (De Jongh, & ten Broeke, 1999)

•Simple phobias (De Jongh, ten Broeke, & Renssen,1999)

•Blood and injection phobias (Kleinknecht, 1993)

Other EMDR Research

•Symptoms arising after a natural catastrophe (Grainger, Levin, Allen-Byrd, Doctor, & Lee, 1997)

•Test Anxiety (Mayfield & Melnyk, 2000)

•Crisis Intervention (Solomon, 1998)

EMDR Research Re: Conduct Disorder

•EMDR Treatment for Children With Treatment Resistant Disaster-Related Distress (Chemolab & Nakashima, 1996)

•Enhancement of Victim Empathy Along With Reduction in Anxiety & Increase of Positive Cognition of Sex Offenders After Treatment With EMDR (Datta & Wallace, 1996)

•EMDR For Boys With Conduct Problems (Soberman, Greenwald, & Rule, 2000)

EMDR & Conduct Disorder (cont.)

•Trauma & Conduct Disorder (Puffer, Greenwald, & Elrod, 1998)

•The Role Of Trauma in Conduct Disorder (Greenwald, 2000)

•A Trauma-Focussed Individual Therapy Approach for Adolescents With Conduct Disorder (Greenwald, 2002)

•MASTR Therapy for Adolescents with Conduct Problems (Greenwald, 2002)

EMDR Research Re: Substance Abuse

•EMDR Treatment Protocol Based on a Psychodynamic Model of Chemical Dependency (Omaha, 1997)

•DETUR: A New Approach to Working With Addictions (Popky, 1998)

•EMDR Chemical Dependency Treatment Manual (Vogelmann-Sine, Sine, Smyth, & Popky, 1998)

EMDR Research

•There is much research in progress.

•See “Efficacy of EMDR,” updated yearly by the EMDR Institute.

•www.emdr.com•www.emdria.org•www.emdrhap.org•www.andrewleeds.net

The Eight Phases of EMDR Treatment

1. Client History and Treatment Planning2. Client Preparation3. Assessment4. Desensitization5. Installation6. Body Scan7. Closure8. Reevaluation

Client History and Treatment Planning

• Intergenerational Genogram

• Negative Cognition Inventory

• Assess Level of Dissociation

• Substance Abuse Assessment

Client Preparation

• Establish Trust

• Stabilization & Safety

• Motivation—External vs. Internal;Precognition, Cognition, Determination,Action, Motivation

• Resource Development—Cognitive, Affective, Self-Soothing (Safe Place)

The Core of EMDR Treatment

ASSESSMENT PHASE

DESENSITIZATI0N PHASE

INSTALLATI0N PHASE

SOMATIC

The Core of EMDR Treatment

ASSESSMENT PHASEPresenting IssuePictureNegative Cognition (NC) and Positive Cognition (PC)Validity of Cognition (VOC)Emotions/FeelingsSubjective Units of Distress (SUDS)Location of Body Sensation

DESENSITIZATI0N PHASEPotential Responses: Pictorial Processing, Cognitive Processing, EmotionalProcessing, Sensory ProcessingAssociative Links and Feeder MemoriesInformational Plateaus: Responsibility, Safety, and Choices

INSTALLATI0N PHASEIntegration of Positive Cognition with Targeted Information and VOC Check

SOMATIC OR BODY SCAN

Brief Therapy Inside Out Video

EMDR: Working Through Grief

Dr. Francine Shapirowith

Jon Carlson, Psy.D., Ed.D.

Diane Kjos, Ph.D.

Childhood Trauma Case Example

ClientA 17 year old male struggling with negative conclusions about himself resulting from being physically abused by his stepmother, witnessing domestic violence, biological mother’s substance abuse.•Presenting Problems: Marijuana dependence, delinquent behavior, truancy, poor peer choices, conflict avoidance, hypervigilence, guilt, self-hatred, mistrust of others, and a sense of hopelessness and helplessness.•Negative Cognitions: I am weak. I need to get high to deal with the pressure.•Positive Cognitions: I can get through anything. I can deal with it without getting high.

Assessment Components•Picture: Stepmother pulling him out of his bed and whipping him—age 5•Negative Cognition: I'm weak.•Positive Cognition: I can get through anything.•VOC=4•Emotions/Feelings: Fear, sadness, anxiety, hopelessness•SUDS=8•Location of Body Sensation: Tension in the neck and shoulders, knots in stomach, palpitations in chest.

Traumatic MemoryAge 5

Physical Abuse byStep-mother

TRIGGERS•Getting ready for school

•Conflict•Female anger

EMOTIONS

BELIEFSSENSATIONS

PICTURESFear, sadness, anxiety, hopelessness

•I am weak. I need to get high to deal with the pressure.

•Tension in neck and shoulders•Knots in stomach•Palpitations in chest

•Stepmother pulling him out of his bed and whipping him—age 5

Childhood Trauma Case Example (cont.)

Childhood Trauma Case Example

Possible Information Processing Shifts:

Responsibility

Safety

Choices

Childhood Trauma Case Example (cont.)

Possible Information Processing Shifts Related to Concepts of Responsibility, Safety, and Choices:

Responsibility:

•I was too young to defend myself.

•Dad never stopped her.

Safety:

•I’ll never have to live with her again.

•I’m not weak anymore.

Choices:

•I don’t need to pity myself.

•I won’t use this anymore as an excuse.

Substance Abuse Case Example

ClientA 17 year old male struggling with negative conclusions about himself resulting from being physically abused by his stepmother, witnessing domestic violence, biological mother’s substance abuse.•Presenting Problems: Marijuana dependence, delinquent behavior, truancy, poor peer choices, conflict avoidance, hypervigilence, guilt, self-hatred, mistrust of others, and a sense of hopelessness and helplessness.•Negative Cognitions: I am weak. I need to get high to deal with the pressure.•Positive Cognitions: I can get through anything. I can deal with it without getting high.

Assessment Components•Picture: Biological mother calling him asking for money—for drugs?•Negative Cognition: I need to get high to deal with the pressure.•Positive Cognition: I can deal with it without getting high.•VOC=5•Emotions/Feelings: Fear, sadness, anxiety, hopelessness•SUDS=6; •Urge to use=6•Location of Body Sensation: Pain in lower back

Substance AbuseTrigger:

Role Reversal & Substance Abuse by

Mother

TRIGGERS•Mother calling•Female need

EMOTIONS

BELIEFSSENSATIONS

PICTURESUpsetting, disappointing,Confusion, frustration,Pressure, temptation

•I am weak. I need to get high to deal with the pressure.

•Pain In Lower Back

•Mother calling him in AM, on way to borrow money

Substance Abuse Case Example (cont.)

URGE TO USE

Substance Abuse Case Example (cont.)

Possible Information Processing Shifts Related to Concepts of Responsibility, Safety, and Choices:

Responsibility:

•I’m doing what I’m afraid she’s doing.

•I use this as an excuse to get high.

Safety:

•I don’t have to feel pressured

•I’m not weak anymore.

Choices:

•I don’t have to take her call.

•I can tell her no.

Resource Development Installation

•Identify Characteristics or Qualities Needed to Deal with Problem

•Identify Existing Examples of Quality

•Own Examples—feelings & body sensation

•Others’ Reports of Own Quality—feelings & body sensation

•Known Others’ Quality—feelings & body sensation

•Others (Fact or Fiction) Quality—feelings & body sensation

•Symbol (i.e. Animal) of Quality—feelings & body sensation

•Reinforce each example with 3 Short Sets of Bilateral Stimulation

•Anchor Cue Word of Quality

•Install Future Templates

Substance Abuse RDI Example

ClientA 15 year old male struggling moderate family conflict, peer pressure.•Presenting Problems: Marijuana dependence, delinquent behavior, truancy, poor peer choices, conflict avoidance, and a sense of hopelessness and helplessness.•Negative Cognitions: I am easily tempted.•Positive Cognitions: I have self control.

Identify Characteristics or Qualities Needed to Deal with Problem

•Picture: Peers talking about using drugs. He thinks about skipping class and getting high.

•Qualities Needed: Self Control, Thinking About Consequences Before Acting, Staying Focused on Goals, Choosing Right From Wrong, Keeping Busy.

Substance Abuse RDI Example (cont.)

•Identify Existing Examples of Quality

•Friend tries to get him to smoke, says no without thinking—proud, good feeling in chest

•Peer asks him to ditch class with him, says no—feels good, shoulders relaxed

•Admires another friend, refuses to get high—admires, gut

•Skateboarder peer doesn’t use—good feeling, warm behind ears

•Jesus, tempted a lot, never gave in—good feeling, chest

Substance Abuse RDI Example (cont.)

Reinforce each example with 3 Short Sets of Bilateral Stimulation (less if negative content arises)

Anchor with “Self-Control”

Install Future Templates re: Peers talking about using drugs, thinking about skipping class and getting high, using anchor & recalling inner resources, imagining doing something different. Note emotions and body sensations, reinforce with short set of bilateral stimulation.

Homework

•Between-Session Work Inherent—Processing Continues

•Noticing what comes up (thoughts, memories, feelings, body sensations, dreams, nightmares, conflicts, etc.)

•Remembering the Big 3—thoughts, feelings, body sensations

•Noticing spontaneous positive changes

•Remembering to Use Self-Soothing Techniques i.e. Safe Place

EMDR Websites

•www.emdr.com

•www.emdria.org

•www.emdrhap.org

•www.andrewleeds.net