emdr therapy with children with complex trauma: new ... · the use of emdr in treatment of ... v...
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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).
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ComplexTraumaticStress
SimpleTraumaticStress
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• Studiesshowincreasedlevelsofcortisolthroughoutthedayinchildrenwithearlydeprivationandtrauma(Gunnaretal.,2001).
• EarlyandLongtermstressappeartocausealterationsintheHPAaxis.Childrenwithhistoryofsevereearlyneglect,chronicabuseandtraumashowdissociation,hyperarousalandhigherlevelsofthestresshormonecomparedtonon-traumatizedchildren(DeBellis etal.,2005).
Complex Trauma in Children
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Tendencytowardshyper- arousal,Re-experiencing,EmotiondysregulationFailureofprefrontalinhibitionoflimbicregions
Tendencytowardshypo-arousal,Detachment&disengagementfromtheemotionalcontent,Dissociationisaregulatorystrategy(Lanius,Paulsen&Corrigan,2014).
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FEELINGTOOMUCH
FEELINGTOOLITTLE
AvoidanceApproach
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VERTICALINTEGRATION(Siegel,1999)NeocortexHigherthinkingskills,problem
solving,analysisandsynthesisofinformation
Mammalianbrain
Emotionalprocesses
ReptilianbrainSurvival:Fight
flightRegulation
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ArousalZones&Attachmentpatterns(Ogden,Minton&Pain,2006- Schore,2003)
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OvertandCovertTargets(Gómez,2009)
OVERTvExplicit,consciousencoding.vClientisabletoverbalizeandacknowledgetheexistenceofsuchevents.
vMechanismsofadaptationsallowfortheconsciousexpressionoftheevent.
COVERTvImplicit,non-consciousencoding.Belowawareness.
vEmotional,non-verbal-sensory.vMechanismsofadaptationoverrideandblockrecollectionorexpressionoftheevent.
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EMDRTherapyStudieswithChildren
20studies§ 1metaanalyses:ItfoundEMDRtherapytobeaffectivefortreatingchildrenwhohaveexperiencedtrauma.Rodenburg etal.(2009)
§ 9 RandomizedStudies§ 10Non-RandomizedStudies
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TypeIITrauma(Terr,1991)- Moresevere,chronicsymptomscausedbyrepeatedexposuretoextremetraumaticstress.Jarero,I.,Roque-López,S.,&Gomez,J.(2013).TheprovisionofanEMDR-basedmulticomponenttraumatreatmentwithchildvictimsofsevereinterpersonaltrauma.Amultimodaltreatmentwasprovided.
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Pre-Treatment Post-Treatment Follow-up
CRTESScores
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Jarero,I.,Roque-López,S.,&Gomez,J.(2013).TheprovisionofanEMDR-basedmulticomponenttraumatreatmentwithchildvictimsofsevereinterpersonaltrauma.A
multimodaltreatmentwasprovided.
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Pre-Treatment Post-Treatment Follow-up
SPRINT
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Jaberghaderi,N.,Greenwald,R.,Rubin,A.,Dolatabadim S.,&Zand,S.O.(2004) agroupof14sexuallyabusedIraniangirlsages12–13yearsreceiving12sessionsofeitherEMDRtherapyorCBT- largeeffectsizeforEMDR
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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
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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
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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
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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”
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ADVANCESINTHECLINICALAPPLICATIONSOFEMDRTHERAPYINCHILDRENWITHCOMPLEXTRAUMA
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AFFECTTOLERANCE®ULATION
1
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Preparation&StabilizationPhase
Length Intention
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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)
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ChangingStateVs
BeingwiththeState
SAD HAPPY
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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?
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Teaching kindness and compassion for our inner ExperiencesHelping children tolerate the intolerable
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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
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Regulationisnotjustaboutthereductionofaffectiveintensity,buttheamplificationandintensificationofpositiveemotions.(Schore,2009)
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GettingDevelopmentalNeedsMet andTolerance&AmplificationofPositiveAffectiveStates(TAPAS)Protocol(Gómez)2014)
§ Psychoeducationonpositiveaffectand“needs”
§ Childexperiencesthroughthecharacterpositivedyadicstates
§ Positiveaffecttemplatesandnetworksarebuiltandenhanced
§ Thechildmovesthroughvariousstagesuntilchildcantolerateplayful-dyadicsessionswithcaregiver.
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Dyadicsessions
Parentmeetingneedsofcharacter-Childastherecipient
Parentmeetingneedsofcharacter-Childasawitness
Parentmeetingneedsofcharacter
Beingtheactiveparticipant
Beingawitness
Charactergettingneedsmet
Manfield (2010)Modified to fit EMDR-SandtrayProtocol with Children(Gómez, 2014)
Gómez, 2013, 2014
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• 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
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InstallationofDyadic-RegulatedStates(IDRS)
• Parentandchildengageinplayfulrelationalactivities.
• Playful-dyadicmomentswherethechildappearstobecalm,happyandsafeareinstalled.
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RESOURCINGANDEMOTIONLITERACY
2
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Sensory-ModulatingActivitiesResourcingthelowerbrain-Up-regulationand
Down-regulation
vSensoryIntegration(SI),withinthefieldofoccupationaltherapy.
vOccupationaltherapytoolssuchasweightedblankets,piecesofspandex,largecrashpillows,foambuildingblocks.
vTraumasensitiveyoga(Emerson &Hopper,2011).
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“Functionalneuroimagingstudiesshowthatmusiccanmodulateactivityinbrainstructuresthatareknowntobecruciallyinvolvedinemotion,suchastheamygdala,hypothalamus,hippocampus,insula,cingulatecortexandorbitofrontalcortex. (Koelsch,2014)
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Lowemotionidentificationskill(EIS)predictedincreasesinfearandsadness,decreasesinpositiveaffect,anddecreasesinthequalityandquantityofsocialsupportinboysandgirls.(Ciarrochi etal.,2008)
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“Whenyouputfeelingsintowords,you’reactivatingtheprefrontalregionandseeingareducedresponseintheamygdala.Inthesamewayyouhitthebrakewhenyou’redrivingwhenyouseeayellowlight,whenyouputfeelingsintowords,youseemtobehittingthebrakesonyouremotionalresponses.”
Lieberman,professorofpsychologyandco-directorofUCLA’sSocialCognitive Neuroscience (SCN)Laboratory
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CognitiveLiteracy
EmotionLiteracy
SomaticLiteracy
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DISSOCIATIONSPECIFICPREPARATIONSTRATEGIESMENTALIZATION
3
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“Theheartoftraumaisdissociation”Onno vanderhart
MILDMODERATE
SEVERE
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TRAUMARELATED
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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)
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Fear of the Fear (van der Kolk)Phobia of the Trauma (van der Hart)
In&OutStrategies
(Gomez,2009,2013)
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ASSESSMENTPHASE
4
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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
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Staging&Strategizing(Gomez,2009)
PreparingtheBrainandtheNervous
System
vIfthechildneedsmovementandplayfulnesstostayengaged,motivatedandwithinthewindowoftolerance:
üStationsüTheEMDRKitforKidsüTheEMDRteamvIfthechildneedssupport:üHelpersthatprotect,nurtureandplay
üAnimaltotemsüAdvisorsüSpecialpowers
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Staging&Strategizing
PreparingtheBrainandtheNervous
System
vIfthechildneedscontainment:üTentsü“Thecushionhouse”“theumbrellahouse”
üThe“shyblanket”vIfthechildneeddistance:üTheEMDR-SandtrayprotocolüTheremotecontrol(Parnell,2007,Gómez,2008,2013)
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DESENSITIZATIONPHASE
5
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• “Itisablessingthattheurgeforsocialplay— forjoyousphysicalengagementwithothers— notlefttochancebyevolution,butisbuiltintotheinstinctualactionapparatusofthemammalianbrain”(Panksepp,2009,pp.16).
• Playhelpsustomobilize(sympatheticarousal)withoutlosingourabilitytostaysociallyengaged(ventralvagus)(Porges,2011).
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THEEMDR-SANDTRAYPROTOCOLFORCOMPLEXTRAUMA
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INTERWEAVES
6
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PlateausofInformation LevelsofInformationProcessing Processing
• Cognitive• Emotional• Somatic-Sensorimotor
Responsibility
• Cognitive• Emotional• Somatic-Sensorimotor
Safety
• Cognitive• Emotional• Somatic-Sensorimotor
Power&Control
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NeocortexHigherthinkingskills,problemsolving,
analysisandsynthesisofinformation
MammalianbrainEmotionalprocesses
ReptilianbrainSurvival:Fightflight,cryforhelp&collapseAutonomicarousal
RegulationCopyright Ana m Gomez, MC, 2007
COGNITIVEPROCESSING
EMOTIONALPROCESSING
SOMATICPROCESSING
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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.
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IampowerlessIamabadparent
Dyadically-sharedfear
shameloneliness
IambadIamnotworthyof
love&careIamnotsafe
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q SURVIVALq FIGHT/FLIGHTRESPONSESq SELF-PRESERVATIONq FOCUSONSELFRATHERTHAN
MUTUAL-REGULATIONq MISINTERPRETATIONSOFCHILD’S
CUES.PERCEPTIONOFTHECHILDISNEGATIVELYSKEWED
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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
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