Integrating EMDR for tailoringtrauma therapy to the needs ofpatients with complex PTSD

Martin Sack, MDKlinik für Psychosomatische Medizin und PsychotherapieKlinikum rechts der Isar, Munich, Germany

Topics

• Complex PTSD  ‐ a useful clinical concept• Treatment needs and treatment planning for cPTSD• EMDR and ‚Gentle Trauma Therapy‘ – principles• EMDR in cPTSD – practice & manual• Modifications for dissociative clients

Complex PTSD (DESNOS)

Judith Herman (1992)

1. Alterations in affect regulation and impulsivity2. Alterations in self-perception3. Dissociative symptoms4. Disturbances in relationships5. Somatization6. Alterations in systems of meaning

Disorders of Extreme Stress not Otherwised Specified

Lancet 2013

Proposal for ICD‐11 Posttraumatic Stress Disorder

IntrusionsNightmares

Flashbacks

AvoidanceThoughts or Emotions

Places, People, Objects

HyperarousalStartle Reactions

Hypervigilance

2 + 2 + 2 = 6 Questions

Proposal for ICD‐11: Complex Posttraumatic Stress DisorderPTSD plusAffect dysregulation 

Negative self‐concept

Interpersonal Disturbances

Proposal for ICD‐11:ICD‐10: Common Critieria of PersonalityDisorder

PTSD plusAffect dysregulation 

Instable (negative) self‐concept

Interpersonal Disturbances

Specific Comorbidity of BPD

Self‐injuring Behavior 30 – 75%Suicide Atempts 70 – 90%

Prevalence PTSD: 50 – 80% Prevalence Trauma History: 60 – 90%

Complex PTSD in Patients with Borderline‐Personality Disorder (N= 136)

80%

20%

Sack et al., Nervenarzt (84) 2013, S. 608‐614

Clinical differentiation of BPD from cPTSD

cPTSD 70%

BPD 30%

cPTSD 90%

BPD 10%

cPTSD 25%

BPD 75%

cPTSD 97%

BPD 3%

kPTBS 5%

BPD 95%

Anger Outbursts

Instable Relationships

Instable Relationships

yesno

no yes

Chi² = 9.2

Chi² = 42.4

Chi² = 16.1

Two varieties of complex PTSDResick (2007)

Emotions/Arousal

Intrusions

Neg. CognitionsInternalizing Syptomscompl. PTSD Type DESNOS

Externalizing Symptomscompl. PTSDType Borderline

Basal reactions Adjustment / Coping

:

Early life stress is the major cause of any psychiatric disorder

Anda & Felitti 2011

Alterations in the dental structure indicate early life stress

Genes and environment: the brain of James Fallon

Positron-Emission-Tomographie (PET): Grossly reduced cortical activity.

Pattern such as in antisocial personalitydisorder

Family history: Several siblings in the fathers line were

violent deliquents or murderersGenetic risk: Monooxygenase A Gen Polymorphism (Risk for agression and violence)

Gewalttätigkeit) Protective factors:

Need for two separate diagnostic approaches

Categorial diagnostic System of classification (ICD-10) Descriptive, free from aetiology Documentation Financial accounting Scientific categorization

Therapy related diagnostic Related to aetiologic hypothesis Individualised, Non-standardized Often implicitly practiced Useful for treatment planning

Stressor (trauma) based therapy

• If possible, therapy should adress the primarystressors (e.g. by using EMDR)

• When necessary, care first for secundaryproblems (symptoms) e.g. when they aredangerous or very distressing

State dependent unlearning

Preconditions to modify traumatic memory and stress relatedinterpersonal schemata

Realisation – this happend to me Reconstruction – Elaboration of a coherent and functional narrative Empowerment – Gaining experiences of acting competence Mastery – Aquiring a perspective of surviving and healing potentials

A pragmatic concept of therapy:How to gain life‐quality as fast as possible

• Fostering social skills and relation capacities• Fostering self‐awareness and self‐care• Reduction of trauma related symptoms

Aspects of suffering as a compass fortherapy

Anger

Grief

Feeling guilty

Helplessness

Shame

Self-blame

Despair

Disgust

cPTSD – General principles of treatment

• Take symptomatic treatment needs into account• Help fostering self‐relatedness and self‐compassion• Clarify individual treatment needs by adressing theindividual suffering

• Include trauma confrontative therapy (EMDR) asearly as possible

The stress-trauma continuum – a model

Traumatic experiences– Fragmentation of memory (peritraumatic dissociation)– Generalized and chronified traumatic anxiety

Neglect– Experiences of lack and deprivation– Unmet developmental needs

Negative experiences in close relationships– Interpersonal learning experiences under ‚high-stress‘

Trauma

Stress

Typical consequences of negative relational experiencesduring childhood

Alterations in self-experiencing Unsecurity about ones own experiences Experiences of powerlesness and helplesnessUnsecure or avoidant binding behavior Fear of beeing completely alone (dependent behavior) Fear of close contact (avoidant behavior)Problems in close relationships Conflict-avoiding behavior Aggressive behavior or violation of boundaries of others Lack of regulative flexibility in relationships

Typical steps in the treatment of disturbances of thecapacity to relate

Establishing of a sustainable working relationship Fostering self-awareness and experiencing of emotions Fostering self-acceptance and self-confidence Helping to recognize ones own emotional needs Learning to tune in into emotional states and needs of others Learning to formulate needs and to advocate hem Learning to recognize boundaries and to defend them Learning to argue out conflicts

Resource oriented treatment of trauma related disorders

Activating resources means activatingpotentials of change

Day-care clinic for resource activation

Activation of personal resources by fostering:– Self-acceptance and problem understanding– Skills and competences for self-regulation– Ability to establish contact and social competence– Creativity and motivation for behavior change

Individualized psychotherapy:Negotiation of individual treatment goals

Amplifying circle of resource oriented therapy

Activation of resources

Positive self-awareness

Positive emotions

Increased well-being

Increased openness to new ideas

More engagement in therapy

Positive feed back loop

Experiences of competence

Recomendations for ‚gentle‘ trauma therapy

Start trauma work by focussing daily symptoms Appply techniques for

– Distancing– Activation of situational needed resources– Changing traumatic narratives

Care for the individual suffering Actively help gaining experiences of mastery

www.martinsack.de

Dosing the stress by the amount of memory actualization

– Activation of situational specific resourcese.g. ‘wedging technique'

– Oscillating between resource activation and activation of trauma memorye.g. CIPOS (Constant Installation of Positive Orientation and Stimulation)

– Distancing techniquese.g. Screen technique, imaginary trauma work

– Accelerated memory processing e.g. EMDR

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Behandlungselemente schonender Traumatherapie – Ein Modell

Adressing the individual suffering (Sensing and validatinge.g. pain, grief anger)

Adding of positive memory to thetraumatic narrative (e.g. having survived, having well acted)

Exploration of the trauma memory(Completing of fragmentized parts of memory)

Therapeutic alliance(Activation of the binding system)

Therapeutic setting(Feeling safe)

Primary aim: modification oftrauma memory

Primary aim: Stress reductionand resource activation

Creating a functional narrative on the traumatic event(Fostering a sense of mastery)

Protection and caring fortraumatized parts of the self(Ego-state work)

Modification of dysfunctionalcognitions(e.g. shame, guilt, self-blame)

Dosing stress duringconfrontation(Distancing techniques, resource activation)

Gentle Trauma Therapy – a treatment manual

1. Identify trauma related stress apparent in daily life symptoms

2. Get informed consent for confrontave trauma work

3. Focussing and actualization of the trauma memory

4. Exploring and gathering of information (EMDR Phase 4)

5. Facilitating experiences of mastery by activating resources, activemodification of the traumatic narrative or by ego-state work

6. If needed: help the patient to care for traumatized parts of the self

7. Evaluation whether the distress is reduced and/or whether furtheractualization of traumatic memory (see 3) is needed

8. Reorientation to the present situation, debriefing

How to regain a reflexive meta-level

Making the agreement to maintain a reflexive position: 'I need you being an active partner in therapy. Therfore, I will ask you from

time to time, what you think from the present posittion abouth your perceptionswhich arise during working on the past traumatic experiences.'

When needed: change to the role of an observer: What do you think now about what happened in the past?'

Reflexive evaluation of emotional reactions: 'What du you think today as an adult about the past situation? Would it have

been possible for the child to defend oneself?'

Dissociation is the key forunderstanding traumarelated symptoms

Unified model of disturbancesCommon underlyingneurobiologyConstitution of specifictreatment strategies

Evidence for a dissociative subtype of PTSDLanius et al. AmJPsychiat 2010

Dissociation – a disorder of disturbedcapacities of relationship• Self‐relatedness (self‐awareness, self‐compassion)• Lack of presence relatedness (lack of awarenessand mentalization)

• Disturbances in interpersonal relationships (socialavoidance, not percieving boundaries of others)

Patient

Ego‐State Therapy for cPTSD

Therapist

Patient

Classical Hypnotherapy

Trauma Therapy

Therapist

Domains of psychotherapeutic work

Competences and skills (cognitive)– Psychoeducation– Behavior modification– Development of Ego-functions (e.g. mentalizing)

Corrective experiences (emotional) ‚Traumatherapy‘– Modification of implicit (fragmentized) memories– Satisfying individual developmental needs– Fostering experiences of mastery

Growth and maturing (personal)– Individuation and personality development– Development and activation of personal (creative) resources– Value orienting and finding of meaning

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www.martinsack.de

Literatur zum Thema:

Sack M, Sachsse U, Schellong J:Komplexe Traumafolgestörungen – Diagnostik und Behandlung von Folgen schwerer Gewalt und VernachlässigungSchattauer Verlag, 2013

Sack, M: Schonende TraumatherapieSchattauer Verlag, 2010

www.martinsack.de