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Advanced Techniques in the Use of EMDR to Treat Complex Trauma

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1 Advanced Techniques in the Use of EMDR to Treat Complex Trauma
Barry Litt, MFT Concord, NH Barrylittmft.com

2 EMDR Consciousness Trauma memory Neocortex Narrative (semantic) Memory
Episodic Memory Stored in Limbic System and Brain Stem Re-lived vs. Remembered Dissociated from Narrative Memory Aspects of Trauma Dissociated from each other (B.A.S.K.) Trauma memory

3 EMDR Why Ego States Matter… Consciousness Trauma memory Fear/avoidance
Negative Transference Distraction Emotional Numbing Blocking Beliefs EMDR Trauma memory Affect Phobia Amnesia Interpersonal Defenses

4 Self as Object Seeking Central Ego Splitting of the Self: 6 – 18 mos.
Object Relations Theory: Fairbairn’s Structural Model of the Self Antilibidinal Ego Libidinal Ego Splitting of the Self: 6 – 18 mos. Central Ego Self as Object Seeking Libidinal ego: need gratification Antilibidinal ego: need frustration

5 Borderline Personality Disorder (Kernberg)
Object Relations Theory: Fairbairn’s Structural Model of the Self Libidinal Ego Antilibidinal Ego Central Ego Ego states split off from central ego to cope with unmanageable anxiety (ambivalence) toward Mother Lack of strong central ego to manage ambivalence and result is borderline personality. Borderline Personality Disorder (Kernberg)

6 Ego Object Relations Theory:
General Model of Introjected Family Members and Their Relationships Ego ID Superego Introjects serve as template for relating to others

7 Introjected Relational Configurations
Object Relations Theory: General Model of Introjected Family Members and Their Relationships Regardless of the family one comes from… Transactional dynamics also introjected Introjected Relational Configurations Yield Relational Attitudes

8 Ego State Theory of Watkins & Watkins
All manner of introjects, including ego cathected roles

9 Pathogenic Family Dynamics
Co-Dependency; Collusive Denial Undifferentiated family ego mass (Bowen) Pseudomutuality (Wynne, 1965) Bilateral transference (Warkentin & Whitaker,1966) Trading of Dissociations (Wynne, 1965)

10 Summary The subjective sense of Self (and corresponding
Pathogenic family dynamics (relational configurations) are internalized as ego state conflicts The resulting ego state system is a structured complementation of the loyalty system The subjective sense of Self (and corresponding relational attitude) is adaptive to the original, formative context

11 Phase 2: Preparation Safety Assessment Self-Harm vs. Stability
(Intrusive Experiences, Dissociation)

12 Phase 2: Preparation Safety Assessment Self-Harm: risk factors
History of Suicidal Ideation History of Suicidal Gestures History of Suicidal Attempts History of Psychiatric Hospitalizations History or Current Reliance of Self-Harm Behaviors

13 Phase 2: Preparation Safety Assessment Self-Harm Interventions
Safety Contract Psycho education DBT Group? RDI, Affect Management Skills Training (AMST) Safe Place

14 Phase 2: Preparation 2. Stability Assessment
Intrusive experiences, including: Fugue, lost time Regression Amnesia Acting-out (e.g., cutting, substance abuse, risk-taking behavior) Panic Attacks; freeze responses Insomnia

15 Phase 2: Preparation 2. Stability Assessment Interventions:
Grounding exercises Mindfulness practice Journaling Present-time orientation Safe-Place work Medication Constructive Avoidance (Forgash) Ego State Work: Daily living team (Twombly)

16 The Overall Structure of Therapy
Three Intertwining Tracks: Cognitive Affective Transformation Relational Repair Cognitive Scaffolding Insight/Psychoeducation Getting it Feeling it Doing it: relational repair, “Making amends,” Improving current relationships, etc. 2. Affective Transformation (EMDR) Relational Repair ; Rejunctive Action; Earning Entitlement

17 Target Selection Kitchur’s Strategic Developmental Model: Genogram-Based Target Selection and Sequence Parents’ Relationship Mother Father Sibling Dynamics Nodal Events

18 EMDR Target Selection, continued
Pathogenic family processes (from genogram) Double binds Split loyalties Intersubjective fusion Dissociated affect from others Affect bridge (floatback) from recent event All likely to surface covert ego states and ego state conflict

19 A. Working with Domains of the Self
Being vs. Nothingness Merit Safety

20 Domains of the Self, continued
Being vs. Nothing Self-Other Dialectic Depersonalization Merit Neurosis Being vs. Nothingness Merit Safety Hypervigilance Safety

21 Cognitive Correlates to Domains of the Self
Being vs. Nothing I don’t exist’ I’m invisible I don’t matter Merit I’m not good enough I don’t measure up I’m a failure I’m bad Being vs. Nothingness Merit Safety I’m gonna die I’m not safe I’m trapped Safety

22 1. Features of the “Being” Domain
Behavior: Acting-out (Better to be bad than to not be at all) Relational conflict and ego state conflict may be “trading up” from not being Cutting; substance abuse; O-C D; etc. Affect: anxiety, panic, fear Sensation: numbing Knowledge (NC): I’m alone, invisible…

23 Working Through the Being Domain
The Importance of Sensation: I think, therefore I am -Descartes I notice that I feel, therefore I am -(Damasio/Litt)

24 Working Through the Being Domain
Event Targets -Rejection -Abandonment, separation, loss -Associations Dynamic Targets: -Narcissistic partner -Partner avoids/withdraws -”As-if” relating

25 Working Through the Being Domain
NC: I don’t exist; I’m invisible; I’m alone; I don’t matter PC: I am; I have myself; I exist even if…

26 Working Through the Being Domain
Body awareness must be maintained EMDR augmented with somatic techniques Sensory integrity necessary for processing Successful processing may “trade up” from numbing to shame/guilt

27 3. Features of the “Safety” Domain
Behavior: avoidance, hypervigilance Affect: anxiety, panic, fear Sensation: autonomic hypoarousal Knowledge (NC): I’m gonna die, I’m not safe…

28 Working through the Safety Domain
Therapist and client work together to maintain some control over fight/flight response Controlled and organized activation of fight/flight motor behavior during desensitization phase Client attention to present condition of body while remembering threat event

29 Parasympathetic Sympathetic
B. Zone of Optimal Arousal for Processing depersonalized abreaction presence absorption Avoiding/relaxed panic Parasympathetic Sympathetic

30 Parasympathetic Sympathetic
Techniques : Distraction Somatic Cueing Present-time Orientation Somatic interweaves Node isolation techniques Olfactory Cueing depersonalized abreaction absorption Avoiding/relaxed panic presence Parasympathetic Sympathetic

31 Parasympathetic Sympathetic
Techniques: Closed eyes Push the NC Node isolation techniques Choosing new target depersonalized abreaction absorption Avoiding/relaxed panic presence Parasympathetic Sympathetic

32 Parasympathetic Sympathetic
Techniques: Breath Control Shift visual perspective (3rd person) Node isolation Distraction Self-soothing techniques “Pushing arms” interweave Present-time orientation Olfactory stimulation Safety Interweave depersonalized abreaction absorption Avoiding/relaxed panic presence Parasympathetic Sympathetic

33 Parasympathetic Sympathetic
Techniques: Self-soothing techniques or, increase absorption Node isolation Silent Breath control cueing depersonalized abreaction absorption Avoiding/relaxed panic presence Parasympathetic Sympathetic

34 Complications in phase Four (Desensitization):
C. EMDR with Ego States Complications in phase Four (Desensitization): Looping Blocking (amnesia; avoidance) Pseudoprocessing “revolving door” ego states Confusion, “overwhelm,” or undifferentiated experience Abreaction (Iatragenic)

35 Phase 3 - 4 Techniques for E.S. Conflict
Change of visual perspective Pushing the NC Node isolation techniques Schiffer Glasses Efficiency Somatic Techniques Affect bridge (floatback) Targeted elicitation of ego state Intervention of the Adult Self Open-ended elicitation of ego state system (e.g., conference room) Demand Characteristic


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