Presentation on theme: "By Lisa Johnson, PhD, LMFT and Margaret, “Peggy” Moore, LISW"— Presentation transcript:
1 By Lisa Johnson, PhD, LMFT and Margaret, “Peggy” Moore, LISW Frankly My Dear I Don't Give a Damn: Could EMDR Help Scarlett and Rhett?By Lisa Johnson, PhD, LMFT and Margaret, “Peggy” Moore, LISW
2 ObjectivesExplore theoretical foundations for coaching couples to use EMDR bilateral stimulation together to manage emotional reactivity.Describe Relationship Enhancement (RE) therapy as an option for incorporating EMDR into therapeutic process.Use Case examples for coaching one couple through Safe Place Exercise and Discussion of emotionally charged topic to manage reactivity of partners during discussion.Explain Case Selection criteria and Areas where caution is warranted.Propose research on this method for keeping couples together during EMDR processing.Although the published EMDR protocols for couples suggest separating partners while EMDR is used to process anxiety provoking material, there may be reasons to keep partners together. For example, when developing a safe place for containment and resource development in EMDR protocol, one partner may be able reference their partner’s calm/safe place to deescalate the conflict. Knowing the connections between the past traumas, present triggers and future projections can provide intimacy that allow the couple a deeper empathic connection, and avoid triggering, or participate in processing future triggers.
4 Can this marriage be saved? The final scene from "Gone with the Wind"
5 Scarlett’s Problems Scarlett’s age Adolescence (incomplete development of the cerebral cortex)ImpulsivityLack of emotional regulationUnbounded energy and imagination
6 Rhett’s problems College dropout Alienation from his family and communityUnwillingness to commit to a cause or a relationshipOpportunist
7 Could EMDR have been helpful? We’ll ask you this question again at the end of this presentationWe are proposing having couples deliver BLS during discussion of emotional charged topics to help manage their emotional reactivity, increase connection and enhance trauma recovery
8 Hypothesis about why this may work The couple becomes the object for safety while discussing emotionally charged memories and experience instead of the therapist.Therapist is there to facilitate and coach the couple in managing emotional reactivity in each other, which builds trust and competency.The couple learns skills for helping their partner soothe and return to "whole brain" functioning that they can implement on their own.When couples come to therapy they may bring individual trauma from their past as well as trauma that emerged in the relationship. There are several forms of therapy to help couples address conflict, but when trauma is present, Eye Movement Desensitization and Reprocessing (EMDR) may be useful to help the couple process the traumas that plague the relationship as well as help improve the communication between them. In Francine Shapiro’s early EMDR trainings, bringing EMDR into a conjoint session with a couple was briefly touched on by citing two cases. The first case involved a therapist who had both husband and wife in the room while the therapist treated the wife for old traumatic memories. The husband was attentive and supportive when he gained new insight into his spouses suffering. In the second case, the husband fell asleep during the EMDR session.Since then, many family therapists have experimented with various ways of using EMDR in couples therapy. One textbook that resulted from these efforts is “EMDR and Family Systems Therapy,” which several chapters are devoted to the work EMDR therapists have done with couples. Most of the published EMDR protocols for couples separate individuals for the EMDR processing, then return them to conjoint care once they have processed their fears (see “Eye Movement Desensitization and Reprocessing (EMDR) Scripted Protocols: Basics and Special Situations” edited by Marilyn Luber Ph.D.). However, Relationship Enhancement (RE) therapy and coaching may provide a format for bringing EMDR into conjoint therapy.
9 Relationship Enhancement 5 minutes Teach/Coach couples to resolve conflict independentlyListen with deep empathy (using Becoming).Express themselves effectively (with Reflection).Discuss by putting empathy and expression together in a conversation.Problem Solving becomes a win/win possibility as each partner's needs are met.In Relationship Enhancement coaching, couples practice showing deep empathy and effective expression to discuss and negotiate problems in a manner that builds connection and trust in the relationship. Deep empathy and effective expression require that one regulates his or her individual affect to set aside his or her own thoughts and feelings to hold a separate concept of the other within their mind while listening and showing understanding. To do so this requires significant mental and emotional restraint, especially when one is learning these skills. Strong emotions like, fear and anger interfere with affect regulation and block one’s ability to empathize with the other. When the partner's behavior triggers or becomes associated with fear, it interferes with the ability to empathize and express feelings and ideas. Hearing memories of trauma from one’s partner’s childhood is less challenging to empathize with than listening to an account of how one’s partner was hurt by one’s own behavior.
10 Neurobiological under pinnings We must have access to whole brain to learn new skills,The Rational/Empathetic part of the brain is disabled when brain stem has been triggered.Memory integration is blocked during overwhelming events.The brain is THE SOCIAL ORGAN of the body, and we need other people to feel in balance.Healthy self-regulation, through relationships and self-reflective observation, may depend on the development of the integrated circuits of these prefrontal regions.Dan Siegel: It is relevant to note that these nine middle prefrontal functions can be seen to emerge not only with mindful awareness practices, but at least the first seven are also associated with the outcome of secure attachment between child and caregiver. This finding may suggest that experiences of “mental attunement” – interpersonal in the case of attachment or internal in the practice of mindful awareness – may be at the heart of developing an integrated brain and well-being. Healthy self-regulation, through relationships and self-reflective observation, may depend on the development of the integrated circuits of these prefrontal regions.One proposal about trauma’s effects on memory is that it may transiently block the integrative function of the hippocampus in memory integration. With massive stress hormone secretion or amygdala discharge in response to an overwhelming event, the hippocampus may be temporarily shut-down. In addition to this direct effect of trauma of hippocampal function, some people may attempt to adapt to trauma by dividing their conscious attention, placing it only on non-traumatic elements of the environment at that time. The resultant neural configuration of blocked hippocampal processing, when reactivated, can present itself as free-floating, unassembled elements of perception, bodily sensation, emotion, and behavioral response without the internal sense that something is coming from the past. Beliefs and altered states of mind may also enter consciousness as the implicit mental models and priming become activated in response to environmental or internal triggers resembling components of the original experience. This “implicit-only” form or memory can be one explanation for the flashbacks and symptomatic profile of Post Traumatic Stress Disorder.The key to memory integration is the neural reality that focal attention allows the puzzle pieces of implicit memory to enter the spotlight of attention and then be assembled into the framed pictures of semantic and self-memories. With such reflective focus, what was once a memory configuration capable of intrusion on a person’s life can move into a form of knowing that involves both deep thoughts and deep sensations of the reality of the past.Our brain is the social organ of the body. The structure of our neural architecture reveals how we need connections to other people in order to feel in balance and to develop well. As we’ve seen in the function of the middle prefrontal regions, the brain integrates input from other people with the process of regulating the body, balancing emotional states, and the creation of self-awareness. This visceral, social, and self integration suggests that our minds are woven from the integration of aspects of reality that on the surface appear to be quite disparate. How could bodily, interpersonal and mental go together? To explore this dimension, let’s use the example of mirror neurons to highlight the integration of these domains of reality.The mirror neuron system offers us a new vista into the neural basis of not only imitation, social behavior and empathy, but also the interpersonal experiences that may promote a state of well-being…. As two individuals share the closely resonant reverberating interactions that their mirror neuron systems make possible, what before may have been unbearable states of affective and bodily activation within the patient may now become tolerable with conscious awareness.
11 RELAXATION RESPONSEEMDR therapists notice that once BLS begins the client usually experiences a relaxation response.Dr Gregory NicossaEEG studies in the early 90’s indicated that the BLS seem to allow the two sides of the brain to communicate better thus the brain is working more efficiently.
12 Mirror NeuronsMarco iacoboni (UCLA) has argued that mirror Neuron systems in the human brain help us understand the actions and intentions of other people.In 2005, iacoboni and his colleagues reported that mirror neurons could discern if another person who was picking up a cup of tea planned to drink from it or clear it from the table.In addition, iacoboni has argued that mirror neurons are the neural basis of the human capacity for emotions such as empathy.
13 Case selection and implementation Pick couples a who are committed to relationship, there is no history of violence within their relationship, or current actual threatening behavior of abandonment or violence.Just like trust needs to be evident with a therapist, trust and capacity for empathy must be available in the relationship. The relationship with the therapist must have sufficient time to develop the couple's trust of the therapist.Assess whether the individuals need their own individual EMDR separate from the couple work
14 Case Study: Linda & Dave Linda and Dave have been living together for 4 years and in a relationship for 11 years.Linda has two adult children from her previous marriage.Linda has PTSD due to child abuse by her biological father and step mother and domestic violence from her first husband. Her mother died when she was young and lived with maternal grandparents in a very loving home prior to moving in with her father and stepfather.Dave reports having anorexia from ages and was treated with hospitalization and family therapy. He reports this issues have been resolved and was in marital counseling “in marriages 1, 2 and 3” and currently attends monthly individual therapy.Linda and Dave learned the basic skills for Relationship Enhancement (RE), and attended a RE weekend workshop.Although they learned the RE skills and use them well when calm, they still struggle with emotionally charged material.
15 Linda & Dave Relationship Challenges Linda kept her trauma history buried to allow her to function, but was triggered when she thinks Dave is angry.When triggered, she sometimes retreated to a bedroom and locked the door, shutting Dave out.When Linda shut Dave out it reminded him of one of his previous marriages when he was locked out of his house and cut off from his belongings.There was no evidence of violence between Linda & Dave. Dave said he wanted to understand what triggered Linda so they can work on it together. He wanted her to feel safe so she didn’t shut him out.Linda would rather share her history with Dave than anyone else.
16 Linda & Dave Safe Place Exercise Linda and Dave learned the basic skills for Relationship Enhancement, and attended a RE weekend workshop and have mastered the skills, but don’t practice much outside of session and still struggle with using the skills with emotionally charged material. We decided to introduce EMDR to manage the emotional reactivity while using the RE skills to discuss emotionally charged issues. Linda attended two sessions alone prior to this session due to Dave’s scheduling conflicts. During those individual sessions she did the Safe Place Exercise and processed one incident of abuse by her father and step mother. She reported she did not like EMDR because it opened up these memories and she had difficulty containing them after the sessions.
17 Linda & Dave Helping Other Change Discussion Dave has expressed his concern about how Linda pushes herself beyond her limits when she is injured. This concerns him because they are both very active (they met while running on the trails) and he wants her to maintain her mobility into their old age together. Linda has reflected his concerns to his satisfaction and she is ready to respond.
18 Linda & Dave Treatment Plan Use BLS while discussing emotionally charged current issues within the relationship to assist each member in managing emotional reactivity and allow each of them to use their whole brain to solve problems.In a previous session, Dan raised a concerns with Linda about his discomfort with her enthusiasm about his campaign for judge.In this session, Dave used “Helping Others Change” RE skill to address his concern about the way Linda pushes herself past pain when injured.In the subsequent session Dan shared what it was like for him when he was a teenager with anorexia.
19 Linda & Dave Treatment Plan part 2 Process Linda and Dave’s past traumas with the partners administering BLS using traditional EMDR protocols to assist them in understanding the others triggers to promote trust and connection during conflicts.I suspect that Dave experienced a form of emotional trauma due to his reaction to being “shut out” by Linda that has not bee fully explored.Dave maintains that he is forthcoming with dealing with his feelings, but with a history of anorexia and three failed marriages there is a history of trauma.
20 Linda & Dave Treatment Plan part 3 Improve Containment and Resource installationLinda admits that she avoids talking and thinking about her trauma history due to interference in her functioning.
21 John and Louise Jack and Flora Two case studiesJohn and LouiseJack and Flora
22 Louise is 62 years old and a retired professional Louise is 62 years old and a retired professional. She was widowed about 10 years ago. Her deceased husband had a lingering debilitating disease. They had two children who are grown and have families of their own.John is 68 year old retired professional. He was divorced from his first wife about 30 years ago. They had one child who lives a great distance away and the realtionship is somewhat strained.
25 John’s History His mother was a “war bride” from Europe John’s father was a violent alcoholic.He was the oldest of 3 childrenHe is a Vietnam veteranHe has been in treatment for PTSD for over 10 yearsJohn says that his family relied on him to protect them from his violent father. On one occasion when he was older he thought that he’d killed his father when he knocked him out. His mother was very passive.
26 Marital HistoryJohn was married about 42 years ago for 3 ½ years and has a daughter and two grandchildren.His relationship with his daughter is strained and he feels his grandchildren disrespect himJohn and Louise met online and dated for about 5 months before they married.
27 Louise’s history Louise and her late husband had 2 children They are both married and have children of their own. John has an excellent relationship with his step childrenLouise took care of her very ill husband for about 10 years before he died.
28 Problems in the Marriage John has developed physical problems that leave him in pain a great deal of the timeLouise resents his disability and feels she was mislead about his health before they were married.Louise gets angry and strikes out verbally at JohnJohn collapses emotionally when this happens
29 Problems con’tLouise feels that John does not respect her intellect and abilities “I’m never right. He argues with me all the time”John feels helpless and powerless to change the interactions once they escalateJohn is described as having OCD
30 Committed to the Marriage Both John and Louise say they are committed to the marriage
32 INDIVIDUAL EMDR PLAN1. work with each one individually around current triggers and past touchstone memories2. when there is improvement in these areas begin conjoint EMDR therapy3. continue individual work as needed
33 Louise’s workLouise is triggered by John’s poor physical health . She thought she was going to have a healthy new husband and she is very resentful.Louise’s work centered around the behaviors that trigger memories of her husband’s illness.
34 John’s work John panics when he feels he is under attack He doesn’t feel safeTouchstone memory was of his father beating down his door in the middle of the nightOther violent confrontations with his father that made him feel that he was a dangerous person.The way I survived my Dad was to dissociate from him . If I dissociate from Louise it’s a dangerous thing. Resolved…I’m more at peace, more than I have ever been in my entire life..I just want Louise to be at peace.
35 Couple’s workOnce both had defused their current triggers they came together and the RE therapy model was used as they tapped on each other's handsThe targets were the issues that had triggered their fights in the past.
36 RESULTS ARGUMENTS BECAME MUCH LESS FREQUENT JOHN NO LONGER PANICKED WHEN ISSUES CAME UP WITH LOUISELOUISE FELT MORE RELAXED AND COMMITTED TO THE RELATIONSHIPIn the individual sessions Louise had said that she was very unhappy in the Marriage and felt she’d made a big mistake but just wanted to be able to tough it out. John on the other hand was totally committed and very much in love with Louise.
38 COMMITTED, BUT IN CONFLICT M75 yoJACK AGE 40FLORA AGE 38Amy age 2
39 Themes of conflict How to raise and discipline their adopted daughter Flora’s conflicts with her mother in lawManaging a relationship that has many demandsSame process as first case but individual session not needed. Husband had individual EMDR work about 5 years prior regarding work issues .
40 Additional workSuggestions on how to manage the additions to their householdMother in laws need to cook every nightSuggestions for parenting
41 Couple completed their counseling after 4 sessions
42 Guidelines for EMDR therapist “Clinicians need to use their own best judgment about what will be beneficial to clients.”Francine Shapiro cited two instances in her book;one where conjoint sessions enhanced the couples connectionone where the partner fell asleep during processing.Sufficient preparation, provide orientation and informed consent, reasonable explanation of what to expect. If you suspect dissociation, screen for dissociation.Restrain the couple from practicing on their own prior to practicing and being coached in therapist presence.Once they have sufficient mastery with coaching, prescribe easy to process topics to use, such as safe place exercise or resource enhancement, such as talking about fun times together that they would like to increase or improve.
43 Could EMDR Help Rhett and Scarlett? Individual work first?Bonnie's deathGrief work together or separately?Rhett’s break from school and family?Scarlett’s impulsive choices?Scarlett’s losses
44 Research suggestions Research that compares the effectiveness of this model is needed.Comparing couples using Conjoint EMDR to couples using individual EMDR may show if this is more effective at building connection .Measuring physiological reactions during couples discussion in conjoint therapy with and without BLS may support the theory that the use of BLS assists in managing reactivityOthers?
45 References and Resources Iacoboni ,M. (2009) Imitation, empathy, and mirror neurons. Annu Rev Psychol. 2009;60:Ortwein, M.C and Guerney, B. (2005) Mastering the Mystery of Love: An easy-reading relationship enhancement program for couples. Leader’s Guide. Relationship Press: Frankfort, KY. curriculum/mastering-the-mysteries-of-love/Scuka, R.F (2005). Relationship Enhancement Therapy: Healing through deep empathy and intimate dialogue. Routledge: NYC.Shapiro, F. (2010). The EMDR Approach to Psychotherapy: EMDR Institute Basic Training Course (weekend one and two) . EMDR Institute: Watsonville, CA.Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing: Basic principles, protocols and procedures. Guilford Press: NYC.Siegel, M.D. (2007). An Interpersonal Neurobiology Approach to Psychotherapy: Awareness, Mirror Neurons, and Neural Plasticity in the Development of Well-Being.