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OEI: O bserved & E xperiential I ntegration for Trauma: A New Trauma Therapy Rick Bradshaw, PhD, RPsych Trinity Western University Laurie.

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Presentation on theme: "OEI: O bserved & E xperiential I ntegration for Trauma: A New Trauma Therapy Rick Bradshaw, PhD, RPsych Trinity Western University Laurie."— Presentation transcript:

1 OEI: O bserved & E xperiential I ntegration for Trauma: A New Trauma Therapy Rick Bradshaw, PhD, RPsych Trinity Western University Laurie Detwiler, M.A., C.C.C. Kwantlen Polytechnic University CCPA Annual Conference Ottawa, ON May 18, 2011

2 Polyvagal Theory & Co-Activation of Sympathetic & Parasympathetic Stephen Porges (2001, 2007) Polyvagal Theory –Social Connection – Ventral Vagal Complex (VVC) – Brake = On –Fight or Flight – Sympathetic Nervous System – VVC Brake = Off –Freeze – Dorsal Vagal Complex OEI – Neuro-Activation & Micro-Attunement together –Mirror Neurons, Embodied Simulation, Intentional Attunement OEI – Switching for Titration, Glitch Massaging, Transference –Extraocular muscles, Intraocular muscles, and Proprioception OEI – Switching for Artifacts, Release Points, Sweeping –Feigned Death (Freeze) responses – Chest, Airway, Stomach

3 Observed & Experiential Integration (OEI): What is it? SWITCH – Alternately covering & uncovering the eyes SWEEP – Covering one eye, guiding other eye across TRACK – Guiding one or both eyes, watching for glitches GLITCH MASSAGE – Guiding eye(s) over/out of glitches GLITCH HOLD – Bilaterally stimulating, holding in glitches RELEASE POINTS – Places to guide eyes for release of: * Hyperventilation & temporary cessation of breathing * Chest compression & throat constriction (LR & Abducens) * Nausea, queasiness, abdominal cramping (SO & Trochlear) * Jaw tension and tooth grinding

4 OEI: What is it used for? Rapid de-escalation of affective & somatic intensity Assessment & treatment of negative transference Avoidance of, and relief from, panic attacks Overcoming addictions, including self-harm Dissolving barriers to performance

5 The Self-Trauma Model: Briere Flashbacks constitute natural attempts of the human brain to desensitize traumatic material, but… In those with severe, prolonged childhood trauma there is often a developed capacity to dissociate when overwhelmed (Lanius) This leads to cycles of abreaction and dissociation (PTSD, CPTSD, DDs)

6 OEI & the Abreaction-Dissociation Cycle Dissociation Abreaction Staying within the… …Therapeutic Window

7 Once upon a time…. Two psychotherapists in Vancouver Canada (Audrey Cook & Rick Bradshaw) Working with abuse, neglect and other trauma Finding ‘talk therapies’ ineffective for PTSD, Complex PTSD, and Dissociative Disorders likely because… Psychological trauma affects different areas of the brain than speaking and listening….

8 1994 & ‘95 Audrey Cook found that: EMDR wasn’t working with some CPTSD/DD clients: –Those with ‘lazy eyes’ couldn’t track their therapist’s fingers with both eyes at the same time –Some clients were too dissociated & disconnected –Some clients were overwhelmed by intense abreactions Thought: “I wonder if it would work one eye at a time” - Led to OEI ‘Switching’ (alt covering eyes) SWITCHING VIDEO DEMO

9 OEI and EMDR: Differences EMDR EMDR Doesn’t address negative transference between therapist & patient OEI OEI Includes transference checks & clearances for individuals & groups No acknowledgement of tiny halts or hesitations in eye movements Involves identification and resolution of tiny halts or hesitations-eye movement No recognition of “side effects” of trauma processing on additional aspects of the past Techniques for resolving “artifacts” like headaches, dizziness/drowsiness, and visual distortions

10 OEI and EMDR: Differences EMDR EMDR Mechanism = eye saccades and rhythmic sounds or taps (PGO region of the brain) OEI OEI Mechanism = different than eye saccades and rhythmic sounds / taps; Can involve simple covering of eyes Cognitions are essential in protocol – Negative Cognition, Positive Cognition, SUDS, VoC Cognitions not in protocol. Numbers optional rather than required. Observe Intensity & Conflict Markers

11 OEI and EMDR: Differences EMDR EMDR Requires use of both eyes simultaneously OEI OEI One eye at a time or two eyes Vision not required. Can use sound or touch to stimulate the brain mechanism Requires vision to sense light & track movement across both visual fields Does not acknowledge or address nausea, hyperventilation & cessation of breathing, chest tightening, or jaw clamping Includes “release points” for nausea, hyperventilation & cessation of breathing, chest tightening, and jaw clamping

12 OEI and EMDR: Similarities Can be performed using both eyes. Procedures in both therapies involve the tracking of a moving object (therapist finger, wand, etc.) Involves focusing on trauma in multi-sensory fashion to expose individual to the intensity of past experiences Involves arousal of fight-or-flight response and/or freeze response via midbrain & forebrain.

13 Speech Area: Speech Production

14 Listening Area – Understanding Speech

15 Limbic & Paralimbic Structures The parts of the brain most involved in producing intense symptoms, like: Panic, flashbacks, startle response, nausea, and throat or chest constriction Are not directly affected by talking or listening

16 Limbic System: Midbrain

17 Anterior Cingulate Gyrus

18 Eye & Brain Connections Both eyes have connections to both halves of the brain Half of each visual field in each eye is associated with half of the brain, and the other half of each visual field is associated with the other side of the brain. Integration can occur with one eye at a time or both eyes

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20 An Overview of OEI Procedures with Treatment Targets by Dr. Rick Bradshaw

21 5 Building Blocks of OEI Switch Sweep Glitch Massage Glitch Hold Release Points Level I Techniques Level II Techniques

22 OBSERVATIONS & DISCOVERIES 1 Core Trauma Symptoms: Encountered during processing of traumatic material In the center or ‘core’ of the body. Symptoms include: Hyperventilation temporary cessation of breathing chest compression throat constriction nausea OEI switching reduce & glitch work dissipates intensity Intensity, type of emotion, & location of body sensation usually differs, depending on which eye is covered

23 Core Trauma vs Artifacts p. 30

24 OBSERVATIONS & DISCOVERIES 2 Dissociative Artifacts: In response to intensity of trauma processing Outside (peripheral to) the core of the body Symptoms include: visual blurring & occlusions headaches & pressures tingling & numbness (hands, face, feet) Dizziness, lightheadedness, loss of balance drowsiness Usually dissipated quickly with switching & sweeping Balance boards to assess & minimize dissociation

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26 OBSERVATIONS & DISCOVERIES 3 Shock: “Can you believe it….?” Incongruence: Severity of incident not accompanied by expected emotional & physical intensity markers Process seems blocked by shock Switching and asking the questions: “Can you believe __(name)__ did that to you?” “Can you believe ___(name)___ was killed?” “Can you believe you can’t believe it?” “Can you believe any man would do that to anyone?” Shifts clients out of disconnected states Not unusual for clients to be connected to the reality of an event with one eye open but not with the other open

27 OBSERVATIONS & DISCOVERIES 5 Eye Dom. & Affective/Somatic Differences Dominance check: The Dominance Factor (Carla Hannaford) Majority of clients = more fear & anxiety w dominant eye = sadness & despair w non-dominant If much early onset abandonment/abuse, less predictable Often ‘sad & mad’ or ‘sad & afraid’ Difficulty holding gaze: shame or fear of disapproval

28 OBSERVATIONS & DISCOVERIES 4 Transference Checking & Clearing During switching for core trauma symptoms and dissociative artifacts, clients disclose differences in perceptions of therapists, depending on which eye is covered, including differences in: Perceived proximity of person (close, distant) Color (green or gray to red or yellow) Perceived age or facial expression (angry, caring) Perceived proportions of head & body Perceived attitude or mood of therapist Switching dissolves these perceptual distortions Sometimes add glitch work for resistant distortions Extended to: Mirror work - body/facial dysmorphic disorder Body image perceptions – eating disorders Families & groups (couples/parenting/attachment) Substitutions (photos, videos, symbols & objects)

29 OBSERVATIONS & DISCOVERIES 6 Release Points: Glitches = most intense place in most intense eye Release = least intense place in least intense eye Respiratory system: cover Dom eye, lowest rib, ND side Gastrointestinal: cover Dom eye, lowest rib, Dom side Jaw Tension: alt cover eyes, level of lips, 180º to 90º VIDEO OF RELEASE POINTS P. 27

30 Release Points P. 27

31 Target Application Technique Release Points Respiratory (Chest) BreathingCompression Jaw Tension Gastrointestinal (Throat) (Stomach) ConstrictionNausea

32 Key External Events :Audrey has discovered use of both objective and subjective applications for glitch resolution EMDR International Association Conference, Las Vegas: First Clinician Manual, First Video* Audrey demonstrating subjective glitch track & hold w bilateral audio stimulation in Las Vegas (video) 2002:2nd ed. of OEI Clinician Manual: Hi’s, Lo’s, I/O, H/V/D 2003:OEI Training DVD, first OEI RCT (delayed C)

33 Key External Events : Combine OEI with body therapies (massage) Start arc patterns to reduce lens refocusing : Comparative experimental RCT (18-mo RCT) Titrate with therapist body & face, postures : 20+ conference papers, OEI Client Handbook Glitch massage: proximal-distal movements

34 TargetApplication Technique Switch Transference PartnersMirrors Clearing Artifact Titration Intensity

35 TargetApplication Technique Sweep Clearing Artifact

36 New Applications & Combinations Process & chemical addictions, eating disorders (urges) Inner voices, self-loathing, and self-harming behaviours Peak performance (focus on goals, target interferences) Dissociative disorders & attachment difficulties (states) Somatic symptoms (fibromyalgia, MS, PNES, chronic pain) Combined w language acquisition & accent reduction Combined w systematic desensitization & psychodrama

37 Cross-cultural applications Indonesia: GAM vs Military conflict & Tsunami expatriates vs locals “Massage your brain using your eyes to lift your heavy heart” Gender differences (vulnerable vs guarded emotions) Korea: ‘Expert’ professionals ‘fix’ problems Somatic symptoms = less loss of face Medical procedures to treat symptoms 1st Nations: Family members & community share Attending to quality of relationships Healing broken attachments (RHAP)

38 Glitch Tracking & Massaging Saw note (EMDR listserve): skips/halts in eye movement Resolution of intensity & dissociation with ‘massage’ Patterns were associated with different targets/events ‘Glitches’ seem to clear after massaging ‘stuck points’ Thought: “I wonder if continued work will bring healing?” Led to OEI Tracking & Glitch Work/Massage TRACKING & GLITCH MASSAGE VIDEO DEMO

39 TargetApplication Technique Glitch Massage Transference PartnersMirrors Clearing Artifact Titration Intensity

40 TargetApplication Technique Glitch Hold with Bilateral Stimulation Restoration Visual Splitting Clearing Artifact Titration Intensity

41 The Future of OEI - Part I Unique Contributions of OEI: Easily & quickly integrated with other therapies Reduces interference with cognition & speech (top down) Psychological “Emergency Room” procedures Self-help procedures facilitate affect regulation Increases midbrain-to-prefrontal integration (bottom up) Reduces addictive & self-harming urges

42 Complex PTSD Symptoms & OEI (CPTSD was defined by Herman, elaborated by Curtois) There are OEI techniques that address these: Affect Dysregulation Dissociation/Numbing Negative Self-Perceptions Internalized Perpetrator Beliefs Difficulties in Relationships with Others Somatic Symptoms – Abuse-Specific, Other Despair & Shattered Assumptions of Hope See one-page handout for details

43 Observed: Therapist watches for glitches while tracking Therapist watches for conflict & intensity markers Therapist watches for visual splitting/dilation Experienced:Client cues therapist during tracking (Track-to-Target) Client notices & reports all artifacts Client notices & reports level of intensity

44 Equalization:intensity, colour, light, body tension Combination:emotions (mad & sad) blend or dissolve Joining:alters (infant, child, teen, adult) merge Sensory:double vision clears, pains resolve Dissolution:visual distortions clear Resolution:objects that were invisible materialize

45 First Study of OEI with PTSD Mixed Traumas (witnessing suicides, MVAs, assaults, accidental deaths) and mixed genderMixed Traumas (witnessing suicides, MVAs, assaults, accidental deaths) and mixed gender Random Assignment to OEI or delayed treatment control group, only switchingRandom Assignment to OEI or delayed treatment control group, only switching Script-driven symptom provocation, C = +2 ExpScript-driven symptom provocation, C = +2 Exp CAPS and IES-RCAPS and IES-R

46 Treatment vs Control: CAPS Clinician-Administered PTSD Scale (CAPS) scores from Time 1 to Time 2 for control group (n = 5) and treatment group (n = 5). The dashed horizontal line reflects a threshold for clinically significant levels of PTSD symptoms (Orr, 1997).

47 IES-R Avoidance/Numbing Impact of Event Scale-Revised (IES-R) Avoidance & Numbing subscale scores, Time 1 to Time 2 for control group (N = 5) and treatment group (N = 5).

48 Presentation by Laurie Detwiler, Faculty Member,

49 The Place of Trauma Therapy in the Process of Recovery from PTSD CCPA Annual Conference May 18, 2011

50 Research Questions What critical incident helped or hindered your process of recovery from PTSD?What critical incident helped or hindered your process of recovery from PTSD? What event or experience helped or hindered your process of recovery from PTSD?What event or experience helped or hindered your process of recovery from PTSD? Follow up questions fit well with the method.Follow up questions fit well with the method.

51 Validity Reliability Validity Reliability Careful definition of the purpose of the researchCareful definition of the purpose of the research Qualified observersQualified observers Final follow upFinal follow up Independent judge sorted 25 incidents into helping and hindering categoriesIndependent judge sorted 25 incidents into helping and hindering categories Interpreter reliability: 92% inter-rater agreement between judge and primary raterInterpreter reliability: 92% inter-rater agreement between judge and primary rater

52 Interpret and Report 8 people, 6 women and 2 men, aged 28 to 54 yrs (average = 45 yrs)8 people, 6 women and 2 men, aged 28 to 54 yrs (average = 45 yrs) 6 Caucasian, 2 Caucasian & First Nations6 Caucasian, 2 Caucasian & First Nations Diagnosed with PTSD in 2003 during a trauma therapy studyDiagnosed with PTSD in 2003 during a trauma therapy study Traumatic incidents ranged from sexual assault, emotional abuse, witnessing a death and car accidentsTraumatic incidents ranged from sexual assault, emotional abuse, witnessing a death and car accidents Range of events & time since traumatic eventRange of events & time since traumatic event

53 Categorical Descriptions (helping) 1.Awareness of Recovery Coming From Involvement in Trauma Therapy Study 2.Resources, including Spirituality, Marital/Family, Financial, & Physical 3.Coping Strategies 4.Developing New & Positive Relationship With Self

54 Categorical Descriptions (helping) 5.Growth From Trauma 6.Understanding Your Own Life Experience 7.The Importance of Being Listened to, Cared For, Validated and Accepted For Who You Are by a Professional Helper 8.Making Personal Choices to Lead a Healthy Life

55 Categorical Descriptions (helping) 9. Unexpected Positive Circumstances 10. Knowing That You Are Not Alone 11. Talking Today Was Impactful 12. Forgiveness

56 Categorical Descriptions (hindering) 1.Limitations in Resources 2.ICBC Is An Unhelpful System 3.When Boundaries Fall 4.Difficulty Coping

57 Categorical Descriptions (hindering) 5.Fear Magnification 6.The Physical Pain Cycle 7.Harmful Healers 8.Being In Situations Similar to the Original Trauma

58 Categorical Descriptions (hindering) 9.Unexpected Negative Circumstances 10.Can Not Forgive Self 11.Sexual Difficulties

59 Follow Up Themes 1.Recovery is a process which includes more than therapy, and all categories are important 2.However, OEI was very important in recovery for all 8 (two said 10/10, average score = 8/10) 3.Lack of Social Support as a theme was big, in particular Brewin’s (2003) “Other as Betraying” 4.Also: “Other as Abandoning” Brewin (2003)

60 Latest Sexual Assault & PTSD Study Comparative Experimental Treatment OutcomeComparative Experimental Treatment Outcome 1 year to recruit 137 women, screened to 33, 18 Months from Start to Finish, Participants1 year to recruit 137 women, screened to 33, 18 Months from Start to Finish, Participants Quantitative, Qualitative & Psychophysiological Measures in cross-over designQuantitative, Qualitative & Psychophysiological Measures in cross-over design

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62 Research Design I Selected Trauma of Interest: 20% of women sexually assaulted in lifetimes and almost 50% of those develop PTSDSelected Trauma of Interest: 20% of women sexually assaulted in lifetimes and almost 50% of those develop PTSD Script-Driven Symptom Provocation: 50- second audiotape of most intense portion of trauma played on 4 occasions + TMI-PSScript-Driven Symptom Provocation: 50- second audiotape of most intense portion of trauma played on 4 occasions + TMI-PS Cross-Over Design: CPT-R in phase I gets OEI in phase II, OEI in phase I to CPT-RCross-Over Design: CPT-R in phase I gets OEI in phase II, OEI in phase I to CPT-R

63 Research Design II Controls: Random (Wave) Assignment to Groups and Therapists within GroupsControls: Random (Wave) Assignment to Groups and Therapists within Groups Assessors Blind to Group AssignmentsAssessors Blind to Group Assignments All Participants Receive Control Condition (B.R.A.I.N.) and Active Therapy Participants Receive 3 sessions of OEI or CPT plus 4 hours of Psychoed (sessions & groups videotaped)All Participants Receive Control Condition (B.R.A.I.N.) and Active Therapy Participants Receive 3 sessions of OEI or CPT plus 4 hours of Psychoed (sessions & groups videotaped) Credibility Checks for all Interventions (COTQ)Credibility Checks for all Interventions (COTQ) Manualized TreatmentsManualized Treatments

64 Results - CAPS Time: F(2,21) = 49.62, p =.04, η2 =.83 Time*Group: F(4,42) = 2.96, p =.03, η2 =.22 Group: F(2,22) = 1.32, p =..29, η2 =.11

65 Results – IES-R Numb/Avoid ▲ Control Group ↑ Cognitive Processing Therapy * One Eye Integration

66 Qualitative Interview Findings Randomly selected cases from OEI & CPTSD groups, interviewed at 3-month follow up: –OEI: More profound reduction of PTSD symptoms –CPT-R: Improved ‘coping’ & self-referencing beliefs When participants interviewed after cross-over: –Majority of participants (~ 75%) chose OEI as ‘most beneficial’ of the two therapies after having both –Therapy preference: Interesting trend by MBTI- Thinkers to prefer CPT-R (“makes sense”, “logical”)

67 Limitations Small N & significant screening process Females, mainly Caucasian, sexual assault Manualization may have affected bond – OEI Script-driven symptom provocation – 1 trauma Small treatment doses (3 hrs. individual plus 4 hours group per therapy, along with exposure & psychoeducation components) Extended periods with no active treatment: (3 months + 3 months), additional traumas

68 The Future of OEI - Part II (You) Diffusion of Innovation Theory Diffusion of Innovations 5th ed. (Rogers, 2003) Lovejoy, Demireva, Grayson, & McNamara (2009) Relative Advantage: better job performance & $’s Compatibility: congruence with existing frames Complexity: difficulty in learning, comprehending Trialability: pilot testability on small scale Observability: visibility of positive outcomes

69 Acknowledgements Dr. Marvin McDonald, Dr. Paul Swingle, Dr. Jose Domene, Kristelle Heinrichs, Dave Grice, Marie Amos, Karen Williams, Kiloko Ndunda, Jessica Houghton, Jake Khym, Becky Stewart, Jen McInnes, Darlene Allard, Tanya Bedford, Heather Bowden, Gillian Drader, Brenda DeVries, Danielle Duplassie, Sandra Dykstra, Ida Fan, Esther Graham, Maren Heldberg, Nadia Larsen, Michael Mariano, Beverly Ogden, Steivan Pinoesch, Mandana Sharifi, Nidhi Sharma, Chris Tse, Dana Vanderwiel, Dawne Visbeek, Melissa Warren, Linda Gibson, Andrea Busby, Melissa Ducklow, Kwantlen nurses, TWU UG Psych students. Fahs-Beck Foundation for Experimental Research New York Community Trust


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