1.  First Responders and EMDR Roger M. Solomon, Ph.D.

2. Know the Culture First responders  Takes a lot for them to seek help and little to turn them off  Action oriented people, hate confinement  Comfortable giving and taking orders  Decisive, assertive, willing to do the job in front of others  Value conformity, tradition, structure and predictability - things that keep them safe  Responsibility absorbers

3. Therapists  Non-directive and contemplative  Careful not to impose views on others or give advice  Work behind closed doors  Value individuality, spontaneity, and emotional expression

4. First responder culture  Make jokes about therapists (sit around, hold hands, sing “Kumbaya”)  Spend effort controlling feelings and hiding stress reactions  Work is about control of self and others; No one wants to see a first responder break down on scene.  Compartmentalization/suppression of emotion important to deal with the stressors of the job

5. First responder culture  They see a lot of gory things, be prepared  They need to talk about what they have experienced with someone who can understand and contain their own reactions  You don’t have to be stonefaced,, but respond calmly and empathically, e.g. “That must have been tough”.

6. Characteristics of first responders  Resilient - hardy, resilient individuals on the healthier end of the mental health continuum. Undergo psychological screening, rigorous training, and a probation period  Ability to deal with conflicting roles - fight a “bad guy” one minute, comfort a child the next  Always ready for danger/changing circumstances

7. Characteristics of first responders  Occupational suspiciousness  Clannish nature – trust only fellow workers  Distrust bureaucracy and administration - have to exercise discretion and good judgment, and many find it stressful coping with a bureaucracy that has strict policy and guidelines.  Cynical - see the worst society has to offer

8. Critical incidents  A critical incident is a term used to describe a potentially traumatizing event that occurs in the performance of one’s duty, and that potentially overwhelms the responder’s sense of vulnerability and control  Can be direct or vicarious involvement  What is traumatizing for one may not be for another

9. Phases of critical incident aftermath The situation explodes:  Physical mobilization  Mental mobilization perceptual distortions (time, visual, auditory)

10. 2) SHOCK/DISRUPTION  the person may initially be dazed, inattentive, confused - this may last for a few minutes-or a few days  Stress comedown reactions: tremors/shakes confusion crying lightheaded hyperventilation nausea rapid pulse chillssweats [These are stress reactions-not signs of weakness]

11. Shock/Disruption  Denial/Dissociation: Feeling of disbelief  Numbness, with occasional anxiety breakthrough  Running on “auto-pilot”

12. Shock/Disruption  Difficulty remembering details of the event  Difficulty comprehending significance of what happened or  Emotional arousal Upset, emotional, Mad/Sad/Scared

13. Shock/Disruption  May feel elated for having survived a critical encounter  Hyper, agitated, irritable, overactive  Feeling of Isolation - "No one really cares or understands ”

14. Shock/Disruption  Heightened sensitivity to the reactions of others  Preoccupation with event "Its all I can think about"

15. Stress Symptoms Difficulty sleeping Anxiety Irritable Depression Difficulty concentrating Fatigue Stomach aches Muscle aches Indigestion Diarrhea Constipation Change in sex drive Dizziness* High blood pressure* (* indicates need for medical evaluation)

16. 3) Emotional Impact (Reaction Phase)  Usually hits within a couple of days. It may continue several weeks or longer depending on the situation, coping skills, and the presence of support

17. Normal reactions to abnormal situations 1. HEIGHTENED SENSE OF DANGER.....................58% 2. ANGER/BLAMING................................................49 3. NIGHTMARES.......................................................34 4. ISOLATION/WITHDRAWAL................................45 5. FEAR/ANXIETY...................................................40 6. SLEEP DIFFICULTIES..........................................46 7. FLASHBACKS/INTRUSIVE THOUGHTS.............44 8. EMOTIONAL NUMBING......................................43

18. Normal Reactions to Abnormal Situations 9. DEPRESSION....................................................42 10. ALIENATION..................................................40 11. GUILT/SORROW/REMORSE.........................37 12. MARK OF CAIN.............................................28 13. FAMILY ROBLEMS.........................................27 14. FEELINGS OF INSANITY/ LOSS OF CONTROL…………………………….23 15. SEXUAL DIFFICULTIES..................................18 16. ALCOHOL/DRUG ABUSE................................14

19. 4) Coping (Repair Phase)  Facing, understanding, working through and coming to grips with the emotional the emotional impact of the incident.  Reactions become more manageable  Renewed interest in life  Make plans for the future

20. Coping SOUL SEARCHING...  WHAT IF?  IF ONLY?  WHY ME?  WHAT ABOUT NEXT TIME?  CAN I DEAL WITH IT AGAIN?

21. Coping  Is the person ready to face the incident and deal with it - in which case person is ready for intervention OR  Does the person need to withdrawal/avoid reminders and stimulation for awhile?

22. 5) Adaptation (Reorientation)  The incident happened, I was part of it, and that's reality.  I am vulnerable, and that's part of the human condition - but I'm not helpless.  I can't control everything, but I can control my response to an incident.  I did the best I could at the time.

23. Adaptation  Fear is a normal reaction to the perception of danger and can be utilized constructively.  By facing and actively processing my emotional reactions, I will come out stronger.

24. Adaptation I CAN RE-EVALUATE MY VALUES, GOALS AND LIFE PRIORITIES:  I now realize what is important in life.  I can stop and "smell the roses".  I can spend more time with people I care about.  Things that used to upset me just aren't that important anymore.  After coming to grips with my own vulnerability I can emerge stronger and utilize this strength when facing life's other challenges

25. 6) Learning to live with it  EXPERIENCING A CRITICAL INCIDENT IS LIKE CROSSING A FENCE...... AND LOSING ONE'S NAIVETE....WITH NO POSSIBILITY OF JUMPING BACK.

26. Learning to live with it  SIMILAR FUTURE INCIDENTS MAY BRING BACK EMOTIONAL REACTIONS  SIMILAR EXPERIENCES OTHERS HAVE MAY TRIGGER MEMORIES  ANNIVERSARY REACTIONS ARE COMMON

27. Learning to live with it WE ARE VULNERABLE! WE HAVE TO ACCEPT IT AND LEARN TO LIVE WITH IT AND USE THIS VULNERABILITY IN POSITIVE, MEANINGFUL, PRODUCTIVE WAYS FOR OURSELVES AND OTHERS

28. EMDR Therapy: Phase 1 History  Talk about what brought client in to see you  If critical incident, get a narrative of what happened  As about how the incident is impacting the responder  Ask about previous incidents - current clinical picture may be the result of cumulative stress

29. Phase 1: History  First responders may be reluctant to talk about feelings  Be supportive of the officer and the role and duties of a police officer (don’t say, “why didn’t you shoot the gun out of his hand?”)  Not for the squeamish therapist

30. Phase 1: History  Childhood/family of origin issues - may be initial reluctance to talk about these, not understand relevance, wants to focus on here and now (current pain) – May be more productive to elaborate on current situation first, then move into past history if needed.

31. Phase 2 Preparation  “You are not going crazy”  Normal reactions to intense situations  Explanation of EMDR and what to expect  First responder does not have to believe that EMDR works and may think it is silly - WORKS ANYWAY if person is willing to cooperate with the process  Coping strategies (safe/calm place, resources, stress reduction strategies)

32. Stress reduction strategies  Talk it out  Write it out  Work it out (exercise)  Relaxation skills  Hobbies/recreation  Social engagement  Eat healthy meals, avoid excessive alcohol/caffeine  Engage in life

33. Phase 2 For a critical incident  Narrative (individual or with co-workers using structured format) to identify salient points - Frame by Frame  A detailed narrative may not be necessary but experience has shown it may be containing, preventing other memories from opening up, provides focus, and may make treatment more efficient

34. EMDR therapy protocols  Recent event protocol (Shapiro, F.) or Recent Traumatic Event Protocol (Shapiro, E. and Laub, B.)  Emergency Room Procedure (Quinn, G.)  Standard protocol  How soon? When the emotional impact has hit, the client can verbalize what happened and stay present with the affect, and has the ability to reflect on it – ALONG WITH THE USUAL EMDR CRITERIA FOR READINESS

35. Phase 3: Negative and positive cognitions Responsibility:  First responders are responsibility absorbers who need to feel in control  “It’s my fault” (I should have been able to do more/had more control”) / I did the best I could

36. Negative and positive cognitions Safety  I’m in danger……I’m going to die  I’m safe today….I survived Control  I’m powerless….I’m helpless….I’m not in control  I have some control….I did the best I could (What I could do, I did do), beyond my control (not my fault)

37. Made a mistake?  EMDR therapy seems to lead to the person taking responsibility for what happened, realizing what factors may have influenced the decisions and actions resulting in the mistake/miscalculation/misperception, and learning from it.  EMDR therapy will not take away appropriate emotions or appropriate responsibility  NC: “I’s bad/defective…” PC I’m okay, the incident does not define me/ I can learn from this/I can go on

38. Phase 4-7 Useful cognitive interweaves (if looping)  Responsibility (looping on “Its my fault”) - Who was in control? ” or “ What other options were there, realistically? ” or, “ There was a reason you did what you did at that moment. What was going on in your mind? ”  Safety (reliving moments of vulnerability)- “ What happened next?” or, “When did you realize the event was over….that you survived?”

39. Useful cognitive interweaves Control (looping on helplessness)-  What happened next?” may help the responder realize forthcoming actions and decisions where control was exercised.  “ Given the circumstances (or your perception of circumstances at the time), could anybody have done more ?” can help the responder realize that, “ There is a boundary where being a human stops and God begins, ” which is a useful interweave in itself.

40. Client is stuck  Float back/affect scan  Childhood issues  Explore world view (e.g. “not supposed to happen to me”, “I’m always in control”, “bad things don’t happen to good people”)  If processing gets stuck, or client’s symptoms are not abating, it is important move into past (attachment) issues and distressing memories

41. Future template  Responder may have to face situation again  Future incident reoccurring is a tragedy and unpleasant - not necessarily traumatic  Build in response contingencies  Skill building

42. Phase 8 Reevaluation Follow-up  Different issues arise over time  Returning to duty (job looks different)  First similar incident  Anniversary reactions

43. Dynamics of Fear  Here comes Trouble – the situation escalates.  Oh Shit! -- The moment of vulnerability awareness...we may feel weak, vulnerable, or not in control.  "I've got to do something" -- we must act to survive or gain control over the situation. We acknowledge the reality of the danger. We make the transition from an internal focus on vulnerability to an external focus on the danger.

44.  Survival -- We focus on the danger in terms of our ability to respond to it. We Consciously or instinctively come up with a plan. We start to react. We feel more balanced and in control.  "Here Goes" -- the moment of commitment - with our resolve to act, whether instinctual or planned, we mobilize tremendous strength. Our frame of mind is focused; characterized by strength, control over this strength, clarity of mind, and increased awareness: the survival resource.  Response -- We go for it, our response fueled by the survival resource.

45. DEALING WITH FEAR  If we focus solely on the danger, we tend to feel weak, vulnerable and out of control. If we focus on our ability and capability to respond to the situation, we feel more balanced and in control. That's why it's important not to dwell just on the danger, but to focus on our ability to respond.

46. DEALING WITH FEAR  While it is important to face feelings of vulnerability, we must also give ourselves credit for what we did to respond.  Acknowledging what we did in the "survival", "here goes" and "response" stages balances out the moments of vulnerability -- we aren't helpless!

47. DEALING WITH FEAR  M ental rehearsal of critical incident situation will help you learn your tactics; get them to the point where they are instinctual, reflexive, and second nature; and prepare for future encounters.  W E ARE VULNERABLE AND CAN ' T ALWAYS CONTROL A SITUATION, BUT WE ARE NOT HELPLESS. W E CAN CONTROL OUR RESPONSE TO A SITUATION, WITH OUR ABILITY TO RESPOND FUELED BY THE RESOURCE FRAME OF MIND.

48. Dealing with Responsibility Guilt  Frame of mind # 1: perception occurring before or during incident  Frame of mind # 2: frame of mind one has when the situation is over, and all the previously unknown facts and consequences are known  Self- Second Guessing/Responsibility Guilt - being in Frame of Mind $2, negatively judging yourself, without taking into account Frame of Mind #1

49. Responsibility Guilt  To change this, get back in touch with Frame of Mind #1 then go through the situation FRAME BY FRAME.  Knowing what was going on in your mind at the time will help you: understand why you did what you did differentiate what was and WHAT WASN'T under you control, and differentiate what you knew at the time from what was impossible to know.

50. Responsibility Guilt  Given your perceptions of the incident, the information you had at the time, your level of experience, available equipment, and so on..... You either did  The right thing (ALL RIGHT!)  The wrong thing (LEARN FROM IT!)  You did the best you could (WHAT MORE COULD ANYBODY ASK?)

51. Why did this happen to me?  It happened because of your role, not because of who you are.  A better question than "Why did this happen to me?" is " How did this happen to me? " We can't always answer why, we can answer how.

52. Peer Support  An important buffer for trauma  Peers have more credibility than mental health professionals  Peers can aid in initial contact, referral, follow-up, and education