Eye Movement Desensitization and Reprocessing

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Eye Movement Desensitization and Reprocessing

• As a Tool for Treatment of Trauma AmongNative
  Americans
• Mary (Mimi) Y. Sa, Psy.D.
• MS Psychopharm
• Taos-Picuris Service Unit
• Indian Health Service
• Mary.sa_at_ihs.gov

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Unique Properties of Trauma Endured by Native
Americans

• Generational in nature
• Caused by fundamental destruction of major areas
  
• - Family
• - Culture
• - Language
• - Identity
• - Introduction of alcohol
• - Introduction of sexual abuse

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History of Trauma Theories

• Janet
• Fixated on trauma
• Unable to focus on the present
• Freud
• Considered the fixated trauma to be biologically
  based
• Pavlov
• Defensive reaction
• US to CR, then CS to CR
• Abraham Kardiner
• Coined phrase posttaumatic stress
• People with traumatic neurosis have enduring
  vigilance to environment

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Physiology of Trauma

• Profound alterations in stress hormones
• Intense stress causes release of cortisol,
  epinephrine, norepinephrine, vasopressin,
  oxytocin and endogenous opioids
• Norepinephrine
• Vietnam veterans found to have higher levels of
  NE in their urine
• Other studies have shown low urinary cortisol
  levels in Vietnam vets (which is negative
  feedback of NE)

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Physiology of Trauma

• 5HT
• Inescapably shocked animals displayed decreased
  CNS serotonin levels (van der Kolk, 1985)
• Decreased serotonin levels associated with
  impulsivity and aggression as well as emotional
  hyperarousal
• Endogenous opioids
• Stress related to analgesia
• Fear associated with release of endogenous
  opioids
• Re-exposure to stimuli similar to original will
  cause opioid release (even two decades later)
• Release equivalent to 8mgs of morphine
• Memory is impaired by release of ne and opioids

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Symptomatology of PTSD

• 3 most significant factors for developing
  disorder
• Magnitude of exposure
• Prior trauma
• Social support
• Abnormal physiological responses
• Response to specific reminders of trauma
• Response to intense, but neutral stimuli
  (startle)

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Symptomatology of PTSD

• Peter Lang
• Associative networks
• Where if one element of the memory reoccurs then
  the entire traumatic experience is relived
• So certain sensations or emotions related to the
  trauma keep reoccurring and do not fade over time
• Kolb
• First to suggest trauma may cause permanent
  neuronal changes
• Those changes can effect learning and stimulus
  discrimination

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Symptomatology of PTSD

• Abnormal startle response (ASR)-hallmark of PTSD
• Studies show 93 of those with PTSD have this
• Even after their symptoms remit
• Versus 22 of normal controls
• People with PTSD have inability to discriminate
  innocuous stimuli and continue to relive the
  threatening stimuli

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Symptomatology of PTSD

• Bimodal response
• Hypermnesia, hyper-reactivity to stimuli and
  traumatic re-experiencing
• Psychic numbing, avoidance, amnesia and anhedonia
• In apparent attempt to counteract hyperarousal,
  traumatized people seem to shut down
• They often go from stimulus to response without
  assessing the meaning
• That makes them prone to freeze or overreact and
  intimidate others in response to minor
  provocations

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Arousal and Traumatic Memories

• High states of arousal may cause person to feel
  traumatized again
• Therefore drugs that stimulate arousal
  (yohimbine, lactate) can cause flashbacks or
  panic attacks
• When traumatized person is under stress, will
  secrete stress hormones (NE, endorphins,
  oxytocin) that interfere with memory consolidation

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Arousal and Traumatic Memories

• Oxytocin may be protective amnesic to help
  mothers forget the experience of childbirth.
• In traumatized people, they will over remember
  the trauma any time they are physically aroused.

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Memory, Trauma And Limbic System

• Amygdala
• Assigns meaning to emotional stimuli
• Hippocampus
• Is suppressed by stress hormones
• Associated with memory and learning
• Decreased hippocampal functioning causes
  behavioral disinhibition
• In animals, stimulation of amygdala suppresses
  hippocampus

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Traumatic memories

• Include sensory memories (implicit vs. verbal)
• These are subcortical systems and lie underneath
  the evaluative processes of the prefrontal cortex
• So are outside of conscious awareness
• Have no linguistic representation
• Implicit memory can interfere with frontal lobe
  activity (executive function) and language
  production (Brocas area)

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Traumatic Memories

• So traumatic memory can be irrational
• In traumatized person, the memory is fragmented
  into pieces
• Non-traumatized people do not have a large
  physiological reaction to most memories that
  include sights, sounds, smells
• When traumatized person has a memory, they live
  it
• Their body re-experiences what it did at the time
  of the trauma
• May not have language to describe it

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Intense Arousal

• When it is too great, individual often too
  overwhelmed to analyze and process sensory input
• So tends to shut down or panic
• Often people self-soothe with drugs or alcohol
• Or increase pain by self-mutilation or anorexia
• Arousal stays intense because the stimuli are not
  properly assimilated into the neural network

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Narrow Interpretation of Stimuli

• Often individuals with PTSD will interpret
  innocuous stimuli as traumatic as their ability
  to attach sensory information to new meaning has
  become inflexible
• Van der Kolk describes PTSD as a frozen sensory
  world
• It is therefore the job of the therapist to open
  up alternative interpretations of sensory data

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Trouble With Talk Therapy for Trauma

• Trauma is often stored in right hemisphere (per
  pet scan research) or subcortical regions.
• Therefore, verbal discussion of trauma not always
  possible.
• Van der Kolk (1994) asserts that understanding
  the physiological arousal to trauma may not help
  a person stop the process.

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Trouble With Talk Therapy for Trauma

• Often individuals are unwilling to
  verbally/intentionally recall the painful event.
• Which may account for large drop-out rates in
  this type of therapy.
• Especially since talk therapy is often slow.
• The task in working with PTSD individuals is to
  help them integrate their fractured memories,
  without too much re-traumatization.

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EMDR

• History
• Francine Shapiro walking through park
• Started experimenting on friends
• Then on clients
• Now research is pervasive

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EMDR

• Explanation
• Information processing therapy
• Assumes humans are physiologically based sensory
  processing systems
• Trauma blocks the natural processing of sensory
  stimuli

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EMDR

• Explanation (cont.)
• Which stops the creation of new neural networks
  to interpret stimuli.
• Adaptive processing is thought to occur when
  targeted memory is linked with neutral cognitions
  and reduced physiological arousal.

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EMDR

• Ideal for trauma victim
• Positive response can come as quickly as minutes
  after treatment.
• Do not need to talk about trauma.
• Do not need to ask for as much trust from client,
  which may be helpful with traumatized individual.

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Proposed Mechanism of Action

• Some theorists suggest the bilateral stimulation
  of the brain simulates REM sleep and that both
  actions cause the integration of sensory
  experiences into long term memory.

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Case Studies

• Veterans
• Children
• Blow down
• The dental example
• Sexual abuse
• Loss of loved one
• Eczema guy

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The Nuts and Bolts

• Seems to work best on discrete trauma.
• Traumatic events (especially those from
  childhood) often cause us to create negative
  beliefs about ourselves.
• Have person identify the positive belief they
  want to have about themselves.
• Identify level of distress
• Have them rate this

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The Nuts and Bolts

• Identify intensity of negative belief.
• Decide which type of stimuli to use (tapping vs.
  eye movements)
• Stimulate for about one minute, then check in
• Follow persons breathing, affect

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The Nuts and Bolts

• Go slowly or stop if person seems overwhelmed.
• Keep going if person seems engaged but tolerant
  of affect.
• Have person continue to rate distress level until
  distress level is low and negative belief seems
  untrue.
• Now continue until positive belief is installed.

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Personal Practices

• My preferred method is tapping.
• Client can close her eyes.
• Some complain of dizziness with eye movement.
• Be careful, however, about issue of touch
• Make sure person is prepared/willing to go on
  huge emotional journey for the next 30 minutes or
  so.
• i.e., make sure they dont have an important
  board meeting afterward
• Give thorough explanation of the theory.
• Then give thorough explanation of what the
  process entails.

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Personal Practices

• Ask permission to sit in front of client.
• Do rating and identification process.
• Begin tapping for about one minute.
• Follow their breathing and affect to decide how
  long.

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Personal Practices

• Keep up process until person appears to have
  dramatically reduced their emotion and their body
  appears calm.
• Finish with a guided imagery scene while you are
  tapping.
• Instruct patient to eat well, hydrate and go to
  bed early as they will likely start to yawn and
  appear very fatigued.
• Some therapists assert that it is like doing 20
  years of therapy in 20 minutes.

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Use in Primary Care Setting

• Mental health professional can be brought in on
  emergent basis to calm distressed individuals in
  hospitals in clinics.
• Can help with anxiety about medical procedures or
  new diagnoses.
• Can help if client discloses profound trauma in
  medical setting and client is in need of
  immediate relief.

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Ways of Integrating Native Traditional
Beliefs/Practices

• Many people report feeling a transfer energy.
• Discussion of clients seeing sprits of their
  deceased loved ones after the grief was resolved.
• If provider follows traditional practices, can
  utilize while tapping.

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Provides a Unique Opportunity for Healing for
Natives

• Because they can enjoy immediate relief, which
  will require less trust of the provider.
• They do not have to discuss the trauma, which
  will possibly improve their willingness to try.

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EMDR Certification

• EMDR.com
• Weekend 1 and weekend 2 training
• Certification
• Must be licensed mental health professional

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Bibliography

• Freud, S. (1919/1954). Introduction to
  Psychoanalysis and Neuroses. Standard Edition
  17 207-210. Translated and edited by Strachey.
  London Hogarth Press.
• Janet, P. (1889). LAutomatisme Psychologique.
• Kardiner, A. (1941). The Traumatic Neuroses of
  War. New York Hoeber.

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Bibliography

• Kolb, L.C., Multipassi, L.R. (1982). The
  conditioned emotional response A subclass of
  chronic and delayed post traumatic stress
  disorder. Psychiatric Annals, 12, 979-987.
• Lang, P.J. (1979). A bio-informational theory of
  emotional imagery. Psychophysiology, 16,
  495-512.
• Pavlov, I.P. (1926). Conditioned Reflexes An
  Investigation of the Physiological Activity of
  the Cerebral Cortex. Edited and translated by GV
  Anrep. New York Dover Publications.

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Bibliography

• Van der Kolk, B. (1994). The body keeps the
  score memory the evolving psychobiology of
  post traumatic stress. Harvard Review of
  Psychiatry, 1(5), 253-265.
• Van der Kolk, B. van der Hart, O. (1991). The
  intrusive past The flexibility of memory and
  the engraving of trauma. American Imago, 48,
  425-454.
• Van der Kolk, B.A., Greenberg, M.S., Boyd, J. and
  Krystak, J.H. (1985). Inescapable shock,
  neurotransmitters and addiction to trauma
  Towards a psychobiology of post traumatic
  stress. Biol Psychiatry, 20, 314-325.

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Native American Clip Art

• www.Firstpeople.us
• Designed by Paul Burke