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First Responders and EMDR

Roger M. Solomon, Ph.D.

Know the CultureFirst 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

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

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

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”.

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

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

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

Phases of critical incident aftermath

The situation explodes:

Physical mobilization

Mental mobilization

perceptual distortions (time, visual, auditory)

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 chills sweats

[These are stress reactions-not signs of weakness]

Shock/Disruption

Denial/Dissociation: Feeling of disbelief

Numbness, with occasional anxiety breakthrough

Running on “auto-pilot”

Shock/Disruption

Difficulty remembering details of the event

Difficulty comprehending significance of what happened or

Emotional arousal Upset, emotional,

Mad/Sad/Scared

Shock/Disruption

May feel elated for having survived a critical encounter

Hyper, agitated, irritable, overactive

Feeling of Isolation - "No one really cares

or understands”

Shock/Disruption

Heightened sensitivity to the reactions of others

Preoccupation with event "Its all I can think about"

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)

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

Normal reactions to abnormal situations

1. HEIGHTENED SENSE OF DANGER.....................58%2. ANGER/BLAMING................................................493. NIGHTMARES.......................................................3

4 4. ISOLATION/WITHDRAWAL................................455. FEAR/ANXIETY...................................................406. SLEEP DIFFICULTIES..........................................467. FLASHBACKS/INTRUSIVE THOUGHTS.............448. EMOTIONAL NUMBING......................................43

Normal Reactions to Abnormal Situations

9. DEPRESSION....................................................42 10. ALIENATION..................................................4011. GUILT/SORROW/REMORSE.........................3712. MARK OF CAIN.............................................2813. FAMILY ROBLEMS.........................................2714. FEELINGS OF INSANITY/ LOSS OF CONTROL…………………………….2315. SEXUAL DIFFICULTIES..................................1816. ALCOHOL/DRUG ABUSE................................14

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

Coping

SOUL SEARCHING...

WHAT IF?

IF ONLY?

WHY ME?

WHAT ABOUT NEXT TIME?

CAN I DEAL WITH IT

AGAIN?

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?

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.

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.

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

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.

Learning to live with it

SIMILAR FUTURE INCIDENTS MAY BRING BACK EMOTIONAL REACTIONS

SIMILAR EXPERIENCES OTHERS HAVE MAY TRIGGER MEMORIES

ANNIVERSARY REACTIONS ARE COMMON

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

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

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

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.

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)

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

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

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

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

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)

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

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?”

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.

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

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

Phase 8 ReevaluationFollow-up

Different issues arise over time

Returning to duty (job looks different)

First similar incident

Anniversary reactions

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.

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.

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.

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!

DEALING WITH FEAR

Mental 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. 

WE ARE VULNERABLE AND CAN'T ALWAYS CONTROL A SITUATION, BUT WE ARE NOT HELPLESS. WE CAN CONTROL OUR RESPONSE TO A SITUATION, WITH OUR ABILITY TO RESPOND FUELED BY THE RESOURCE FRAME OF MIND.

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

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.

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?)

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.

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