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Integrating EMDR for tailoringtrauma therapy to the needs ofpatients with complex PTSD
Martin Sack, MDKlinik für Psychosomatische Medizin und PsychotherapieKlinikum rechts der Isar, Munich, Germany
Topics
• Complex PTSD ‐ a useful clinical concept• Treatment needs and treatment planning for cPTSD• EMDR and ‚Gentle Trauma Therapy‘ – principles• EMDR in cPTSD – practice & manual• Modifications for dissociative clients
Complex PTSD (DESNOS)
Judith Herman (1992)
1. Alterations in affect regulation and impulsivity2. Alterations in self-perception3. Dissociative symptoms4. Disturbances in relationships5. Somatization6. Alterations in systems of meaning
Disorders of Extreme Stress not Otherwised Specified
Lancet 2013
Proposal for ICD‐11 Posttraumatic Stress Disorder
IntrusionsNightmares
Flashbacks
AvoidanceThoughts or Emotions
Places, People, Objects
HyperarousalStartle Reactions
Hypervigilance
2 + 2 + 2 = 6 Questions
Proposal for ICD‐11: Complex Posttraumatic Stress DisorderPTSD plusAffect dysregulation
Negative self‐concept
Interpersonal Disturbances
Proposal for ICD‐11:ICD‐10: Common Critieria of PersonalityDisorder
PTSD plusAffect dysregulation
Instable (negative) self‐concept
Interpersonal Disturbances
Specific Comorbidity of BPD
Self‐injuring Behavior 30 – 75%Suicide Atempts 70 – 90%
Prevalence PTSD: 50 – 80% Prevalence Trauma History: 60 – 90%
Complex PTSD in Patients with Borderline‐Personality Disorder (N= 136)
80%
20%
Sack et al., Nervenarzt (84) 2013, S. 608‐614
Clinical differentiation of BPD from cPTSD
cPTSD 70%
BPD 30%
cPTSD 90%
BPD 10%
cPTSD 25%
BPD 75%
cPTSD 97%
BPD 3%
kPTBS 5%
BPD 95%
Anger Outbursts
Instable Relationships
Instable Relationships
yesno
no yes
Chi² = 9.2
Chi² = 42.4
Chi² = 16.1
Two varieties of complex PTSDResick (2007)
Emotions/Arousal
Intrusions
Neg. CognitionsInternalizing Syptomscompl. PTSD Type DESNOS
Externalizing Symptomscompl. PTSDType Borderline
Basal reactions Adjustment / Coping
:
Early life stress is the major cause of any psychiatric disorder
Anda & Felitti 2011
Alterations in the dental structure indicate early life stress
Genes and environment: the brain of James Fallon
Positron-Emission-Tomographie (PET): Grossly reduced cortical activity.
Pattern such as in antisocial personalitydisorder
Family history: Several siblings in the fathers line were
violent deliquents or murderersGenetic risk: Monooxygenase A Gen Polymorphism (Risk for agression and violence)
Gewalttätigkeit) Protective factors:
Need for two separate diagnostic approaches
Categorial diagnostic System of classification (ICD-10) Descriptive, free from aetiology Documentation Financial accounting Scientific categorization
Therapy related diagnostic Related to aetiologic hypothesis Individualised, Non-standardized Often implicitly practiced Useful for treatment planning
Stressor (trauma) based therapy
• If possible, therapy should adress the primarystressors (e.g. by using EMDR)
• When necessary, care first for secundaryproblems (symptoms) e.g. when they aredangerous or very distressing
State dependent unlearning
Preconditions to modify traumatic memory and stress relatedinterpersonal schemata
Realisation – this happend to me Reconstruction – Elaboration of a coherent and functional narrative Empowerment – Gaining experiences of acting competence Mastery – Aquiring a perspective of surviving and healing potentials
A pragmatic concept of therapy:How to gain life‐quality as fast as possible
• Fostering social skills and relation capacities• Fostering self‐awareness and self‐care• Reduction of trauma related symptoms
Aspects of suffering as a compass fortherapy
Anger
Grief
Feeling guilty
Helplessness
Shame
Self-blame
Despair
Disgust
cPTSD – General principles of treatment
• Take symptomatic treatment needs into account• Help fostering self‐relatedness and self‐compassion• Clarify individual treatment needs by adressing theindividual suffering
• Include trauma confrontative therapy (EMDR) asearly as possible
The stress-trauma continuum – a model
Traumatic experiences– Fragmentation of memory (peritraumatic dissociation)– Generalized and chronified traumatic anxiety
Neglect– Experiences of lack and deprivation– Unmet developmental needs
Negative experiences in close relationships– Interpersonal learning experiences under ‚high-stress‘
Trauma
Stress
Typical consequences of negative relational experiencesduring childhood
Alterations in self-experiencing Unsecurity about ones own experiences Experiences of powerlesness and helplesnessUnsecure or avoidant binding behavior Fear of beeing completely alone (dependent behavior) Fear of close contact (avoidant behavior)Problems in close relationships Conflict-avoiding behavior Aggressive behavior or violation of boundaries of others Lack of regulative flexibility in relationships
Typical steps in the treatment of disturbances of thecapacity to relate
Establishing of a sustainable working relationship Fostering self-awareness and experiencing of emotions Fostering self-acceptance and self-confidence Helping to recognize ones own emotional needs Learning to tune in into emotional states and needs of others Learning to formulate needs and to advocate hem Learning to recognize boundaries and to defend them Learning to argue out conflicts
Resource oriented treatment of trauma related disorders
Activating resources means activatingpotentials of change
Day-care clinic for resource activation
Activation of personal resources by fostering:– Self-acceptance and problem understanding– Skills and competences for self-regulation– Ability to establish contact and social competence– Creativity and motivation for behavior change
Individualized psychotherapy:Negotiation of individual treatment goals
Amplifying circle of resource oriented therapy
Activation of resources
Positive self-awareness
Positive emotions
Increased well-being
Increased openness to new ideas
More engagement in therapy
Positive feed back loop
Experiences of competence
Recomendations for ‚gentle‘ trauma therapy
Start trauma work by focussing daily symptoms Appply techniques for
– Distancing– Activation of situational needed resources– Changing traumatic narratives
Care for the individual suffering Actively help gaining experiences of mastery
www.martinsack.de
Dosing the stress by the amount of memory actualization
– Activation of situational specific resourcese.g. ‘wedging technique'
– Oscillating between resource activation and activation of trauma memorye.g. CIPOS (Constant Installation of Positive Orientation and Stimulation)
– Distancing techniquese.g. Screen technique, imaginary trauma work
– Accelerated memory processing e.g. EMDR
Amou
nt o
f ac
tual
izat
ion
Behandlungselemente schonender Traumatherapie – Ein Modell
Adressing the individual suffering (Sensing and validatinge.g. pain, grief anger)
Adding of positive memory to thetraumatic narrative (e.g. having survived, having well acted)
Exploration of the trauma memory(Completing of fragmentized parts of memory)
Therapeutic alliance(Activation of the binding system)
Therapeutic setting(Feeling safe)
Primary aim: modification oftrauma memory
Primary aim: Stress reductionand resource activation
Creating a functional narrative on the traumatic event(Fostering a sense of mastery)
Protection and caring fortraumatized parts of the self(Ego-state work)
Modification of dysfunctionalcognitions(e.g. shame, guilt, self-blame)
Dosing stress duringconfrontation(Distancing techniques, resource activation)
Gentle Trauma Therapy – a treatment manual
1. Identify trauma related stress apparent in daily life symptoms
2. Get informed consent for confrontave trauma work
3. Focussing and actualization of the trauma memory
4. Exploring and gathering of information (EMDR Phase 4)
5. Facilitating experiences of mastery by activating resources, activemodification of the traumatic narrative or by ego-state work
6. If needed: help the patient to care for traumatized parts of the self
7. Evaluation whether the distress is reduced and/or whether furtheractualization of traumatic memory (see 3) is needed
8. Reorientation to the present situation, debriefing
How to regain a reflexive meta-level
Making the agreement to maintain a reflexive position: 'I need you being an active partner in therapy. Therfore, I will ask you from
time to time, what you think from the present posittion abouth your perceptionswhich arise during working on the past traumatic experiences.'
When needed: change to the role of an observer: What do you think now about what happened in the past?'
Reflexive evaluation of emotional reactions: 'What du you think today as an adult about the past situation? Would it have
been possible for the child to defend oneself?'
Dissociation is the key forunderstanding traumarelated symptoms
Unified model of disturbancesCommon underlyingneurobiologyConstitution of specifictreatment strategies
Evidence for a dissociative subtype of PTSDLanius et al. AmJPsychiat 2010
Dissociation – a disorder of disturbedcapacities of relationship• Self‐relatedness (self‐awareness, self‐compassion)• Lack of presence relatedness (lack of awarenessand mentalization)
• Disturbances in interpersonal relationships (socialavoidance, not percieving boundaries of others)
Patient
Ego‐State Therapy for cPTSD
Therapist
Patient
Classical Hypnotherapy
Trauma Therapy
Therapist
Domains of psychotherapeutic work
Competences and skills (cognitive)– Psychoeducation– Behavior modification– Development of Ego-functions (e.g. mentalizing)
Corrective experiences (emotional) ‚Traumatherapy‘– Modification of implicit (fragmentized) memories– Satisfying individual developmental needs– Fostering experiences of mastery
Growth and maturing (personal)– Individuation and personality development– Development and activation of personal (creative) resources– Value orienting and finding of meaning
Res
ourc
eac
tivat
ion
www.martinsack.de
Literatur zum Thema:
Sack M, Sachsse U, Schellong J:Komplexe Traumafolgestörungen – Diagnostik und Behandlung von Folgen schwerer Gewalt und VernachlässigungSchattauer Verlag, 2013
Sack, M: Schonende TraumatherapieSchattauer Verlag, 2010
www.martinsack.de