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May 29th, 2014

5/29/2014

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My latest Article about Co-Occurring Substance Abuse and Trauma (PTSD) treatment is published in the June 2014 issue of Counseling Today.  Read article:
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A Publication of the American Counseling Association
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Counseling Today, Features EMDR for the co-occurring population By Jeanne L. Meyer May 29, 2014

In my work with clients with co-occurring mental health and substance use disorders, it became clear to me early on that most have experienced trauma in their lives — trauma that they must resolve to achieve and maintain a healthy recovery.

These traumas are sometimes categorized as little “t” or big “T” traumas. Big “T” traumas include childhood sexual, physical or emotional abuse, natural disasters, war experiences, severe car accidents and rape. Little “t” traumas can be just as damaging, especially because they tend to occur over time and build on each other. This complicates the overall effects of the trauma as well as the trauma treatment. Some examples of little “t” traumas include ongoing emotional abuse or neglect, experiences of shame, being humiliated and being bullied. Incidents involving racism, sexism or homophobia could be classified as either big “T” or little “t” traumas depending on the severity. These traumas might involve one or two distinct incidents, or be more complex, ongoing experiences. The result is a primary belief that the world is not safe. In some cases, individuals who are traumatized learn to expect pain, dishonesty and betrayal from the people they love the most.

In the case of clients with addiction, even if they have not experienced trauma prior to the onset of their disease, they most likely have experienced violence, rage, betrayal, abuse (sexual, physical or emotional), incarceration, homelessness or a whole host of other negative experiences while using alcohol or other drugs.

There are two clinically appropriate strategies for treating posttraumatic stress disorder (PTSD) with people in substance abuse recovery. One strategy is to address the trauma or abuse immediately as the client enters the beginning stages of recovery. The other is to wait until the client’s ability to achieve and maintain abstinence has stabilized.

How do we know which strategy will be successful? Ultimately, the client is the one who knows. If the ability to maintain abstinence from alcohol or other drugs is precarious or impaired due to memories, suicidal ideation or self-harm, it is essential to treat the cause of these symptoms from the beginning. For these clients, recovery will likely remain elusive until their trauma is addressed. If the client is relatively stable, however, waiting until the later stages of recovery is indicated. Clients who are pressured into addressing their trauma issues before they are ready are likely to relapse into active addiction.

According to recent brain research described in Uri Bergmann’s 2012 book Neurobiological Foundations for EMDR Practice, when someone experiences an event or multiple events that cause intense fear, it can change the neural pathways, or maps, in the brain. Whenever something is experienced as a reminder of the trauma, clients can relive that trauma, making them afraid of certain places, tones of voice, objects or even other people with certain body types. Smells can also trigger intense anxiety and fear. The repetitive experience of anxiety and fear can result in panic attacks, health problems, chronic pain, sleeping difficulties and eating difficulties. The individual eventually becomes self-centered, focusing so much on self-protection that there is little objectivity or ability to have empathy for others. This makes every relationship unstable.

The good news is that several proven therapeutic techniques, including eye movement desensitization and reprocessing (EMDR), can alleviate symptoms stemming from past traumas. EMDR uses the mechanism by which information from frightening and horrifying events is processed into memory and stored in the brain. By manipulating the brain’s intrinsic information processing scheme, a practitioner can help clients release themselves from the intense hold those memories have on them. EMDR combines sensory bilateral stimulation (visual, auditory or physical sensations) with emotional memory and the underlying belief system to lessen the intensity of the experience. It does not erase the memory, but it can reduce or alleviate many of the associated symptoms.

The mystery of EMDR

It is not known precisely how EMDR works, but various research studies have verified its effectiveness in the treatment of trauma. Twenty-four randomized controlled (and 12 nonrandomized) studies have been conducted on EMDR. Most of these studies address simple rather than complex trauma. For a list of these studies, visit the EMDR Institute website at emdr.com and click on the “Research Overview” link under the General Information tab.

In developing EMDR, Francine Shapiro postulated that PTSD is caused by a disruption in the adaptive information processing system. Because the fear and helplessness experienced by clients stays attached to the memory of the traumatic event, it creates havoc in their lives. It is as if the trauma is continuing to happen to them. Because it is still occurring neurologically, it cannot be processed as a memory.

EMDR changes the configuration of the neural connections or map of that event, detaching the dysfunctional physiological and emotional components so that it becomes a more manageable memory. This helps the client “let go” of the past because the neurons are literally letting go of some connections and replacing them with new ones.

In my experience, EMDR is the fastest, most effective and least intrusive way to help clients release trauma, regardless of whether it stems from childhood abuse, sexual abuse or assault, accidents, disasters or combat, and regardless of whether it is the result of a single event or multiple experiences. I have also seen EMDR reduce or eliminate chronic pain, headaches, fibromyalgia and cravings for alcohol and other drugs. One of the best things about EMDR is that it doesn’t require clients to retell their horror stories. In my view, when people don’t have words to describe what they are experiencing, don’t remember the original incident, have somaticized their pain or are too emotionally raw to put the experience into words, it is essential to offer treatment that does not require verbalization.



 The eight phases

To practice EMDR, a clinician must have a master’s degree, counseling experience and the proper EMDR training. Although the process may seem simple to an outside observer, it requires both an understanding of how the brain and emotions work with trauma and a specific protocol. As shown in the table below, there are eight phases of treatment.

We’ll use “Carrie” to highlight how each phase of the EMDR treatment protocol might be carried out with a client.

  • History taking and treatment planning (Phase 1): This is used in most counseling therapies. The therapist and client review biopsychosocial history and trauma history, assess client resources and strengths and determine the frequency and level of any dissociation symptoms. The therapist will suggest different targets and strength-building skills depending on the overall emotional stability of the individual.
“Carrie” comes to the clinic requesting help with night terrors and anxiety. While obtaining her background history, it becomes clear she has survived many traumatic events, has few financial or social resources and is currently separated from her abusive husband. She smokes cigarettes, uses marijuana, uses some mindfulness tools and practices breathing techniques to manage her distress and anxiety. The therapist determines it is essential to improve her emotion regulation and distress tolerance skills, along with targeting various symptoms such as her recurring nightmare.

  • Preparation (Phase 2): The therapist explains the adaptive information processing system and how trauma disrupts it. The mechanics of treatment are reviewed. Emphasis is placed on clients nonjudgmentally observing their reactions and awareness, and communicating those observations to the therapist. Rapport is established. Relaxation and self-soothing techniques are taught and practiced.
In Carrie’s case, she is able to best understand the adaptive information processing system with the help of a simple illustration the therapist draws to engage her in the therapeutic relationship. The therapist says, “I will show you exactly what the technique looks like. We can use eye movements, sounds using headphones, or I can tap the back of your hands. Which feels most comfortable to you?” When Carrie chooses eye movements, they arrange the chairs so Carrie and the therapist are facing each other. The therapist holds a pen in front of Carrie and asks, “Is that comfortable? Do I need to change the distance or the pen I’m using? What I will do is wave my pen back and forth, and you follow it with just your eyes.” The therapist does this, and Carrie follows the pen easily.

  • Assessment (Phase 3): The client and the therapist determine exactly what the target is, including any images, physical sensations or memories that are associated with the emotionally loaded material. They rate the intensity of the feelings that are attached using the Subjective Units of Distress Scale (SUDS). An “irrational belief” (as defined by Albert Ellis) is identified by the client as the negative cognition. The client chooses a more reasonable belief to use as the positive cognition and rates the perceived validity of this statement.
In Carrie’s case, she remembers parts of her dream: She is in a dangerous situation with people looking for her; she crawls through a hole in a wall to discover she is in a bunker with gunfire all around her. She rates the fear she feels as she recalls the nightmare at a SUDS score of 9. She identifies her belief when these feelings come up as, “I am never safe.” The therapist asks her what she would rather believe.

Carrie responds, “That I am safe, I guess.”

“Are you safe?” the therapist asks.

“No, not always,” Carrie says.

“But sometimes you are safe.”

“Yes, sometimes I am safe.”

The positive cognition becomes “I can be safe.”

The therapist asks, “How true does that statement feel right now?”

Carrie rates it on a Validity of Cognition (VOC) scale as a 1, indicating it feels “like a lie.”

  • Desensitization (Phase 4): The cognition, the emotion and body awareness are combined with bilateral stimulation. The therapist changes the bilateral stimulation speed with eye movement, tapping and sounds throughout and between sets. A set is composed of a series of bilateral stimulations. For example, moving the eyes back and forth 10 times would represent a set. The therapist varies the length of a set depending on the intensity of the material the client is experiencing. In between sets, the therapist determines that the process should continue by asking the client if he or she is noticing any changes. This pattern continues until the client reports no change between sets and the SUDS score has been reduced to a 0 or 1.
For example, the therapist tells Carrie, “Bring up that memory, crawling through the hole and being in the bunker. Remember the sounds and smells. Notice how your body feels. Allow the thought, ‘I am never safe,’ to float in your mind. Do not try to direct your thoughts. Let your mind wander. Wherever it goes is where it’s supposed to go.”

Carrie watches the therapist move the pen back and forth, causing her eyes to move from left to right rhythmically. After a set of 10 eye movements, the therapist stops and says, “Take a deep breath. Tell me what you are noticing right now.”

The therapist makes a note of Carrie’s response and starts another series of bilateral stimulations. The process continues until Carrie reports several times that she feels “nothing.” When recalling her nightmare, her SUDS score is 0.

  • Installation (Phase 5): The positive cognition is strengthened for the client. The bilateral stimulation is used as the client thinks of the positive cognition. The sets are shorter and slower to allow the positive experience to establish itself. The VOC is measured again until a score of 6 or 7 (“completely true”) results.
  • Body scan (Phase 6): The therapist asks the client to pay attention to the way her body feels from head to toe (or vice versa) and report it.
Carrie notices some trembling in her hands. The therapist uses more sets of eye movements until the trembling ceases.

  • Closure (Phase 7): The therapist ensures clients are safe to leave the session and navigate their way to their next destination. They are guided through self-calming rituals. The therapist explains that the client may feel spacey or very tired for anywhere from one hour up to a few days. Clients are given an assignment to journal their experiences, emotions, thoughts and dreams until the next session.
  • Reassessment (Phase 8): This phase occurs at the beginning of the following session. The targeted material is recalled and the client’s SUDS score is determined. The VOC of the positive cognition is also reevaluated. Any residual processing that occurred between sessions is discussed. If there is a change in either the SUDS or VOC score, it indicates there are more aspects of the target to process.
At Carrie’s next session, she reports the nightmare has not returned. When she remembers it, her SUDS score is 1. The positive cognition, “I can be safe,” is rated at a VOC of 7 (“completely true”).

Conclusion

When I work with a client, I keep meticulous notes about the intensity of the individual’s negative emotions and the perceived validity of the positive cognitions before and after a treatment. I keep this record partly so that I can review it with the client in the future. Many times, the client possesses no memory of having the original problems and emotions. The client still remembers the traumatic incident and has feelings about it, but the incident does not haunt the client any longer.

My experience of utilizing EMDR with clients has been no less than amazing. I continue to be surprised at its effectiveness addressing a number of concerns. It works relatively quickly, and its results are maintained. After the initial setup, it relies on clients’ own processing and therefore validates their experience completely. With EMDR, there is also a shorter period of intense unpleasant emotion that clients experience than with other talk or exposure therapies. It engages the parasympathetic nervous system, leading to relaxation or drowsiness when the process is complete.

Whether EMDR is used at the beginning of addiction recovery or after a period of abstinence, clients are able to manage their recovery more easily and more successfully when PTSD symptoms are alleviated.

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Jeanne L. Meyer, a licensed mental health counselor, licensed professional counselor and master addictions counselor, is a co-occurring therapist with Choices Counseling in Vancouver, Washington. She is also a member of the American Counseling Association Trauma Interest Network. Contact her at jmeyer@ChoicesCounseling.org.

Letters to the editor: ct@counseling.org

Tags:
eye movement desensitization and reprocessing, PTSD, Substance Abuse & Addictions, Trauma and Disaster

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Eye Movement Desensitization and Reprocessing

10/28/2013

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Can you benefit from EMDR?

Part I
  1. Have you had an experience that horrified or terrified you? 
  2. Have you had an illness or problem that changed everything?
  3. Do you have disturbing and distressing memories of your experiences?
  4. Do you have nightmares or night terrors?
  5. Do you have trouble sleeping?
  6. Do you have relationship trouble?
  7. Do you have trouble feeling safe in private, in public, in a quiet environment, in a noisy environment?
  8. Do you have difficulty trusting?
  9. Do you lose your temper easily?
  10. Do you have back pain, stomach problems or headaches that started after your experience?
                # yes answers      

Part II
  1. Can you sit for 15-90 minutes at a time?
  2. Can you identify the feelings you are having?
  3. Can you identify your negative beliefs?
  4. Do you know what you want to believe?
  5. Can you trust your own experience?
  6. Can you tolerate intense emotions for a short period of time?
  7. Do you have 1-3 hours after a session to relax?
  8. Can you follow a moving object with your eyes?  OR listen to sounds using headphones or earbuds?  OR allow the back of your hands or knees to be tapped?   
                # yes answers____

If you have answered yes to 5 or more questions in Part I, and 6 in Part II, you are a good candidate for EMDR.
Read an article by Francine Shapiro by clicking here
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You have to live with it for the rest of your life.

9/10/2013

2 Comments

 
The shock of any trauma, I think changes your life. It's more acute in the beginning and after a little time you settle back to what you were. However it leaves an indelible mark on your psyche.
Alex Lifeson - Rush
Xena: See how calm the surface of the water is. That was me once. And then....(throwing a  rock in the lake)....the water ripples and churns. That's what I became.
Gabrielle: But if we sit here long enough it will go back to being still again. You'll go back to being calm.
Xena: But the stone's still under there. It's now a part of the lake. It might look as it did before but it's forever changed.
Xena: Warrior Princess, Dreamworker [1.03]
I was talking with a couple of women about working with children in the foster care system.  During the discussion, one of them said the children have been through so much in their life that they will always have to live with.  She looked to me to agree with her.  A wave of sadness swept over me.  Maybe for these kids that's true.   I hope not.  Abuse, neglect and trauma do not have to haunt them (or us) for the rest of our lives.  There is a treatment that can assist these kids in healing from the traumatic things they have lived through, so they can make good choices and have a happier life.  Counseling, these women told me, doesn't help these kids.  They go to the counselor not trusting anyone.  That makes sense.  Why would they trust another adult they associate with "the system?"

I told them about Eye Movement Desensitization and Reprocessing (EMDR) and how it can work with kids.  The beauty is the kids do not have to talk about or even know why they are upset.  It starts with whatever feeling the child is having.  The process works without having to articulate anything.  Traditional "talk therapy" does not work for everyone for a variety of reasons. 

One of the things I love about EMDR is you don't have to talk.  It works on a neurobiological level.  It works relatively quickly.  If someone has experienced one traumatic event, like a car accident or witnessed an assault, it can work in 2-5 60 minute sessions.  People feel better when a session is over than they did when they walked in.  Once the traumatic event is processed, the nightmares, anxiety and flashbacks are gone and do not come back.

When people have been exposed to multiple incidents, it becomes more complicated and takes more time.  Although generally speaking, not every incident must be processed in order for a person to heal, the process happens much more quickly than exposure or talk therapy.

To find out more information, go to my page on EMDR, the EMDR web-site, or contact me.
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Depression.  More than feeling depressed.

5/14/2013

3 Comments

 
It feels like being in a Black Hole.  There is no light and you just keep getting sucked in further and further  There is no way out.
Black HoleLet me out!!


Snap out of it! 
Things are not that bad!


How many times has someone been impatient with you feeling negative and gloomy?  How many times have you given up trying to explain, because it doesn't make any sense?  There's no particular reason you feel so bad, you just do.  Then you don't want to be around your friends and family because you can't explain why you're not happy AND being around happy people just makes it worse.  You feel more and more alone.  You start feeling like everyone would be better off if you just weren't around.  So you stay away.  Eventually people stop trying to pull you out of your isolation and depression.  Being around you is a bummer.  "You see the dark cloud in every silver lining."   

You feel better when you're sleeping, so you sleep as much as you can.  Or the opposite happens, when you can't sleep.  You either can't get to sleep, can't stay asleep or wake up way too soon.  Then you're tired all the time.  You have no energy.  Nothing is fun.  Nothing is funny.  You can't concentrate.  Things seem harder and harder.  Food tastes bland.  Sometimes you eat anyway.  Sometimes you have no appetite.  Sometimes you snap at people and hate the world.  Sometimes you cry when you "should" be happy.  You know there's something wrong, so does everyone else.  Everyone's attempt at trying to help pisses you off.  Even your dog looks at you with pity.  You just want to be left alone......but not really.


Depression is like walking around with no skin. 
Everything hurts.  Anything that brushes up against you causes pain.  A hug feels bad.  Regular, normal things that happen to everyone throughout the day are at the least irritating, at most painful.  You spend your time avoiding anything that could hurt.  People say things that you take personally.  You get your feelings hurt easily.  Everything seems huge.  It requires so much effort, it often doesn't seem worth it.  You feel like Eeyore all the time.  You hate it, but nothing helps.  You lose hope that it will ever get better. 

Does anything help?
The short answer is yes.  We know some things that can help someone with depression feel better.

When I drink or get loaded, or have sex I feel normal.
What that tells us is that when your brain chemistry changes the symptoms get better.  That is a very important clue!  It is definitely the right idea, just not the right chemicals.  Addiction has a way of biting us in the rear and causing our lives to be miserable....not to mention hurting the people we care about most.

I'm not taking those pills!  I don't want to be a guinea pig.
Medicine is not right for everyone.  If medicine is necessary, there is no blood test to determine which one will help the most.  Prescribers discuss the symptoms you are having and match you with the medicine that will alleviate the most of them.  Mental health treatment is not an exact science.  Sometimes if one medicine doesn't work, another one will.

This is what we know.  There is a difference between feeling depressed and having a clinical depression.  Feeling depressed is only one symptom of clinical depression.  There are several forms of depression.  Some depression is fatal, resulting in suicide or death from risky behavior.  Treatment for depression must take into consideration which type of depression you have. 

Sadness is not depression.  Grief is not depression.  If you have lost something or someone important to you, you will feel sad.  This is normal and healthy.  There is not a set period of time for people to grieve.  Grieving comes in waves.  Sometimes you feel better, then it hits you again.  It does get better over time. 

According to the National Institute of Mental Health, symptoms of depression may include the following:

  • Difficulty concentrating, remembering details, and making decisions
  • Fatigue and decreased energy
  • Feelings of guilt, worthlessness, and/or helplessness
  • Feelings of hopelessness and/or pessimism
  • Insomnia, early-morning wakefulness, or excessive sleeping
  • Irritability, restlessness
  • Loss of interest in activities or hobbies once pleasurable, including sex
  • Overeating or appetite loss
  • Persistent aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment
  • Persistent sad, anxious, or "empty" feelings
  • Thoughts of suicide, suicide attempts

Types of depression:

1.  Major depression:  When the bottom drops out, sometimes people are unable to work or parent.
2.  Dysthymia:  Just generally feeling blah, washed out all the time for no particular reason
3.  Bipolar I:  A cycle, extreme mood swings, sometimes the depression takes over followed by times of feeling great, almost too great,
4.  Bipolar II:  Times when the bottom drops out, followed by a time when things feel a little better, but still not good. Sometimes for a while there is a lot of energy, people can't sleep, are very distracted, talk fast and then for a while everything slows down.
5.  Postpartem:  A major depressive episode after having a baby.
6.  Seasonal Affective Disorder (SAD)  Feeling more depressed in the winter or when the weather is gloomy.

It is extremely important to have a professional determine which type of depression you are experiencing especially if you are considering taking psychiatric medication.  Medication meant for a unipolar depression, major depressive disorder, dysthymia or post-partem depression will probably make Bipolar I & II much worse.  It easy for someone to get a wrong diagnosis with Bipolar because they usually ask for help when they are experiencing the depression symptoms, not the manic or hypomanic symptoms.

Types of treatment:
Nonmedical
    Exercise
    Distraction
    Spending time with people you love
    Getting involved in something important to you
    Vitamins
    Healthy nutrition
    Good sleep
    Being outside
    Working with animals

Clinical
    Talk therapy
    Cognitive/Behavioral Therapy (changing the way we think and behave)
    Skills training (Dialectical Behavioral Therapy, stress management, etc)
    Hypnosis
   
Medical
    Various types of medicines, from SSRI's, SSNRI's, mood stabilizers to tricyclics and MAOI's
    Biofeedback
    ECT
    Sleep disorder treatment with medication or CPAP
    Pain management
    Hospitalization either for crisis stabilization, or longer term if symptoms do not respond to treatment

  The most important thing to know is that depression is treatable.  You are not the only one who has experienced it.  You do not have to be alone.





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Jeanne L. Meyer, LMHC, LPC, MAC
Choices Counseling
(360) 949-2524

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    Author

    Jeanne L. Meyer, LMHC, LPC, MAC is a private mental health therapist in Vancouver, WA.

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