Advanced Techniques Advanced Techniques in the Use of in the Use of

EMDR EMDR to Treat to Treat

Complex TraumaComplex Trauma

Barrylittmft.comBarrylittmft.comBarry Litt, MFTBarry Litt, MFT

Concord, NHConcord, NH

Trauma

memory

Consciousness• Neocortex• Narrative (semantic) Memory

EMDR

• Episodic Memory

• Stored in Limbic System and Brain Stem

• Re-lived vs. Remembered

• Dissociated from Narrative Memory

• Aspects of Trauma Dissociated from each other

(B.A.S.K.)

Trauma

memory

Consciousness• Fear/avoidance• Negative Transference• Distraction• Emotional Numbing• Blocking Beliefs

EMDR

• Affect Phobia

• Amnesia

• Interpersonal Defenses

Why Ego States Matter…Why Ego States Matter…

Object Relations Theory: Fairbairn’s Structural Model of the Self

Central Ego

Self as Object Seeking

Antilibidinal Ego

Libidinal Ego

Splitting of the Self: 6 – 18 mos.

Object Relations Theory: Fairbairn’s Structural Model of the Self

Antilibidinal Ego

Libidinal Ego

Central Ego

Borderline Personality Disorder (Kernberg)

Object Relations Theory: General Model of Introjected Family Members and

Their Relationships

Superego

EgoID

Introjects serve as template for relating to others

Object Relations Theory: General Model of Introjected Family Members and

Their Relationships

Introjected Introjected Relational ConfigurationsRelational Configurations

Yield Yield

Relational AttitudesRelational Attitudes

Ego State Theory of Watkins & Watkins

All manner of introjects, including ego cathected roles

Pathogenic Family DynamicsPathogenic Family Dynamics

• Co-Dependency; Collusive DenialCo-Dependency; Collusive Denial

• UndifferentiatedUndifferentiated family ego mass family ego mass (Bowen)(Bowen)

• Pseudomutuality Pseudomutuality (Wynne, 1965)(Wynne, 1965)

• Bilateral transference Bilateral transference

(Warkentin & Whitaker,1966)(Warkentin & Whitaker,1966)

• Trading of Dissociations (Wynne, Trading of Dissociations (Wynne, 1965)1965)

SummarySummary

• Pathogenic family dynamics (Pathogenic family dynamics (relational relational configurations) configurations) are internalized as ego state are internalized as ego state conflictsconflicts

• The resulting ego state system is a structured The resulting ego state system is a structured complementation of the loyalty systemcomplementation of the loyalty system

• The subjective sense of Self (The subjective sense of Self (and correspondingand corresponding relational attitude) relational attitude) is adaptive to the original, is adaptive to the original, formative contextformative context

Phase 2:Phase 2:PreparationPreparation

1.1. Safety AssessmentSafety Assessment

• Self-Harm vs. StabilitySelf-Harm vs. Stability

(Intrusive Experiences, Dissociation)(Intrusive Experiences, Dissociation)

Phase 2:Phase 2:PreparationPreparation

1.1. Safety AssessmentSafety Assessment

• Self-Harm: risk factorsSelf-Harm: risk factors

a) History of Suicidal Ideation

b) History of Suicidal Gestures

c) History of Suicidal Attempts

d) History of Psychiatric Hospitalizations

e) History or Current Reliance of Self-Harm Behaviors

a) Safety Contract

b) Psycho education

c) DBT Group?

d) RDI, Affect Management Skills Training (AMST)

e) Safe Place

Phase 2:Phase 2:PreparationPreparation

1.1. Safety AssessmentSafety Assessment

• Self-Harm InterventionsSelf-Harm Interventions

Phase 2:Phase 2:PreparationPreparation

2. Stability Assessment2. Stability Assessment

• Intrusive experiences, including:Intrusive experiences, including:

a) Fugue, lost time

b) Regression

c) Amnesia

d) Acting-out (e.g., cutting, substance abuse, risk-taking behavior)

e) Panic Attacks; freeze responses

f) Insomnia

Phase 2:Phase 2:PreparationPreparation

2. Stability Assessment2. Stability Assessment

a) Grounding exercises

b) Mindfulness practice

c) Journaling

d) Present-time orientation

e) Safe-Place work

f) Medication

g) Constructive Avoidance (Forgash)

h) Ego State Work: Daily living team (Twombly)

• Interventions:Interventions:

The Overall Structure of TherapyThe Overall Structure of Therapy

Three Intertwining Tracks:Three Intertwining Tracks:

1.1. Cognitive ScaffoldingCognitive ScaffoldingInsight/PsychoeducationInsight/Psychoeducation

2. Affective Transformation (EMDR)2. Affective Transformation (EMDR)

3.3. Relational Repair ; Rejunctive Relational Repair ; Rejunctive ActionAction; ; Earning EntitlementEarning Entitlement

CognitiveCognitive

Affective TransformationAffective Transformation

Relational RepairRelational Repair

Kitchur’s Strategic Developmental Model: Kitchur’s Strategic Developmental Model: Genogram-Based Target Selection and Genogram-Based Target Selection and

SequenceSequence• Parents’ RelationshipParents’ Relationship

• MotherMother

• FatherFather

• Sibling DynamicsSibling Dynamics

• Nodal EventsNodal Events

Target SelectionTarget Selection

EMDR Target Selection, EMDR Target Selection, continuedcontinued

• Pathogenic family processes Pathogenic family processes (from genogram)(from genogram) Double bindsDouble binds Split loyaltiesSplit loyalties Intersubjective fusionIntersubjective fusion Dissociated affect from othersDissociated affect from others

All likely to surface covert ego states and ego state conflict

• Affect bridge (Affect bridge (floatback)floatback) from recent event from recent event

A. Working with Domains A. Working with Domains of the Selfof the Self

Being vs. Nothingness

Merit

Safety

Domains of the Self, Domains of the Self, continuedcontinued

Being vs. Nothingness

Being vs. Nothing

•Self-Other Dialectic

•Depersonalization

Merit

Merit

•Neurosis

SafetySafety

•Hypervigilance

Cognitive Correlates to Domains of the SelfCognitive Correlates to Domains of the Self

Being vs. Nothingness

Being vs. Nothing

•I don’t exist’

•I’m invisible

•I don’t matter

Merit

Safety

Safety

•I’m gonna die

•I’m not safe

•I’m trapped

Merit•I’m not good enough

•I don’t measure up

•I’m a failure

•I’m bad

1. Features of the “Being” Domain1. Features of the “Being” Domain

• BBehaviorehavior: Acting-out : Acting-out (Better to be (Better to be badbad than to than to not be not be at all)at all) Relational conflict and ego state conflict Relational conflict and ego state conflict

may be “trading up” from may be “trading up” from not beingnot being Cutting; substance abuse; O-C D; etc.Cutting; substance abuse; O-C D; etc.

• Affect: anxiety, panic, fear

• Sensation: numbing

• Knowledge (NC): I’m alone, invisible…

Working Through the Being Working Through the Being

DomainDomain

I think, therefore I amI think, therefore I am-Descartes-Descartes

I notice that I feel, therefore I amI notice that I feel, therefore I am-(Damasio/Litt)-(Damasio/Litt)

The Importance of Sensation:

Working Through the Being DomainWorking Through the Being Domain

• Dynamic Targets:

-Narcissistic partner

-Partner avoids/withdraws

-”As-if” relating

• Event Targets

-Rejection

-Abandonment, separation, loss

-Associations

Working Through the Being DomainWorking Through the Being Domain

• NCNC: : I don’t exist; I’m invisible;I don’t exist; I’m invisible;

I’m alone; I don’t matterI’m alone; I don’t matter

• PCPC: : I am; I have myself; I exist even if…I am; I have myself; I exist even if…

Working Through the Being DomainWorking Through the Being Domain

• Body awareness must be maintainedBody awareness must be maintained EMDR augmented with somatic techniquesEMDR augmented with somatic techniques Sensory integrity necessary for processingSensory integrity necessary for processing

• Successful processing may “trade up” Successful processing may “trade up” from from numbing to shame/guiltnumbing to shame/guilt

3. Features of the “Safety” 3. Features of the “Safety” DomainDomain

• BBehaviorehavior: avoidance, hypervigilance : avoidance, hypervigilance

• AAffectffect: anxiety, panic, fear: anxiety, panic, fear

• SSensationensation: autonomic hypoarousal: autonomic hypoarousal

• KKnowledgenowledge (NC): (NC): I’m gonna die, I’m not I’m gonna die, I’m not safe…safe…

Working through the Safety DomainWorking through the Safety Domain

• Therapist and client work together to maintain Therapist and client work together to maintain some control over fight/flight responsesome control over fight/flight response

• Controlled and organized activation of fight/flight Controlled and organized activation of fight/flight motor behavior during desensitization phasemotor behavior during desensitization phase

• Client attention to Client attention to presentpresent condition of body condition of body while remembering threat eventwhile remembering threat event

depersonalized

Avoiding/relaxed

abreaction

panicpresence

absorption

B. Zone of Optimal Arousal for ProcessingB. Zone of Optimal Arousal for Processing

Parasympathetic Sympathetic

Parasympathetic Sympathetic

presence

absorptiondepersonalized

Avoiding/relaxed

abreaction

panic

Techniques :

•Distraction

•Somatic Cueing

•Present-time Orientation

•Somatic interweaves

•Node isolation techniques

•Olfactory Cueing

Parasympathetic Sympathetic

presence

absorptiondepersonalized

Avoiding/relaxed

abreaction

panic

Techniques:

•Closed eyes

•Push the NC

•Node isolation techniques

•Choosing new target

Parasympathetic Sympathetic

presence

absorptiondepersonalized

Avoiding/relaxed

abreaction

panic

Techniques:

•Breath Control

•Shift visual perspective

(3rd person)

•Node isolation

•Distraction

•Self-soothing techniques

•“Pushing arms” interweave

•Present-time orientation

•Olfactory stimulation

•Safety Interweave

Parasympathetic Sympathetic

presence

absorptiondepersonalized

Avoiding/relaxed

abreaction

panic

Techniques:

• Self-soothing techniques

or, increase absorption

• Node isolation

• Silent Breath control cueing

C. EMDR with Ego C. EMDR with Ego StatesStates

Complications in phase Four (Desensitization):Complications in phase Four (Desensitization):

• Looping

• Pseudoprocessing

• “revolving door” ego states

• Confusion, “overwhelm,” or undifferentiated experience

• Abreaction (Iatragenic)

• Blocking (amnesia; avoidance)

Phase 3 - 4 Techniques for E.S. ConflictPhase 3 - 4 Techniques for E.S. Conflict

Demand Characteristic

Effi

cien

cyChange of visual perspective

Pushing the NC

Targeted elicitation of ego state

Intervention of the Adult Self

Affect bridge (floatback)

Open-ended elicitation of ego state system (e.g., conference room)

Node isolation techniques

Somatic Techniques

Schiffer Glasses