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Trauma,  EMDR  &  Addic1ons:    A  Complete  Course  for  Clinicians  

(Part  2)    Presented  by  Jamie  Marich,  Ph.D.,  LPCC-­‐S,  LICDC-­‐CS  

Owner/Operator,  Mindful  Ohio  Independent  Consultant  &  Instructor  

EMDRIA  Approved  Consultant  &  CerGfied  Therapist  

 

Factors  to  Consider  Before  Going  Farther:  

•  Does  the  client  have  emoGonal  support  resources,  including,  but  not  limited  to,  an  AA  sponsor  or  other  recovery  mentor,  home  group  and  support  network,  a  church  group,  access  to  healthy/friends  and  family  that  the  client  can  easily  telephone?  

 •  Is  the  client  able  to  reasonably  calm  and/or  relax  herself  when  distressed?  

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Factors  to  Consider  Before  Going  Farther:  

•  Is  there  a  sufficient  amount  of  adapGve,  healthy  material  in  the  client’s  life?    The  absence  of  this  does  not  necessarily  rule  out  use  of  EMDR;  however,  more  advanced  preparaGons  (i.e.,  resource  development)  will  be  needed.    

Factors  to  Consider  Before  Going  Farther:  •  Can  the  client  maintain  a  dual  awareness  between  the  present  and  the  past?      

 •  If  the  client  is  under  care  for  any  psychiatric  disorders  besides  PTSD  or  a  substance  use  disorder,  is  he  under  psychiatric  care  and  stable?  

 •  Have  you  evaluated  the  nature  of  the  living  situaGon?      •  Have  you  evaluated  your  number  of  sessions  available?  

•  Have  you  evaluated  the  quality    over  the  quan1ty  of  sobriety  and  the  nature  of  the  addicGon/behavior?    

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 The  Stages  of  Change:    

An  Addic1on  Field  Classic  

•  PrecontemplaGon  •  ContemplaGon  •  PreparaGon  •  AcGon    •  Maintenance  •  TerminaGon    

SOURCE: Prochaska, Norcross, & DiClemente, 1994

Where  a  person  is  “at”  in  the  stages  of  change  is  a  useful  guide  for  how  deeply  you  can  go  with  the  EMDR.    

The  Great  Debate    

Could  you  reasonably  begin  EMDR  with  someone  who  is  ac;vely  using  substances?  

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The  Great  Debate    

The  perspec;ve  of  this  instructor  is  that  reprocessing  cannot  be  safely  commenced  if  a  person  is  s;ll  

engaged  in  the  behavior;  however,  prepara;on  work  with  BLS  is  

advantageous.    

12  Steps  in  Sum:  

� Trust  God        � Clean  House  

� Maintain  House        � Help  Others  

Think Critically: How may these activities be especially troubling for an addict with trauma issues? How can EMDR help?

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Case  Study:  Nancy    (Marich,  2009a)  

•  AZer  EMDR,  Nancy  was  able  to  do  the  clean  house  steps  for  the  first  Gme  aZer  12  years  of  a]empGng  A.A.  recovery.  

•  Nancy  described  her  inability  to  do  these  steps  during  those  12  years:  

   You  can’t  put  anything  in  the  proper  perspec;ve.  And  you  can’t  really  get  a  heads  up  on  what  really  happened  because  you  were  so  trauma;zed  and  you  had  such  bad  experiences  and  like  in  my  case,  I  had  the  trauma  then  I  had  the-­‐  I  call  it  the  aMer-­‐effect  of  my  ex-­‐husband-­‐  pounding  over  and  over  and  over  and  over  it  for  like  14  years  aMer  that.  I  took  so  much  responsibility  for  it.    It  was  almost  like  I  vic;mized  myself  all  over  again  in  my  mind.      

NANCY  (con’t):     “  [EMDR]  dug  deep  into  my  soul  or  into  my  mind.  And  along  with  the  trash  came  the  pain,  the  shame,  the  guilt,  the  remorse,  whatever  went  along  with  the  situa;on.    When  I  faced  it,  and  I  dealt  with  it,  and  I  talked  about  it,  and  I  analyzed  it,  and  then  I  was  able  to  release  it  and  forgive  myself  and  others  for  what  had  been  done  to  me  and  what  I  had  done  to  other  people.    And  then  I  felt  a  great  sense,  I  felt  freer.”  

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•  10  females  ranging  from  age  27-­‐54    (mean=  41.7;  median=  46.5)  •  ConGnuous  sobriety  ranging  from  1-­‐6  years      (mean=  3.75  years;  median=  3.625  years)  •  5  Caucasians,  4  African  Americans,  1  Middle  Eastern    descent  •  2  college  graduates,  7  in  school    (6  college;  1  G.E.D.  prep)  •  7  parGcipants  had  children,  3  did  not  •  The  majority  of  the  parGcipants  idenGfied  religious  upbringing  

as  a  developmental  factor    

Marich  Disserta1on  Project  (2009b/2010)  

Sample  Ques1ons  from  Interview  •  Background  Ques;ons  

 -­‐How  would  you  describe  yourself  when  you  were  in  acGve  addicGon?    -­‐If  you  have  made  a]empts  at  addicGon  recovery  in  the  past,  what  were  some  roadblocks  that  you  have  encountered  in  staying  clean/sober?  

•  EMDR  Experience    -­‐What  were  your  iniGal  reacGons  when  your  therapist  suggested  EMDR  treatment?    -­‐To  what  extent  did  EMDR  help  you  with  the  roadblocks  to  recovery  that  you  have  encountered  in  past  a]empts  at  recovery?    -­‐What  role  did  the  EMDR  therapist  play  in  your  treatment?    

•  EMDR  and  Overall  Recovery        -­‐What  other  elements  besides  EMDR  helped  you  to  achieve  your  current  level  of  recovery?      -­‐To  what  extent  are  you  feeling  confident  in  your  recovery  at  this  point?  

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Marich  (2009b):  Thema1c  Category  1  

SAFETY    Subthemes  (ways  that  safety  was  fostered):  

 •  The  treatment  seZng  •  Quelling  ini;al  skep;cisms  about  EMDR  •  The  role  of  the  EMDR  therapist  •  Features  of  the  EMDR  approach  

Fadalia  (Study  Par1cipant):  

“The  people  that  I  worked  with  here  communicated  to  me  somehow  that  they  believed  that  I  could  really  stay  clean.  I  never  really  experienced  that  before.”    

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Quali1es  of  a  Good  EMDR/Trauma    Therapist  Marich  (2010)  

caring  trustworthy  intuiGve    natural          good  common  sense  connected          smart  comfortable  with  trauma  work  consoling  skilled          validaGng  accommodaGng      gentle  magical          nurturing    wonderful          facilitaGng    

Cindy  &  JoElle:  Descrip1on  of  Nega1ve  Experience  with  Their  First  EMDR  Therapist    

•  rigid  •  scripted    •  detached    •  anxious  •  unclear    •  uncomfortable  with  trauma    

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Marich  (2009b):  Thema1c  Category  2  

ACCESSING  THE  EMOTIONAL  CORE  

 Subthemes:  

•  Recovery  roadblocks  •  The  role  of  EMDR  in  addressing  core  emo;ons  •  Impact  on  recovery  

Sasha  (Study  Par1cipant):  

“I  was  a  chronic  relapser.  And  I  think  that  was  because,  now  that  I  have  some  awareness  of  a  lot  of  that,  I  think  it  was  because  I  didn’t  get  to  none  of  my  core  issues…  AZer  I  got  to  the  core  and  knew  what  to  idenGfy  with,  that  really  helped  me  to  look  at  me.”      

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Thema1c  Category  2  

Some  Common  Recovery  Roadblocks:    •  Inability  to  feel/desire  not  to  feel  anything  •  Inability  to  express  any  feeling  but  anger  •  Shame-­‐based  idenGGes/  “Black  sheep”  •  Ability  to  make  sense  of  traumas  cogniGvely    while  unable  to  handle  them  emoGonally  •  External  financial  barriers  

Fadalia:    

“EMDR  was  the  process  that  allowed  me  to  untangle  my  thoughts,  feelings,  and  experiences…before  they  were  all  stuck,  like  a  ball  of  yarn.”    

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Marich  (2009b):  Thema1c  Category  3  

LIFESTYLE  CHANGE    Subthemes:  

 •  Characteris;cs  of  ac;ve  addic;on  •  Perspec;ve  shiM  •  Behavioral/aZtudinal  change  

Becky  (Study  Par1cipant):  

“Before  treatment  I  was  resistant  to  talk  about  my  mother’s  death;  I  was  in  denial  about  my  mother’s  death  for  many  years,  despite  being  haunted  by  it.  Through  EMDR,  I  realized  that  her  death  was  not  the  end  of  the  world,  and  that  I  did  not  have  to  drink  or  use  because  of  it.  I  also  saw  that  my  mother  is  now  in  a  be]er  place  and  did  not  choose  to  abandon  me.”      

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Thema1c  Category  3  

Alfred Adler viewed the life-style as an “individual’s characteristic way of overcoming or compensating for feelings of inadequacy” (VandenBos, 2007; p. 536.). Adler, who contended that the life-style originated in childhood, described life-style as the pair of glasses through which every individual saw her world (Mozak, 2000).

In Adlerian terms, EMDR was a primary factor in helping the participants acquire a new set of glasses, or at very least, get an adjustment on their prescriptions.

Marich  (2009b):  Thema1c  Category  4  

USING A COMBINATION OF FACTORS FOR SUCCESSFUL TREATMENT

Subthemes:

•  The treatment program’s groups, classes, and services •  12-step recovery •  Self care measures •  Motivational factors

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The  themaGc  conclusions  drawn  from    this  study  indicate  that  there  is  a  place    for  EMDR  as  part  of  a  comprehensive  [addicGon]  recovery  program  when  applied  properly  (Marich,  2009b).  

AXer  Prepara1on,  You  Have  3  Major  Op1ons:  

•  Take  the  “recovery  roadblocks,”  (barriers  to  sobriety  and/or  wellness)  through  Phases  3-­‐6  for  reprocessing    

 •  Target  the  craving  or  urge  using  standard  protocol  or  one  of  the  specialty  protocols  (e.g.,  DeTUR,  LOU)  

 •  Proceed  with  EMDR  as  you  normally  would  based  on  your  assessment  of  client  readiness  

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My  General  Recommenda1on  

•  Proceed  with  the  recovery  roadblock  or  targeGng  the  craving/urge  (depending  on  the  client)  

 •  See  what  that  processing  reveals  and  then  move  into  more  standard  targeGng  of  past  traumas  using  the  floatback  

 •  Remember  Shapiro’s  three-­‐pronged  protocol  

Three-­‐Pronged  Protocol  

•  Past    •  Present    •  Future  

With  addicts  or  other  individuals  where  healthy  distress  tolerance  might  be  a  problem,  going  as  far  back  into  the  past  as  possible  with  a  floatback  is  generally  not  opGmal.    In  general,  it  is  wise  to  start  with  something  that  is  more  present-­‐tense,  and  then  let  it  floatback  organically/naturally.    

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Marich  (2009b)  Some  Common  Recovery  Roadblocks:    •  Inability  to  feel/desire  not  to  feel  anything  •  Inability  to  express  any  feeling  but  anger  •  Shame-­‐based  idenGGes/  “Black  sheep”  •  Ability  to  make  sense  of  traumas  cogniGvely    while  unable  to  handle  them  emoGonally  •  External  financial  barriers  

Recovery  Roadblocks:  Common  NCs  •  I  cannot  show  my  emoGons.  •  I  cannot  trust  anyone.  •  I  have  to  be  perfect.    •  I  am  not  deserving.    •  I  am  permanently  damaged.  •  My  body  is  hateful.  •  I  cannot  handle  it.  •  I  cannot  Trust  God/Higher  Power.    •  My  addicGon  is  my  idenGty.    •  I  cannot  cope  without  (drugs/alcohol/food,  etc.)  

See  handout  for  more  examples  

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I  Cannot  Show  My  Emo1ons  (Marich,  2011)  

•  The  case  of  Bri]a:  26-­‐years  of  a]empts  at  sobriety,  idenGfied  “I’m  not  good  enough”  as  primary  cogniGon  to  work  on.  

•  AZer  preparaGon,  Bri]a  kept  shupng  down  in  processing  (Phases  3-­‐6).  

•  Despite  trying  interweaves  and  a  variety  of  other  adjustments,  Marich  decided  to  reset  the  target  to  “I  cannot  show  my  emoGons”  since  Bri]a  did  not  seem  comfortable  with  emoGon.  

•  Processing  opened  up  right  away  with  this  simple  adjustment.    

 •  The  three  “unwri^en”  rules  of  the  alcoholic  home:  

ü Don’t  talk  ü Don’t  trust  ü Don’t  feel    

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 Also  consider  what  may  stand  in  the  way  of  body  awareness:    •  Abuse  issues  may  play  a  factor,  in  addiGon  to  religious  or  

societally  shaming  messages  about  the  body    •  Whatever  the  cause,  addicts  and  those  engaged  in  

problemaGc  compulsions  have  been  out  of  touch  with  their  bodies.  

 •  Don’t  simply  expect  someone  with  addicGon  issues  to  be  

able  to  process  somaGcally  or  answer  quesGons  like  “what’s  happening  in  your  body?”  without  preparaGon  in  body  cuing,  or  targeGng  negaGve  cogniGons  that  may  stand  in  the  way.    

   

EMDR  Demonstra1on    

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   Ques1ons/Comments  Needs  Assessment    

 

Popky  (2005)  

•  Developed  an  EMDR  protocol  for  targeGng  addicGon  cravings,  urges,  or  triggers  called  the  DesensiGzaGon  of  Triggers  and  Urge  Reprocessing  (DeTUR)  

•  Solid  theoreGcal  components  of  the  AIP  with  exisGng  knowledge  about  addicGon  in  the  protocol;  Popky’s  protocol  has  been  disseminated  widely  into  the  EMDR  community  despite  lack  of  formal  research  validaGon  

•  For  more  info  on  DeTUR,  see  R.  Shapiro  (2005)  

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De  TUR  ®  Basics  

•  Posi;ve  treatment  goal:    AbsGnence  or  controlled  using  is  not  a  treatment  goal,  but  the  aZer  product  of  a  successful  treatment  plan  (Popky,  2005)  

 The  posiGve  treatment  goal  is  the  focal  point  of  the  treatment  plan.  Such  posiGve  treatment  goals  should  be:  

 stated  in  posi;ve  terms    ;me-­‐related  (not  too  distant  future)    

De  TUR  ®  Basics  

•  Bring  up  the  picture,  along  with  any  words,  tastes,  smells  that  go  with  it  

•  How  strong  is  the  level  of  urge  (LOU)  at  present,  from  0  to  10?  

•  Where  are  you  feeling  that  urge  in  your  body?  •  AMer  each  bilateral  set,  ask  “what  are  you  geZng  now?”  

•  ConGnue  unGl  LOU  is  0  

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De  TUR  ®  Basics  •  Popky  advises  that  if  the  client  abreacts,  keep  going  with  bilateral  sGmulaGon  unGl  it  passes  

•  Advises  use  of  similar  supporGve  statements  or  tradiGonal  interviews  used  in  standard  protocol  

•  Popky  also  advises  that  is  core  issues  open  up,  follow-­‐up  it  through  to  compleGon,  alternaGng  to  the  more  standard  protocol  if  necessary  

Hase  (2006)  Addic1on  Memory  Protocol  

•  Incident:  relapse  (for  example)  •  Image:  being  in  the  grocery  store  ready  to  pick  up  the  mouthwash  

•  Level  of  Urge  (LOU):    10  •  NegaGve  CogniGon:    I  am  stupid.  •  PosiGve  cogniGon:    I  am  making  healthy  choices    •  VOC:    4  •  EmoGon:    shame  •  Body:    core  

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Miller  (2012):  Feeling  State  Addic1ons  Protocol  (FSAP)  

•  The  Feeling-­‐State  AddicGon  Protocol  (FSAP),  based  on  the  feeling-­‐state  theory  of  behavioral  and  substance  addicGon,  proposes  that  just  as  single-­‐event  traumas  can  become  fixated  with  negaGve  feelings,  intensely  posiGve  events  can  become  fixated  with  posiGve  feelings.  This  fixated  linkage  between  an  event  and  a  feeling  is  called  a  feeling-­‐state  (FS).

Miller  (2012):  Feeling  State  Addic1ons  Protocol  (FSAP)  

1.  IdenGfy  the  exact  behavior  that  has  the  most  intense  posiGve  feeling.  2.  IdenGfy  the  exact  feeling  that  underlies  that  behavior.  3.    A  modified  form  of  EMDR  is  uGlized  to  break  the  connecGon  between  the  feeling  and  behavior.  4.    The  negaGve  beliefs  that  underlie  the  compulsive  fixaGon  are  processed.

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   Dr.  Marich’s  Cau1on  About  

These  Protocols  From  a  Tradi1onal  Perspec1ve  

 

Common  Presen1ng  Problem:  “I’m  just  having  a  hard  ;me  leZng  go  of  this  one…”    

•  Dr.  Marich’s  adapGon  of  Parnell’s  modified  protocol:    

 -­‐  Think  about/bring  up  whatever  it  is  that  you  are  having  a  hard  Gme  lepng  

go  of.  -­‐  NoGce  where  you  feel  that  pull  to  hold  on  in  your  body.  -­‐  Is  there  any  negaGve  belief  coming  up  with  that?  -­‐  Any  image  (or  sound)  a]ached  to  that  body  feeling?  -­‐  What  emoGons  are  coming  up  with  that?  -­‐  OPTIONAL:  How  intense  are  those  emoGons  right  now  (get  a  SUDs  level  if  

desired)  -­‐  DESENSITIZE!      

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Let’s  Try  It!    

   

Needs  Assessment/Prac1cum  

 

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Ques1on  &  Answer  Case  Conceptualiza1on  

 

Let’s  Revisit  the  Ac1vity  

•  Recall  the  brief  case  synopsis  with  addicGon  or  related  issues:  

 ü An  actual  client  (using  a  pseudonym)  ü A  composite  client  ü A  “famous”  example  (presenGng  for  clinical  a]enGon)  

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Discussion:    Your  ReacGons  and  Experiences  

For  Con1nued  Development  

•  What  are  my  personal  barriers  with  addicGon  and  trauma?  

•  How  do  I  handle  intense  affect  and  abreacGon?    •  What  factors  may  inhibit  me  from  being  effecGve  with  a  traumaGzed  addict?    

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To  contact  today’s  presenter:    Jamie  Marich,  Ph.D.,  LPCC-­‐S,  LICDC-­‐CS  Mindful  Ohio    jamie@jamiemarich.com  www.mindfulohio.com  www.jamiemarich.com  www.drjamiemarich.com  www.dancingmindfulness.com    www.TraumaTwelve.com        Phone:  330-­‐881-­‐2944