Psychotherapy Perspectives

Thursday, December 17, 2009

EMDR—TWENTY YEARS LATER

By Amy Konkle, M.D.
May 2, 2009

(Accepted for Publication in the Spring 2009 Issue of the Indiana Psychiatric Society Newsletter)

This year marks twenty years since the publication of the first study of Eye Movement Desensitization and Reprocessing (EMDR) for the treatment of post traumatic stress disorder. This article attempts an overview description of the current status of EMDR: what it is, what the research says, and theories as to the mechanism of action. In addition I will share some observations and clinical vignettes from my own practice.

EMDR is a psychotherapeutic approach, rather than a technique or a protocol. EMDR’s underlying theory has two hypotheses: (1) much of psychopathology has its origins in experience implicitly or explicitly perceived as traumatic and (2) there is a block in the central nervous system’s innate ability to process, i.e., to adaptively access and integrate aspects of the trauma into a coherent and temporally updated context. Traumatic experience is understood to exist in a wide range, from a parent’s dismissive remark to an embarrassing childhood experience to the DSM Criterion “A” events that anyone would identify as major trauma. While EMDR appears to “jump start” this innate ability for processing which has become blocked, its mechanisms of action are undetermined and discussions remain lively around just exactly what is happening and what are the minimal essential components of EMDR. Although the preponderance of research looks at EMDR treatment of post traumatic stress disorder (PTSD), most EMDR clinicians perceive little difference in the effectiveness of EMDR in treatment of major trauma and in the reprocessing of the day to day traumas that may appear small but nevertheless shape self-perception, perception of the world, and ways of relating to others. When EMDR is used to treat the lifelong smaller events that shape personality, the duration of the treatment is longer than that of type I PTSD.

A typical EMDR session identifies an event experienced as traumatic by the patient and apparently related to the presenting problem. Even a recent event meeting criterion “A” definition may have an antecedent in childhood which affects the way in which the current event is processed. Components of the trauma—sensory phenomena, negative cognitions about self, emotions and somatic re-experiencing—are elicited. A protocol facilitates the activation of these components so that they are accessible for processing and integration. Desirable alternatives are identified, intensities are measured, and a ground-work is laid to follow progress. These traumatic components are activated and paired with some type of alternating bilateral or dual-attention stimulation, e.g., eye movements, auditory tones, tapping, or vibrating electrodes, which are applied in sets lasting about 20-30 seconds

For example, if eye movements are chosen as the type of stimulation, the assessment is completed as described above. The patient then holds in mind the image representing the worst of the trauma (“I see the truck crossing the median and coming straight at me”), the negative belief about self connected to that image (“I’m going to die”), and where the memory is felt in the body (“my chest, my throat, my shoulders. My whole body feels tense.”) The therapist moves two fingers rapidly from side to side approximately 20 to 30 times in front of the patient, who tracks the finger movement with his eyes. At the end of each set of eye movements, feedback is elicited as to change or lack of change in one or more components, essentially “What comes up now?” If processing is not progressing, that is if some change is not occurring, the therapist has a number of options to help get the processing going again, using the least interference possible. Processing continues until the memory is no longer upsetting, the negative self cognition (usually about safety, responsibility, or choice) is changed to a more positive one, and the body is cleared of disturbance. Ideally past, present and future anticipated triggers are processed to resolution. My experience is that successful processing is in general accompanied by lasting changes in the life of the client, such as decrease or elimination of symptoms, loss of diagnosis, or noticeable difference in life choices. Positive spiritual changes, such as a deep sense of peace, are not uncommon.

Approximately twenty randomized controlled trials exist which positively compare EMDR to antidepressant medication, exposure therapy, cognitive behavioral therapies, and other psychotherapies in the treatment of PTSD. Many treatment guidelines, including the American Psychiatric Association, the International Society for Traumatic Stress Studies, and the Department of Defense, have rated EMDR at the highest level of evidence-based effectiveness in the treatment of PTSD. Numerous meta-analyses show no difference in effectiveness between EMDR and CBT treatments for PTSD, although EMDR requires no homework. The findings in a few studies indicate that it may require fewer sessions than CBT. Although some positive research exists for EMDR’s effectiveness with veterans, children, disaster survivors, and adults abused in childhood, and many clinicians report success with these types of clients, more research is needed for these specific populations. In my own practice childhood abuse survivors have expressed deep gratitude for the transformation that EMDR has brought to their lives. Others have described feeling a “lightness” to life previously unknown.

Although EMDR’s efficacy has been established in the treatment of PTSD, research is still in the preliminary stages for its treatment of other disorders. For example, while EMDR has successfully eliminated secondary depressive symptoms in many PTSD studies, no published study has yet investigated EMDR treatment of primary depression. Similarly, research on EMDR treatment of panic disorder (with agoraphobia) has had uncertain results. It has been suggested that anxious patients may need lengthier preparation before targeting distressful experiences. For example, a recent case study with a woman who had suffered for 12 years from panic disorder with agoraphobia, provided 6 preparatory sessions and 15 EMDR sessions, with complete remission of symptoms and maintenance of positive behavioral changes at one-year follow-up. A clinical series of 4 patients with generalized anxiety disorder were provided with 15 EMDR sessions to each participant to treat etiological memories. At follow-up, two patients were still symptomatic, but all had lost the diagnosis.

There is also some indication that EMDR may be helpful for somatic symptoms with traumatic etiology. Several case studies provided preliminary evidence for EMDR treatment of phantom limb pain. In one case series, 5 patients with chronic (1-16 yrs) phantom limb pain, previously treated in both inpatient and outpatient settings, received 3 to 15 sessions of EMDR. Post-EMDR, there was a significant decrease or elimination of phantom limb pain, reduction in depression and PTSD symptoms to sub-clinical levels, and significant reduction or elimination of medications related to the phantom pain. There are also promising studies of EMDR as adjunct treatment for chemical dependency, conduct disorder, and sexual offense.

Current theories as to how EMDR works include the following: (1) synchronization of the two hemispheres, (2) de-conditioning caused by a relaxation response, (3) “jump-start” of a process similar to that of REM sleep, (4) the initiation of an orienting response, (5) the promotion of thalamocortical temporal binding in 40 Hz neural oscillation range which helps to integrate somatosensory, sensory, cognitive and affective material, and (6) the activation of the cerebellum, setting off a sequence of information processing which activates the thalamus and eventually the frontal lobes, increasing dorsolateral and orbitofrontal processing. Neuro-imaging studies pre- and post-EMDR show changes compatible with any successful treatment of PTSD but do not really clarify the mechanism of EMDR. Dismantling studies which have attempted to demonstrate whether or not eye movements are an essential component of the treatment, have significant methodological flaws and so far add little information. Numerous studies have shown that eye movements reduce the emotionality and vividness of distressing memories, produce physiological relaxation, and enhance episodic memory recall. While research has yet to investigate the effects of the other forms of bilateral or dual-attention stimuli (auditory tones, tapping, etc.) most clinicians report the various stimulation modalities to be equally effective, although they may prefer one over another.

In my own clinical experience with EMDR over the past 12 years, I find it to be a highly effective treatment approach. As with any treatment, EMDR is not appropriate for everyone. However, I have used it with good results in a wide range of patients, including veterans, rape victims with and without significant childhood trauma, accident victims, those witnessing the traumatic death of a loved one, patients with medical traumas such as awaking during surgery, men with anger-management problems stemming from their own childhood abuse, women with childhood physical, sexual and emotional abuse, selected patients with borderline personality disorder and still others with dissociative disorder.

Most (approximately 75 to 90%) of single-episode adult traumas in an otherwise relatively healthy person can be adequately resolved in one to three 90-minute sessions. The greater the number of traumas and the younger the person at the time the traumas occurred, the greater the care required in the stabilization and preparation phases of treatment, and the greater the care required not to “flood” the person with their traumas, resulting in destabilization and re-traumatization. “Fractionation” of the trauma, i.e., processing one aspect of the trauma at a time, may be required. Treatment in those with complex trauma histories, heavy reliance on dissociative defenses, and involvement of the structure of personality formation remains a lengthy process. However, for a number of such patients, therapy can be shortened significantly with the judicious use of EMDR in the hands of a skilled therapist. For many with fewer traumas even if they are severe, and with basically good ego strength, EMDR can produce results which are rapid and dramatic, unlike anything I have seen with other modalities. Results tend to be long-lasting, and positive effect may actually increase with time.


Amy Konkle, M.D.
May 2, 2009

Wednesday, November 04, 2009

Emotionally Wired and Addicted to the Computer

by Garth Mintun, LCSW, ACSW, CSW-G


There has been an awareness of a sharp increase in addictive behaviors to computers, as well as Blackberries, iPhones, etc., in our psychotherapy practice in Indianapolis. Many young adults, older adults and children are wired in and don’t know how to quit. Because of this, some people are jeopardizing their relationships, losing their friends, losing their jobs, and/or flunking out of school. There is an increase in sedentary lifestyle, and the sacrifice includes physical health as well as emotional wellbeing.

We have see couples coming in for marital and relationship counseling because of the significant time a partner is spending (upwards of 17-20 hours per day) playing on the internet. The internet games and interactions (role play games) have begun to replace the real life relationships. Partners and family members are feeling ignored, sacrificed, and replaced. The wired person is so into his/her virtual role that sometimes they struggle to distinguish the line between their real world self and the roles they play (which may include changing one’s age, gender switches, animals or fantasy creatures, etc.) on their internet virtual world. Family members complain that an addicted person spends more time with their fantasy relationships than connected to life with the people in their household. In the absence of contact, some partners have resorted to join them in their virtual world as a means of having a relationship.

It is not uncommon for relationships to be broken and couples to separate over the loss of communication, contact, and engagement from the one who is plugged into the computer.

Internet games are not the only way people are wired to their computers. With the convenience of palm computers and/or laptops, work has now become a 24/7 phenomena. Families now have to compete with work and online entertainment in order to have any engaging interaction with their loved one. This behavior condones and promotes work addiction. The Blackberry and iPhone light up for each email, enticing and compelling a response to work when at home, on vacations, or in other spare time. The poor economy exacerbates this when employees are stretched thin and there are plenty of competent unemployed folks who are ready to replace them.

With easy access to technology, Twitter, Facebook, instant messaging, text messaging, ebay, social networking, gambling, and dating sites, one can become compulsive and ultimately addictive, much like drugs and alcohol. An individual may have a full blown addiction and might need an inpatient hospital treatment due to the decline of one’s health and family relationships. In these cases, an individual may be literally in danger of harming themselves due to their compulsion with the computer.

Like food addiction, we cannot give up computers or the internet. We need to be wired to live in this modern world; technology is not the problem. However, like food, we need to moderate our use or we become a slave to it. We can overdo anything, even healthy foods, and/or technological applications. It becomes a compulsion or an addiction when we cannot stop it and/or when we have knowledge of its destructive influence in our life and our family.

In the USA, computer addiction is not acknowledged as an addiction or illness. Other countries, such as China, Taiwan and South Korea, take computer addiction as a serious mental health problem. Internet addiction is becoming more recognized in this country. For example, there is a residential program in a suburb of Seattle, Washington (Fall City) which treats individuals addicted to the internet. Hilary Cash, Executive Director for RESTART Center for Internet Addiction, states that three of the following symptoms suggest abuse and five or more suggest addiction:

Increasing amounts of time on the internet
Failed attempts to control behavior
Heightened euphoria while on Internet
Craving more time on Internet; restless when not there
Neglecting family and friends
Lying to others about use
Internet interfering with jobs and school
Feeling guilty or ashamed of behavior
Changes in sleep patterns
Weight changes, backaches, headaches, carpal tunnel
Withdrawal from other activities.

Psychotherapy /counseling help people and families recognize and heal from the fall out caused by “wired in” behaviors. Self awareness, recognition of the patterns, and the use of human supports to help break the compulsive pattern are necessary components of individual psychotherapy. There are also many kinds of support groups ranging from 12-step programs to Smart Recovery programs designed to help regain balance in a person’s life. If the person is in the early stages of neglecting self and the family, often an intervention in therapy to recognize the destructive nature of the compulsion and limit the amount of time on the computer per day can help. Repair of the broken relationships is also needed in the early stages of therapy, which requires finding alternate ways of coping with stress.

The computer and the internet are wonderful in moderation. We all need balance in our lives, and we can achieve that balance if we ask for help from our families and mental health counselor/psychotherapist. We all need other people, and in our “real time” relationships we can experience love and belonging.

Thursday, September 17, 2009

When Symptom Relief Happens, Counseling has Only Just Begun!!

By Garth Mintun, LCSW, ACSW,CSW-G

You and/or your spouse have been engaged in counseling for a few sessions. It is your first time in psychotherapy and you have expressed yourself, you have been heard, you begin to have a fresh look at yourself and your life… and you are starting to feel hopeful; things can be great. Your anxiety is decreased, your relationship with your spouse has improved, and/or your child is remarkably better. Perhaps you are experiencing work to be less stressful now. Maybe you have some relief from depression. You are not in the midst of a crisis anymore, so you think about quitting the counseling. After all counseling is expensive and you feel better now, so why not quit?

This belief is often attached to the notion that it is time to quit because you feel better. Weeks or months go by, however, and the problems not only come back, but seem to get worse. What happened? Was therapy not effective?

As a new client (especially as a new client who is in psychotherapy for the first time), it is important to understand the following:

1. When you start counseling, often you feel better quickly because you feel symptom relief.
2. Symptom relief is good because it often means that there is awareness of old patterns of problems and therapy begins to solve the surface problems.
3. Symptom relief does not heal the underlying deeper problem/patterns; that process takes a longer time.
4. If you quit too soon when you experience the first symptom relief, you will not undo the fundamental patterns, therefore new symptoms or old symptoms often return more forcefully. This is because you have not yet changed the deeper systemic nature of the problem.
5. It is best to stay long enough to work on the deeper pattern, so you will substantially decrease the likelihood that the old problem will reemerge in other aspects of your life. It may take a little longer, but in the long run it saves money and creates a higher degree of success.

When the initial symptom relief occurs, it probably means that you have just started therapy and feel good about your work, but your work is not yet done. Now the real work starts, which often involves grappling with the underlying issues, such as old fears and traumas. At first this next step may create a little angst; you might feel a bit uncomfortable accepting that is part of the healing. Yes, the painful process starts after the initial symptom relief. Therapy helps you uncover fears, sadness, grief, and trauma that you may have previously ignored. Furthermore, therapy helps you make the connections between patterns and problems, so that you can get to the root or source of the problem and explore new behaviors and beliefs. This has the potential to enrich your experiences.

So, roll up you sleeves, take a deep breath, and know that you are in a safe and supportive environment which will help you address the issues that keep you stuck in old familiar and destructive patterns. You can now begin to make lasting changes that will create a healthier sense of yourself and help your relationships to thrive and be more resilient.

Keep up the good work, because you are not in crisis mode! Continued counseling pertaining to underlying patterns will enable you to avoid continued years of emotional pain. This may be hard work in the short term, but it will be beneficial for many years to come.

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Tuesday, May 12, 2009

Luxury of Anxiety

In my thirty plus years of working with people in Indianapolis Indiana, struggles with anxiety have come up most often in therapy sessions. Most people that I see are anxious about a variety of issues. They may ask themselves the following questions for the future:

Will I have enough money?
Is my partner right for me?
Will he/she leave me?
What will I do if ________ dies?
Will I ever be peaceful?
When will somebody love me?
Will I ever find happiness?
Will I lose my job?
How will I sabotage this?
What is the matter with me?
What is wrong with me?

Or a person may have anxiety about the past:

Why was I so stupid?
Why did I do that to myself?
Why did I make so many mistakes?
Didn’t I take in consideration of the consequences?
How I was blind sighted and didn’t see it coming?

Anxiety is a luxury in the sense that we really don’t need it. It does not help us survive. If a tiger charged at us we would either flee if we could or, if backed into a corner, we would fight for our life. If a tiger is not present, however, we could worry about what might happen if a tiger were to come into our space. Perhaps we may even believe that our anxiety about a tiger may help us prepare for survival if a tiger were to approach us one day.

Most people who come to see me don’t worry about tigers, but they do have their symbolic tigers that create anxiety. In the present economy, a person may worry about money. One may read about job losses and imagine losing their job. They could even take it to the imagined worse case scenario and think about homelessness. Anxiety often is the worse case scenario and, as we brace for the worst, our adrenaline is pumped, our heart beats faster, and we become mentally involved in our fantasy of anxiety. Our body is equipped for this sudden burst of energy when there is danger, but not all the time when we experience constant anxiety. Consequently, we may become physically tired and sometimes unwittingly cause the worse case scenario to happen because we are not in tune to the present.

The luxury of anxiety keeps us from enjoying the present. Generally, in the moment, we are actually quite safe. Anxiety often causes people to be less safe, however, particularly if something in our reality needs to be responded to. For example, if you are anxious about your relationship while driving in the car, you may fail to see that red light in front of you and could expose yourself to danger. If you are overly pre-occupied with the luxury of anxiety, you may not see your significant other person’s non verbal signs that they are unhappy. For example, you may not see or hear the verbal and physical cues around you and become “blind sighted” when your partner tells you that they are leaving. When we receive the consequences of not paying attention, we may self-loath, which is again the luxury of anxiety bordering on depression. If we continue on the treadmill of the luxury of anxiety, we continue to not see the world around us, with the consequences of a loss of intimacy, job or self-respect.

Some of us may take this anxiety and obsess and create rituals to keep our anxiety at a low level, which may include compulsive acts of counting or creating patterns to feel safe. This continues to debilitate us and make us more vulnerable, and we may not even notice the proverbial tiger in the room.

The key is to lessen anxiety and gently return to the reality of the present:
Some ways to reduce anxiety are the following:

Stay in the present moment (you are doing just fine sitting in that chair)
Breathe with your belly not with your shoulders or chest (deep breathing)
Remember that anxiety usually does not help you
Remember that life has infinite possibilities and your anxiety has just a few
Anxiety is just one or two of thousands of thoughts that you attach to in one hour
Engage in physical exercise to have an outlet for your anxiety
Nurture yourself and love yourself just the way you are
Focus on how you are safe this present moment
Ask if your negative anxiety thought is 100% true (Byron Katie)
Think of anxiety as apart from you and try not to engage or make it personal
Develop a meditative process to practice letting anxiety go

If anxiety is overwhelming, compulsive, and restricting your life, you may need some help to lessen anxiety by going to psychotherapy. If you believe that you cannot cope with your anxiety, talk therapy and/or medication is essential. A therapist can help you get to the root of the problem, as well as offer you some useful techniques.

Anxiety cheats us out of the safety of the present. Anxious thoughts are always about the future or the past; they are never about the present. Anxiety limits us from viewing all of the options available to us. Anxiety is a luxury we simply cannot afford.