Treatment of Attachment Trauma and the Dissociative Sequelae Through The Lifespan: EMDR and Case Conceptualization

When earliest relationships are traumatic, attachment
injuries can significantly change the trajectory of one’s
life. Bonding and attachment are neurobiologically
driven survival mechanisms; but when irreconcilable
conflict exists within the innate mechanisms of survival
and attachment, individuals can experience extreme
distress leading to mental health disorders and physical
disease. Although these conditions may begin in infancy,
if untreated they can endure for a lifetime. It is so
essential that attachment disruptions be addressed in
both children and adults experiencing complex trauma
reactions, including Axis II conditions and dissociation.
EMDR provides a comprehensive, integrative, and
effective approach to the treatment of attachment and
the dissociative sequelae.

WORKSHOP OBJECTIVES
 List 3 aspects that form the theoretical basis for
conceptualizing treatment with EMDR for children,
adolescents, and adults based on the neurobiological
underpinnings of attachment
 Describe how the Adaptive Information Processing
model addresses the impact of attachment trauma
while providing support for the efficacy of EMDR as an
integrative treatment approach
 Illustrate how therapists integrate treatment strategies
throughout the eight-phase EMDR approach for clients
of all ages suffering from attachment disruptions
 Explore the practical usage of various theories linking
the contribution of attachment trauma to dissociative
symptoms with recommendations for treatment to
successfully repair attachment trauma and to improve
client symptom presentation
 Demonstrate 3 creative treatment techniques for both
improving developmental deficits and infusing an
emotional scaffolding for adaptive resolution of
traumatic experiences through the use of EMDR.

WORKSHOP DATES AND LOCATIONS

February 25-26, 2012

Reno, Nevada

November 3-4, 2012

Raleigh Durham, North Carolina

WORKSHOP AGENDA
8:00-8.30am Registration/Coffee Service
8:30-5:00pm Workshop
12:00-1:00pm Lunch Break (Lunch on own)

EMDR Institute

For more information:

831-761-1040

www.emdr.com

EMDR and the Art of Psychotherapy With Children

Dr Adler-Tapia’s workshop, based on her book and treatment manual, will focus on basic and advanced skills in adhering to the EMDR protocol for treatment of children. Case conceptualization will be presented through the lens of the Adaptive Information Processing Model (AIP). She will explain how to change the language of EMDR to meet the child’s developmental needs, and how to specifically apply the 8 phases with children. Participants will learn how to develop a comprehensive treatment plan and create child-oriented methods for Resource Development Installation (RDI) and Cognitive Interweaves. In addition, Dr Adler-Tapia will discuss child development theory as it applies to the AIP model. Participants will learn how to use EMDR with complex cases and with a variety of special topic areas, including: ADHD, giftedness, OCD, attachment, dissociation, and sexual reactivity. This interactive workshop includes videos, practica, and didactic material, to deepen participants’ understanding of how to implement EMDR with children and enhance their skills in working with children.

WORKSHOP OBJECTIVES
 Conceptualize the AIP Model with children
 Demonstrate child languaging for EMDR
 Describe child-oriented methods for RDI, CI, & mapping
 Develop treatment plan using Attachment Genograms, Mapping, & Reverse Protocol
 Describe "Launching targets into the future"
 Explain the stages of child development through the lens of the AIP Model
 Describe EMDR application for complex cases
 Demonstrate 3 creative treatment techniques for both improving developmental deficits and infusing an emotional scaffolding for adaptive resolution of traumatic experiences through the use of EMDR.

WORKSHOP AGENDA
8:00-8.30am Registration/Coffee Service
8:30-5:00pm Workshop
12:00-1:00pm Lunch Break (Lunch on own)


This workshop will be offered in multiple locations throughout the US and UK. Additional locations are being added.

WORKSHOP DATES AND LOCATIONS:

April 21-22, 2012
Best Western Rio Grande Inn
1015 Rio Grande Blvd NW
Albuquerque, NM 87104
505-843-9500

EMDRIA CHILD SIG ANNUAL PROGRAM
June 8-9, 2012
Location to be announced

July 13-14, 2012
Historic Plains Hotel
1600 Central Ave
Cheyenne, WY 82001
307-638-3311

August 25-26, 2012
DoubleTree Overland Park (Near Kansas City)
10100 College Boulevard
Overland Park KS 66210
913-451-6100

Completion of an EMDRIA Approved
Basic Training is required to register.


EMDR Institute Inc
Advanced Clinical
Applications Workshop
831-761-1040
Fax: 831-761-1204
www.emdr.com

New Book on Child Psychotherapy

I am very excited to announce the publication of my new book! This book will be published by Springer Publishing, New York in May of 2012. http://www.springerpub.com/product/9780826106735

CHILD PSYCHOTHERAPY:

INTEGRATING DEVELOPMENTAL THEORY INTO CLINICAL PRACTICE

Robbie Adler-Tapia

All too often children are diagnosed and medicated without the consideration that their symptoms may actually be a healthy response to stressful life events. This integrative guide for mental health practitioners who work with children underscores the importance of considering the etiology of a child's symptoms within a developmental framework before making a diagnosis. Providing advanced training and skills for working with children, the book guides the therapist, step-by-step, through assessment, treatment planning case conceptualization, and treatment with a focus on the tenets of child development and a consideration of the impact of distressing life events. The book first addresses child development and the evolution of child psychotherapy from the perspectives of numerous disciplines, including recent findings in neurodevelopmental trauma and neurobiology. It discusses assessment measures, the impact of divorce and the forensic/legal environment on clinical practice, recommendations for HIPAA compliance, evidence-based best practices for treating children, and the requirements for an integrated treatment approach. Woven throughout are indications for case conceptualization including consideration of a child's complete environment.

Key Features:

Provides an integrative approach to child psychotherapy from the perspective of healthy development

Offers an alternative to the medical model

Discusses key theories of child development and psychotherapy

Integrates a multimodal approach that considers a child's daily environment

Includes a template for organizing and implementing a successful practice

Practical steps in pacing, titrating and managing EMDR therapy

This is taken from a new chapter I have written for an edited book by Allen Rubin. Even though this title focuses on EMDR for children in the child welfare system, the section on "targets of opportunity" and "episodes of care" applies to EMDR with any client of any age. This section helps therapists conceptualize how to pace and titrate therapy given the limitations of number of visits and length of sessions.

I am frequently asked if I can do EMDR in a 50 minute session, and I do. For some clients who do not come every week, I will do a 90 minute session twice a month, but weekly clients I do 50 minute sessions. How? The end of this exert from the chapter tells you how I think about the work.


THE IMPACT OF CHILD WELFARE INVOLVEMENT ON EMDR WITH CHILDREN

The stability of the child’s living situation is a complicated factor in treating children in the child welfare system. Because children in the child welfare system may experience multiple placements, changes in caregivers and school placements, legal proceedings including visitation with the parents who have not protected and/or abused the child, along with attachment fractures and the unknown future, psychotherapy is challenging. With instability of the child’s placement often impacting the child’s consistency of attendance for psychotherapy, the EMDR protocol needs to be titrated in episodes of care. These episodes of care often include case conceptualization in EMDR with each session considered as the one session and only session or the last session for the child. This type of realistic case conceptualization does not prevent the use of EMDR in psychotherapy, but just an adjustment in case conceptualization with consideration of the possibility of targets of opportunity with children and unique case conceptualization rotating between installation of mastery along with trauma reprocessing focused on those targets of opportunity.

Targets of Opportunity
Targets of opportunity are those with which the child presents in therapy. The therapist can reprocess the target identified by the child while also taking the adaptive resolution to present and future events in the child’s life. Each target can be reprocessed through the three pronged approach of EMDR where one target is the focus of treatment – past, present, and future. The goal is one target at time through the three pronged approach. This allows the therapist to conceptualize each session of therapy as a microcosm of the entire therapy process.

Session Case Conceptualization
The flow of a typical 50 minute session starts with review of progress and identification of successes the child has accomplished since the last session. Then installation of mastery for approximately 10 minutes followed by trauma reprocessing through phases 3-6 of the EMDR protocol through past, present, and future triggers fill the majority of the session. Sessions end with review of work accomplished and plans for between sessions.

Because of environmental instability, case conceptualization for children in the child welfare system is paced through episodes of care with EMDR. Each session has to be conceptualized as potentially the child's one and only session. The plan for each session must take into consideration the amount of psychotherapeutic work that can realistically be completed for the child's best interest. The session should start with a brief check in with the child about the time since the last session and a review of any previous treatment. This is followed by probing for successes and mastery experiences that can be installed. This mastery installation provides a foundation to support the child in reprocessing a target of opportunity (the target that appears to be the most salient for the child), and then reprocessing through the 3 pronged approach – past/present/future. The session ends with the therapist enacting closure skills for stabilization between sessions. This can be done in 50 minutes once you know the EMDR protocol.

When probing for successes and mastery experiences, the therapist may ask the child, “Tell me something that made you feel good or that you felt proud of that you did this week.” The child may need assistance in identifying positive symptoms, and the therapist needs to listen closely for any positives that can be utilized to improve self-esteem, confidence, and feelings of competency for the child. Unfortunately, children in the child welfare system often feel unwanted and unimportant; therefore, the review of successes is even more important for this population. Once a specific event has been identified, the therapist can instruct the child, “Notice the positive or good feelings you get from being successful and where you feel those good feelings in your body.” The therapist can instruct the child to do a butterfly hug or the therapist can implement 2-3 saccades of bilateral stimulation for installation of a positive experience for the child. After several sets of saccades, the therapist can then proceed with the trauma reprocessing phases of EMDR. It is important for the therapist to keep a list of mastery experiences for future reference to remind the client of the positive and success the client has experienced. With this structure for psychotherapy, even if the child does not return to your office, the child is more likely to realize the benefits of participating in therapy and more likely to engage with the next therapist.

If the child who comes to your office has previously participated in EMDR and can recall any work from the previous sessions, the therapist can continue with the next phase of the EMDR protocol indicated in the child’s process. If the child has not previously identified any targets, the therapist can ask the child to identify a target. Targets of opportunity are often most helpful to the child and engage the child in the EMDR process by providing the child with the feeling of power from treatment.

The therapy sessions continues for as much time as is available with the therapist allowing 5-10 minutes for closure at the end of each session. On-going therapy continues to focus on reprocessing as much trauma as is possible given the client’s stability and time available for psychotherapy services.
-------------------------------

This section from my chapter was intended to give you a few additional tools on managing the EMDR process in your office. Let me know if you have questions.

Happy New Year!

I'm a KKiC by Dr. Robbie

I'm working on a new project to help children with cancer and the families who care for them. I have a workbook written collaboratively with my daughter. The new workbook is called, "I'm a KKiC" on kids kicking cancer. I also have a second workbook to help children and families with resources during the medical journey that includes creating resources to help with what can be intrusive and traumatic medical procedures. Stay tuned for the workbooks to be available to the public.

Pay it Forward

I find great wisdom and joy in reading quotes.
I am sharing these two quotes because I have had many reminders
over the last several days of the incredible people in my life and
the challenges I have over come because I have so many loving people to support me.

As I can never repay the debt I owe to the people who have loved me,
supported me, challenged me and demanded that I be true to myself
while striving to be who I have the potential to be,
I can only try to repay my debt to the amazing people in my life
by sending out to others this kindness and love.

So today on "Youth Day" in South Africae where the we celebrate
the activities of school students who contributed to the end of Apartheid,
I thought that writing about joy and paying it forward seemed apropos.



Live.
Breathe.
It is not fear that we need to live by, but joy, hope.
Inside you, in your ocean, maybe it seems barren;
maybe it feels as if there is no hope, no kindness,
no reason for happiness.
But deep within you, undeniably, something rumbles,
cries out, wants to be born.
Allow the joy to come forward.
Allow the hope to exist.

Maharaji



Hope is a state of mind, not of the world.
Hope, in this deep and powerful sense,
is not the same as joy that things are going well,
or willingness to invest in enterprises
that are obviously heading for success,
but rather an ability to work for something
because it is good.

Vaclav Havel

A Proposal for an EMDR Reverse Protocol

Introduction

As a psychologist for the child welfare system working with severely and chronically traumatized children and families, and as a psychologist for law enforcement, I returned to my office following my EMDR Basic Training I struggled to implement the protocol with my clients. In my 25 year career, I cannot recall ever encountering one client with a single incident trauma. So how then could I use EMDR? Because literature has discussed that EMDR trauma reprocessing (Phases 3-7) must be delayed due to the client’s need for extended resource development and skills to manage intense affect, I initially abandoned case conceptualization with EMDR because time and external resources did not afford my clients the opportunity to complete the entire targeting sequence plan. My clients were consistently presenting with intense and complex trauma histories.

I continued to provide psychotherapy as I had practiced all along, while I also explored opportunities with clients to develop resources to prepare for trauma reprocessing with EMDR. Yet I noticed that many clients still struggled because they had no hope for the future. Many clients had been in therapy and believed that therapy was to help them learn to cope with symptoms. EMDR offered the opportunity for the client to reprocess symptoms so those symptoms no longer would be present in the future; however, most clients could not imagine a future at all, let alone a future with no mental health symptoms.

The children referred from the child welfare system adamantly avoided the past because they were young and their pasts were horrendous. In addition, the future was not something these children could imagine nor was the present a pleasant existence for many of them either. Many clients struggled to exist in the moment and to cope with each day. I struggled to integrate EMDR into my practice even though I was working with severely and chronically traumatized clients who needed EMDR.

So how could I think conceptually through Shapiro’s Adaptive Information Processing (AIP) theory in my treatment approach and yet not focus on reprocessing past events first? Could I help clients with those horrendous past events that were maladaptively stored in the client’s memory thereby preventing the client from seeing any kind of future at all? It was evident to me that many of my clients came to psychotherapy for symptom relief without the expectation of a healthier, happier future. Was it possible for me to assist my clients to reprocess the client’s foreshortened sense of future that was driven by the past events they had experienced?

What is the EMDR Reverse Protocol?

The Reverse Protocol is the EMDR 3-Pronged Approach targeting in reverse order - Future-Present-Past. This protocol uses all 8 phases of the standard protocol. It is not beginning therapy with a future template or resource development (Korn & Leeds, 2002; Leeds, 2001). Some who are familiar with Solution Focused Brief Therapy (SFBT) (de Shazer, Berg, Lipchik, Nunnally, Molnar, Gingerich, & Weiner-Davis, 1982) will recognize a flavor of focusing on the solution rather than the problem in that this EMDR reverse protocol focuses on addressing the client’s negative beliefs about the future before reprocessing past traumas. This reverse protocol reprocesses the anxiety and negative cognitions about the future before reprocessing present triggers followed by reprocessing past events. Many clients with trauma, dissociation and depression exist in survival mode and cannot participate in past trauma reprocessing because they experience life through the lens of trauma with a foreshortened sense of future. These clients need extended psychotherapy focused on skill building, affect regulation, and developing emotional intelligence in which the client can identify and tolerate intense emotions. Past trauma cannot be reprocessed without significant time in the Preparation Phase of EMDR. Another potential for case conceptualization is to reverse the temporal order of the targeting sequence plan. This idea still considered that maladaptively stored information from the client’s history were driving current symptoms; however, the client was not developmentally capable of focusing on trauma reprocessing about the past until the client could imagine a future.

This is the essential proposal for a Reverse EMDR Protocol

1. The Reverse Protocol is about a beginning therapy by reprocessing future targets before present triggers and past events. Treatment begins with identifying a positive future and the negative cognitions about why the client cannot consider the future and/or does not entertain a future free of symptoms. Future reprocessing is also a resource focused on the client anticipating using replacement behaviors integrated with plans for what to do in the future when you have these symptoms. The therapist might ask the client, “How do you see the future without these symptoms that brought you into treatment? What prevents you from accomplishing this future goal (NC)?”.

2. Present symptoms: While reprocessing the future targets, therapy simultaneously monitors triggers, stressors and the use of self-soothing/self-calming skill. After the client has reprocessed negative cognitions, emotions, and body sensations about the future, then present triggers are reprocessed.

3. Past events: Past events/targets are reprocessed using the standard protocol. This still includes reprocessing the past target, present triggers and completing the target by installing a positive future template consistent with the standard EMDR protocol. Essentially the temporal order of therapy is future-present-past (reverse protocol) and then past-present-future (standard protocol.) Why use the reverse protocol and the standard protocol? The therapist may consider the Reverse Protocol because the client cannot initially manage the standard protocol.

If you are interested in learning more about the Reverse Protocol, please listen to one of my trainings, attend a new one, or look for this complete article to be published.