Day 1: Bessel van der Kolk is lovely. He's humble, he's funny, and he is the premiere researcher on the neurobiology and/or efficacy of trauma treatments in the world. And cute and brilliant, of course.
Here are nearly random gems from 3 hours of notes:
With trauma, there are no stories, only sensory experience: images, affect, and tactile, olfactory, and auditory experience. Bleure (1920): People can't hold the memory of the trauma–can't tell the story. The solution is taking action against the person who hurt you or telling the story over and over. (Prolonged exposure). Bessel says "No. Telling the story is not enough!" Later: "When people are into their trauma, they cannot talk about it. They become dumbfounded." Because Broca's area in the brain shuts down. "When the left brain shuts down, we must shift to right brain processing."
"Our job as trauma therapists is to bring the frontal lobe on line." (He said that GW Bush showed himself to be a "limbic" president with his "Let's kill them all" speech after 9/11. "A dangerous limbic-run man.")
The body relives and reinstates the initial trauma state, even the stress hormones.
Exposure therapy "blasts people's brains with the trauma and drives them crazy. That's supposed to be good for people?" And said the CBT literature is full of the treatment triggering suicide attempts, substance abuse, and worse symptoms.
He talked about his amazing EMDR vs Prozac study. 80% of adult onset trauma completely cleared PTSD & Depression after 8 weeks of tx. Prozac people felt better until they stopped taking the drugs. EMDR folks got better and better for months after tx and stayed that way. Cool study and he had trouble getting published despite 3X the success of CBT. Politics.) http://www.emdr.dk/artikler/07_kolk.pdf
Bessel and many of the top child psychiatrists and psychologists are lobbying for an new DSM 5 diagnosis: Developmental Trauma Disorder: http://www.traumacenter.org/products/pdf_files/Preprint_Dev_Trauma_Disorder.pdf
It's much needed. I have so many clients who need this diagnosis! (gai
Developmental Trauma Disorder
1. Multiple or chronic exposure to one or more forms of developmentally adverse
interpersonal trauma (abandonment, betrayal, physical assaults, sexual assaults, threats to
bodily integrity, coercive practices, emotional abuse, witnessing violence and death).
2. Subjective Experience (rage, betrayal, fear, resignation, defeat, shame).
B. Triggered pattern of repeated dysregulation in response to trauma cues
Dysregulation (high or low) in presence of cues. Changes persist and do not return to
baseline; not reduced in intensity by conscious awareness.
•Somatic (physiological, motoric, medical)
•Behavioral (e.g. re-enactment, cutting)
•Cognitive (thinking that it is happening again, confusion, dissociation,
•Relational (clinging, oppositional, distrustful, compliant).
• Self-attribution (self-hate and blame).
C. Persistently Altered Attributions and Expectancies
•Distrust protective caretaker
•Loss of expectancy of protection by others
•Loss of trust in social agencies to protect
•Lack of recourse to social justice/retribution
•Inevitability of future victimization
D. Functional Impairment
Bessel talked about vagal nerves (see Porges–later) and said that you can change the way you feel by changing the state of your body (thus our affinity for alcohol, drugs, and sugar.) Drugs, tai chi, karate, yoga, meditation and exercise manipulate the vagus nerves. Do yoga, etc. to affect the state of your body.
"Emotional Regulation is the most important issue in psychotherapy."
Cloitre 2007: '"If treatment relationship lead to affect regulation, the patient gets better."
In a study with chronically traumatized clients: 8 weeks of Yoga class beet 8 weeks of CBT with 28 hours of homework.
In PTSD, the thalamus goes offline. The thalamus orients you to where and when you are in a autobiographical context. Much of the brain goes offline when immobilized and there are no available receptors for attachment or problem-solving.
"Thinking has no avenues of access to the emotional brain. (You can't talk yourself into loving Dick Cheney, whatever the incentive.) . . . Traumatized people don't have a sense of being deeply present because the anterior singulate is off-line. . . Keep clients oriented to 'now' in themselves: 'How does your body experience that feeling?' . . .Help clients process what's inside of their here and now consciousness."
Trauma survivors see the trauma or the "bad thing" as outside of themselves, not as their own response to something that happened. "Bring attention to the body, to internal landscape: What's the sensation? Where do you feel it? What happens if you try something? Take a deep breath, right now. Do TFT tapping on the collarbone spot. . . Notice what comes up and remember how it will come to an end. How can we give the miserable, alone, frightened part of you some company? . . . Tell her you know how terribly lonely it was."
"You can't do trauma work without people deeply observing their own level of consciousness and then deeply connecting on the outside with you."
"The emotional brain runs the show." Feelings should be guides rather than a source of terror.
Bessel spoke of the importance of EMDR and Somatic therapies in working with trauma and showed a moving video of a formerly DID client who was "organized" by neurofeedback. "EMDR is the opening for understanding trauma. You can't do trauma treatment without EMDR or something else that knits the sensory experiences together."
Part II: Francine Shapiro, the brilliant maven of EMDR, looking well and energetic.
Much of what Francine said was material you can find at emdria.com or the EMDR Institute website: The Adaptive Information Processing model and the steps of EMDR treatment. Today I heard her say some different things: The importance of targeting the "small t" traumas. Much of the trauma that can severely impact a life does not fit the criteria for PTSD. She gave many examples of people who developmentally stopped at some distressing, non-life threatening event, until an EMDR session, years later, released them. (It happens. I've seen it many times.)
"Neurophysiology does not equal destiny." There is neuroplasticity in adult brains. Shrunken hippocampi grow again, after the trauma is resolved. Don't give up! A study: 8 sessions of EMDR, 20% increase in hippocampal growth.
Beliefs are a manifestation of trauma. CBT/Exposure = extinction. EMDR = reconsolidation. In prolonged exposure, the memory of the rape doesn't change, but get a competing new memory. But the clients relapse when around a trigger, because the old memory is still there. EMDR reconsolidates memory changes, so the initial triggers won't work.
"Processing dysfunctional and positive memories are the focus of EMDR treatment. Process the negative and integrate the positive. Every positive attunment or modeling by the therapist links the positive information in. . . You need to have positive adaptive memory networks for tx to work."
Process: Family of origin issues, memories that are encoded; Defenses, i.d. the earliest childhood event that caused that pathway to develop; cognition, process the memories that created the cognition–the cause is the encoded earlier event; Somatic/Emotive, "When's the 1st time you felt that way?"; Developmental, "What events derailed attachment?"
(I'm getting too tired to give you all the rest, so I'll hit a few highlights:)
ADHD: some of it is PTSD, some real ADHD.
Body dysmorphia: usually from childhood humiliation, sometimes just one comment. Clears with a few sessions. (There's a chapter in Solutions II about this.)
Small t traumas cause more pathologies than PTSD.
Axis II (personality dx's) are a constellation of attributes, each rooted in earlier events.
Borderline Personality Dx: Cool stuff– too much to write. But Axis II is moveable and cureable if you go after the childhood antecedents. (I know because I have ex-borderline clients and ex-narcissists.)
If you are treating kids, treat the parents attachment issues and the kids get better. Include in this: targeting the non-bonding event with the child, then make a story about an easy pregnancy, each trimester, an easy delivery, the first breath, first hours, coming home — better than real life, and install it.
In family systems, you can treat the family of origin issues in every one, all the behavior. Teach skills after the trauma is gone, when it can sink in.
Depression. Yes, See the first 5 chapters in Solutions II.
Phantom Limb Pain. Yes. See the PLP chapter in Solutions I–Wilson
Grief: "There is more positive recall of the loved one after EMDR (for traumatic grief) than after CBT. (Sprang, 2001)
EMDR increases resilency and engenders a new sense of self.