The Missing Piece: A case for EMDR-based treatment for Posttraumatic Stress Disorder and cooccurring Substance Use Disorder Susan Brown, LCSW, BCD

Transcription

1 1 The Missing Piece A Case for EMDR-Based Treatment for Posttraumatic Stress Disorder and Co-Occurring By Abstract This paper proposes that integrating Eye Movement Desensitization and Reprocessing (EMDR) into treatment for the dual diagnosis of PTSD and s provides a missing piece needed to improve client outcomes. The problems related to treating this population are summarized. An overview of EMDR is then provided, underscoring its apparent positive impact on the sensory imprinting associated with trauma. The article closes with a description of how EMDR is used to treat PTSD and ways it has been adapted to address s, often co-occurring with PTSD. The author and her associates have developed an integrated PTSD/SUD treatment program utilizing EMDR as the primary trauma processing component. The authors are currently conducting research of its efficacy with this dual diagnosis population. The Problem Prisons, juvenile correctional facilities, hospitals, clinics, recovery centers, counseling and psychiatric offices are filled with them. They are the dually diagnosed, also known as co-occurring disorders (COD), which means the presence of more than one psychiatric problem occurring at the same time, such as Posttraumatic Stress Disorder (PTSD) and (SUD). Accurate diagnosis can be difficult, effective treatment even more difficult. It is emotionally challenging simply to cope with one psychiatric illness. Imagine the complicating factors of managing two, for the client and the treatment provider. The symptom manifestations of PTSD include nightmares, insomnia, re-experiencing (flashbacks), intrusive thoughts, anxiety, depression, hyper-arousal, exaggerated startle response, and avoidance of activities that are a reminder of the original experience. It is an insidious, often chronic, debilitating disorder. Because of the nature of the symptoms associated with PTSD, substance abuse is often a convenient way to escape, avoid and/or numb the symptoms to a tolerable level. Unfortunately this only creates an even more insidious, chronic and debilitating disorder coupled with the one already in place. Adding force and speed to the 1

2 2 roller coaster ride is the fact that the lifestyle of substance abusers typically leads them into more traumatizing environments and activities than a non-substance abuser encounters on a daily basis, thereby further imprinting new trauma into\ their brain and nervous system. In the areas of both substance abuse and PTSD, one often hears the term trigger. Triggers (both internal and/environmental) are stimuli that under ordinary circumstances would evoke no particular emotional or visceral disturbance, such as the scent of a particular cologne. A trigger response refers to an exaggerated, extremely uncomfortable visceral reaction to a current stimulus that is in some way reminiscent of a traumatic event. For example, an individual who has been sexually abused by someone wearing a particular cologne might come in contact with a scent similar to that worn by his or her abuser from years prior. They might then find themselves in the grip of a flashback, which is the re-experiencing of an event that is not happening in the present moment, but feels like it is. The fact that a stimulus could still hold the power to activate a person so intensely is a primary indicator that the traumatic material associated with the event has not been fully processed. These trigger reactions are often the key to uncovering the origin and nature of presenting psychiatric behavior patterns, such as depression, anxiety, dissociation, PTSD, and substance abuse. These psychiatric complaints are often found together in bits and pieces, overlapping and co-occurring in a variety of different ways, frequently with a trauma history at their core. The co-occurrence of PTSD and substance abuse is one of the most commonly cited treatment challenges emerging in the fields of trauma, addiction and criminal justice. Despite the prevalence of this complex clinical presentation, there is a scarcity of published, empirically based integrated treatment models shown to effectively treat this multiply diagnosed population. National studies commissioned by the federal government estimate that 10 million to 12 million Americans have co-occurring mental and addictive disorders. The prevailing research confirms that integrated treatment for co-occurring disorders is much more effective than treating these illnesses separately. Integrated treatment means mental illness and addictive disorders services and interventions are delivered simultaneously at the same treatment site, ideally with cross-trained staff. What is not considered integrated treatment is sequential treatment (treat one disorder first, then the other) or parallel 2

3 3 treatment (in which two treatment providers at separate locations use separate treatment plans to treat each condition separately, but at the same time). (NAMI; 2002) Though short on integrated models of treatment for the dually diagnosed, there are currently accepted, empirically supported treatment models for each of these disorders individually. PTSD is treated with variations of cognitive behavioral therapy (CBT), psychopharmacology and exposure/desensitization treatments (Foa and Kozak, 1986). Substance abuse is primarily treated with a combination of 12 step programs, CBT and group therapies. This article proposes that the addition of an EMDR based treatment component could fill a missing piece adjunctively with other therapies currently in use. That missing piece is the processing of the sensory imprints associated with trauma, a gift of EMDR. Sensory imprints are the disturbing nervous system memories which sometimes remain long after a traumatic event has occurred. When these memories have not been fully integrated by the brain/body/mind continuum, it causes one to react disproportionately and inappropriately in the present, to stimuli evoking memories of the past event. Those memory fragments can serve as triggers for relapse for those people who are also chemically addicted. The sensory imprinting referred to in PTSD has actually been documented for over a century and is understood in terms of the way in which traumatic events are coded and stored in the brain. (Janet, 1889, 1894; Siegel, 1999; van der Kolk, 1994; van der Kolk & Fisler, 1995; van der Kolk, et. al. 2001). It is this sense memory which seems to be responsible for the visceral reactions experienced when one is exposed to current reminders of past traumas. Recent neurological research suggests that when a person experiences a traumatic event that they are unable to process to an adaptive state, it seems to get frozen in their brain and nervous system with all the attendant state-specific characteristics. (Siegel, 1999; van der Kolk, 1999). These would be the visual, auditory, olfactory, emotional, and visceral states experienced at the time of the actual event. With the advent of nuclear medicine (PET, MRI and SPECT scanning), it is even possible to see what level of activation (or de-activation) is present in different areas of the brain during recall of a traumatic event prior to effective treatment. In addition, brain changes can also 3

4 4 be noted pre and post EMDR treatment showing increased normalization of affected areas of the brain. (Amen, 2002; Levin, Lazrove and van der Kolk, 1999). It is important to note that not every substance user is suffering from unresolved trauma, and not every trauma survivor is using substances to cope. However, the percentage of people for whom this does co-exist is extensive and results in increased use and higher costs of treatment services, often without integrated treatment programs to address them. The presence of co-morbid posttraumatic stress disorder (PTSD) has been associated with poorer substance use disorder (SUD) outcomes. For example, Brown, Stout, and Mueller (1996) compared substance-dependent women with and without a co-morbid diagnosis of PTSD, on their alcohol and drug-use status 3 months post-discharge from inpatient substance abuse treatment. Women with PTSD were found to relapse more quickly than women who did not have PTSD. In another prospective study, Brown and Stout (1997) tracked 56 SUD patients (32 with PTSD and 24 without PTSD) for 6 months after their discharge from inpatient substance abuse treatment. Compared with non-ptsd patients, PTSD patients relapsed faster, drank more on those days when they did drink, and had heavier drinking days during the follow-up period. (Brown, P. J., et al. 1999). Overview of EMDR EMDR was first introduced by Francine Shapiro, PhD. in It is called an Adaptive Information Processing Model (Shapiro, F. 1995, 2001). Essentially, this refers to the apparent ability of EMDR to tap into a natural, intrinsic capacity of the brain to process disturbing information to a neutral (non-over-reactive) state, once it is activated and linked to the more adaptive associations within the person s own experience over time and with maturity. EMDR has shown itself to be a creative, effective and efficient treatment for PTSD. Since its discovery, it has been one of the most intensely researched, written about and critiqued psychological methods to appear in the clinical community during the last decade. It is a development in the field that seems to have compelled a great divide. It is, on the one hand, touted as a breakthrough therapy for PTSD, which is traditionally one of the most chronic and difficult psychological disorders to treat. On the other hand, it has been dismissed as simply a repackaging of old therapies already known to the clinical world. Perhaps it is a bit of both. Whichever it may be, this author has conducted hundreds of clinical hours of EMDR, after having utilized psychodynamic and cognitive behavioral therapy with good results for more than 20 4

5 5 years, prior to becoming certified in EMDR. However, once this treatment method was added to the arsenal of therapeutic tools, remarkable, deeper, long-lasting changes were noted with one client after the next. The changes that were especially intriguing were with those clients who had already presumably completed traditional therapy, having gone as far as they could cognitively, yet continuing to be vulnerable to visceral triggers. Once triggered, behaviors followed that could be seen as useless and even destructive, yet the client felt unable to stop, (e.g.: overreacting to a parent with whom they had serious unresolved issues) creating much frustration and confusion. After completing EMDR treatment, those triggers became neutralized, thereby freeing the client to have a wider array of behavioral choices, which had previously seemed out of reach. Observations of this type of transformation became the fundamental evidence that there was a missing piece needing to be addressed for a more complete recovery. Fourteen years after the discovery of EMDR, there is now extensive anecdotal and empirical evidence of EMDR s efficacy (see for a complete list of controlled studies to date). It is presently considered to be empirically efficacious by the International Society for Traumatic Stress Studies (ISTSS), the American Psychological Association (APA) and The United Kingdom Department of Health. EMDR has had a particularly positive impact in an area of treatment that has always seemed mysteriously intractable. That is, the shifting of viscerally disturbing material to a neutral state, where the disturbance is a result of an irrational belief that has grown out of a traumatic experience. In CBT and insight-oriented therapies, clients report that they intellectually understand, for example, that they were not responsible for their sexual and/or emotional abuse as a child, however they still seem unable to shake the feeling and the irrational belief that they are/were somehow responsible, often leading their self-worth to plummet. It is as if the bridge between emotion and the intellect has been destroyed, leaving elements of the traumatic experience frozen in time in an area of the brain that seems inaccessible with customary talking and insight-oriented oriented therapies. Human behavior is precipitated by a person s held beliefs, whether rational or irrational. In the case of irrational beliefs that emerge as a result of trauma, real change can only be expected first at the level of belief and second at the level of behavior. 5

6 6 EMDR s Unique Contribution: The Neurological Piece The brain has a bottom-up organization. The bottom regions (i.e., brainstem) control the most simple autonomic functions such as respiration, heart rate and blood pressure, while the middle and top areas, limbic and cortex respectively, control more complex functions such as planning, analysis and other higher executive function and regulating emotions. (Perry, B. and Marcellus, J. 1997). EMDR is often referred to as a bottom-up therapy, designed to activate targeted memories from the brainstem up, which is the order in which the brain is actually developed and grown. The brainstem is also where the visceral fight, flight, freeze response originates. Cognitive behavioral therapies are thought to target from the top down, primarily activating the cortex (top) of the brain first, which is responsible for higher-level executive functions such as problem solving, decision-making, articulation of ideas and rational thinking. Developmentally speaking, this part of the brain is the last to develop. Thus, traumatic experiences may have been endured early in childhood and gotten locked into the nervous system long before much of the higher brain functions were even in existence. Therefore our ability to learn and access the skills, both cognitive and behavioral, to cope with the disturbing manifestations of a trauma history are often not even available as a resource until long after the trauma has already passed. A stimulus such as hearing someone s voice or smelling an odor that reminds a person of a trauma (eg: the cologne worn by a sexual perpetrator early in life), has the power to activate that bottom part of the brain which holds (in a manner of speaking) the unprocessed material. In PTSD, an auditory or olfactory stimulus such as this can lead directly to hyper-arousal of the nervous system, flashbacks, and extreme panic, even though in the present moment the person presenting the voice or odor is of no true danger at all. What is triggered is the body/mind memory (there is a distinct lack of language for newly emerging knowledge in neuroscience) of the past danger, held in a neural network the way it was first encoded and continues to be able to be activated (Siegel, D.J. 1999; Van der Kolk, 1999; et al). When this happens, the part of the brain that is being activated is the brainstem (fight/flight/freeze), and the limbic system (emotions), not the cortex (rational, analytical thought). 6

7 7 In fact, when faced with the visceral triggers of PTSD, it has been reported that the brain s frontal lobes often effectively shut down, leaving mostly the brainstem, sensory circuits and limbic areas dominating operations (Van der Kolk, 199?; Siegel, 1999 P.259). EMDR is a method that deliberately targets and activates areas of the brain more holistically and from the bottom up. The goal of this intervention is to rebuild the bridge between cognitions, emotions and sensations that leads to processing and integrating disturbing material from the past into a more adaptive timecorrected state. The presumption is that you can t change what you don t activate (Perry, B. 2002). This is the real gift of EMDR. The Application of EMDR to PTSD When EMDR is used to treat the identified trauma (e.g.: abuse), the target is the entire bio-psychological package including: 1) The worst part of the image of the event; 2) The negative cognition one now holds about oneself, e.g.: It s my fault ; 3) The emotions evoked by the event, e.g.: terror, guilt, shame, etc; and 4) The disturbing somatic sensations experienced when focusing on this targeted event (stomach churning, chest tightening, etc.). After the targeted event is activated in this manner, bilateral stimulation is introduced, using either eye movements, auditory tones or tapping. Treatment proceeds systematically back and forth between focusing on the disturbing material, conducting sets of bilateral stimulation, and a dually held attention in the present. As the person follows the flow of the memories internally, the external report of thoughts, feelings and body sensations seems to become more adaptive and calm. The ability of our brain/body/mind to accomplish this type of resolution is what was referred to earlier as Adaptive Information Processing, which presumes that the brain and nervous system, just like the body, has an innate capacity to heal after being traumatized. EMDR appears to be an efficient, effective intervention for activating that natural healing process. (Shapiro; 1995, 2001). After successful treatment with EMDR, the client who previously reported an inability to feel any differently about a sense of guilt and responsibility for their own abuse (no matter how true it seemed intellectually), would most likely be able to realize and internalize: It wasn t my fault; I was just a child without power or choices. I can keep myself safe now. This would be a more adaptive and valid cognition to be held about oneself in the aftermath of childhood abuse. 7

8 8 After successful completion of a processed target, people typically report the ability to truly feel the validity of this more adaptive statement in all 3 targeted areas: cognitively, emotionally and somatically. This particular type of integrated shift is what sets EMDR apart from other frequently used therapies. It leads to a true changed belief and hence the natural outcome of changed behaviors. The Application of EMDR to Substance Abuse Treatment After the development of EMDR for use with PTSD, it became clear that it s potential for the treatment of additional psychiatric disorders had just begun. One of them was addiction. A number of EMDR-trained clinicians and researchers began to develop and tailor specialized protocols for use with the addiction population. (Omaha, J.; Popky, A.J.; Vogelmann-Sine & Sine.) These protocols incorporated specialized uses of EMDR, such as Resource Development Installation (RDI; Korn, D. & Leeds, A. 1998), Desensitization of Triggers and Urge Reprocessing (DeTUR; Popky, A. J. 1998) and Affect Management Skills Training (AMST), (Omaha, J. 1998). Resource Development Installation (RDI) refers to the building and strengthening of internal resources that a person may lack, such as a sense of safety, courage, assertiveness, and self-esteem. Many individuals who have been raised in homes where they experienced abuse and/or neglect, do not feel internally strong or capable enough to tolerate the pain, discomforts and challenges of life, nor have their brains been hard-wired for effective affect regulation in the first place as a result of insufficient attachment and safety during the earliest part of life. In addition, adult living skills such as independence, self-sufficiency, and positive interpersonal relationships are severely impaired. This occurs first as a result of extreme negative experiences in their early childhood environment, and later by the after-effects of trauma and addiction, always fraught with fear, guilt and shame. RDI allows people to strengthen their inner selves in preparation for addressing highly disturbing past trauma. This aspect of preparation for EMDR trauma processing is vital when treating this particular population with EMDR, since the treatment experience can be highly activating and can overwhelm a fragile, unprepared client. In cases where internal resources and ego states are stronger, such additional preparation might not be so essential prior to trauma work. 8

9 9 Another specialized EMDR based protocol is called Desensitization of Triggers and Urge Reprocessing (DeTur; Popky, A. J. 1998). The skills learned in this protocol help an addict desensitize their particular substance-using triggers, which is such a critical aspect of substance abuse treatment and is often quite treatment resistant. Remember that a trigger is an activating experience that creates internal discomfort, often leading to an urge to use a mind/body altering substance to quell the disturbing feelings. EMDR focuses on neutralizing the disturbance(s) still connected to a past traumatic event, such that reminders of it have no present-day, upsetting emotional charge. It is simply a sad memory from the past that the person has survived and integrated fully, and perhaps has even grown stronger from. If substance-using triggers can be neutralized and therefore the associated urge to use lessened or eliminated, it follows that the compulsion to use chemicals to alter one s state would no longer feel necessary to tolerate the past (and present shame, guilt, etc.). Since one of the benefits of substance use to a traumatized individual is that it serves the purpose of helping them manage intolerable feelings (affect), it is a critical element of treatment for the person to be able to learn to tolerate their feelings without using substances to do so. Affect Management Skills Training (AMST; Omaha, J. 1998), which utilizes the same bilateral, dual attention stimulation as does EMDR, has been used to teach people to identify disturbing emotions such as fear, shame, anger and disgust, increase awareness of how these are expressed and felt in the body and then taught to just observe, distance and ground themselves, and allow the feelings to pass without reacting or responding to them. This set of skills leads the person to the belief and the experience of having the internal resources necessary to understand, tolerate and choose an alternative response. Learning to manage one s own powerful emotions gives the person an internalized sense of control, which in the past has been sought through the destructive, external means found in addiction. Affect management skills give the person the confidence that they can effectively handle these types of challenges in their lives with internalized, very personal resources and strengths that no one else has given them and no one can take away. They have built them with their own resources and 9

10 10 experiences (and the help of their treatment partnership) and can continue to build on them for the rest of their lives, with a true choice to be free of substances and the residue of trauma. Future Directions EMDR offers specialized treatment protocols which, combined with a comprehensive treatment program, promises to add a deeper dimension to the healing of the addictive disorders co-occurring with PTSD. Currently, a pilot research trial is being conducted in The Thurston County Drug Court in Olympia, Washington, combining the best elements of these addictionoriented EMDR protocols. The goal is to establish a fully formed, integrated treatment program for this co-occurring problem. (Brown, S. & Gilman, S Lifeforce Services, Inc., San Diego, CA). The preliminary results thus far have indicated that this type of trauma treatment can fill a missing piece in the currently available treatment options for this dually diagnosed population. In addition, the program could be replicated in order to create a sound research base to support its use. Future papers will summarize the integrated protocol, the results of the pilot study and additional research findings as other studies are conducted. 10

11 11 REFERENCES Amen, D. (2002) Healing the Hardware of the Soul. Mindworks Press Brady, K.T., Killeen, T., Saladin, M.E., Dansky, B. & Becker, S. (1994). Comorbid substance abuse and posttraumatic stress disorder: Characteristics of women in treatment. The American Journal on Addictions, 3, Brown, P. J., Recupero, P. R. & Stout, R. L. (1995). PTSD substance abuse comorbidity and treatment utilization. Addictive Behaviors, 20, Brown, P. J. & Stout, R. L. (1997, November). Six-month post-treatment outcomes of substance use disordered patients with and without comorbid PTSD: Preliminary findings. (Paper presented at the annual meeting of the International Society for Traumatic Stress Studies, Montreal, Ontario, Canada.) Brown, P. J., Stout, R. & Mueller, T. (1996). Post-traumatic stress disorder and substance abuse relapse among women: A pilot study. Psychology of Addictive Behaviors, 10, Brown, P. J., Stout, R. L. & Mueller, T. (1999). and Posttraumatic Stress Disorder Comorbidity: Addiction and Psychiatric Treatment Rates. Psychology of Addictive Behaviors, June, Vol. 13, No. 2, Brown, S. & Gilman, S. (2002) Lifeforce Services, Inc. San Diego, CA. Thurston County Drug Court Pilot EMDR Trials. Foa, E.B., & Kozak, M.J. (1986) Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, Janet, P. (1889). L automatisme psychologique. Paris: Alcan. Kessler, R. (1995). The Epidemiology of co-occurring addictive and mental disorders. NCS Working Paper # 9. Invited conference paper, presented at the SAMHSA sponsored conference; Improving services for individuals with co-occurring substance abuse and mental health disorders. Kessler, R., Price, H. Primary Prevention of Secondary Disorders Kessler, R. (1995). The National comorbidity survey: Preliminary results and future directions. International Journal of Methods in Psychiatric Research; 5: Kofed, L., Friedman, M. J. & Peck, R. (1993). Alcoholism and drug abuse in patients with PTSD. Psychiatric Quarterly, 64, Leeds, A. & Korn, D. (1998). Clinical applications of EMDR in the treatment of adult survivors of childhood abuse and neglect. Paper presented at EMDR Conference, Baltimore, MD. Levin, Lazrove, & van der Kolk, 1999; van der Kolk, Burbridge, & Suzuki, 1997; Zoler, 1998) Levin, P., Lazrove, S., & van der Kolk, B.A. (1999). What psychological testing and neuroimaging tell us about the treatment of posttraumatic stress disorder (PTSD) by Eye Movement Desensitization and Reprocessing (EMDR). Journal of Anxiety Disorders, 13, Levine, P. (1997). Waking the Tiger: Healing Trauma. North Atlantic Books, Berkeley, CA. 11

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13 13 Vogelmann-Sine, Sine, Smyth, & Popky. (1998) EMDR Chemical Dependency Treatment Manual Copyright 2003 Susan Brown 13