When words are not enough

PARADIGM SHIFT IN TRAUMA THERAPY: HEALING THE BRAIN AND BUILDINGEMOTION REGULATION THROUGH THE SUBCORTICAL BRAIN

MARJORIE ROBB, CHEO, U OTTAWA, MARCH 2017

Learning objectives

u 1. To understand the effects of trauma on various parts of the brain, and the implications for trauma treatment

u 2. To identify and briefly describe at least three types of subcortical brain interventions

u 3. To list four advantages of working therapeutically with the subcortical brain

Potential conflicts

u None, other than that I am training to be a trainer in two of the modalities discussed

Overview

u Trauma and the brainu Psychotherapies and the brainu The subcortical brain and the ”unconscious”u Evidence for psychotherapies for trauma and stress related

problemsu Newer therapies and the subcortical brain

u EMDR

u Brainspotting

u Progressive Counting

u SMART – Sensory Motor Arousal Regulation Treatmen

Effects of traumatic stress

u Posttraumatic stress disorder (PTSD) affects about 8% [of Americans] at some time In their lives (Foa et al 2013, Kessler et al 2005)

u Affects about 5% of childrenu Significantly inhibits normal functioningu Development of effective treatments is limited by our knowledge

gaps about the underlying neurobiological mechanismsu Traumatic stress can lead to depression, substance abuse,

personality disorders, health problems and impaired functioning..u High comorbidity rate – 88% (Emerson et al 2009)u Increased risk of suicide (Kessler, 2000)

Sequelae of early exposure to traumatic stress

u Disorders of self-regulation, attachment, anxiety and affective disorders in infancy and childhood

u Addictions, aggression, social helplessness and eating disordersu Dissociative, somatoform, cardiovascular, metabolic and

immunological disordersu Sexual disorders in adolescence and adulthoodu Revictimization(Dube et al 2001, Felitti et al 1998; van der Kolk et al 2003, 2014)

Key Abuse Sensitive Structures

Adapted from: Teicher, Martin Harvard Medical School “Windows of Vulnerability: Neurobiology of Childhood Abuse” PDF

Normal threat response

u Multiple sensory inputs converge in the thalamus where they are integrated into a coherent pattern

u The sensations are then relayed both down to the amygdala and up to the frontal cortex

u Amygdala = the smoke detectoru Perceived threat -> amygdala receives information & sends

message to hypothalamus and brainstem -> stress hormones and autonomic nervous system (ANS) respond -> whole body is prepared for defense

u The medial prefrontal cortex (MPFC) is the watchtower which allows us to stop-think-respond

The stress response and the brain

u Brain areas implicated in the stress response include the amygdala, hippocampus, and prefrontal cortex.

u Studies of patients with PTSD show u smaller hippocampal and anterior cingulate volumes

u increased amygdala function

u decreased medial prefrontal/anterior cingulate function

u increased cortisol and norepinephrine responses to stress

u Changes can be lastingu Traumatic stress is associated with increased cortisol and

norepinephrine responses to subsequent stressors.

Functions of key affected areas

Amygdala: “smoke alarm”, fight/flight – turnson stress hormones and autonomic nervous system

Thalamus: Receives, integrates, relays sensoryinput

Hippocampus: memory

Anterior cingulate: decision making, emotion regulation, physiological regulation

Medial prefrontal cortex: thinking, judgment, “stop and think”

EXECUTIVE FUNCTIONAREA DISENGAGED

FIGHT OR FLIGHT AREAS ENGAGED

STRESSRESPONSE

Treatment of trauma and stressor related disorders

u The mainstay: psychotherapyu The most evidence exists for

u Prolonged exposure therapy (PE)

u Cognitive Processing Therapy (CPT)

u Trauma Focused CBT (TF-CBT) for children

u EMDR – Eye Movement Desensitization and Reprocessing (rated level 1 evidence for adults but not yet for children)

u Many other forms of talk therapy usedu More recently, body-based and nonverbal/less verbal therapies are

increasingly popular

EXECUTIVE FUNCTIONAREA DISENGAGED

FIGHT OR FLIGHT AREAS ENGAGED

STRESSRESPONSE

Much of the problem is subcortical

Where is the action?u Many of the problems related to trauma and stress are physiologially

located in the subcortical part of the brainu Amygdala becomes overactive, hyperalert for possible danger, failing

to return to baseline -> chronically raised stress hormonesu Thalamus’ – filter system working poorly, can’t distinguish relevant from

irrelevant, ability to integrate sensory inputs compromised; events may be recorded as an incoherent jumble of sights, sounds

u Hippocampus – memory problems; memories may be inconherent, jumbled

u Sensory self awareness compromised – areas of MPFC, anterior cingulate, parietal cortex, insula, posterior cingulate

u Emotion regulation fails: Intense fear, anger, and sadness increase the activation of subcortical brain regions involved in emotion and reduce the activity of the medial prefrontal cortex (MPFC) -> failure of emotion regulation, loss of reflective ability, impulsive reactivity

Top-down vs bottom-up approaches

u Cognitive based therapy approaches focus on learning to manage or over-ride the mental model “I am not safe”, emotional reactivity, and associated sx - “top-down” regulation techniques

u The underlying mental model and emotional reactivity remain. u We can Instead use the brain's ability to reconsolidate memory – to

permanently modify the underlying mental model and eliminate the emotional reactivity

u And we can teach the body to help calm the brain – “bottom-up” regulation techniques

Other considerations: accessibility

u Many young people don’t want to talk much. Either they don’t feel safe, or they literally can’t because Broca’s area (speech) can go offline when traumatic memories sufficiently activated

u Trauma can be preverbal; memories are not verbally encodedu Some people do psychotherapy for a long time but remain easily

emotionally dysregulated and overactivated. Words have not been enough for them to attain “calm and safe”.

Other considerations: acceptability

u A recent study explored dropout rates from “real life” treatment with prolonged exposure or cognitive processing therapy

u Dropout rates were very high although RCT dropout rates were not excessively high

u Hypothesized that in many RCTs “real world” clients with comorbid substance abuse, depression, personality disorders are excluded

u (Najavits, 2015)

What are other options?

u “Trauma treatments” have multiplied substantially in the past 2 decades

u Many have little evidence and many have evidence indicating they are not effective

u However, EMDR was at first an unproved therapy with no evidence –we have to do the research on promising therapies

u Many treatments are described as “brain-based” or “body-based”u “Brain-based” is not a helpful term; EVERYTHING we do is “brain-

based”. u Generally the term refers to therapies that are largely nonverbal and

often focus on subcortical/nonconscious processes

Examples of subcortical treatment

EMDR – Eye Movement Desensitization and Reprocessing

u EMDR is an evidence-based psychotherapy for Posttraumatic Stress Disorder (PTSD). Has also documented success for other problems eg anxiety, depression, pain, phobias, etc.

u Developed by Francine Shapiro in 1987u Based on theory that much of psychopathology is due to the

maladaptive encoding and/or incomplete processing of traumatic or disturbing adverse life experiences.

u Traumatic memories “stuck” in limbic system as a memory network, associated with emotions and physical sensations, and disconnected from the language-using prefrontal cortex. These traumatic memories can be continually triggered even when there is no conscious memory.

EMDR – what happens?u 1. Thorough history, treatment plan: what are we working on?u 2. Preparation: trust in therapist, relaxation skillsu 3. Assessment: specific protocol identifies target memory, negative

self-beliefs, desired positive beliefs, negative emotions, physical sensations, and distress level

u 4. Reprocessing and desensitization. Client watches therapist's finger moving backwards and forwards across the visual field. Stop, and client is asked to report changes in thoughts, images and feelings. With repeated sets of eye movements, the memory tends to lose its painful intensity and simply becomes a neutral memory of an event in the past. Other associated memories may also heal – ‘ripple effect”.

EMDR

u 5. Installation: establishment of new positive cognitionu 6. Body Scan: ensuring that the original memory no longer

associated with body tension/discomfortu 7. Closure: each session should end with client feeling in control and

better than at the start. u 8. Re-evaluation: each session opens with checking on how the

feelings, beliefs, and body have been since last session

u EMDR deals with past memories, present challenges, and skills that will be needed for the future

EMDR Case - Natalie

u 16 year old Grade 10 studentu Previously doing well in school, part-time job, good social lifeu Threatened by a pair of men one night while she was taking a

shortcut to the bus stop at night – terrified, but not hurtu Since then: anxious ++, afraid of the bus (but takes it)u Doesn’t want to go out or be out after darku Interferes ++ with her social lifeu Interferes with work – has to get home after dark

Natalie - EMDR

u After Natalie told her story, explained EMDR (steps 1,2)u Session 2: steps 3, 4 – did EMDR for 20 minutesu Initial SUDs – 7/10u Rose to 8.5/10u After 20 minutes reported SUDs of 0u Said she felt good and thought she could wrap upu Three weeks later, reported that she was doing well, taking the bus

without being nervous, and had resumed her social lifeu This was an exceptionally short treatment for single-episode trauma

that was not severe or prolonged

EMDR – pros and cons

Prosu Strong evidence base

u Clients are not required to talk much

u Can be more efficient

u Allows resolution at a subcortical level of previously unprocessed memories

u Difficult memories processed much more quickly than a verbal method would allow

Consu Intensive training required; quite

expensive to learn

u Clients required to tolerate intense emotion

u Can be tiring physically for therapist

u Potential for overly intense reactions during process which can feel out of control

Brainspotting

u Developed in 2003 by David Grand, an experienced EMDR therapistu Derived from EMDR, but no eye movement u A “Brainspot” is the eye position which is related to the

physical/emotional activation of a traumatic/emotionally charged issue

u Therapist helps client position their eyes on a brainspot; as the spot is held in the gaze, the memory or emotion is processed so that the distress level decreases, body discomfort reduces

u “Dual Attunement”: therapist simultaneously attunes to the therapeutic relationship and to the brain-body response of the person in therapy.

Brainspotting

u Aims to identify, process and release core neurophysiological sources of emotional/body pain, trauma, dissociation and a variety of other challenging symptoms.

u Can be integrated with most other forms of therapy; seen as a tool to support the therapeutic relationship

u Brainspotting works with the deep brain and the body; gives direct access to the autonomic and limbic systems

u Allows clients and therapists to process experiences and symptoms that are often out of reach of the conscious mind and language capacity

Case example: Tara

u Tara is an 18-year old girl who was molested at age 6 by older brother. Parents protected her by making sure that for the next 12 years they were never alone together. Tara did not feel protected or validated.

u Tara had struggles with substance use, choices of boyfriends, and was sexually assaulted by three boys when she was in mid-teens

u Had completed DBT; decided she needed to “tackle” her constant anxiety and depression

u Did brainspotting with her for about 40 minutes. She cried, talked about a kaleidoscpe of memories, and then said “it wasn’t my fault!” Soon after that, she felt calm and peaceful

Brainspotting – pros and cons

Prosu Powerful intervention which often

helps clients feel much better within an hour

u Talking is optional for clientu Therapists agree that results

happen much more quickly than in most other therapies

u Feels safe and controlled for both client and therapist

u Can be used with childrenu Can be used for many issues

Consu Lack of evidence! This is a new

therapy which requires research

u Not for everyone

u Can feel uncomfortably intense for client

u Lack of professional oversight, no organization with clear criteria

Progressive Counting

u Developed by Ricky Greenwald, an EMDR therapist

u PC is preferably done within a phase model of trauma-informed treatment, so that the client understands the rationale of trauma work, and is sufficiently motivated, stable, and strong as to be likely to be successful with PC.

u PC is done individually, with one person at a time.

u The memories to be targeted with PC are systematically identified as relevant to the client’s presenting problem.

u If more than one memory is to be treated with PC, the memories are treated in chronological order, once the client is judged to be capable of doing this.

u The therapist guides the client to identify a beginning and ending of the movie, each of which (beginning and ending) are not part of the distressing event, but rather outside the event, and part of the broader life story.

u The therapist counts aloud from 1-10 (then 1-20, etc., as per the PC system) while the client watches the movie of the distressing memory, in imagination, from beginning to end each time.

u The therapist briefly obtains feedback from the client including a current distress rating. The feedback guides the therapist’s next step.

u The therapist recognizes when the client is stuck (as per the PC system) and utilizes a range of possible interventions (as per the PC system) to assist the client in getting unstuck and continuing to make progress.

u The therapist persists with PC until the client reports no remaining distress associated with the memory, and no further changes in memory-related thoughts, emotions, or physical sensations.

u The therapist follows up with the client to determine whether any memory-related distress remains, and if so, treats it with PC.

u When PC is used with parents in conjunction with parenting-focused intervention, it is typically used to treat those memories which arepresumed to interfere with the parent’s capacity to parent up to the level of their natural competence. For example, a parent who is short-tempered with the child might be treated for his or her own history of abuse, which tends to lead to calmer parenting

u Progressive counting (PC) is a psychotherapy technique developed by Ricky Greenwald designed for trauma resolution based on the counting method.[1] It is used to reduce or eliminate symptoms such as anxiety, depression, guilt, anger, and post-traumatic reactions. It can also be used to enhance psychological resources such as confidence and self-esteem. The procedure involves having the client visualize a series of progressively longer "movies" of the trauma memory while the therapist counts out loud (first to a count of 10, then 20, then 30, etc.). By repeatedly imagining the movie of the memory, the memory gets "digested" or healed, via desensitization, emotional processing, gaining perspective, or other means

u References[edit]u Jump up ^ Greenwald, Ricky (2008). "Progressive Counting: A new trauma resolution method.". Journal

of Child & Adolescent Trauma. 1: 249–262.u Jump up ^ "PC Frequently Asked Questions". Trauma Institute & Child Trauma Institute.

u Jump up ^ Greenwald, Ricky (2015). "Progressive Counting: The Next Trauma Treatment of Choice?". International Journal of Trauma Research and Practice. 2 (1): 31–33.

u Jump up ^ Greenwald, Ricky; McClintock, Scott; Bailey, Tyson (2013). "A Controlled Comparison of Eye Movement Desensitization & Reprocessing and Progressive Counting". Journal of Aggression, Maltreatment & Trauma. 22 (9): 981–996. doi:10.1080/10926771.2013.834020.

u Jump up ^ Greenwald, Ricky (2013). Progressive Counting Within A Phase Model Of Trauma-Informed Treatment. NY: Routledge.

u Jump up ^ Greenwald, Ricky (December 2008). "Progressive Counting for Trauma Resolution: Three Case Studies". Traumatology. 14 (4): 83–92.

u Jump up ^ Greenwald, Ricky; McClintock, Scott; Bailey, Tyson (2013). "A Controlled Comparison of Eye Movement Desensitization & Reprocessing and Progressive Counting". Journal of Aggression, Maltreatment & Trauma. 22 (9): 981–996. doi:10.1080/10926771.2013.834020.

u Jump up ^ Greenwald, Ricky; McClintock, Scott; Jarecki, Kriss; Monaco, Annie (November 3, 2014). "A Comparison of Eye Movement Desensitization and Reprocessing and Progressive Counting Among Therapists in Training". Traumatology

u Two studies have been completed comparing PC to EMDR. A pilot study compared EMDR and PC for volunteers from the community who reported having a disturbing memory; some met criteria for PTSD and some did not. Ten experienced EMDR-trained therapists were briefly trained in PC, and participants were randomized to treatment condition. No significant differences between EMDR and PC were found. The treatments were rated by participants as equally difficult. EMDR had a trend of fewer dropouts whereas PC had a trend of greater efficiency.[7] In the other comparison study, 109 therapists in either EMDR or PC training programs worked on several of their own upsetting memories in practicums during the course of the training. For each treated memory they recorded treatment time as well as pre/post memory-related distress ratings; ratings were repeated at 2 and 10 weeks post-treatment via e-mail. Participants also rated the perceived difficulty of the treatment they experienced. Participants in both conditions reported significant reductions in memory-related distress, which persisted at 2 weeks and 10 weeks post-treatment. There were no differences in effect size or maintenance of gains. PC was 37.5% more efficient than EMDR, and was rated by those in the client role as being less difficult

Summary

u 1. Bremmer JD. Traumatic Stress: effects on the brain. Dialogues Clin Neurosci. 2006 Dec; 8(4): 445–461.

u 2. Najavitz LM. The problem of dropout from “gold standard” PTSD therapies, F1000Prime Rep. 2015; 7: 43. Published online 2015 Apr 2. doi: 10.12703/P7-43

PMCID: PMC4447050The problem of dropout from “gold standard” PTSD therapiesLisa M. Najavits 1

,21

Published online 2015 Apr 2. doi: 10.12703/P7-43PMCID: PMC4447050The problem of dropout from “gold standard” PTSD therapiesLisa M. Najavits 1

,21

The problem of dropout from “gold standard” PTSD therapiesLisa M. Najavits 1

,2

Insecure/disorganized attachment and dysregulation…

u Abused and neglected children learn that they are helpless and powerless to effect change

u Lack of safety and synchronicity with their caregiver prevents infants from developing the capacity to regulate their bodies and emotions

u Infants with disorganized attachment pattern develop:u Serious problems by kindergartenu Increased risk for a range of psychiatric problems (Lyons-Ruth,

1996)u Physiologic stress :

u Elevated heart rate, decreased heart rate variabilityu Overactive Stress hormone responses, impaired immune

system functioning (Porges et al, 1996; Hertsgaard et al, 1993)

Trauma alters the alarm systemu Overactive Alarm system: Trauma causes the amygdala to be

overactive, hyperalert for possible danger, failing to return to baselineu Stress hormones are chronically raisedu Filter system functions poorly: Thalamus’ ability to integrate sensory

inputs compromised; events may be recorded as an incoherent jumble of sights, sounds, etc.

u Memory formation blocked: High cortisol blocks hippocampal function -memories may be non-coherent, non-verbal and non-narrative

u Emotion regulation fails: Intense fear, anger, and sadness increase the activation of subcortical brain regions involved in emotion and reduce the activity of the medial prefrontal cortex (MPFC) -> failure of emotion regulation, loss of reflective ability, impulsive reactivity

u Sensory self awareness compromised – areas of MPFC, anterior cingulate, parietal cortex, insula, posterior cingulate

u Fight, flight, or freeze take over

Why subcortical?u Unlocking the Emotional Brain (Ecker, Ticic, & Hulley, 2012)u Recent brain research has worked to map the deep structure of

healing via memory reconsolidationu We can say that most presenting problems are driven by schemas

or mental models that are locked in the brain as a result of traumatic events (broad use of the term) that have not been fully processed or integrated

u Cognitive based therapy approaches focus on learning to manage or over-ride the mental model, emotional reactivity, and associated sx

u The underlying mental model and emotional reactivity remain. u We can Instead use the brain's ability to reconsolidate memory – to

permanently modify the underlying mental model and eliminate the emotional reactivity