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Treating Post Traumatic Stress disorder in Children


Permission graciously given by the author to reproduce this paper.

Treating Post Traumatic Stress disorder in Children

Chris Starets-Foote
2007

After reading some of the various theories about how to treat PTSD I found, Eye Movement Desensitization and Reprocessing (EMDR).  EMDR is a recently developed psychotherapy method for working through traumatic memories and related psychological problems. Recent literature reviews find strong support for EMDR's superiority to traditional approaches to trauma therapy.  EMDR appears to be a promising new resource for helping children and adolescents recover from trauma and loss.

Eye movement desensitization and reprocessing (EMDR) is a recently developed psychotherapy method which is best known as a treatment for traumatic memories and their psychological squeals. In 1987, a psychology graduate student named Francine Shapiro noticed that her own upsetting thoughts faded when her eyes spontaneously moved rapidly from side to side. Over the next several years, she and her colleagues developed and refined this discovery into a systematic therapeutic approach.

EMDR is a complex method which combines elements of behavioral and client-centered approaches, in a manner which is hypothesized to stimulate and facilitate the innate psychological healing processes (Greenwald, 1995b; Shapiro, 1995). To oversimplify, the client is asked to concentrate intensely on the most distressing segment of a traumatic memory while moving the eyes rapidly from side to side (by following the therapist's fingers moving across the visual field). Following the initial focus on the memory segment, after each set of eye movements (of about 30 seconds), the client is asked to report anything that "came up," whether an image, thought, emotion, or physical sensation (all are common). The focus of the next set is determined by the client's changing status. For example, if the client reports, "Now I'm feeling more anger," the therapist may suggest concentrating on the anger in the next set. The procedure is repeated until the client reports no further distress and can fully embrace a positive perspective. Shapiro (1995) has presented this method in detail.

Although many of these studies have focused on trauma and/or PTSD, EMDR has been applied to numerous conditions, including dissociative disorders, grief, somatic problems, anxiety, depression, and addictions (Shapiro, 1995). Generally the approach is to locate and reprocess the disturbing memory and/or memories at the root of the disturbance. However, some applications also rely on the apparent enhancement effect of EMDR on other techniques, including hypnosis, visualization, affirmation, and learning. This range of application is consistent with Shapiro's (1995) proposition that EMDR induces accelerated information processing.

Briefly, in EMDR a qualified therapist guides the client in vividly but safely recalling distressing past experiences ("desensitization") and gaining new understanding ("reprocessing") of the events, the bodily and emotional feelings, and the thoughts and self-images associated with them. The "eye movement" aspect of EMDR involves the client moving his/her eyes in a back-and-forth ("saccadic") manner while recalling the event(s).

As within any therapeutic framework, it is important to establish rapport with the client in order to engender trust and make it clear that one is not simply applying a "quick fix" without understanding the person. During this process the therapist should move from history taking to identifying the presenting problem and obtaining some idea (preferably with quantification) of how it interferes with daily functioning. Next, she should introduce the process and provide the client with a suitable rationale, appropriate to his level of understanding, of how the technique works, what he can expect during the session, and how it may affect him later.

Traumas cause a pathological change in the brain at the neural level resulting in these incidents becoming "locked" in the nervous system and not being processed in the normal way and, therefore, not being dealt with. Repetitive eye movements may be the body's natural way of desensitizing the person to the memory and so, inhibiting anxiety, the traumatic "overload" becomes resolved.

The benefits reported following EMDR include:  Feeling less troubled by trauma memories and reminders while awake and in dreams (PTSD intrusive re-experiencing symptoms).  Feeling able to cope with traumatic memories and reminders without simply trying to avoid troubling thoughts, conversations, people, activities, or places (PTSD avoidance symptoms).  Feeling more able to enjoy pleasurable activities and to be emotionally involved in relationships, as well as feeling that there is a future to look forward to (PTSD numbing and detachment symptoms).  Feeling less tense, stressed, irritable or angry, easily startled, and on-guard, and more able to sleep restfully, concentrate on activities, and deal with pressure and conflict (PTSD hyperarousal/hypervigilance symptoms).  Feeling less anxious, worried, fearful or phobic, and prone to panic attacks.  Feeling less depressed (down and blue, hopeless, worthless, emotionally drained, or suicidal).  Feeling an increased sense of self-esteem and self-confidence.   

EMDR consists of eight phases, each considered essential for effective application (Shapiro, 1995; Shapiro & Forrest, 1997). EMDR utilizes a direct holistic approach, attending to ongoing affective and physiological changes throughout the session.  

During the first two phases the therapist develops a treatment plan, assesses the client's suitability for EMDR, and prepares the client by educating him about the process and teaching him self-control techniques and affect management skills. Client preparations may take several sessions and includes the development of resources and strengths, the establishment of client safety, and stabilization.

In the third phase the client chooses which specific memory he wishes to target, and selects the most distressing visual image connected to that event. The therapist assists him in recognizing the present-day thoughts and feelings that are elicited by the visual image. The client identifies a current negative cognition about himself related to the target memory. Negative cognitions are beliefs such as "I'm powerless", or "I am worthless". Next he chooses a potential positive cognition, which expresses a desired sense of empowerment and agency, such as "I'm competent", or "I have value as a person". He then rates the accuracy of this positive belief on the Validity of Cognition Scale (VOC), where 1 represents "completely false" and 7 represents "completely true".

The client next identifies the emotions that are elicited when the visual image is combined with the negative belief. He rates the level of distress on the Subjective Unit of Disturbance (SUD) scale, where 0 is "calm" and 10 is "the worst possible distress" and identifies and locates the body sensations accompanying the emotions.

The fourth phase is the desensitization phase. The client focuses on the visual image, and the identified negative belief, emotions, and body sensations, while experiencing bilateral stimulation in sequential dosed exposures. The client holds all these elements in mind while simultaneously moving his eyes from side to side for 15 or more seconds, following the therapist's fingers as they move across the visual field. Other bilateral stimuli such as hand-tapping or aural stimulation can replace the eye movements (Shapiro, 1991; 1994b; 1995). After the set of eye movements the client is told to take a deep breath, and then is asked what material was elicited in the process. Generally this material (image, thought, sensation, or emotion) then becomes the target of the next set of eye movements. This cycle of alternating focused exposure and client feedback, is repeated many times and is accompanied by shifts in affect, physiological states, and cognitive insights (e.g., Vaughan et al., 1994). If the processing stalls, specialized interventions are worded and timed in a specific manner to facilitate processing. The SUD level is usually not reassessed until emotional, physical, and cognitive resolution is apparent. A SUD rating of 0 or 1 generally indicates completion of this phase.

In the fifth phase, cognitive installation, the therapist invites the client to pair the previously identified, or an emergent, positive self-statement with the original traumatic image, using bilateral stimulation. The efficacy of this phase is measured by the client's self-reported VOC. An attempt is made to increase the VOC to a score of 6 or 7.

In phase six, the clinician asks the client, while thinking of the image and the positive cognition, to notice if there is any tension or unusual sensations in his body. Because emotional distress is also often experienced physiologically, processing is not considered complete until the client can bring the traumatic memory into consciousness without feeling any body tension. Any sensations found in the body scan are targeted with more eye movements; this continues until the tension is relieved. In phase seven, closure, the therapist assesses that the material has been adequately worked through, and if not, assists the client with self-calming interventions.

Reevaluation (phase eight) takes place at the beginning of every subsequent EMDR session. The therapist checks with the client to assure that the treatment gains have been maintained, via SUD, VOC and body self-report measures. These reevaluations assist the therapist in continuing to direct the treatment to achieve maximum benefit for the client.

EMDR is based on a theoretical information processing model, which posits that symptoms arise when events are inadequately processed, and can be eradicated when the memory is fully processed. It is an integrative therapy, synthesizing elements of many traditional psychological orientations, such as psychodynamic, cognitive behavioral, experiential, physiological, and interpersonal therapies.

References

Greenwald, R. (1995a). Evaluating Shapiro's stance on EMDR training. OnLine Journal of Psychology, 1, 130-134. Modem 209-271-9025.

Greenwald, R. (1995b). Eye movement desensitization and reprocessing (EMDR): A new kind of dreamwork? Dreaming, 5, 51-55.

Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures. New York: Guilford Press.

Shapiro, F. (1992). Three day training course (levels 1 and 2) in EMDR. Gold Coast, Australia.

Shapiro, F., & Silk Forrest, M. (1997). EMDR: The breakthrough therapy for overcoming anxiety, stress, and trauma. New York: Basic Books.

Vaughan, K., Armstrong, M.S., Gold, R., O'Connor, N., Jenneke, W., & Tarrier, N. (1994). A trial of eye movement desensitization compared to image habituation training and applied muscle relaxation in post-traumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 25 (4), 283-291.

Shapiro, F. (1991). Stray thoughts. EMDR Network Newsletter, 1-3.