Grief Over the Death of a Client

One of my clients died and I feel incredibly sad about it.

She was a very special woman.  She was sadistically abused from the age of three and had tremendous strength, courage and  an unshakeable faith, despite all the trauma she endured. 

 

I worked with her for eleven years helping her to heal from all the neglect and abuse she had suffered as a child.  It was a shared journey.  I felt her pain when she suffered and felt her joy when the suffering was transformed.  I shared my reactions so she would know the impact she had on me.  She needed to know she touched my heart and soul, that it wasn't just a job to me. That is what made it possible for her to feel safe enough to reveal her pain to me.

 

I learned so much from her.  She was one of the most traumatized clients I have ever worked with and I kept having to expand my toolkit to be able to help her.  I was grateful for her willingness to try new things with me.

 

At one point in our work together I was feeling stuck about how to help her overcome a particular obstacle and was searching for new approaches to try.  She was desperate for relief from her suffering but was trapped in her self-blame and shame.  That is what motivated me to go for EMDR training seven years ago.  I will always be grateful to her for her role in that. 

 

This amazing survivor had just recently stopped having flashbacks and was looking forward to the next chapter in her life.  Then she was diagnosed with brain cancer.  It seemed so incredibly unfair.  Yet she faced this new obstacle with such grace, accepting whatever God had planned for her.
 

First she fought to survive, then when her chance of survival was so low and her ability to function was deteriorating, she chose to go into hospice and die with dignity. I learned another important lesson as I struggled to catch up with her and accept her decision so that I could be there for her and say goodbye.

 

She wanted others to learn from her experience overcoming childhood trauma and had wanted to write about it, but the brain cancer made that impossible.  So she asked me to tell her story. This is one way of honoring her request.

Answers to Questions about EMDR

After my last blog post and the #MHON twitter chat about EMDR, several people asked me follow up questions about EMDR memory reconsolidation and what EMDR looks like.  So here are some answers to the questions and a link to a CBS News video that shows  how EMDR works.

What is memory consolidation?

Memory consolidation involves taking the component parts of a memory and combining them into one unified whole.  In the first few months after an event occurs, it is still fragmented into its component parts. After that the different parts of the memory come together into more of a single whole entity.

What does the term "overconsolidation" mean?

When a memory is overconsolidated, it is continually re-activated  by reminders and does not fade with time. Traumatic memories are often overconsolidated into flashbacks. Every time a flashback occurs, it reinforces the overconsolidation of the memory, making it more and more resistant to change.

What is meant by reconsolidation?

It was previously believed that the consolidation process occurred just once, but research findings indicate that memory retrieval activates reconsolidation, a process that either reinforces or alters memory.* Reconsolidation of the memory means that the whole memory network is altered because of new information.  Younger and weaker memories are more easily reconsolidated than older and stronger memories.*

How does EMDR facilitate reconsolidation?

EMDR reprocessing involves brief retrieval of a traumatic memory with delineation of all of its component parts (sensory, cognitive, affective and somatic aspects). Bilateral stimulation is added to facilitate reprocessing that updates the memory with new adaptive information. This reconsolidation of the memory puts it in a different perspective, so that reminders no longer trigger  flashbacks or fight/flight/freeze reactions.

Trauma-based memory networks are like files in a filing cabinet that are isolated from the other files. With EMDR, the isolated files are able to access files with information needed to put a traumatic event in time perspective, create a coherent narrative and find meaning in the experience.

How is this different than what happens with prolonged exposure (PE)?

With  PE, extinction is achieved by repeatedly re-exposing subjects to the feared situation without the feared result.  In this way, over time, the feared situation no longer elicits the fear-based response. In my understanding, extinction does not involve the elimination of the original association, but involves new learning that competes with the original conditioning to weaken the conditioned response. Therefore, extinction of emotional arousal and urges does not eliminate the underlying traumatic associations, just the symptoms.

With EMDR reconsolidation, the original association appears to be unlinked and the new learning is linked to the original events and resulting beliefs, feelings and body-based symptoms.

In summary, the EMDR and Prolonged Exposure methods of treating trauma involve two different approaches to  therapeutic memory retrieval and initiate two different processes: reconsolidation and extinction. According to recent studies using crab and medaka fish, the duration of the re-exposure may be an important factor regarding the type of memory processing that is elicited: brief retrieval led to reconsolidation, while more prolonged retrieval resulted in memory extinction.*

What does the EMDR experience look like?

 For a taste of what EMDR therapy is like, here is a link to a CBS News report on Healing Post Traumatic Stress about a gulf war soldier who received EMDR from San Diego trauma therapist Sara Gilman, past president of the EMDR International Association (EMDRIA).

http://www.youtube.com/watch?v=LM_nw5N3n-I

Source:

Suzuki, A., et al. (2004). Memory Reconsolidation and Extinction Have Distinct Temporal and Biochemical Signatures.  The Journal of Neuroscience, 24(20):4787-4795. http://www.jneurosci.org/content/24/20/4787.full

EMDR: An Evidence-Based Treatment for Trauma

Eye Movement Desensitization and Reprocessing (EMDR) was discovered quite by accident in 1987 by Francine Shapiro, PhD.  She went for a walk  in the park and noticed that by the end of the walk she was no longer upset about something that had been bothering her.  When she thought about what had happened, she realized that she had engaged in spontaneous rapid eye movements while contemplating the problem and hypothesized that this had helped her to process and resolve her distress.  She later realized that most people do not spontaneously engage in these eye movements when awake, so she experimented with having people follow her fingers back and forth while focusing on their problems and discovered that it resolved their problems as well. 

In 1988, Dr. Shapiro graduated from using EMDR with "mundane problems" to experimenting with the "highly-charged memories" of people with post traumatic stress disorder (PTSD).*  She had similarly promising results using EMDR with this population.  At the time, PTSD was a fairly new diagnosis (it was first introduced in 1980) and there was no rigorous research about treatment effectiveness, other than studies that came out at about the same time evaluating cognitive behavioral therapy (CBT) as a  PTSD treatment .

There is now a substantial body of research that demonstrates the effectiveness of EMDR for the treatment of PTSD.**  In fact, only CBT and exposure therapy (and to a lesser degree stress inoculation therapy), have as much research supporting their use as a treatment for people suffering from PTSD. Despite this, some clinicians continue to mistakenly believe that EMDR is not evidence-based. 

Other clinicians mistakenly believe EMDR is just another exposure therapy.  EMDR uses brief exposure to the traumatic event, combined with bilateral stimulation (eye movements, tones, vibrations or tapping) and sensory, cognitive, affective and somatic components, to facilitate  adaptive information processing (AIP) and reconsolidation of the traumatic experience.

There are several theories about the role of the bilateral stimulation (BLS). One theory is that focusing on a distressing memory and a neutral visual, auditory or tactile stimulus at the same time helps to keep one foot in the present and one foot in the past to prevent retraumatization and facilitate adaptive reprocessing. Another theory is that the sensory stimulation may help process disturbing events in a mechanism similar  to dream sleep, also known as REM (rapid eye movement) sleep.  A third theory is that the bilateral stimulation activates both hemispheres of the brain to link right brain intuitive, sensory information with left brain logical, sequential, language-based information. Studies have been conducted about each of these theories and research continues to be done to answer our questions about how EMDR works.

What questions do you have about EMDR? What experience have you had with EMDR therapy, as a client and/or as a therapist?  What are your impressions about its effectiveness? Please share your comments and questions below. 

*See the recent article by Francine Shapiro in the Huffington Post online  where she talks about this: http://www.huffingtonpost.com/francine-shapiro-phd/ptsd-military_b_1250202.html)

**See http://emdrnj.com/emdr_research.html for citations and a brief summary of practice guidelines for PTSD treatment from the International Society for Traumatic Stress Studies (ISTSS), the American Psychiatric Association, the American Psychological Association, Cochrane Database of Systematic Reviews,  Department of Veteran's Affairs & Department of Defense (VA/DoD), and the Substance Abuse and Mental Health Services Association (SAMHSA)

Bearing Witness to the Pain of Child Abuse Survivors

The chorus of the popular song "Jar of Hearts" by Christina Perri has been playing in my head recently:

And who do you think you are

Running around leaving scars
Collecting your jar of hearts
And tearing love apart...

The song sounds like it was written from the perspective of a woman who was mistreated by her partner.  But I keep thinking of it in terms of someone who was abused as a child.  I've worked with hundreds of survivors of childhood physical, emotional and sexual abuse over the course of my career and at one point or another in their healing journeys , one way or another, almost all end up asking, "who do they think they are?!"

It's a good question. We live in a sick society, where cruelty to animals was a crime long before child abuse laws were enacted. And even now, after a few decades of awareness campaigns, business is still booming for child protective services workers in this country.  Abuse begets more abuse. The intergenerational impact of childhood abuse is staggering.  When parents abuse their children, it is unfortunately common for the children to end up marrying abusers or become abusers themselves --  and the abuse is passed on from generation to generation until somebody breaks the cycle by seeking help.

Help is available. However, it is very difficult for survivors of abuse to trust anyone after their trust has been betrayed by the very people who were supposed to protect them from harm.  And unfortunately, therapists often don't fully understand the implications of this and get frustrated or angry when they feel criticized or rejected by the clients they are trying to help.
Survivors often interpret therapist interventions based on their deeply ingrained expectations regarding  relationships, rather than the actual interactions.  When I say "I have to get off the phone" my client might interpret that as anger or rejection and when I  say" I care what happens to you" my client might respond, "you only care about me because you are getting paid."   No matter how many times I explicitly state that I am paid for my time, not for caring, because my caring can't be bought, many survivor clients continue to believe I only care because I'm paid, until we have done a lot of experiential work on our therapeutic relationship.

I've learned that even if a client can cognitively grasp what I'm saying that doesn't mean that it sinks in on an emotional level.   I had a very rude awakening when I first started doing EMDR therapy with a client who was abused from the age of 4.  The first time we reprocessed a sexual abuse memory with EMDR, she exclaimed in a surprised tone "it’s really not my fault!"  I had been trying to tell her this for two years and found out that she had only been paying lip service to what I was saying because she didn't want to contradict me.  It turned out that every time I said "It's not your fault"  she thought to herself  "yeah, right" with tremendous sarcasm.  Boy did I learn a valuable lesson that day!

As a psychotherapist who specializes in helping survivors of abuse, I am honored to be a partner in their healing.  I bear witness to their pain and help them to know they are no longer alone.  I accept their distrust and I own my own mistakes instead of blaming them, especially since they have often been blamed unfairly by their abusers.  I help them to go from surviving to prevailing and thriving, as I have done in my own healing journey. 

What experiences have you had with helping child abuse survivors to heal? Do you have any wisdom to add? Please page down to comment.

A Sexual Abuse Survivor Speaks Out

In response to my blog article about the Penn State sexual abuse scandal, Nancy Smyth commented that people stand by and do nothing, at least in part because they don't understand the tremendous impact that sexual abuse has on children.  Then I received a response from a child sexual abuse survivor who spoke about the impact from personal experience. So I decided to share a survivor's perspective to help us all understand a little more about why it is so important to take action to stop sexual abuse. I am grateful to the author for giving me permission to feature this description of what a child sexual abuse survivor can go through.

"As a trauma victim, I would just like to say we have to do something about sexual abuse in this world. People can't ignore it and turn their heads. It just keeps it going more and more.  "You see, even though they hid it years ago it still happened. The worst part is the abuser  says "if you tell, no one will believe you" and  "this isn't bad what I'm doing; I am supposed to do this to you" and "it's all your fault; you're the troublemaker or you wouldn't be in this position."  So you keep it quiet for as long as you can, thinking you're the bad one, not the abuser. Trying to keep everything to yourself until it has you in such a state that your stomach constantly hurts, you become very nervous, and you have fainting spells."

"Then you get enough nerve to tell but you are too young to know the words, so you make up your own words for it. You tell a police officer that these people are "bothering" you.  Well, all the officer does is to tell them to stop bothering you because he doesn't know what "bothering" means and the abusers made it seem like it was only a joke - all in fun. Then another day you get brave again and you tell a teacher. Now keep in mind you're just in first grade at the time. The teacher just says "that's a very big  accusation you're making on these people; they can get in big trouble for  this. Are you sure you want to say this about them?" Well first of all you have no idea what a big accusation is, except that its a really, really big word. Then you hear the word "trouble" and that is just what the abuser told you from the beginning:  "If you tell, no one will believe you and any way they would say it's your fault; you're the troublemaker." So you just freeze, not wanting to cause more trouble, just wanting to take back anything you said about the abuser at all. And keep silent hoping you won't get hurt again."

"The next thing you do is just try to forget about it. You go through life saying  "ok no one found out about it today so I'm good."  You continue doing this every damn day of your life until you get so scared and sick and put it so far out of your mind you don't even know it happened. Until years later when you start having flashbacks and eventually wind up in therapy. If you're lucky like me you get a good therapist. You start to trust someone with your secrets for the first time in your life.  Then  you remember more about the abuse and you immediately go into denial. Then you go back to believing it happened, but you tell yourself  "it was my fault; I was a troublemaker."  So the abuser still wins because here you are blaming yourself and acting as if the abusers are innocent and it was your fault. So you spend a lot of years in therapy with PTSD*, until the whole thing clicks and with EMDR** you are able to get yourself back together.  But unfortunately the more times the abusers abuse you, the more things trigger flashbacks and you get confused and blame yourself all over again. Then sticking with therapy you get to the point with EMDR where you realize "hey this really isn't my fault." 

"So yes, it is uncomfortable to talk about but just think of how uncomfortable it is for a child or a teen to go through it. Day after day having to keep it a secret until they're sick to their stomach or passing out. Then later on after you blanked it all out of your mind and you don't want to believe it, then it comes back to haunt you.  You question if it's real because you think you would know if it happened. But you don't know until you face it again. PTSD causes a lot of suffering up into adulthood. Sometimes you can't even work if it  is so traumatic that you keep forgetting where you are and feel like a child being abused all over again, right in the middle of the workplace.  So basically your life is ruined but the abusers are so damn sneaky they get away with it."


"Just like Penn State--from what I think I understand, people knew it was happening and didn't care to stop it.  Well how about we stop it NOW!  How many more victims do we have to ruin?  How many victims can't even go to work because no one wants them flipping out in the workplace?  How many victims can't even go to people's homes visiting or to the store because they don't know if they will be triggered, and are actually afraid to go out by themselves?  How many more children, young teens, even young adults are going to be victims of sexual abuse?  Why?  No one wants to talk about it.  Like Andrea said, they turn their  head, don't believe it or simply change the subject.  And if  the victims don't get the correct help they go on forever trying to keep it quiet.  Feeling ashamed, blamed, or hurt so bad they think suicide could be  in order.  Is It fair?"

*Post traumatic stress disorder (PTSD) occurs when traumatic experiences from the past keep intruding on the present.  There are three categories of symptoms:

 Re-experiencing symptoms:

     •Flashbacks; reliving the trauma

     •Nightmares about the trauma

     •Intrusive recollections of the trauma

Avoidance symptoms:

     •Avoiding reminders of the trauma

     •Emotional numbness; hypoarousal

     •Blocking out memories of the trauma

Hyperarousal symptoms:

     •Hypervigilance; always in fight/flight mode

     •Exaggerated startle response

     •Anger outbursts

     •Sleep disturbances

 **Eye Movement Desensitization and Reprocessing (EMDR) is an eight phase therapy method developed by Francine Shapiro to treat trauma. Traumatic experiences can be so overwhelming that the ability to process them and gain perspective is blocked. These traumatic events can get stuck in the nervous system the way they were initially perceived, with the same images, sounds, smells, tastes, and body sensations and resulting emotional reactions, urges and beliefs.  EMDR stimulates the memories and allows the brain to digest them, determining what is useful and necessary and discarding the thoughts, feelings, sensations and physiological arousal that are no longer needed.  New information is linked to the original events and related beliefs, feelings and body-based symptoms using bilateral eye movements, sounds or sensations.  This is believed to jumpstart stalled adaptive information processing  in a manner similar to what takes place during REM (rapid eye movement)  sleep.  Traumatic experiences are reprocessed and put in perspective so that they no longer interfere with day-to-day living. For more information about EMDR, see my new website http://EMDRNJ.com