Navigating Complex PTSD with EMDR: Tailored Approaches for Effective Healing
EMDR for Complex PTSD. Does it work?
Yes! EMDR is an effective method for Complex PTSD with the right adaptations.
When I was first trained in the basic protocol for Eye Movement Desensitization and Reprocessing (EMDR) I was amazed at its effectiveness with most clients, but completely perplexed at its ineffectiveness with about 20% of my client population. For these clients, the basic EMDR approach led to increased symptoms, therapy avoidance, dissociation, or overwhelm.
What was happening?!
These clients with more complex presentations of PTSD did not have the appropriate level of stabilization work prior to EMDR desensitization, understandably leading to overwhelm, dissociation, and increased fear of the treatment process.
Years later, with the benefit of multiple advanced trainings and certifications under my belt, it became clear that EMDR could successfully be adapted to meet the needs of more complex trauma presentations, or what we call Complex PTSD (C-PTSD).
Let’s take a closer look at C-PTSD and how we can adapt EMDR to meet the needs of these worthy clients:
First off. What is EMDR?
Eye Movement Desensitization and Reprocessing is a therapy modality developed by Francine Shapiro in the 80s, used to help individuals process distressing memories and experiences (“unprocessed” material) in order to alleviate symptoms of PTSD. EMDR is based on the idea that traumatic experiences can be “stuck” in the brain leading to symptoms such as traumatic flashbacks (visual, sensory, emotional, somatic), emotional distress, and physiological arousal (fight, flight, freeze, submit). EMDR involves accessing the traumatic memory and using BLS (bi-lateral stimulation) to support the process of memory desensitization and related positive shifts in perspective.
EMDR is an 8-phased treatment approach as follows:
History Taking and Treatment Planning
Preparation: Establishing client safety and stability
Desensitization: Reducing the level of distress connected to the memory/experience
Installation: Resourcing adaptive (positive) beliefs and emotions related to the desensitized memory
Body Scan: Alleviating any residual somatic discomfort connected to the memory
Closure
Re-evaluation
Read more about the 8 Phases of EMDR here.
What is Complex PTSD (C-PTSD) and how does it differ from PTSD?
Unlike single incident trauma, Complex PTSD typically has one or more of the following complexities:
1. Prolonged or repeated exposure
CPTSD often develops in individuals who have endured prolonged and severe trauma over an extended period. This trauma may include physical, emotional, or sexual abuse during childhood, repeated exposure to domestic violence, ongoing bullying, or toxic cultures.
2. Trauma combined with attachment (relational) wounding
We can think of trauma as something that happens “to us.” Conversely, we can think of attachment wounding as “not getting what we needed” in childhood or relationships. Children who grew up in dysfunctional families marked by neglectful, emotional abuse, or parental substance abuse are at greater risk.
3. Disorganized attachment style
Disorganized attachment is an attachment style characterized by a lack of consistent, coherent strategies for managing distress, particularly in close relationships. This attachment style typically develops in the context of early childhood experiences marked by significant disruption, inconsistency, or threats within the primary caregiving relationship. Children and adults with disorganized attachment find it challenging to achieve a felt sense of safety in the body (it’s not OK to feel safe), and instead oscillate between innate protective modes, such as fight, flight, freeze, submit, or cry for help.
4. Survival depended on frequent dissociation in childhood
Dissociation is a brilliant psychological defense mechanism that involves disconnection or detachment from one’s own thoughts, feelings, sensations, body, sense of time, memories, or identity. Dissociation is a way for the mind to cope with overwhelming stress, trauma, or emotion. All humans have the capacity to dissociate and do on a range from normal everyday dissociation (daydreaming, losing time when scrolling through your phone) to more pathological forms. In early childhood, if home was chaotic or unsafe, dissociation provided a means for emotional survival and necessary social development (tune out the discomfort and hyperfocus on other things). Though adaptive during times of early chaos/trauma, habitual dissociation generally blocks the successful reprocessing of traumatic material, thus leading to more complex presentations of trauma later in life.
5. Preverbal trauma
Preverbal trauma is trauma experiences in the first few years of life, prior to language development and prior to the development of explicit (story based) memories. Preverbal trauma stored in implicit memory can influence the child/person’s perceptions, beliefs, and relational patterns throughout life.
6. Secondary traumatization
Professionals working in high-stress environments, such as healthcare workers, first responders, or humanitarian workers, may develop CPTSD due to repeated exposure to traumatic events.
Adaptations to basic EMDR for complex trauma:
(A special thanks to all the incredibly bright and committed researchers who have contributed to the growing knowledge about CPTSD, attachment, dissociation, and how to adapt trauma treatment accordingly).
Though every case is unique, EMDR adaptations for CPTSD typically fall into one or more of the following categories:
1. Extended Preparation Phase
As we say in the field, “slow is fast” when it comes to treatment. This means that slowing down and spending more time in certain stages of therapy, will actually facilitate the healing process, leading to better outcomes down the road. For C-PTSD, this is extremely true of extending the preparation phase of EMDR. In the preparation phase we are working with the client to expand their window of tolerance, develop skills for self-regulation, and build their own sense of competence in relation to staying regulated while accessing traumatic material.
2. Attachment Resourcing
As described above, many clients with CPTSD have attachment wounding (not getting what they needed from caregivers) in additional to trauma (something bad/scary happened to them). In attachment resourcing, we are strengthening adaptive memories or engaging in imaginal exercises to download positive attachment experiences – such as feeling loved, protected, nurtured, and/or celebrated.
3. EMDR “target” memories are approached in reverse order – often focusing on future or present targets, prior to moving to more vulnerable targets from childhood
In a more traditional EMDR approach, the earlier traumatic memories are often reprocessed earlier in treatment, while the present day or future targets are reprocessed later. In general though, the earlier the memory, the younger the client was at the time, leading to more vulnerable emotional re-experiencing, such as powerlessness, terror, or aloneness. With CPTSD it often makes sense to address memories from adulthood first, as the client works towards increased stability and regulation, prior to addressing memories from early childhood.
4. Interventions specific to dissociation
As discussed above, dissociation can become the habituated, go-to response to trauma activation. Why? Because it works (at least in the moment). Unfortunately, chronic dissociation can lead to Post Traumatic Decline. Post traumatic decline is specifically a worsening of the avoidance that comes with unresolved trauma. Dissociation, or turning away from pain/trauma, prevents the healthy resolution of trauma over time. The traumatic material is left unresolved and over time, the psyche will generalize the fear source leading to increased avoidance of potential trauma triggers, and thus increased symptomology related to the trauma. Interventions specific to dissociation often involve a pendulation approach of “dipping a toe into trauma,” them immediately moving back into grounding/resourcing/stabilization. When this pendulation approach is repeated over time, the client strengthens the ability to access trauma material without dissociating.
5. Parts-work, or inner child work
Engaging in inner child work facilitates the integration of fragmented aspects of the self, allowing individuals to reconnect to disowned or fragmented parts of their identity. By embracing all aspects of themselves, including the vulnerable inner child, individuals can experience a greater sense of wholeness and self-acceptance. Inner child work often involves “reparenting” or providing nurturing and compassionate care to the wounded inner child. By learning to cultivate self-compassion, individuals can offer themselves the love, validation, and support they may have been lacking in early childhood experiences.
6. Titration techniques
In Eye Movement Desensitization and Reprocessing Therapy (EMDR), titration techniques refers to the process of carefully adjusting the pace and intensity of the therapeutic intervention to match the client’s readiness and tolerance for reprocessing traumatic material. It involves breaking down the traumatic material into smaller, more manageable components, allowing the client to process the material more gradually without becoming overwhelmed.
The take home message is a hopeful one. Trauma treatment is advancing, and more clients with CPTSD are finally getting the help they need through modalities such as EMDR.
EMDR therapists – you can access a library of advanced trainings found here.
Sources: Title: "Eye Movement Desensitization and Reprocessing (EMDR): Basic Principles, Protocols, and Procedures"
Author: Francine Shapiro
Publisher: The Guilford Press
Year: 2001
ISBN-13: 978-1572306721