emdr for early trauma & neglect

LIMITATIONS OF EMDR THERAPY STANDARD PROTOCOLS
Sandra Paulsen & Katie O’Shea observed the limitations of standard EMDR when applied to early injuries, specifically:

1) there is no explicit memory in the first years of life, only implicit memory, so the standard procedure of targeting a memory of trauma could not apply;

2) if a client were able to access early experience in EMDR therapy, it could easily be overwhelming, without adequate preparation,

3) early experience, when accessed, also accesses the client’s felt sense from that early time, with all the limits of self and inner structure that went along with pre-natal, infant, and early childhood developmental stages;

4) because of the paramount importance of relationship and caregiver attachment in infancy, the processing of early experience required modification to ensure the client had the felt sense of the therapist’s compassionate and attentive presence; and,

5) because very early experience is ephemeral and does not consciously register as pictures or videos (as later memories may be), the process needed to explicitly accommodate the subtlety of some early processing. For all these reasons, a four step protocol was developed.

THE FOUR STEPS OF THE EARLY TRAUMA PROTOCOL
Early Trauma reprocessing includes the following steps to provide remedies to the limitations of standard EMDR therapy approaches described above. (Please note that there is substantially more involved in the treatment than is described in this brief summary.)

1) Cultivating structured containment of all experience yet to be “learned from or sorted through,” to leave a clear “emotional desktop” for the work to take place;

2) Developing a felt sense of safety as a starting point for the work, which is achieved by tapping into and strengthening a naturally occurring (but sometimes hidden) “safe state” in the body. Both steps 1 and 2 may require client practice;

3) The most mysterious step-—resetting the affective circuits–involves clearing the emotional pathways that develop in each of us early on during our development in the womb, but which may be congested from maladaptive early learning and inhibitions about whether emotions are okay and safe. Once the circuits are clear, they can function as they were intended, to conduct emotional information between the brain and the body. This step may work directly on subcortical affective circuits, according to Jaak Panksepp, researcher and author of the groundbreaking book, Affective Neuroscience. For individuals with complex trauma histories and/or emotional dysregulation and imbalance, there may need to be additional preparation, most commonly ego state work; further education about healthy emotion, brain functioning and/or trauma; and sometimes somatic work; and,

4) Clearing the early trauma, which happens by processing small time periods, beginning with a time before conception (owing to generational, cellular memory), then moving on to conception, gestation in the womb, birth, and on through the first few years of life. These time periods are variable with the client, depending how “gnarled” the roots of the tree have become by growing around early obstacles. The clearing may be of somatic/implicit memory or of explicit memory, or mental constructs related to the time periods. For each time period, if it doesn’t resolve spontaneously, there is an imaginal good outcome of “what you needed, the way you needed it to be.”

As already noted, there is much more to it, but for many individuals, the careful application of these steps produces a critical emotional shift with subsequent increase in emotional stability, comfort, and peaceable relation to one’s emotions and the self.

MECHANICS
The experience of the infant is almost entirely a ‘felt’ sense; there is not much cognitive happening at the beginning. Therefore, when the therapy taps into those early felt senses, it often occurs without as much access to the more conscious and cognitively informed resources usually available to adults. Because of its central role in early life, this felt sense is an ideal entry point for attending to early, emotionally overwhelming experience so that it can be reprocessed and cleared.

As we are relying upon the most primitive information available to reprocess early experience, the standard EMDR therapy modality of eye movements or taps conducted with equipment may be too scary, too technical, and too alienating for some. Therefore, the reprocessing is facilitated by tapping on the client’s ankles, while the client is reclined in a comfortable, reclining chair. Because the processing may occur over a period of hours, people often want to take off their shoes. This certainly makes it easier to tap on the ankles, and is mentioned here because people sometimes wish they’d worn different socks!

Early trauma reprocessing is designed to come in from the beginning, ‘under the floor-boards’, so to speak, so it is typically quite gentle and tolerable. Grounding is needed much less than in standard EMDR therapy procedures. People learn a lot about their own story in this lovely and very powerful procedure.

Highly dissociative people are only appropriate for this method if they have already established considerable groundwork in therapy and the self-system is likely to allow the work. I am experienced in working with dissociative clients and addressing concerns protective parts may have. If you are dissociative and, after the initial evaluation, I agree to work with you using the early trauma procedure, it will require you to have an ongoing therapeutic relationship to receive you after leaving the intensive work, assuming you won’t be working with me ongoing. It will be necessary for you to grant written permission for me to collaborate with your primary therapist before and/or after our work together.

INTENSIVE OR WEEK-BY-WEEK TREATMENT?
Although early trauma reprocessing can occur piecemeal, from week to week, hour by hour, this is terribly inefficient and not particularly cost-effective. The ideal way to experience this type of reprocessing is in extended, face-to-face sessions. Because the work is subtle, deep, and more felt than thought about in a conscious way, extended sessions allow the work to unfold viscerally and deeply. It’s akin to being on a commercial flight from Chicago to Minneapolis versus a flight from Chicago to Tokyo: yes, you get somewhere in both cases, but if you’re on the long-haul flight, you’re up in the air longer, you move more quickly, and your fuel efficiency is significantly better.

If, however, we determine that week-by-week treatment is the only way to go–either because you’re not able to do the intensive work, either because you’d like to use your insurance coverage because you couldn’t afford it otherwise, or because you’d like to do the work in the context of longer-term therapy work with me–then expect that it will take a number of months to complete the process of clearing early trauma. Owing to the importance of structuring an appropriate, responsive, and personalized treatment for you, I am not able to conduct early trauma work in shorter (i.e., less than day-long) blocks unless you are seeing me on a weekly basis. Feel free to schedule a free phone consult to discuss further your specific situation.

It is not easy to predict whether a client will need one, two, or more days of intensive work to clear the entirety of early disturbances and replace it with a felt sense of well-being. This goal is typically possible, but not necessarily easy to schedule or predict. Most people who have participated in intensives require two to three days, or more, to clear the first few years. The time required is variable, based upon how many traumatic experiences there were, how much neglect there was, and how maladaptive the learning outcomes were from those experiences. (Note that it’s not you as an adult who consciously assesses all of what was traumatic in those early times. Your brain did that for you before you were even consciously aware that wounding was taking place.)

IS INTENSIVE TREATMENT FOR EARLY TRAUMA AND NEGLECT RIGHT FOR YOU?
An initial 20 – 30 minute phone consult is free of charge for all prospective clients, so that I can get a sense of where you are in your life and the nature of any therapeutic work you’ve done up to now, and so that you may ask questions that you may have about early trauma reprocessing. At this point, we can schedule an initial, diagnostic assessment. When assessing for appropriateness specifically for early trauma reprocessing, we will either meet in person or via secure weblink, or else speak on the phone, for either 90 or 135 minutes (two or three back-to-back 45 minute sessions). The length of the initial meeting depends on how much you already know about your symptoms.

Diagnostic assessment involves us looking at the following: 1) your present safety and stability; 2) your capacity for freely experiencing emotion and body sensation without a sense of overwhelm; 3) any internal conflicts that may complicate or block trauma resolution; 3) medical concerns; 4) substance use; and 5) any evidence of structural dissociation, which would require additional assessment and potentially significant preparation prior to embarking on trauma resolution work of any kind.

Biographical assessment, which will follow a bit later if it seems viable to move forward with scheduling an intensive–will be mostly completed electronically. The biographical assessment covers areas of your history such as work, education, military service, nutrition and self-care, basic family history, spiritual and cultural experience, and so on.

FEES FOR INTENSIVES
The cost of intensives is considerable, so many will need to save for some time to afford this important investment. The rate is $125.00 for a 45 minute session (with 45 minutes being equal to a ‘clock hour’ for this type of work). A typical intensive treatment day may include 6 – 8 sessions (roughly 3 – 4 90-minute ‘blocks’ of time), distributed according to needed breaks. The most common cost for a full day of intensive work is approximately $875.00, which can range from about $750.00 to $1,000.00 for a day, times the number of days reserved at the your request. We’ll collaborate on when to take breaks and how long to work.

The Mathematics of Fees for an Intensive
If we work from 9:00am until 12:00pm, take a lunch break, then resume our work from  from 1:00pm to 4:00pm, on a particular day, then this does not translate to 6 hours x $125.00 equals $750.00. Rather, the cost is determined by the following:

The total number of treatment minutes (which I closely track), not including breaks and lunch, divided by 45 (the basic unit of time per session), multiplied by $125.00 for each 45 minute unit. According to this formula, if we worked from 9:00am to 10:30am, with a 15 minute break, then 10:45am to 12:00pm, that equals 165 minutes. In the afternoon, if we worked from 1:00pm to 3:00pm, took a 15 minute break, then worked from 3:15pm to 4:00pm, that equals another 165 minutes. This equals a total for the day of 330 minutes, divided by 45, equals 7.333 units, multiplied by the rate of $125.00, which leaves us with a grand total of $916.67 for that particular day.

You will pre-pay for the bulk of the work, on the following schedule:

Deposit is due at the time of scheduling to reserve the time for you, based on the number of days you are reserving—unless you have made other arrangements with me for payment of the deposit.

Pre-payment is due two weeks before the intensive, assuming that you will incur, at minimum, $750.00 (six 45 minute sessions) per day in fees. So, if you want to reserve…

1 day   =====> $ 250.00 deposit + $ 450.00 additional pre-payment

2 days =====> $ 500.00 deposit + $ 1,000.00 additional pre-payment

3 days =====> $ 750.00 deposit + $1,500.00 additional pre-payment

At the close of the intensive sessions, you will owe any remainder over and above the $750.00 per day already pre-paid. It is typical for people to engage in somewhere between six and nine 45 minute ‘hours’ per day, so you may owe up to $1,125.00 for a really ‘full’ day. So, although you prepaid $750.00 for each of, for example, two days ($1,500.00), if we actually worked eight ‘units’ on the first day and nine on the second day, you’d owe an additional $625.00 on the last day. If you have an absolute budget, please notify me of this ahead of time so that we can collaborate to use an appropriate amount of time. If you do not notify me ahead of time, it could have a significant, unforeseen impact on the treatment outcome. If you know that you do not want to participate in longer days, please notify me ahead of time so that I can adjust my schedule to accommodate both your and other clients’ needs.

PAYMENT
Many people find the cost challenging, and as a result need to save for some months or more to be prepared to pay for the work prior to undertaking the work. You can pay as you go. Unfortunately, I cannot carry a balance (i.e., you owe me for work already done). Because of this, it is important to schedule only once you are financially prepared for such a large and important commitment.

I accept payment for intensive treatment via personal check or bank check, money order, or ACH bank transfer through Chase QuickPay. I also accept credit card payment via PayPal, Visa, Mastercard, American Express, and Discover. If I have not received payment by the specified due dates (unless other arrangements have been made), the time you have reserved will be released in favor of others’ scheduling needs.

Please be aware that I an unable to accept your insurance for this treatment format. Additionally, it is unusual, in my experience, for clients to receive an appreciable reimbursement from their insurer when they submit bills for intensives. Nevertheless, invoices will be made available to you to submit if you decide to do that.

CANCELLATION POLICY FOR INTENSIVES
Due to the amount of time being held for you when we schedule intensives as part of your healing, the cancellation policy, for any reason, is as follows:

• Early cancellation after paying deposit: no return on deposit but it may be applied if rescheduled.

• Cancellation after prepayment is paid and more than one week prior to doing intensive sessions: 50% of pre-payment will be returned.

• Cancellation for any reason after prepayment is paid and less than one week prior to intensive sessions: Neither deposit nor pre-payment will be returned.

• Cancellation after intensive has begun: Neither deposit nor pre-payment will be returned.

LOGISTICS
Seattle is a fabulous city, full of art, music, sport, great food, and everything else under the sun (and the clouds and rain—it is Seattle, after all). If you’re visiting from out of town for your intensive and have never been to Seattle before, it can be a bit of an adventure to navigate. There is one airport, Seattle-Tacoma—known as ‘SeaTac’—to the south of Seattle. Michael’s office is accessible via public transportation, and this mode of transport is highly recommended. Car rental can be a viable option, as long as you make certain you know the parking rules around my office. Another alternative is taxi cabs, but passenger beware: It can get a bit pricey. For more information on public transit in the Seattle Metro area, direct your web browser to http://metro.kingcounty.gov.

For many, we will use Thursday and Friday for your intensive. When people come from a long distance they may wish to devote additional days. People who live closer may come one day or a partial every month, for budgetary reasons.

LODGING

22. Hotels, motels, B&Bs, we have it all in Seattle. I recommend the following as helpful resources for booking (and with which he is not associated in any way, beyond liking them on a personal level):

Bed and Breakfast dot com

http://www.bedandbreakfast.com/seattle-washington.html

TripAdvisor dot com

http://www.tripadvisor.com

Yelp!

http://www.yelp.com/

Please note that my office is located at 2401½ 10th Avenue E, Suite B, Seattle, Washington 98102. Be kind to yourself by using this information as a guide in deciding how close to (or far away from) the work you’d like to be, and how far you’d like to commute, each day.

PREPARATION FOR AN INTENSIVE
Before finalizing air travel, if you are traveling from a notable distance, please be certain to confirm that you are in fact on my schedule during the window that you understand yourself to be.

As described above, both a deposit to save the dates and pre-payment of the minimum likely fee for the intensive are required. Cancellation policies apply as described above.

You’ll need to review and complete general intake documentation ahead of time, and this will be provided via my secure client portal following our initial phone consult. I prefer to schedule an initial intake session in person, via secure weblink, or by phone to ensure that we are using our time wisely during the intensive. There may be times when only basic assessment can take place initially, and subsequent time will need to be set aside for history taking. We both need to agree the approach is appropriate for you, your story, and your needs; this format of treatment isn’t for everyone. Sometimes the time devoted in session to collecting history can be curtailed if you are able to provide a written narrative to include key areas of functioning: where you were born and raised; how far you have progressed in your education; specific ‘sticking points’ or ‘hot spots’ related to your family relationships; medical and psychological treatment history; work history; and, related matters. Regardless, there are some areas that I will still need to look at myself, owing to the sensitivity of some subject matter.

If you are local, you may consider scheduling a 90 or 135 minute session to accomplish the preparation steps of the early trauma approach, because then the time set aside for trauma accessing can be most effectively used for clearing early traumatic experience. Those preparation steps are described above, but typically include: 1) container imagery, 2) establishing a safe state or other resources, 3) resetting the affective circuits.

For some people, more complex maneuvering is involved in preparation, including getting the self-system ‘on board’ with the treatment, as well as introducing information about the function of emotions (and the fight, flight, and freeze responses) and how they operate in all mammals for survival and safety. I will also make certain that you can look at emotions from a distance and not just feel taken over by them willy-nilly. This is an important piece in ensuring successful reprocessing.

For some, additional assessment and evaluation may be indicated before embarking on the journey of intensive early trauma work, to better ensure your safety and strength in the face of trauma.

WHERE TO EAT DURING THE DAY(S) OF YOUR INTENSIVE

Ah, Capitol Hill is a wonderful neighborhood…and my office is located in the ‘sleepier’ northern edge of it, and just a short walk from ‘Eastside’, as well. Tastes vary, so the best way to scout for tasty eats is to click/press here to consult the oracle known as Yelp!.

WHAT ELSE IS NEAR THE OFFICE?

Maybe a better question is, ‘What isn’t there to do nearby?’ There are all sorts of things to do in Seattle–and lots of resources for finding them–and so I suggest starting on Capitol Hill, since you’ll be so close to what many consider one of the very best neighborhoods in Seattle.

DURING AND AFTER EARLY TRAUMA REPROCESSING/INTENSIVES

On the first day of the intensive, we’ll ensure that all the necessary preparatory steps have either already been undertaken, or we’ll begin there in the work together.

It is not unusual to feel ‘drained’ after early trauma reprocessing has taken place. Most people don’t want to do much in the evenings after an intensive session. The work is profound and will take some time set aside for introspection just plain rest. Self-care is key in this work, so plan on drinking plenty of water, getting plenty of sleep, inviting yourself to dream, eat good food, maybe take some anti-oxidants because you’ll be releasing energetic holdings. Fruits and vegetables will be put to good work in reconfiguring your new you. If you’re traveling from a different time zone, ensure you are taking Melatonin or some other supplement (as approved by your primary care physician, as appropriate) to manage the effects of jet lag.

After the work, your nervous system will be “knitting and purling” for a time, and this is usually gentle and comfortable. Occasionally, if we ran out of time in a gnarly hurtful baby spot, you may feel stuck there. It’s important to let me know if you need help in person or by phone moving through one of these spots.

Please keep in mind that any unusual experiences during the work or in the time right after the work may be related to the work. Think of them as ‘vapors leaking up from King Tut’s tomb’. So, for example, if your spouse, partner, or a good friend seems, for whatever reason, suddenly to resemble demon spawn, consider the possibility that something about the early work has a theme of demon spawn in it somewhere. Similarly, if it seems to you that I am suddenly just like the meanest parent ever, please mention this to him, because, although it may have a basis in present time (and my dogs might agree with you, depending on which chew-thing I’ve liberated from them that day), we’ll consider that, often those kinds of feelings and perceptions are part of the client’s story, telling itself without words. We use information in the room and about what is happening between us as clues to that story. We’ll be detectives together, and we’ll hear your story together, however it seems to want to be heard.

The most common unsettling experience after the ET work is to feel oddly inert or flaccid. This seems to be part of a baby state, as if baby is just sitting, waiting, not mobilized for much action.

CLOSING THOUGHTS
I feel very honored to do this important early trauma work with my clients, and I am fortunate to have been trained in it both by its originator Katie O’Shea and by Sandra Paulsen, PhD, with whom Katie collaborated (rather intensively) to bring it to public consciousness and develop it into a ‘teachable’ process for healing early wounding.

Dr. Paulsen is my mentor, having reared me in conducting early trauma and ego state work in her—frankly—inimitable way, and so I think I’ll echo her words, when she says, ‘I consider this work a sacred trust. It is my privilege to hear the story of baby you that may never have been told or heard before, except in symptoms or reenactments. I’ll help you review, release and repair very early experience in a way that provides a felt sense of well-being. Spend a little time before we meet identifying, if you don’t already know, what your highest resource is, and what your relationship is to the spiritual realm. Then I can support your process in a way that makes sense to you on your own terms. This is the most helpful way I know to repair very early injuries, hurts, betrayals and disappointments’.

The content on this page was originally based on and has been adapted, with permission, from documents created by Sandra Paulsen, PhD, for intensive treatment provided through the Bainbridge Institute for Integrative Psychology, Bainbridge Island, WA.

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