Guest blog by Dr. Sandra Paulsen (left) & D. Michael Coy, MA, LCSW
[First I discovered it deep within myself and called it “trauma since the sperm hit the egg.” Then I read that Bessel van der Kolk calls it “developmental trauma,” in his drive to have it finally recognized by the psychiatric profession. Dr. Allan Schore calls it “trauma in the first 1000 days, conception to age two.” Earlier it was “complex PTSD” or C-PTSD. In EMDR therapy, Dr. Sandra Paulsen, therapist Katie O’Shea, LCPC (who began this work), and D. Michael Coy, MA, LCSW, use “Early Trauma” (ET). The science is in Chaps. 16 & 20 of Paulsen’s 2014 book.1 Well: “ET, phone home!” Dr. Paulsen & friends have good news: they’ve created new EMDR therapy protocols to heal developmental trauma. -Kathy Brous ]
Eye Movement Desensitization and Reprocessing (EMDR) therapy “enables people to heal from the symptoms and emotional distress that result from disturbing life experiences,” says Dr. Francine Shapiro’s EMDR Institute website. Standard EMDR therapy has been shown to heal traumatic memories with a conscious, visual component, also called “explicit” memory. As EMDR clinicians, we have seen frankly astounding changes in our clients, both in how they see themselves and in how they experience and take initiative in the world.
But with in utero and infant Early Trauma (ET) occurring from conception to age three, also called developmental trauma, there is no conscious, explicit narrative memory — infants have not developed the parts of the brain which can think. These traumas precede the existence of consciousness, so they’re called pre-conscious or “implicit” memories. Such memories are “somatic,” that is, held purely in the body — so healing is far more challenging.
How can we listen to the unspoken experience when, so early on, there were no words to tell it? How can we help the body tell its silent—or silenced—story?
Limitations of EMDR Therapy Standard Protocols
Sandra Paulsen and colleague Katie O’Shea (right) observe the limitations of standard EMDR as applied to early trauma, specifically:
1) There is no explicit memory in the first years of life, only implicit memory, so the standard EMDR 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; 2
4) Because of the paramount importance of relationship and caregiver attachment in infancy, the processing of early experience via EMDR therapy 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), the new EMDR therapy needed to explicitly accommodate the subtlety of infant early processing.
For these reasons a four step protocol was developed, starting with the work of therapist Katie O’Shea, who later brought it to the attention of Sandra Paulsen. They then worked to make these new ideas coherent with the latest neurobiology research by Jack Panksepp, Allan Schore, Daniel J. Siegel, et. al.
Four Steps of the Early Trauma (ET) Approach to EMDR Therapy
Early Trauma reprocessing includes the following steps to provide remedies to the limitations of standard EMDR therapy approaches above. NB: There is substantially more to the treatment than 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 work to occur;
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 outside of therapy sessions;
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 in his 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; sometimes somatic work; and,
4) Clearing the early trauma, which happens by processing small time periods, beginning with a time before conception (owing to what is theorized to be 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 noted, there is much more to it, but for many, the careful application of these steps produces a critical emotional shift with subsequent increase in emotional stability, comfort, and peaceful relation to one’s emotions and the self.
The Mechanics of the Early Trauma Approach
The experience of the infant is almost entirely a “felt sense,” as there is not much cognition at the beginning. So when therapy taps into those early felt senses, it often occurs without as the 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 sitting back in a comfortable, reclining chair.
Because 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 in comparison to consciously-focused EMDR therapy. 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 there is a self-system to allow the work. The early trauma therapist ideally is experienced in working with dissociative clients and addressing concerns protective parts may have, as this piece is critical to ensuring positive outcomes in early trauma resolution work. If a potential client is dissociative and, after the initial evaluation, the early trauma therapist agrees to work with the client using the EMDR early trauma approach, it is necessary that the client have an ongoing therapeutic relationship to receive them after leaving the intensive work, assuming that the client is not working with the early trauma therapist in an ongoing treatment relationship. When the client has a primary therapist, it is typically necessary for the client to grant written permission for the early trauma therapist to collaborate with the primary therapist before and/or after the early trauma work takes place.
Intensive or Week by Week Treatments?
Although early trauma reprocessing can occur piecemeal, from week to week, hour by hour, this can be both 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.
Notably, Dr. Paulsen uses the intensive approach exclusively. In some instances where there is an ongoing therapy relationship, and insurance coverage is involved, the early trauma therapist and client may resolve that week-by-week treatment is the only way to go. This is the only option for a number of the clients who see Michael, either because the client is not able to do the intensive work immediately (owing to extended preparation being needed), wishes to use their insurance in order to afford it, or they’d like to do the work in the context of longer-term therapy work.
However, the client should expect that it will take a number of months to complete the process of clearing early trauma. Michael does both intensive and week-to-week early trauma resolution work, as appropriate and necessary. Other therapists experienced in the EMDR early trauma approach likely structure the work in a way that fits the needs of their own practice and clients.
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 any kind of wounding was taking place.)
Is This Treatment Right for You?
As different EMDR early trauma therapists may handle assessment differently, we will speak here to how we approach it. Diagnostic assessment involves looking with the client at the following factors: 1) the client’s present safety and stability; 2) the client’s capacity for experiencing emotion and body sensation; 3) any internal conflicts that may complicate or block trauma resolution; 3) medical concerns; 4) substance use; 5) any evidence of structural dissociation, which would require additional assessment and preparation prior to embarking on trauma resolution work of any kind.
Biographical assessment is also an important piece of assessment. The biographical assessment covers areas of the client’s history such as work, education, military service, nutrition and self-care, basic family history, spiritual and cultural experience, and so on. Biographical assessment can provide both a helpful ‘fly over’ of the client’s experience, as well as point out the ‘smoke trails’ emanating from the client’s early, unresolved experience.
During and After Early Trauma Intensive/Reprocessing
On the first day of the intensive, the therapist and client ensure that all the necessary preparatory steps have either already been undertaken, or they will begin there in the work together.
It is not unusual for a client 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 and just plain rest.
Self-care is key in this work, so plan on drinking plenty of water, getting plenty of sleep, inviting oneself to dream, eat good food, maybe take some anti-oxidants because the client will be releasing energetic holdings. Fruits and vegetables will be put to good work in reconfiguring a ‘new you’. If the client is traveling from a different time zone, it is recommended that they are taking Melatonin or some other supplement (as approved by their primary care physician, as appropriate) to manage the effects of jet lag.
After the work, the nervous system will be “knitting and purling” for a time, and this is usually gentle and comfortable. Occasionally, if the work was paused in a gnarly hurtful baby spot, the client may feel stuck there. In those instances, the client may need help in person or by phone to move through such a spot.
It is also really important to keep in mind that any unusual experiences during the work or in the time right after the work may be related to the work. One can think of these as ‘vapors leaking up from King Tut’s tomb’. So, for example, if the client’s spouse, partner, or a good friend seems, for whatever reason, suddenly to resemble demon spawn, they are encouraged to consider the possibility that something about the early work has a theme of demon spawn in it somewhere.
Similarly, if it seems to the client that the early trauma therapist is suddenly just like the meanest parent ever, they are encouraged to mention this, because, although it may have a basis in present time (and, for Michael, his dogs might agree, depending on which chew-thing he’s rescued 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. The therapist and client use
information in the room and about what is happening between them, moment to moment, as clues to that story. Client and therapist become detectives together, hearing the client’s story together, however it seems to want to be heard. The most common unsettling experience after early trauma 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
We feel honored to do this important early trauma work with our clients. Michael was fortunate to have been trained in the EMDR early trauma approach both by its originator Katie O’Shea and by Sandra Paulsen, PhD, with whom Katie has collaborated to bring it to public consciousness and develop it into a replicable, systematic process for healing early wounding that can be used safely and effectively even in the most complex situations. (Notably, a cartoon book for therapists and clients on the EMDR early trauma is currently in press.)
We consider this work a sacred trust. It is such a privilege to hear the story of the baby within that may never have been told or heard before, except in symptoms or reenactments. The EMDR early trauma therapist’s intention is to help the client review, release and repair very early experience in a way that provides a felt sense of well-being. We encourage our clients to spend a little time before we meet identifying, if they don’t already know, what their highest resource is, and what their relationship is to the spiritual realm. Then we are more able to support the client’s process in a way that makes sense to them, on their own terms. This is the most helpful way we know to repair very early injuries, hurts, betrayals and disappointment.
See also the EMDR therapist finder directory of the EMDR International Association: http://www.emdria.org/search/custom.asp?id=2337
Sandra Paulsen, PhD, is the founder of the Bainbridge Institute for Integrative Psychology and a leading edge practitioner who has integrated her knowledge of Ego State Therapy, somatic therapies, and EMDR therapy to effectively treat clients struggling with complex trauma and dissociation safely and effectively. Dr. Paulsen accept clients for early trauma treatment in the intensive format but only via therapist referrals at this time. See: http://www.bainbridgepsychology.com/ET-Referring-Clinicians.html
D. Michael Coy, LCSW, LICSW, is a Master’s level therapist in independent practice in Chicago, IL, certified in EMDR therapy and also trained in clinical hypnosis, Ego State Therapy, and essential somatic methods for enhancing trauma resolution work. Michael’s primary focus is with clients who struggle with complex PTSD and/or dissociative disorders. Michael is also a clinical associate of the Bainbridge Institute for Integrative Psychology. For more information about Michael, see https://www.dmcoy.com.
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Kathy’s blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.
Kathy’s news blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.
Footnotes
“Neurobiology and Treatment of Traumatic Dissociation: Toward an Embodied Self,” by Lanius, Paulsen, and Corrigan, 2014,http://www.amazon.com/Neurobiology-Treatment-Traumatic-Dissociation-Embodied/dp/0826106315
See also especially Dr. Paulsen’s website:http://www.bainbridgepsychology.com/EarlyTraumaOShea.html.
For Eugene Gendlin’s foundational work on the “felt sense,” a term he developed, see Gendlin, Eugene T (1978), Befindlichkeit: Heidegger and the philosophy of psychology. Review of Existential Psychology and Psychiatry 16 (1–3): 43–71.
Dr. Peter A. Levine uses Gendlin’s “felt sense” work strongly in his “somatic experiencing” trauma healing: Levine, Peter A., PhD, “Healing Trauma: A Pioneering Program for Restoring the Wisdom of Your Body,” ‘Sounds True, Inc.,’ Boulder CO, 2005; ISBN 1-159179-247-9
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