Jeff Dwarshuis – Page 4 – Jeff Dwarshuis LMSW ACSW

Combining EMDR and Schema Therapy for Complex Posttraumatic Stress Disorder

By Jeff Dwarshuis LMSW ACSW

What is Eye Movement Desensitization and Reprocessing?

Eye Movement Desensitization and Reprocessing (EMDR) was developed by Francine Shapiro in 1989 as a method of treatment for Posttraumatic Stress Disorder (PTSD).

Over time, researchers and therapists expanded the use of EMDR to include several other mental health diagnoses besides PTSD. It was discovered that not only did EMDR eliminate the impacts of acute memories leading to PTSD, but it also eliminated the negative impacts and irrational self-perceptions caused by nonacute memories and bad experiences in general. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Stress Disorder (Complex PTSD).

Due to the many complexities found in the assessment and treatment of Complex PTSD, EMDR treatment required added interventions and assessment tools. These tools can be found in Schema Therapy. This article explains how EMDR and Schema Therapy can be combined for increased speed and effectiveness for treatment of individuals suffering from Complex PTSD.

EMDR and Neurobiology

EMDR is a treatment method used to quickly and effectively eliminate the negative impacts of traumatic memory. EMDR is a neurobiological intervention that makes use of eye movements to facilitate a physiological impact on brain functioning which creates permanent emotional and cognitive change in an individual when thinking about or visualizing a traumatic memory.

Recent studies on brain scans of individuals indicate that traumatic experience and traumatic recall negatively impact brain functioning and that EMDR corrects it. Specifically, during trauma a part of the brain called the amygdala, which controls many of our emotions and is responsible for autonomic responses associated with fear and fear conditioning, becomes over activated and this creates an impasse between itself and the hippocampus. The hippocampus plays an important role in the consolidation of information from short term memory to long term memory and spatial memory which is responsible for recording information about one’s environment and spatial orientation.

It is recognized that this impasse between the hippocampus and the amygdala creates symptoms found in generalized anxiety, panic attacks and posttraumatic stress disorder. During EMDR, this impasse is corrected as eye movements will both enlarge and activate the hippocampus so it can receive the overwhelming amount of information from the amygdala and then sort it. The hippocampus then completes the proper brain processing by sending information to the anterior cingulate cortex, which is involved in aspects such as attention, decision making, reward anticipation, ethics, morality, impulse control and emotion. The impact of opening this impasse and restoring proper brain functioning means that a negative memory, once too overwhelming to manage, is put into the proper context of time and space, has affective and cognitive aspects of the memory merged, is viewed with more rational thought, reason and control and exists in a clear distinction between the past and the present.

EMDR and the Two Primary Positive Treatment Reactions

During EMDR treatment, which is administered by a psychotherapist, a client responds to the neurobiological process described above and experiences two primary reactions to a traumatic memory. First, there is a distancing from the memory

that includes an elimination of the negative emotional reactions related to the trauma. Second, the client experiences an increased level of rational perception related to the memory. This increased rational thinking is called Adaptive Information Processing (AIP). AIP is the result of successful EMDR reprocessing and allows the client to hold a more rational view of personal safety, personal responsibility and personal choice while visualizing or discussing a traumatic memory. AIP also allows the client to hold an accurate positive self-perception or cognition while visualizing the trauma. This assists the client in problem solving how he or she would react, or prefer to react, differently in a similar situation. Repeating the EMDR procedure over a series of planned interventions targeting traumatic memories relieves the person of the negative impacts the memories have created. Due to its neurobiological quality, the changes from successful EMDR reprocessing are permanent and generates dramatic symptom reduction across the spectrum of most all mental health diagnosis.

What Is Schema Therapy?

Schema Therapy is a branch of Cognitive Therapy that was developed by Jeffrey Young PhD and includes several different psychotherapeutic interventions including Behavioral, Gestalt, Psychoanalytic and Relational Therapies. Schema Therapy argues that if individuals are abused or neglected as children, they may develop “maladaptive schemas”. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex PTSD. Maladaptive schemas (known as schemas) can be defined as self-defeating emotional and cognitive patterns that begin in early childhood and continue throughout life. The goal of Schema Therapy is to eliminate the schema(s) by recognizing, challenging and replacing it with more effective behaviors through a series of exercises as listed below.

Schema Recognition

The first step in Schema Therapy is schema recognition or evaluating if an individual has any schemas. This can be done in several ways. First, individuals can read “Reinventing Your Life” by Jeffrey Young PhD and complete a brief set of questions on each schema listed throughout the book. This will illustrate both the existence and intensity of the schema. Second, in a therapeutic setting, an individual can complete a questionnaire which will identify the presence of certain schemas as well as their intensity. After a schema is recognized, the person can read schema descriptions, provided in the book or by the therapist. These descriptions can bring clarity and definition to emotional and relational hardship.

Testing Schema Validity

After an individual knows about their schemas and understands the description of the schema, they can begin to challenge the schema by testing its validity. Schemas, in general, are inaccurate negative representations of the person and can reasonably be disproven through evidence. However, people often will identify with their schemas and see a schema as a representation of who they are. Therefore, creating a list describing how the individual sees themselves relating to the negative qualities of the schema can easily be done. However, creating a list of evidence about how the person is different from the schema, can be difficult.

Testing the validity of the schema can be done by first listing all evidence from the past and present to support the reality of the schema. There should be a general consideration of these questions. How does this description of the schema apply to me? How do I act it out? How might others see me as acting out this schema? Following this, the person should make a list of all the evidence that refutes the schema. The person can do this by evaluating their realistic accomplishments, intentions and capacity shown throughout their life that are different from the schema.

Schema Reframing

After testing the schema’s validity, the individual should challenge the reality of the schema by reframing it. This can be done by taking each piece of evidence that supports the schema and attributing it to another more rational cause. For example, instead of thinking “I am unlovable” the person might instead say “I was not given enough attention and was taught to think I was unlovable” or instead of thinking “I am a failure” the person might list or say “I was not given enough opportunity to recognize my potential.” Typically, these causes have to do with the person’s childhood family, especially the parents who had control over the person’s life and events that may have contributed to the schema development. To complete this exercise, it is important to not personalize the schema but to rationally consider the influences of its development.

Identifying the Advantages and Disadvantages of the Coping Behaviors

Schemas are themselves emotional and cognitive patterns and each person has a set of behaviors that are used to deal with, display, represent or ignore the schema(s). These behaviors are called “coping responses”. Coping responses generally fall into the behavioral categories of avoiding, surrendering or overcompensating for the schema. One can think about and then list these coping responses then evaluate both the pros and cons of what the coping responses do or don’t do. It is important to recognize that these behaviors may have been adaptive as a child and as an adult might help to decrease emotional reactivity. However, the behavior generally does not create effective solutions for adult problems.

Schema Problem Solving

With the initial exercises completed, one is a better position to coordinate and use the learning on a day to day basis through Schema Problem Solving. The goal is to use some of the understandings and growing awareness from the previous exercises and apply them to daily relational and emotional challenges perpetuated by the schema(s).

Completing the framework sentence below will allow for gradual change and the elimination of schemas. The goal is to get to the point of being able to do the exercise automatically in real life settings.

I feel (emotion) because of (causal event). This event has triggered my (schema) and has caused me to want to do (coping behavior). Although my schema causes me to believe that I am (negative self-belief) I am (rational positive self-belief) as evidenced by (supporting evidence). Although I would like to do (negative behavior) instead I will do (positive behavior).

Combining EMDR and Schema Therapy for Complex Posttraumatic Stress Disorder

Both EMDR and Schema Therapy are highly effective treatment methods for the treatment of Complex PTSD. Combining these methods leads to a faster and more effective level of change by using their relative strengths. EMDR is fast and highly effective in eliminating the negative impacts of negative memories. Additionally, the changes are permanent. However, individuals with Complex PTSD present with complicated histories and a set of symptoms that do not allow the therapist using the EMDR Protocol to accurately assess negative contributing memories leading to Complex PTSD symptoms. Schema Therapy provides a plausible explanation for the development of Complex PTSD since it is based on understanding the impacts of unmet childhood needs and its related negative experience and memory. The EMDR therapist can use this relationship of events to create a list of treatment target memories that are the most effective for client change.

Below is a list of the five treatment steps that are needed to combine EMDR and Schema Therapy safely and effectively.

1.Create a safe environment for the client – Creating a safe environment for the client involves using practical steps at the beginning of treatment to protect the client from unpredictability, overwhelm and danger.

First, EMDR can be difficult to understand and most clients entering treatment do not know about it. Because of this, the therapist should decrease the sense of unpredictability one might experience during EMDR by explaining its preparation stage, procedure, successes and structure. Also, clients should understand the possibility of increased recall of negative memories that often come during EMDR reprocessing. The therapist should explain ways to successfully manage these possible reactions. As the therapist better understands the client’s schemas, he or she will be able to better predict possible negative responses during EMDR reprocessing.

Second, therapists need to watch for patterns of client dissociation and substance abuse. Dissociative reactions can intensify if the client is flooded with too much negative memory during EMDR reprocessing. This can have a negative impact on client safety if the client is having difficulty grounding themselves during treatment. Also, substance abuse will confuse the process of treatment causing both the therapist and client to be unsure of the impacts of treatment. Additionally, the use of substances can increase the likelihood of high-risk behavior outside of sessions. The recognition of client schemas can assist the therapist in understanding the reasons the client abuses substances and therapy can prioritize to target those reasons. Additionally, schema recognition can assist the therapist in measuring the possible intensity of memory reactions as well as triggers leading to dissociation. This recognition can assist the client and therapist in creating a self-monitoring plan to decrease risk.

Third, it is important to maintain a focus on established EMDR safety procedures. The therapist should generously use “the safe place” procedure to assist clients in recognizing their capacity to both see and maintain safety. Also, therapists and clients should consistently consider the client’s “window of tolerance” by keeping EMDR eye sets brief if necessary and allowing the client to have some control over the order of the memories reprocessed. Completing the schema exercise of “identifying the advantages and disadvantages of coping behaviors” should assist the client and therapist in assessing the client’s window of tolerance since it illustrates patterns of client defense behaviors.

2. Use EMDR to reprocesses the memories creating PTSD symptoms first – Complex PTSD can consist of both major traumatic memories as well as memories of repetitive nonacute occurrences. Following the initial assessment, it should be determined if the client has symptoms of PTSD. If it is the case, those memories leading to PTDS should be reprocessed first using EMDR. This is done for two reasons. First, eliminating the negative impacts of traumatic memory leading to PTDS will bring the most amount of relief to the client in the fastest way. This relief will then allow for better functioning in and out of sessions as well as more ego strength to manage the treatment process. Second, PTSD generates a specific set of symptoms that are debilitating and will interfere with reprocessing memories that are nonacute. Eliminating these symptoms will assist the client in better listing and reprocessing nonacute memories found in Complex PTSD.

3. Use the schema assessment to develop a list of nonacute memories leading to Complex PTSD – The impacts of repetitive abuse in a relationship or in childhood will have a profound negative and confusing impact on a person’s cognitive, social, and emotional life. Schema Therapy is based on the idea that people will react in specific ways if their childhood needs are not met. Therefore, after a schema assessment is completed, the client and therapist can evaluate the origins of the schema(s). As this is done, an EMDR target memory list can be created which represents the negative, nonacute events of repetitive trauma and loss leading to schema development. Completing this process will decrease or eliminate the schema as well as the symptoms of Complex PTSD.

4. Determine if a schema is unconditional or conditional when planning the order of EMDR memory completion. – According to schema theory, an unconditional schema is a direct result of not getting one’s needs met in childhood. A conditional schema is often (but not always) the result of an individual reacting to or attempting to manage an unconditional schema. Thus, EMDR target memories should first be applied to the events leading to the development of an unconditional schema since the reprocessing of these memories could also lessen or eliminate the conditional schema reinforcing it. See the list of unconditional and conditional schemas below and use them in EMDR treatment planning.

Unconditional Schemas –The list of unconditional schemas is – abandonment/instability, mistrust/abuse, emotional deprivation, defectiveness, social isolation, dependence/incompetence, vulnerability to harm or illness, enmeshment/undeveloped self, failure, negativity/pessimism, punitiveness, entitlement/grandiosity, insufficient self-control/self-discipline.

Conditional Schemas – The list of conditional schemas is – subjugation, self-sacrifice, approval-seeking/recognition- seeking, emotional inhibition, unrelenting standards/hypercriticalness.

5. Reframe “too much of a good thing” schemas to highlight loss and hardship. – Most all schemas are caused by not getting one’s childhood needs met through loss, abuse or negligence. However, in some situations a schema is developed by a child having “too much of a good thing”. This is shown, for example, in the dependence/incompetence schema where a child is rescued from the normal expectations of life. Another example is the entitlement/grandiosity schema which comes from not receiving appropriate limitations. For the effective use of EMDR, the schema causes in both cases should be reframed to illustrate childhood loss or hardship from the events creating the schema. For example, with the dependency/incompetence schema, instead of focusing on the “ease” of being rescued, EMDR target memories might be based on recollections of childhood fear when having to confront typical challenges, Also, they could be recent memories of resentment for being rescued as an adult or child. Concerning the entitlement/grandiosity schema, instead of focusing on the “joy” of not having limitations, the schema could be reframed to highlight memories of social hardship resulting from the negative actions of entitlement or it could highlight feelings of defectiveness leading to the overcompensation seen in the entitlement/grandiosity schema.

6. Complete EMDR reprocessing before schema exercises – Focusing first on the reprocessing in EMDR should be done for several reasons. First, EMDR changes negative cognitions, physical reactions, emotions and related behaviors leading to PTSD and Complex PTSD quickly and effectively. Because the client will be less triggered and more emotionally regulated, this change should assist the client in more effectively being able to do the schema exercises. Also, PTDS and Complex PTSD have a neurobiological impact on the brain that impairs the client’s ability to understand, describe and hold a personal narrative. EMDR Therapy should bring relief, symptom reduction and personal focus. However, successful EMDR does not have a structural process designed specifically to assist with individual narrative. Schema Therapy allows for an understanding of the personal impacts of unmet childhood needs, the impacts on mood, identity, thinking, feeling, relationships and behavior. These are necessary understandings for personal narrative. Additionally, schema exercises assist the client in distancing themselves from the schema’s power and its impacts, thus allowing them to understand and discuss the reality of their past and hope for their future more freely.

Resources

Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures by Francine Shapiro PhD (2001)

EMDR as an Integrative Psychotherapy Approach: Experts from Diverse Orientations Explore the Paradigm Prism Edited by Francine Shapiro PhD (2002)

Getting Past Your Past: Take Control of Your Life with Self Help Techniques from EMDR Therapy by Francine Shapiro PhD (2012)

Schema Therapy – A Practitioner’s Guide by Jeffrey Young PhD, Janet Klosko PhD and Marjorie Weishaar PhD (2003)

Reinventing Your Life by Jeffrey Young PhD and Janet Klosko PhD (1993)

Schema Therapy by Eshkol Rafaeli, David Bernstein and Jeffrey Young (2011)

Negative Thinking Patterns: A Schema Therapy Self – Help and Support Book by Gitta Jacob, Hannie Van Genderen and Laura Seebauer

Cognitive Therapy – Basic and Beyond by Judith Beck (1995)

Cognitive Therapy for Personality Disorders – A Schema Focused Approach by Jeffry Young (1999)

Cognitive Therapy of Personality Disorders by Aaron Beck, Arthur Freeman and Denise Davis (2004)

Combining EMDR and Schema Mode Therapy for Complex Posttraumatic Stress Disorder

By Jeff Dwarshuis LMSW ACSW

What is Eye Movement Desensitization and Reprocessing?

Eye Movement Desensitization and Reprocessing (EMDR) was developed by Francine Shapiro in 1989 as a method of treatment for Posttraumatic Stress Disorder (PTSD).

Due to the many complexities found in the assessment and treatment of Complex PTSD, EMDR treatment required added interventions and assessment tools. These tools can be found in Schema Therapy and one of its interventions called “Schema Mode Therapy”. This article explains how EMDR and Schema Mode Therapy can be combined for increased speed and effectiveness for treatment of individuals suffering from Complex PTSD.

EMDR and Neurobiology

EMDR and the Two Primary Positive Treatment Reactions

that includes an elimination of the negative emotional reactions related to the trauma. Second, the client experiences an increased level of rational perception related to the memory. This increased rational thinking is called Adaptive Information Processing (AIP). AIP is the result of successful EMDR reprocessing and allows the client to hold a more rational view of personal safety, personal responsibility and personal choice while visualizing or discussing a traumatic memory. AIP also allows the client to hold an accurate positive self-perception or cognition while visualizing the trauma. This assists the client in problem solving how he or she would react, or prefer to react, differently in a similar situation. Repeating the EMDR procedure over a series of planned interventions targeting traumatic memories relieves the person of the negative impacts the memories have created. Due to its neurobiological quality, the changes from successful EMDR reprocessing are permanent and generate dramatic symptom reduction across the spectrum of most all mental health diagnosis.

What Is Schema Therapy?

Schema Therapy is a branch of Cognitive Therapy that was developed by Jeffrey Young PhD and includes several different psychotherapeutic interventions including Behavioral, Gestalt, Psychoanalytic and Relational Therapies. Schema Therapy argues that if individuals are abused or neglected as children, they may develop “maladaptive schemas”. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Stress Disorder. Maladaptive schemas (known as schemas) can be defined as self-defeating emotional and cognitive patterns that begin in early childhood and continue throughout life. The goal of Schema Therapy is to eliminate the schema(s) by recognizing and challenging it and replacing it with more effective behaviors. One of the ways to accomplish this goal is through Schema Mode Work.

Schema Modes

Schema modes can be defined as moment to moment emotional states and their related behaviors that all individuals use to manage life events. Often a life event will trigger a schema and then the person will switch their behavior and thought process to a maladaptive mode. Schema modes can be adaptive or maladaptive and the goal of Shema Mode Therapy is to recognize maladaptive modes and replace them with adaptive modes.

Modes are measured by both their level of rigidity and intensity. For people who are responding to life events in a healthy way, their responses tend to be flexible and not ridged. The flexibility between changing modes during a healthy reaction is spontaneous and the individual can switch from one mode to the next as well as easily recall their thoughts, feelings and actions when shifting from one mode to the next.

Also, an adaptive reaction to a life event consists of a reasonable level of intensity. While some events in life are extreme and have major emotionally reactions, others are not extreme. The quality of healthy mode reactivity is rational and parallels the intensity of the event.

Unhealthy behavior is more ridged in quality. For example, one might quickly switch from a healthy adult mode to a more childlike mode and the intensity of the child mode will take over the person’s thinking and behavior. Thus, the person appears to lose control over their behavior as well as the stability of identity. These sudden mode switches impact the sense of cognitive, emotive and behavioral maintenance and the overwhelm of the mode causes difficulty recalling healthy mode experiences. This is shown in its most extreme forms during states of dissociation which schema therapists would describe as a process of extreme mode switching and reactivity.

Also, an unhealthy reaction to a negative life event consists of an unreasonable level of reactivity to that event. Thus, if a person switches to an unhealthy mode they might appear to overreact to situations that are minor, or they might appear to have very little or no reaction to life events that are overwhelming or critical.

Schema Mode Categories and the Nine Schema Modes

Schema Therapy defines nine schema modes as the basis for mode behavior. In a sense, all these modes are universal. In other words, all people tend to embrace each mode. Again, the concerns have to do with the person’s level of rigidity and/or intensity when in the mode. The nine schema modes fall into three categories. Below is a description of each category followed by a description of each mode within that category. A description of the healthy adult mode is included.

Child Modes – Child modes are characterized by childlike feelings, thoughts and behaviors. The impact of a child mode can be mild yet in extreme forms the person might give the mode an identity. This, according to Schema Therapy, is the foundation for the switching and reactivity found in Dissociative Identity Disorder.

1. The Vulnerable Child Mode – The individual in a vulnerable child mode will experience dysphoric, anxious and sad feelings when triggered by a life event or memory. Other emotions might include loneliness, isolation, overwhelm, self-questioning, neediness, helplessness, hopeless, abandonment, fragility, weakness and oppression. The behavior of the vulnerable child depends on which dysfunctional coping mode they use to manage their reactions.

2. The Angry Child Mode – The individual in an angry child mode is fueled by feelings of victimization and bitterness which then leads to pessimism, jealousy and rage. The individual often feels unsupported and may have urges to yell, scream, throw or break things or injure themselves or others. Often a trigger for the switch to an angry child mode is the sense that one’s needs are not being met.

3.The Impulsive or Undisciplined Child Mode – The individual in an impulsive or undisciplined mode acts on their desires of “at the moment” needs. The individual generally acts impulsively and in a selfish and/or uncontrolled manner. The person has a desire to get his or her own way and has difficulty delaying short-term gratification. Emotionally the person feels anger, rage, frustration and impatience when these desires or impulses are not met. The person generally appears to be “spoiled”.

4. The Happy Child Mode – The individual in the happy child mode feels at peace because their core emotional needs are being met. Generally, the person experiences love, validation, safety and connection. The person thinks they are special, lovable, important and strong.

Dysfunctional Coping Modes – Dysfunctional coping modes are used to prevent emotional distress but end up reinforcing or perpetuating the schema. These coping modes parallel the core emotional, cognitive and physical reactivity seen in fight, flight or freeze behaviors referred to in schema language as overcompensation, avoidance and surrender, respectively.

1.The Overcompensator Mode – The individual in the overcompensator mode will adopt a coping style to counteract feelings of defectiveness or feelings related to not getting their emotional needs met. The individual appears inordinately grandiose, aggressive, dominant, competitive, arrogant, haughty, condescending, devaluing, controlling, rebellious, manipulative, exploitative, attention-seeking and status-seeking. The individual in this mode perpetuates their schema patterns since they actively deny the schema’s existence.

2. The Detached Protector Mode – The individual in the detached projector mode cuts themself off from their own needs and feelings and presents with an overall appearance of avoidance. The person will detach emotionally from others and reject outside assistance. The person appears to be withdrawn, distracted, disconnected, depersonalized, empty, bored or aloof. The individual may compulsively and excessively pursue distracting, self-soothing, or self-stimulating activities. The individual in this mode perpetuates their schema patterns since they cut themselves off from problem recognition.

3. The Compliant Surrenderer Mode – The individual in the compliant surrenderer mode typically acts in a passive, submissive, approval-seeking or self-deprecating way to avoid conflict or rejection. Individuals in this mode will tolerate abuse and mistreatment and will not express their own needs. The individual in this mode perpetuates their schema patterns since they are avoiding effective problem-solving.

Dysfunctional Parent Modes – Dysfunctional parent modesare internalizations of critical, demanding, or harsh parental voices. When someone is in this set of modes they will take on and own the messages taught to them through abusive behavior and will act as if the message is real and appropriate. Although this is described as a “parent” mode, the negative abuse messages can come from anybody including teachers, religious leaders, siblings, relatives or peers.

1. The Punitive Parent Mode – The individual in the punitive parent mode generally believes that they deserve punishment and blame. Often the person will be self-abusive shown by self-mutilation, anorexic behavior, bulimic behavior, self-sabotage, self-loathing, self-blame, self-criticism and suicidal thoughts and behaviors. The individual will present with a tone that is harsh, unforgiving and critical. Relative to norms and rules there is a preoccupation with the style of rule enforcement rather than rule appropriateness.

2. The Demanding Mode – The individual in the demanding parent mode is preoccupied with perfectionism, achievement, order, status and efficiency. The individual will appear irritated, anxious, demanding and/or emotionless. There is a tendency for the person to devalue both spontaneity and emotional expression. Relative to norms and rules there is an emphasis on the act of meeting high standards rather than on the style of implementation or the general effectiveness of meeting a particular purpose.

Healthy Adult

The Healthy Adult Mode – The individual in the healthy adult mode presents as being comfortable in their decisions, problem-solving, impulses, ambitions, limitations and relationships. The individual acts in a way that is responsible, thoughtful, participatory and self-nurturing. Relationally the person can maintain presence without a preoccupation for the past or future. Schema Therapy concentrates on the role of the adult mode to use its resources as a method of self-parenting when other modes have taken control.

Schema Mode Treatment

Schema Therapy emphasizes the role of five primary steps for useful mode work. Generally, these steps are taken within the context of treatment, but benefits can also come by doing the exercises alone. The end goal of these initial five exercises is to be able to do schema problem solving as defined in the next section. List your answers.

1. Schema Mode Identification – The first step is schema mode identification. This involves learning about the different schema modes and identifying the most common modes used including both negative and positive modes. One can read the schema mode descriptions and with an understanding of the characteristics, begin to list the modes that are most often used.

2. Origin and Adaptive Use – The second step is recognizing the schema mode’s origin and adaptive use. The origin of the schema mode typically comes from the family of origin, usually a parent. However, it could also include other significant figures from youth. Following this, begin to think about how it was helpful or adaptive for use as a child in order to survive but as an adult, is ineffective.

3. Triggers Identification – The third step is trigger identification and involves the recognition of the most common life events that initiates mode switches. It can be helpful to think about sudden shifts in mood or an awareness of others’ change in reaction to behavior.

4. Mode Advantages and Disadvantages – The fourth step is recognizing the advantages and disadvantages of the mode. This can be done by putting oneself at a distance from the behaviors and evaluating its negative and positive impacts on social, emotional and physical being as well as its general impacts on life. The recognition of mode advantages and disadvantages is an important part of the process of self-parenting.

5. Self-Parenting – The fifth step is self-parenting. Generally, this involves the processes of seeing and adapting the use of both the Happy Child Mode and the Healthy Adult Mode. Change occurs as one uses these healthy modes to nurture or redirect unhealthy modes. This can be done by the imagery of changed behavior or the imagery of seeing oneself in a healthy mode providing safety or direction to an unhealthy mode.

Schema Mode Problem Solving

With the initial exercises completed one is a better position to coordinate and use the learning on a day to day basis. The goal is to use the understandings and growing awareness from the previous exercises and apply them to daily relational and emotional challenges perpetuated by the modes(s).

Completing the framework sentence below will allow for gradual change and the elimination of unhealthy schema modes. The goal is to get to the point of being able to do the exercise automatically in real life settings.

Use the framework sentence below to talk, write or think through a challenging life situation.

I feel (emotion) in (this part of my body) and the emotion was caused by (causal event). This event has triggered my (mode) which was taught to me by (family of origin influence). This mode reaction has caused me to exaggerate or overreact by (behavior). The mode may have been helpful when I was (age or situation) but today it is ineffective because of (disadvantages). Although my schema causes me to believe that I am (negative self-belief) I am (rational positive self-belief) as evidenced by (supporting evidence). Although I would like to do (negative behavior) instead I will do (positive behavior).

Combining EMDR and Schema Mode Therapy for Complex Posttraumatic Stress Disorder

Both EMDR and Schema Mode Therapy are highly effective treatment methods for Complex PTSD. Combining these methods leads to a faster and more effective level of change by using their relative strengths. EMDR is fast and highly effective in eliminating the negative impacts of negative memories. Additionally, the changes are permanent. However, individuals with Complex PTSD present with complicated histories and a set of symptoms that do not allow the therapist using the EMDR Protocol to accurately assess negative contributing memories leading to Complex PTSD symptoms. Schema Therapy provides a plausible explanation for the development of Complex PTSD since it is based on understanding the impacts of unmet childhood needs and its related negative experience and memory. Schema Mode Therapy explains the related patterned behaviors that are a result of these schema developments. The EMDR therapist can use this understanding of schema behavioral reaction to better target interfering memories leading to those behaviors.

Below is a list of the eight treatment steps that are needed to safely and effectively combine EMDR and Schema Mode Therapy.

1. Use EMDR to reprocesses the memories creating PTSD symptoms first – Complex PTSD can consist of both major traumatic memories as well as memories of repetitive nonacute occurrences. Following the initial assessment, it should be determined if the client has symptoms of PTSD. If it is the case, those memories leading to PTDS should be reprocessed first using EMDR. This will allow for the greatest amount of relief for the client in the fastest way. Also, it will allow in better functioning in and out of sessions and more ego strength to manage the Mode Therapy treatment process.

2. Use EMDR to target memories leading to schema development. – The impacts of repetitive abuse in a relationship or in childhood will have a profound negative and confusing impact on a person’s cognitive, social, and emotional life. After a schema assessment is completed, the client and therapist can evaluate the origins of the schema(s) and create an EMDR target memory list which represents the negative, nonacute events of repetitive trauma and loss leading to schema development. Completing this process will decrease or eliminate the schema and decrease the need of schema mode behaviors.

3. Use EMDR to target the origins of the modes. – The origin of a schema mode typically comes from the family of origin, usually a parent. However, it could also include other significant figures from youth such as peers, siblings, teachers, religious leaders or extended family members. The therapist should identify with the client the people who are a part of the schema mode’s origin and then create an EMDR target list accordingly. Reprocessing these memories should decrease the susceptibility to and intensity of mode shifts

4. Use EMDR to target triggers leading to mode switching – Triggers are specific life events or memories leading to a stress reaction and the internal need to switch to a maladaptive mode. The client and therapist should create a list of triggers that occur in and out of sessions, treat each trigger like a target EMDR memory and apply the standard EMDR protocol. This should assist the client in being less reactive in similar future situations.

5. Use EMDR to target the disadvantages of mode behavior – After a client has put themself at a distance from the mode behaviors and evaluated its negative and positive impacts, the therapist and client should treat the disadvantages as a negative memory and apply the standard EMDR protocol to this memory. This will allow the client to distance themselves from the negative emotional consequences of the mode behavior and to envision a changed narrative by integrating the positive cognition during the EMDR phase five installation procedure. The process parallels the schema mode intervention of reparenting.

6. Use EMDR to target self-abusive and aggressive behaviors by using the punitive parent mode – Outside of sessions the client should track times of self-abuse and aggression. These events can be discussed in treatment and reframed as a punitive parent mode behavior. The client and therapist can then evaluate the origin of the punitive mode (i.e. parent, sibling, teacher…) and create an EMDR target memory related to the origin. This process should allow for emotional distance from the origin, increased rational perspective regarding esteem and decrease mode potency.

7. Use known dysfunctional coping modes as a guide for EMDR targets. – Dysfunctional coping modes are used to prevent emotional distress but end up reinforcing or perpetuating the schema. These coping modes parallel the core emotional, cognitive and physical reactivity seen in fight, flight or freeze behaviors referred to in schema language as overcompensation, detached protector and compliant surrenderer, respectively. As a client recognizes their coping modes, they should identify the event leading to the mode behavior. This event should be listed as an EMDR target and reprocessed. This should assist the client in creating more effective methods of change that are less defensive.

8. Evaluate if the positive cognitions of EMDR represent a description of the healthy parent mode – After an EMDR target list is created or completed, the therapist and client should evaluate if the positive cognitions used in the EMDR phase five installation procedure represent the quality of the Healthy Adult Mode. If they do not, then these qualities should be listed and used in other Schema Mode exercises or EMDR memories. It is likely that the cognitions and healthy mode will be much the same since the client’s stated desire for cognitive change against the imagery of impaired self-perceptions seen in the EMDR procedure represents a clear illustration of healthy functioning. However, the exercise of healthy adult imagery may lend to the client another method of internal resources leading to self-healing.

Resources

Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures by Francine Shapiro PhD (2001)

EMDR as an Integrative Psychotherapy Approach: Experts from Diverse Orientations Explore the Paradigm Prism Edited by Francine Shapiro PhD (2002)

Getting Past Your Past: Take Control of Your Life with Self Help Techniques from EMDR Therapy by Francine Shapiro PhD (2012)

Schema Therapy – A Practitioner’s Guide by Jeffrey Young PhD, Janet Klosko PhD and Marjorie Weishaar PhD (2003)

Reinventing Your Life by Jeffrey Young PhD and Janet Klosko PhD (1993)

Schema Therapy by Eshkol Rafaeli, David Bernstein and Jeffrey Young (2011)

Negative Thinking Patterns: A Schema Therapy Self – Help and Support Book by Gitta Jacob, Hannie Van Genderen and Laura Seebauer

Cognitive Therapy – Basic and Beyond by Judith Beck (1995)

Cognitive Therapy for Challenging Problems by Judith Beck (2005)

Cognitive Therapy for Personality Disorders – A Schema Focused Approach by Jeffry Young (1999)

Cognitive Therapy of Personality Disorders by Aaron Beck, Arthur Freeman and Denise Davis (2004)

Combining EMDR and Polyvagal Therapy for Complex Posttraumatic Stress Disorder

What is Eye Movement Desensitization and Reprocessing?

Eye Movement Desensitization and Reprocessing (EMDR) was developed by Francine Shapiro in 1989 as a method of treatment for Posttraumatic Stress Disorder (PTSD).

Due to the many complexities found in the assessment and treatment of Complex PTSD, EMDR treatment required added interventions and assessment tools. These tools can be found in Polyvagal Therapy. This article explains how EMDR and Polyvagal Therapy can be combined for increased speed and effectiveness for treatment of individuals suffering from Complex PTSD.

EMDR and Neurobiology

EMDR is a treatment method used to eliminate the negative impacts of traumatic memory quickly and effectively. EMDR is a neurobiological intervention that makes use of eye movements to facilitate a physiological impact on brain functioning which creates permanent emotional and cognitive change in an individual when thinking about or visualizing a traumatic memory.

EMDR and the Two Primary Positive Treatment Reactions

Polyvagal Theory and Psychotherapy

Polyvagal Theory was developed by Dr Stephen Porges PhD in 1994 as a method of understanding the relationship between individual heart rate variability and the Autonomic Nervous System. In recent years the field of psychotherapy has had great interest in Polyvagal Theory as Polyvagal Theory has been able to provide neurophysiological explanations for several of the experiences described by individuals who have experienced trauma. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Disorder. This interest has led to numerous psychotherapeutic exercises assisting people with self-regulation, relational management and an articulation of the subjective experiences of danger and safety.

Polyvagal Theory and The Perception of Safety and Danger

Polyvagal Theory assumes, of course, that there are both dangerous and safe situations, but that people will have emotional, physical, cognitive and relational hardship if their perception of those safe or dangerous situations is inaccurate. It is important that people approach relationships and daily tasks with an accurate assessment of both the safety and the danger involved in those settings. In some cases, people who have a history of abuse, neglect or trauma will misread situations and inaccurately see a situation either as more dangerous than it is or safer than it is. Exaggerating danger might be shown by being easily offended, having difficulty accepting criticism or having irrational fears like phobias, generalized anxiety or panic. Also, people might misread situations as being safer than what they are. This happens when people stay in abusive relationships, voluntarily frequent threatening environments or allow verbal, physical or emotional boundary violations.

The Three States of the Autonomic Nervous System

Polyvagal Theory argues that people are regularly moving through three different autonomic states throughout their daily lives. This movement is caused by reactions to life events and the attempt to survive emotionally or physically, to restore oneself, or connect with others. These three states are the ventral vagal state (safe and social), the sympathetic state (mobilized for fight or flight) and the dorsal vagal state (immobilized and collapsed). Each state is managed by a specific set of nerves and each state serves a specific set of biological and social needs.

1.Ventral Vagal State – The ventral vagal state is a physical, emotional and cognitive experience facilitated by a set of nerves in the upper part of the body connecting the brain to the heart, neck, face, mouth, eyes and ears. The ventral vagal state, also known as the “safe and social state”, is responsible for detecting, accepting, evaluating and reciprocating states of social safety. Also, it regulates the other two defensive autonomic states listed below. Being in a safe situation and then actively looking for and seeing safety will activate the ventral vagal state. The activation of the ventral vagal state facilitates self-regulation and eliminates unnecessary defensive thoughts, feelings and behaviors. In a relational sense, people in the ventral vagal state feel safe which leads to a sense of connection, trust, comfort, restoration and happiness. It is best that individuals solve relational problem(s) in the ventral vagal state. If they do not, they will switch involuntarily to the sympathetic state and attempt to solve their problem(s).

2.The Sympathetic State – The sympathetic state is a physical, emotional and cognitive experience facilitated by a set of nerves coming from the center of the spine and connecting to various organs. This set of nerves alerts and activates people when they detect danger and prepares the body to act. The sympathetic state, also known as “mobilized for fight or flight state”, moves through various levels of intensity measured by both the level of fear experienced and the related amount of physical and mental energy that is given to deal with the event. When someone is in this state, they are pulled out of the ventral vagal state, lose the benefits of feeling safe and begin to disconnect from people. Relationally it is a state of conflict and fear. Clinically the sympathetic state parallels anxiety, anger, posttraumatic stress, relational discord, obsessions and cognitive distortions leading to self-questioning. Physical symptoms include headaches, high blood pressure, heart disease and joint pain. If the problem or event is not solved in the sympathetic state, the person will then involuntarily activate the next state which is the dorsal vagal state.

3.The Dorsal Vagal State – The dorsal vagal state is a physical, emotional and cognitive experience facilitated by a set of nerves that extend from the Vegas Nerve to the organs located below the diaphragm. When the dorsal vagal state, also known as “the immobilized and collapsed state”, is activated an individual will shut down. Often this will follow the overwhelm of energy and fear caused by the sympathetic state. This overwhelm can be physical, emotional, or cognitive. The body will grow cold, weak, slow and lacking in energy. Socially the individual feels disconnected from others. Clinically this state triggers symptoms of depression, dissociation, performance anxiety, paranoia and cognitive distortions leading to challenged self-concept. Physical symptoms consist of low blood pressure, immune system disorders, stomach problems, obesity, fibromyalgia and irritable bowel syndrome.

The Vagal Brake and The Window of Tolerance

The vagal brake is a term created by Stephen Porges PhD to describe the process of stopping physiological reactivity to life events that lead either to the sympathetic or dorsal vagal defensive state. It is important that individuals accurately read the level of both safety and danger in life events in order to not overuse a defensive state position. People who have a history of trauma and nonacute trauma found in PTSD and Complex PTDS have histories where it was necessary to maintain states of high defense. However, in different life settings, or in adulthood, the level of threat generally is less and the need for a defensive state is less. An unnecessary overactivation of a defense state will create emotional, physical and cognitive overwhelm and a relational management style that is ineffective. The activation of the vagal brake, at the right time, will ease a defense reaction and leave the individual in a position to self-regulate and return to a ventral vagal state of safety. The development of an accurate vagal brake response can be done by polyvagal exercises as well as by the reprocessing of traumatic memory through the EMDR protocol. These interventions are central to the treatment of Complex PTDS.

The window of tolerance is a clinical term used to describe the parameters of one’s state of non-defense. It is necessary to recognize one’s own window of tolerance since it will determine what are manageable tasks, thoughts, memories, relationships and topics in and out of therapy. Thus, the awareness of one’s window of tolerance will assist in self-regulation and with creating the most likely positive results from the use of internal resources and therapeutic suggestions. A goal of treatment is for the client’s window of tolerance to increase over time so one can actively problem solve needed topics of change while maintaining a ventral vagal state position. As this relates to the vagal brake, the window of tolerance will expand as one can more quickly use their vagal brake to inhibit defense response, maintain a state of safety and “tolerate” life events. The window of tolerance is expanded by Polyvagal exercises and EMDR since both will decrease the automatic activations of unnecessary defensive states.

What is Coregulation?

Coregulation is the moment to moment act of managing a relationship to self regulate. Coregulation is based on attachment theory which argues that the regulation of a child doesn’t simply come from the “good enough” behavior of the parent but is a process by which the child feels calm in reaction to the parent’s self-regulation which is in response to the child’s initial signs of self-soothing. In relationships, coregulation is the processes of keeping a relationship safe in an effort of bring oneself to state of regulation. In Polyvagal terms, the individual has an awareness of both their window of tolerance and sensitivity to their vagal brake and will use methods to manage the relationship in order to remain in or return to a ventral vagal state. This often requires the need to defuse the defensive states of sympathetic defense and dorsal vagal defense that occur both in oneself, but also in others. Often individuals with a history of abuse or neglect leading to PTSD or Complex PTSD have a history of strained and conflictual relationships and do not have a background of guided experience leading to self-regulation through relational management.

The Polyvagal Hybrid States

Polyvagal Theory argues that the three states of the autonomic nervous system listed above, the ventral vagal, sympathetic, and dorsal vagal states, are not mutually exclusive nor antagonistic but rather comingle and coexist to create a full spectrum of cognitive, relational, behavioral and emotional experiences. These coactivated states are called “hybrid states” states. There are two hybrid states which are the combined ventral vagal and sympathetic state and the combined ventral vagal and dorsal vagal state. Polyvagal hybrid states represent how polyvagal awareness and creative application can facilitate the process of using internal client resources for self-regulation and solving problems. For more information on this topic and useful exercises see “Polyvagal Hybrid States and Complex Posttraumatic Stress Disorder” by author.

Combining EMDR and Polyvagal Therapy for Complex PTSD

Combining EMDR with Polyvagal Therapy makes use of the strengths of both methods. Polyvagal Therapy is a unique method of evaluating autonomic states and state shifts as well as a helpful framework for understanding reactivity and resolve in relationships. EMDR is a highly effective method of treatment that makes use of neurobiological mechanisms to eliminate the negative impacts of traumatic memory. Additionally, EMDR has a significant impact on increasing the rational perception of events. This lends itself to be a method of individual resource for the process of change, particularly related to cognitions and imagery. Combining these two methods assists someone dealing with Complex PTSD to have quicker and more effect resolve. Follow these six steps below.

1.Complete the polyvagal profile map first – To begin combining EMDR with Polyvagal Therapy first complete the polyvagal profile map. This will be an introduction to polyvagal theory and will begin to assist in recognizing the subjective experience of the various states, the triggers for those states and a recognition of the internal resources needed to avoid states of defense. Additionally, it will prepare one to target memories more effectively for EMDR reprocessing and will be a vehicle of the narrative of change following EMDR reprocessing. See the article “Polyvagal Profile Maps for Complex Posttraumatic Stress Disorder” by author for directives on this process.

2. Use EMDR for PTSD memories first – Complex PTSD can consist of both major traumatic memories as well as memories of repetitive nonacute occurrences. Following the initial assessment, it should be determined if there are symptoms of PTSD. If it is the case, those memories leading to PTDS should be reprocessed first using EMDR. This is done for two reasons. First, eliminating the negative impacts of traumatic memory leading to PTDS will bring the most amount of relief in the fastest way. This relief will then allow for better functioning in and out of sessions as well as more ego strength to manage the treatment process. Second, PTSD generates a specific set of symptoms that are debilitating and will interfere with reprocessing memories that are nonacute. Eliminating these symptoms will assist in better listing and reprocessing nonacute memories found in Complex PTSD.

3. Use EMDR for nonacute traumatic memories – The impacts of repetitive abuse in a relationship or in childhood will have a profound negative and confusing impact on a person’s cognitive, social, and emotional life. These impacts will significantly impact one’s level of defense and reactivity. Also, many of the triggers related to switching to more defensive states in the polyvagal profile are triggered by memories. The elimination of these triggers will allow for better use of the polyvagal exercises, decreasing defense in conflicts and finding more restoration in relationships.

4. Do polyvagal problem solving following PTDS memory reprocessing – After one has completed the list of acute and nonacute traumas using EMDR, they will be in a much better position cognitively, emotionally and behavioral to make use of polyvagal problem solving. Polyvagal problem solving is a process of managing and changing day to day relational hardship and requires using the gains of EMDR in combination with a growing understanding of an autonomic state. Thus, it pulls together growth and understanding on a consistent basis while solving daily problems. Polyvagal problem solving then increases one’s window of tolerance since their capacities to manage stressful situations increases and the need for defense is less. For directives on completing Polyvagal problem solving see “Polyvagal Problem Solving for Complex Posttraumatic Stress Disorder” by author.

5.Use EMDR to reprocesses polyvagal problem-solving examples – As one begins to consistently use polyvagal problem solving, they can begin to use EMDR and treat each problem as if it were a trauma. The therapist should use the standard EMDR protocol for this procedure. This process will assist in further distancing the memory but will also allow one to use the EMDR positive cognition resource to activate states of ventral vagal safety more quickly and consistently.

6. Use EMDR as a resource installation technique for polyvagal hybrid states – Polyvagal hybrid states are unique combination states coactivating the ventral vagal state with the two defensive states to create states of safe mobilization and safe immobilization. One should first complete the exercise found in “Polyvagal Hybrid States and Complex Posttraumatic Stress Disorder”. EMDR can be used primarily as a resource installation technique. For example, an individual completing the hybrid exercise might envision decreasing a personal conflict found in a sympathetic state by introducing the concepts of competitive play which is a safe and social ventral vagal position. The standard EMDR procedure could be done on the conflict itself while the positive cognition would be developed based on an imagery of someone involved in play. In this way, EMDR is used as an installation technique to reprocesses a negative memory using a polyvagal framework. Another example might consist of someone who has been triggered and is in the dorsal vagal, immobilized shutdown state. Again, using the concept of play, the person might envision play tactics of teasing, flirtatiousness, friendly competition, and playful touch in order to challenge the shutdown state and create a state of collective immobilization leading to closeness and intimacy. Again, EMDR can be used to treat the attempted connection as a trauma using the standard protocol and the EMDR resource installation would allow for distancing from the picture combined with the rational thinking facilitated by EMDR and the increased capacity to form intimate bonds through states of nondefense.

Resources

The Pocket Guide to Polyvagal Theory: The Transformative Power of Feeling Safe by Stephen Porges (2017)

The Polyvagal Theory in Therapy by Deb Dana (2018)

The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment Communication and Self-Regulation by Stephen Porges PhD (2011)

Traumatic Stress: The Effects of Overwhelming Experience on The Mind, Body and Societ y by Bessel Vander Klok, Alexander Mc Farlane, and Lars Weisaeth (2007)

Yoga Therapy and Polyvagal Theory: The Convergence of Traditional Wisdom and Contemporary Neuroscience for Self-Regulation and Resilience by Sullivan, Erb, Schmalzi, Moonaz, Tylor, and Porges from Frontiers in Human Neuroscience February 2018.

Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures by Francine Shapiro PhD (2001)

EMDR as an Integrative Psychotherapy Approach: Experts from Diverse Orientations Explore the Paradigm Prism Edited by Francine Shapiro PhD (2002)

Getting Past Your Past: Take Control of Your Life with Self Help Techniques from EMDR Therapy by Francine Shapiro PhD (2012)

Schema Therapy – A Practitioner’s Guide by Jeffrey Young PhD, Janet Klosko PhD and Marjorie Weishaar PhD (2003)

Reinventing Your Life by Jeffrey Young PhD and Janet Klosko PhD (1993)

Schema Therapy by Eshkol Rafaeli, David Bernstein and Jeffrey Young (2011)

Negative Thinking Patterns: A Schema Therapy Self – Help and Support Book by Gitta Jacob, Hannie Van Genderen and Laura Seebauer

Cognitive Therapy – Basic and Beyond by Judith Beck (1995)

Cognitive Therapy for Personality Disorders – A Schema Focused Approach by Jeffry Young (1999)

Cognitive Therapy of Personality Disorders by Aaron Beck, Arthur Freeman and Denise Davis (2004)

Schema Therapy for Complex Posttraumatic Stress Disorder

Schema Therapy for Complex Posttraumatic Stress Disorder

By Jeff Dwarshuis LMSW ACSW

What Is Schema Therapy?

Schema Therapy is a branch of Cognitive Therapy that was developed by Jeffrey Young PhD and includes several different psychotherapeutic interventions including Behavioral, Gestalt, Psychoanalytic and Relational Therapies. Schema Therapy argues that if individuals are abused or neglected as children, they may develop “maladaptive schemas”. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Disorder. Maladaptive schemas (Known simply as schemas) can be defined as self-defeating emotional and cognitive patterns that begins in early childhood and continue throughout life. The goal of Schema Therapy is to eliminate the schema(s) by recognizing and challenging it and replacing it with more effective behaviors.

Schema Recognition

Testing Schema Validity

After an individual knows about their schemas and understands the description of the schema, they can begin to challenge the schema by testing its validity. Schemas, in general, are inaccurate negative representations of the person and can reasonably be disproven through evidence. However, people often will identify with their schemas and see a schema as a representation of who they are. Therefore, creating a list supporting how the individual sees themselves relating to the negative qualities of the schema can easily be done while creating a list of evidence about how the person is different from the schema can be difficult.

Schema Reframing

After testing the schema’s validity, the individual should challenge the reality of the schema by reframing it. This can be done by taking each piece of evidence that supports the schema and attributing it to another more rational cause. For example, instead of thinking “I am unlovable” the person might instead say “I was not given enough attention and was taught to think I was unlovable” or instead of thinking “I am a failure” the person might list or say “I was not given enough opportunity to recognize my potential.” Typically, these causes have to do with the person’s childhood family, especially the parents who had control over the person’s life and events that may have contributed to the schema development. It is important to not personalize the schema but to rationally consider the influences of its development.

Identifying the Advantages and Disadvantages of the Coping Behaviors

Schemas are themselves emotional and cognitive patterns and each person has a set of behaviors that are used to deal with, display, represent or ignore the schema(s). These behaviors are called “coping responses”. Coping responses generally fall into the behavioral categories of avoiding, surrendering or overcompensating for the schema. One can think about and then list these coping responses then evaluate both the pros and cons of what the coping responses do or don’t do. It is important to recognize that these behaviors may have been adaptive as a child but are no longer beneficial or appropriate as an adult. Then, after listing the coping responses, one can list and use an alternative healthy behavior.

Schema Problem Solving

With the initial exercises completed one is a better position to coordinate and use the learning on a day to day basis. The goal is to use some of the understandings and growing awareness from the previous exercises an apply them together to daily relational and emotional challenges perpetuated by the schema(s).

Completing the framework sentence below will allow for spontaneous change and the elimination of schemas. The goal is to get to the point of being able to do the exercise automatically in real life settings.

I feel (emotion) because of (causal event). This event has triggered my (schema) and has caused me to want to do (coping behavior). Although my schema causes me to believe that I am (negative self-belief) I am (rational positive self-belief) as evidenced by (supporting evidence). Although I would like to do (negative behavior) instead I will do (positive behavior).

Resources

Schema Therapy – A Practitioner’s Guide by Jeffrey Young PhD, Janet Klosko PhD and Marjorie Weishaar PhD (2003)

Reinventing Your Life by Jeffrey Young PhD and Janet Klosko PhD (1993)

Schema Therapy by Eshkol Rafaeli, David Bernstein and Jeffrey Young (2011)

Negative Thinking Patterns: A Schema Therapy Self – Help and Support Book by Gitta Jacob, Hannie Van Genderen and Laura Seebauer

Cognitive Therapy – Basic and Beyond by Judith Beck (1995)

Cognitive Therapy for Challenging Problems by Judith Beck (2005)

Cognitive Therapy for Personality Disorders – A Schema Focused Approach by Jeffry Young (1999)

Cognitive Therapy of Personality Disorders by Aaron Beck, Arthur Freeman and Denise Davis (2004)

Polyvagal Problem Solving for Complex Posttraumatic Stress Disorder

Polyvagal Problem Solving for Complex Posttraumatic Stress Disorder

By Jeff Dwarshuis LMSW ACSW

Polyvagal Theory and Psychotherapy

Polyvagal Theory was developed by Dr Stephen Porges PhD in the 1994 as a method of understanding the relationship between individual heart rate variability and the Autonomic Nervous System. In recent years the field of psychotherapy has had great interest in Polyvagal Theory as Polyvagal Theory has been able to provide plausible neurophysiological explanations for several of the experiences described by individuals who have experienced trauma. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Disorder. This interest has led to numerous psychotherapeutic interventions assisting people with self-regulation, relational management and an articulation of the subjective experiences of danger and safety.

One of Polyvagal Theory’s applications to therapy is the evaluation and problem solving of both the safety and danger in life events. This is done by listing both the safety and danger in specific settings while considering three things. These are the quality of social connectedness, the details of the social context and the related individual body reactions the situation creates. Polyvagal Theory assumes, of course, that there are both dangerous and safe situations, but that people will have emotional, physical, cognitive and relational hardship if their perception of those safe or dangerous situations is inaccurate.

The Perception of Safety and Danger

It is important that people approach relationships and daily tasks with an accurate assessment of both the safety and the danger involved in those settings. In some cases, people who have a history of abuse, neglect or trauma will misread situations and inaccurately see a situation either as more dangerous than it is or safer than it is. Exaggerating danger might be shown by being easily offended, having difficulty accepting criticism or having irrational fears like phobias, generalized anxiety or panic. Also, people might misread situations as being safer than what they are. This happens when people stay in abusive relationships, voluntarily frequent threatening environments or allow verbal, physical or emotional boundary violations.

The Polyvagal Exercise for Safety and Danger Recognition

The Recognition of Danger

The first step in this Polyvagal exercise is to recognize danger. To do this, imagine or recall an event in the past, present or future that causes some level of negative emotional reactivity such as anxiety, terror, anger, confusion or sadness. With this event or future picture, address the three topics below and list your responses by first evaluating the sense of danger or threat the memory or event causes. Use the stated questions as a guide.

Polyvagal Body Language – Polyvagal Theory highlights the importance of the evaluation of other peoples’ body language and what it says about their level of social connectedness to both you and others. First, see the picture or memory and begin to evaluate the people in the picture and ask these questions. Is the person(s) looking at you and visually engaged? Do they have an angry or warm look in their eyes and around their eyes and forehead? Do they seem to be working to listen to you including the subtle changes in your voice tone and volume? Does the direction of their body and head reflect an interest in you and a desire to be engaged? Does their body, head and eyes indicate an active yet subtle reciprocity to your level of engagement with them? Does the movement of their mouth or the tone of their voice indicate a predictable, safe and appropriate response to your behavior? List your answers.

Context – Second, again imagine or recall the picture and think about the context of the situation considering time, location, patterns and repeated behaviors. Reflect on these questions. Does this situation happen often or is it a rare or one-time occurrence? Does this situation fit a pattern of behavior by the individual(s) that makes you think they might repeat dangerous or threatening behavior to you? Look at the other people in the picture. Are they reacting with fear or with comfort? Are the other people in the picture supportive of you or are they supportive or aligned with the possibly dangerous person(s)? Does this individual remind you of someone in your past who was abusive, threatening or dangerous? List your answers.

Body Sensations – Third, while seeing the picture or memory and then evaluating all your answers, address these questions. What do I feel in my body? Where do I feel reactivity to this picture in my body? Evaluate its location and intensity then try to name what emotion is causing the body reaction. Then ask these questions. Is this a positive or negative emotion? Do I feel safe or in danger? List your answers.

The Recognition of Safety

The second part of this Polyvagal exercise is to recognize safety. Polyvagal Theory is the study of the physical experience of safety and danger. Included in this experience is the concept of Ventral Vagal State. Ventral Vagal State is a physical, emotional and cognitive experience facilitated by a set of nerves in the upper part of the body connecting the brain to the heart, neck, face, mouth, eyes and ears. The Ventral Vagal State is responsible for detecting, accepting, evaluating and reciprocating states of social safety. Also, it regulates the other defensive states known as fight, flight or freeze which are activated in situations that are dangerous or perceived to be dangerous. Being in a safe situation and then actively looking for and seeing safety will activate the Ventral Vagal State. The activation of the Ventral Vagal State will then facilitate self-regulation and eliminate unnecessary defensive thoughts, feelings and behaviors.

Return to the imagined picture or memory and reread all the questions in the topics of Polyvagal body language, context and body sensations. This time, instead of listing cues of danger, list cues of safety.

Polyvagal Problem Solving

Evaluating all the information you have listed about danger and safety recognition, ask yourself this question. Do I see this memory or event as being safer or more dangerous than it is? If you see it as more dangerous than it is, begin to evaluate and list what you can do to notice more safety and then decrease your perception of danger. Ask yourself the following questions. Can I connect with others in the picture who seem safe? Can I question the validity of seeing something as dangerous when it is safe? Can I test myself to not react to my perception of danger and observe how the event plays itself out? Also, actively think about and notice the cues of safety you listed and notice their validity. Use relaxation methods to calm your body reactions. Diminishing the perception of danger and nurturing the reality of safety will increase your Ventral Vagal State and facilitate the feelings of trust needed for connection. It also will diminish fight, flight or freeze behaviors that create conflict, confusion, self-questioning and disconnection.

If you see the situation as safer than it is and didn’t initially see the danger, it will be necessary to problem solve how to make the situation less dangerous. Use your list of noticed dangers as a starting point. Simply listing possible or existing dangers can assist in noticing the actual danger in the situation. Also, this list of danger might allow you to make sense of why your body was detecting danger while your thoughts were disconnected from the danger. Consider decreasing the danger by asking these questions and making changes. Do I need to leave the situation or set other physical, emotional or communicative boundaries to increase my personal safety? Can I effectively influence the threatening or dangerous individual to calm them enough, so I feel safe?

Make It Automatic

Polyvagal Problem Solving is a powerful method of self-regulation and relational management for those with Complex Posttraumatic Stress Disorder. Using this exercise frequently will assist you in fine tuning your recognition and reactions to the daily events around you and provide you with a method of physical, emotional and relational welling being and safety. The goal is to get to the point of being able to do the exercise automatically in real life settings.

Resources

The Pocket Guide to Polyvagal Theory: The Transformative Power of Feeling Safe by Stephen Porges (2017)

The Polyvagal Theory in Therapy by Deb Dana (2018)

The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment Communication and Self-Regulation by Stephen Porges PhD (2011)

Traumatic Stress: The Effects of Overwhelming Experience on The Mind, Body and Society by Bessel Vander Klok, Alexander Mc Farlane, and Lars Weisaeth (2007)

Integrated EMDR for Codependency

By Jeff Dwarshuis LMSW ACSW

Integrated EMDR

Eye Movement Desensitization and Reprocessing (EMDR) is a treatment method that dramatically reduces or eliminates the negative impacts of traumatic memory leading to Posttraumatic Stress Disorder (PTSD). Therapists have expanded the use of EMDR to include other presenting concerns besides PTSD such as depression, anxiety and relational hardship by addressing the underlying negative experiences leading to the problem. EMDR, when combined with other treatment suggestions such as cognitive therapy or psychoeducational work, is called Integrated EMDR since it is a combination of approaches to meet the needs of the client. (For a description on EMDR and Integrated EMDR see my articles “What is EMDR?” and “Integrated EMDR”)

Codependency Defined

Codependency is a psychological and relational problem that causes an individual to feel compelled to focus on the needs of others while ignoring or neglecting their own needs. Often times the person shows an overreliance on the approval of others to develop or hold a sense of identity.

Codependency can be described as a disease of the loss of self and codependent relationships consist of unhealthy communication, poor boundaries, reactivity and problems in intimacy. Relationships are often unbalanced with the codependent person attaching themselves to people who are in need due to the effects of substance abuse, poor health or dependency. These unbalanced relationships serve the need of the codependent person to continue their compulsion to over help. For this reason, codependents often times take the role of being a rescuer, confident and supporter in relationships. Codependent relationships happen mainly in families but they also exist in friendships, romantic relationships and the workplace.

Codependency is not a formal disorder listed in the Diagnostic and Statistical Manuel of Disorders but is a term that has been created through literature having to do with substance abuse and dysfunctional relationships. Because of this it does not have a formal and universally accepted definition or treatment approach. In general, however, people with codependency come to therapy most often with the primary concerns of depression, anxiety and relational hardship. Physical problems and psychosomatic problems are also very common. Often times clients in the midst of chaotic codependent patterns do not realize the existence of the disorder or know they have it. They generally see their emotional and relational patterns as normal.

Codependency and Causes

The development of codependency has a variety of possible causes. Each cause might exist in a single person. The most common understanding of the development of codependency is that it occurs as the result of emotional abuse. This may have happened in childhood, a close adult relationship or both. Because of abuse the individual‘s self esteem is challenged and the person develops patterns of pleasing others to increase their own sense of worth and esteem. Since the effort is based on external acceptance and not self acceptance the person continues to feel empty. The individual will easily solidify a pattern of this behavior since they receive reward for what they are doing. Helping behavior is generally self rewarding and feels good. Also, society highly rewards individuals who are helpful. This relational and social cycle combined with the person’s challenged esteem and identity perpetuates a negative cycle of need and overworking.

Codependency also can develop through longstanding family expectations that a child take on inappropriate family roles. Specifically a child might have the expectation that he or she take the role of the fixer, emotional support or pseudo parent. This family cycle occurs in homes where there is substance abuse with a parent. In this case, the child may have to pick up the pieces for the overwhelmed enabling parent and take on family tasks beyond his or her age. Also the child could develop emotionally reactive behavior to the substance abusing parent’s core defenses of denial and blame projection which often times causes the child to develop patterns of self blame, low self esteem, undue personal responsibility and personal denial of self needs. This codependent pattern can also occur in families that are overwhelmed with physical illness, financial hardship or parental limitations and incapacities. In these families the development of codependency is possible but not likely. In families with substance abuse however, the development of codependency is both predictable and expected.

Codependency is also developed by an addictive pattern that serves to help the person avoid their emotional pain, emptiness and hopelessness of their social life. Behaviorally the individual uses the excessive behavior of helping others as a method of distraction from their own problems. Due to this need to distract the codependent can grow irritated when others do not accept their offers of help and then maintains a controlling nature that can lead to perfectionism. Generally the person is completely unaware they are doing these things.

EMDR and Brain Functioning

Eye Movement Desensitization and Reprocessing (EMDR) is a treatment method used to quickly and effectively eliminate the negative impacts of traumatic memory. EMDR is a neurobiological intervention that makes use of eye movements to facilitate a physiological impact on brain functioning which creates permanent emotional and cognitive change in an individual when thinking about or visualizing traumatic memory.

It is recognized that this impasse between the hippocampus and the amygdala creates symptoms found in generalized anxiety, panic attacks and posttraumatic stress disorder. During EMDR, this impasse is corrected as eye movements will both enlarge and activate the hippocampus so it can receive the overwhelming amount of information coming from the amygdala and then sort it. The hippocampus then completes the proper brain processing by sending information to the anterior cingulate cortex which is involved in aspects such as attention, decision making, reward anticipation, ethics, morality, impulse control and emotion. The impact of opening this impasse and restoring proper brain functioning means that a negative memory, once too overwhelming to manage, is put into the proper context of time and space, has affective and cognitive aspects of the memory merged, is viewed with more rational thought, reason and control and exists in a clear distinction between the past and the present.

During the EMDR procedure, which is administered by a psychotherapist, a client experiences two primary reactions to the traumatic memory. First there is a distancing from the memory that includes an elimination of the negative emotional reactions related to the trauma. Second, the client experiences an increased level of rational perception related to the memory. This increased rational thinking is called Adaptive Information Processing (AIP). AIP is the result of successful EMDR reprocessing and allows the client to hold a more rational view of personal safety, personal responsibility and personal choice while visualizing or discussing a trauma memory. AIP also allows the client to hold an accurate positive self perception or cognition while visualizing the trauma. This allows the client to problem solve how he or she would react or prefer to react differently in a similar situation.

EMDR for Codependent Behavior

The EMDR Protocol for the treatment of codependency targets memories of abuse, patterns of addictive behavior and negative cognitions leading to low self esteem. Typically the memories of abuse involve emotional or verbal abuse such as negative talk from an addicted parent or spouse, feelings of loss due to excessive demands for caring for the family or longstanding patterns of self blame in the face of hopelessness to change a bad situation. In some cases codependent behavior is linked to all forms of child abuse including verbal, sexual, physical abuse and neglect and the person additionally has symptoms of posttraumatic stress disorder.

To create a list of traumatic memories in preparation for EMDR it may be important for the therapist to discuss specific aspects of the client’s childhood as well as discuss clear definitions of what qualifies as abuse. It is not uncommon for people with codependency to have been abused in many ways yet have no understanding or consideration that what they endured was abusive in any way. Clients may also have a history of abuse from adult relationships. These memories also must be listed as topics of EMDR reprocessing.

A cognitive ranking can be helpful for targeting EMDR memories. Due to patterns of emotional avoidance, clients with codependency have difficulty creating associations between life events and the development of low self esteem. Evaluating cognitive thought patterns can assist. The therapist verbally states a list of negative cognitions and the client responds by indicating how much they believe the negative cognition by applying a number ranking. Referring to the most challenged cognitions reviewed the therapist then asks when the person started believing the negative cognition and how they learned it. This process then begins to illustrate to the client and therapist which life events have impacted self esteem. The event then is a target for EMDR processing.

Once the memories are listed the client follows the EMDR Protocol. As stated previously, successful EMDR will create a distance from the memory as well as create a more rational perspective of self and others. The distance from the memory allows the individual with codependency to be less emotionally reactive to recalls of the memory as well as to situations that are like the memory such as repeated relational patterns. Also, a decrease in emotional reactivity allows the person to remain more thoughtfully present when using learned skills of management.

The increase in rational perception resulting from successful EMDR creates a more realistic perspective of one’s self and abilities. In general this creates an increase in self esteem. As self esteem increases the need to please others to aid one’s self esteem decreases. Additionally the client is more able to rationally distance themselves from unfair self blame and begin to create a broader narrative applied to personal choice and management of personal safety. The distance from emotional reactivity combined with increased rational thinking will cause the client’s symptoms of anxiety and depression and posttraumatic stress to decease or end.

As stated, people will use codependent behavior as a method to avoid what they are feeling. As this cycle of need and partial reward intensify the behavior becomes additive. The EMDR protocol can be used to break this cycle. For more information on this see my article “EMDR for Addictions” to see how it can be used for codependency.

As the client continues to experience success with these topics there are typical times of crisis when an old pattern might occur. These instances are treated as a trauma memory and reprocessed with EMDR.

Integrated EMDR and Codependency

Typically clients with codependency will need additional objectives to the EMDR for proper treatment since many skills commonly developed in childhood have not been provided. For example, clients generally need communication exercises to formulate and manage their increasing assertion. Parenting material is also commonly needed as well as tools for relational management. Following EMDR processing treatment should consist of problem solving therapy as the client will be faced with the many challenges of restructuring their family and social life to parallel their increased need of self care and deceased focus on others. Eventually the client ends codependent behavior, the anxiety and depression disappear and the times of relational stress grow both less frequent and less intense. The client then is able to manage.

Integrated EMDR for Relationships

By Jeff Dwarshuis LMSW ACSW

Imago Therapy

Imago Therapy was developed by Harville Hendrix as a type of Marital Therapy. It is recognized as a highly effective relational intervention because of its unique approach to understanding the nature of human attraction as well as its practical methods of relational change. Imago Therapy maintains that people are attracted to individuals who have both the negative and positive qualities of their own parents, that people try to get in their relationships the things they didn’t receive as children and that people attempt to repeat the joys of youth by reliving the same events that brought pleasing emotions as children.

Childhood Disappointments and Behavioral Reactions

Imago Therapy also asserts that people negatively impact their relationships by repeating the same reactive behaviors they did as children in response to parental disappointment. For example, if a child’s parents were not available to them and they reacted with aggression to this disappointment they will most likely repeat the behavior of aggression in their marriage during times of conflict. Another example is if a child is abused physically and as a child they responded to this aggression with avoidance and self blame they then will continue this reaction in their marriage in a more adult form such as using substances and self denigrating language.

The Imago Setup

In Imago Therapy the word Imago means “Image” and represents the type of person to whom we are attracted. An individual can find their “Imago” by completing an Imago worksheet that elicits information about one’s childhood family. This worksheet is shown below. Completing sections A- E provides information that can be applied to the frame sentence found at the end of the setup and this gives a description of unconscious attraction. The form is as follows –

List the bad qualities of your mother and father.
List the good qualities of your mother and father
Complete the sentence – “What I wanted and needed most as a child was…”
List good memories of your childhood and how you responded emotionally.
List the disappointments of your childhood and how you responded behaviorally.

After sections A- E are completed the client uses the corresponding answers from the statements above to fill in the blanks below get a complete description of their relational tendencies.

I am trying to find a person who is (A) to always be (B) so I can get (C) and feel (D). I stop myself from getting this sometimes by (E).

Completing this worksheet allows one to understand the type of person to whom they are attracted as well as the things they are hoping to resolve, repeat and enjoy in their adult relationship(s). For the purpose of Integrated EMDR, the primary interest is the last section (Section E) which states the person’s behavioral responses in reaction to disappointments. These behavioral responses are a description of the counterproductive and reactive behaviors which continue into adult relationships.

Integrated EMDR

Eye Movement Desensitization and Reprocessing (EMDR) is a treatment method that dramatically reduces or eliminates the negative impacts of traumatic memory leading to Posttraumatic Stress Disorder (PTSD). Therapists have expanded the use of EMDR to include other presenting concerns besides PTSD such as depression, anxiety and relational hardship by addressing the underlying negative experience leading to the problem. EMDR, when combined with Imago Therapy, is a type of Integrated EMDR since it is a combination of approaches to meet the needs of the client.

EMDR for Reactive Reduction

As stated in prior articles, EMDR eliminates the negative impacts of traumatic or negative memories that lead to negative emotions, self concept, body reactions and related behaviors. (See “What Is EMDR’ and “What Is Integrated EMDR?”) The client seeking help with their relationship can refer to the Imago worksheet section E on childhood disappointments and create a list of specific memories of disappointment leading to reactive behavior. These memories can be used as EMDR targets and reprocessed using EMDR. The reprocessing of these memories takes away any negative emotions, self concept or behavior reaction in response to repeated themes of childhood disappointment happening in their adult relationship. This allows the client to remain objective rather than reactive during times of emotional conflict. A client can then respond in their relationship with problem solving or listening or being in a better position to use treatment objectives such as communication skills.

Organizational Strategic Problem Solving

By Jeff Dwarshuis LMSW ACSW

Anxiety in Organizations

I. Introduction

A. Systems Thinking – Systems thinking is a way of looking at individual behavior by evaluating how someone interacts within a group and how that person impacts the group. Some of the major topics of Systems Thinking consist of – Anxiety Types, Conflict Types, Anxiety Effects and Triangulation. Understanding these ideas will allow someone to be able to see their workplace as a large number of interacting parts that is in constant movement responding to internal and external stress.

B. Problem Solving – Problem Solving is a technique for changing dysfunctional organizational patterns. Problem solving uses Systems Thinking to recognize how anxiety impacts employees and then uses a specific protocol to address and change the negative pattern. The focus of problem solving is behavioral as opposed to emotional or insight oriented. There is an emphasis on creating solutions that are doable and measurable. Using Problem Solving in an organization or workplace allows for optimal performance.

II. Anxiety Types

A. Acute Anxiety –Acute Anxiety comes from usual day to day stressors. Acute Anxiety is easily recognized and generally it is easy to understand its impacts on a group of people. Examples of Acute Anxiety are – workplace accidents, broken equipment, being understaffed or getting to work late.

B. Chronic Anxiety – Chronic Anxiety is a long term anxiety that is caused by past organizational events and employee reactions. It is usually hidden, very difficult to detect and contagious. Chronic Anxiety has many forms. For example, it may be initiated by a traumatic event in an organization and unknowingly spread through people and across time. Examples might be an employee death, chronic illness, the loss of a CEO, and mergers. Due to anniversaries, constant reminders, communication, perceived threats and unspoken reactions, Chronic Anxiety will spread from one generation to the next. A new employee may feel anxiety on their first day of work due to an event that occurred a decade before. Chronic Anxiety may be experienced to a higher degree if the employee’s past consists of several common themes or conflicts to the traumatic past event of the organization.

III. Anxiety and the Workplace

A. Anxiety in the workplace is variable over time – Both Acute and Chronic Anxiety are common in the workplace and are always changing due primarily to outside forces such as the economy, the availability of resources, and personnel changes.

B. Increased anxiety causes physical, social and psychological consequences for employees.

1. Physical Consequences – Headaches, tightness in the chest, heart palpitations, muscle tension, sleeplessness, stomach problems, dry mouth and psychosomatic reactions.

2. Social Consequences – Drug use, gambling, overeating, verbal outbursts, impatience, conflicts and tardiness.

3. Psychological Consequences – poor concentration, worry, low mood, confusion and forgetfulness.

C. Anxiety in the workplace is contagious and spreads across people and time – Anxiety will spread through a workplace as people react to the initial cause of anxiety. Employees are susceptible to anxiety as they are exposed to constant reminders spoken and unspoken.

IV. Anxiety and Employee Reactions.

A. Closeness – As an employee grows anxious he may respond with getting too close to fellow employees, managers or customers. This may be shown by private complaining, secrecy, hidden agendas and inappropriate decision making.

B. Distance – Anxiety may cause an employee to become distant from everyone else. This may be shown by a decrease in communication with colleagues, hiding behind closed doors, leaving work early and a non-participatory attitude. The extreme form of distance is a complete cutoff.

C. Over and Under Functioning – As an employee feels stressed he may bond unconsciously with another worker in a pattern of over/under functioning. This is shown by an uneven sharing of a workload. One becomes lazy while the other picks up the pieces.

D. Projection – As an employee becomes stressed he may revert to a personal defense of projection. Projection is shown by an irrational behavior shown to one person when it is actually meant for another person. It has the quality of being unfair and unreasonable.

The Movement of Anxiety through Organizations

I.Triangulation

A. Triangles and People – Triangles are a symbolic representation of a group of three people. In the area of Social Science, Family Therapy and Systems Theory the three person unit is seen as the basis for understanding group behavior, social change, anxiety management and dysfunction. The reality and impacts of triangulation are universal and inescapable for all people. How people manage the pressures of triangulation is an indication of their ability to maintain health and optimal social behavior. Triangles are in constant motion in all human organizations and institutions.

B. Triangles are the cell of all human social interchanges – It is nearly impossible for two people to exist without involving a third person either through personal contact or discussion. This is especially true as anxiety increases during the interaction of the two people. As the third person is introduced through discussion or contact this is considered the creation of a triangle. Additionally, it is nearly impossible for three people to remain in equal relational balance without creating exclusiveness between two of them and then ostracizing the third. This relational balance of the triangle is constantly changing. Generally this shift is seen as normal, expected behavior but when members of the triangle become stressed two of people take on the negative anxiety reactions listed above – closeness, distance, over/under functioning and projecting.

C. Triangles and Social Hierarchy – All of society has the understanding that hierarchy is necessary to avoid chaos and maintain order. In other words, we need leaders. This structure of hierarchy is held together by rules. Hierarchy is first presented to people through the order of the family and recognized as the order of society through all organizations including the workplace. Stress in a workplace combined with the reality of triangulation threatens the order of hierarchy as there is a triangulation shift that involves employee and leader. A group of three under stress may create exclusiveness between an employee and a leader and will then ostracize the once connected leader. The interaction of triangles and social hierarchy has the potential to create dysfunction as employees are put into inappropriate roles and important decisions are made under this poorly functioning order. On the other hand, a healthy triangle is when leaders are aliened and exclusive with subordinates being the more distant third of the triangle. If this healthy pattern is challenged by workplace anxiety, the hierarchy is disturbed and organizational performance decreases.

D. Triangles, anxiety and change – Social Science, Psychotherapy and Family Therapy have a long term understanding that most all problems related to behavior, mental health and emotional development are caused by some form of inappropriate triangulation leading to a challenge of hierarchy and authority and the improper placement of responsibility onto those unable to manage it. This is particularly well understood in families and there is a growing understanding of its role in organizations. Change and optimal organizational performance comes when these unhealthy triangles are recognized and then changed to the more proper, expected pattern.

II. Triangulation applied to Conflict Types (Some Examples)

A. Closeness leading to Triangulation – There are two sales managers that had a good working relationship. However, during a time of losing a key employee, the entire department became stressed and one of the managers found comfort from stress through his relationship with one of the staff. As time went on, the relationship became more exclusive with the sharing of managerial concerns and agendas. The other sales manager had less and less contact with his partner. Communication decreased, decisions were poorly made and the company lost a big customer.

B. Distance leading to Triangulation – Two architectural partners were professional and very good at their jobs. However, they did not like each other personally. For the most part they could get along well enough to run a business but when one of them went through some family stress he had no interest in communicating his high stress and reasons for poor performance to his partner. Instead, he turned to the draftsman for some key business decisions and his relationship with his partner grew more distant. The other partner felt excluded and was unaware of all of the transactions with customers. Angry, he threatened to leave the firm.

C. Over/Under Functioning leading to Triangulation – Two VP’s maintained a good working relationship but when the company grew overwhelmed with more business and not enough help, one of the managers began to take on extra work. One of the VP’s allowed this to happen and even encouraged it. As this pattern continued, the manager began to take on some of the VP’s responsibilities. The VP, relieved of his overwhelm, did not step in to address it. As the pattern continued, the manager played an inappropriately powerful role as he began to assist in decision making with the other VP. A number of problems occurred as the CEO recognized the decline in the VP’s work performance as well as recognizing that key decisions were changing the course of the organization.

D. Projection leading to Triangulation – An employee performed well in a successful food distribution company. He was successful and got along well with his bosses. Unfortunately, his direct manager reminded him of his father and his childhood relationship with his father consisted of a great deal of conflict. For the most part, this was not a problem except for times of increased stress around the time of the anniversary of his father’s death. Unable to deal with his direct manager, the employee avoided him and got directives from the shift supervisor. The employee’s performance decreased as the shift supervisor openly expressed his irritation with the employee demands and questioned the manager’s ability to take charge. (Note the generational triangle)

Problem Solving, Triangle Types and Results

I. The Five Stages of Problem Solving

A. The Initial Stage

1. After a leader recognizes a triangle or a series of triangles he should arrange a meeting to problem solve for change. The leader may be involved in one of the triangles or recognize it from the outside. Leaders should order the solving of triangles by first addressing triangles that involve the most senior members.

2. The leader should decide if he wants a facilitator. The facilitator is generally the outside trainer or consultant. Also, facilitators can be trained inside of the company to do this specific organizational task. In general, the company should make it a goal that all leaders problem solve independently.

3. The leader should plan the meeting time in a quiet place such as an office or conference room. The length of the meeting should parallel the seriousness of the problem.

4. The leaders may discuss the issue prior to the meeting time but should be careful to not ostracize the employee. Leaders should sit near each other to symbolize the intended shift in triangulation.

B. The Problem Stage

1. During the problem stage, each person states what they see as being the problem. The leader may have to begin as the purpose of the meeting may have to be explained to the other members.

2. The leaders should hear each problem statement while challenging themselves to see it as a systemic problem caused by the group and not one individual.

3. The leaders should maintain an attitude that is helpful. Leaders and facilitators should keep from giving advice, interpreting behavior or asking how one feels about the problem.

C. The Interaction Stage

1. At this stage the members begin to discuss the problem with each other. If a facilitator is involved they should take a less active role.

2. All members should bring the action into the meeting. In other words, if there was a loss in sales, evidence of this should be brought in and explained. If leaders recognize that their relationship has been changed or challenged, they should openly discuss this in the company of the employee.

D. The Change Stage

1. Each member says what change they would like to see related to the stated problem. The changes should be stated in terms that are measurable, solvable and realistic. If they are stated in this way it can be recognized in the future as solved or unchanged.

2. The leaders make the final decision regarding the expected changes. The leaders must come to a stated agreement that is heard by the employee. As the leaders do this, they are shifting the power of the triangle to its original healthy position. As all members participate in the suggested change, they are agreeing with and encouraging this healthy change.

3. The leaders may not completely agree on how to solve the problem but it is more important that they come to as close an agreement as possible and implement the change suggestion.

E. The Completion of the meeting

1. The leaders should make sure everyone understands the expected change in behavior and can provide a picture of how that will appear. The leaders should decide if there is a need to set a follow up meeting to evaluate change and facilitate accountability.

II. The Four Types of Triangulation

A. Hierarchy – This is the most basic and common form of Triangulation. It occurs when two leaders are disengaged through conflict or distance and a subordinate person takes the leader’s place. One of the leaders is left outside of the authority pair and usually is ostracized and responds with negative reactions.

B. Two Generation Triangles – This occurs when one leader becomes exclusive with one of two subordinates. This might occur when a manager relies on one employee more than another and then allows him to begin making decisions that are inappropriate for his title.

C. Three Generational Triangles – This again is a very common form of organizational dysfunction. This occurs when a subordinate bypasses his immediate boss and turns to a boss in a higher position for problem resolution. The problem occurs when the higher leader allows it. This also can go in reverse with the higher boss bypassing the middle boss and giving direction to the employee. This triangulation can easily be started by a complaining customer.

D. Organizational Sequences – Organizational sequences occur when one triangle creates another. The sequence can be seen if leaders group together and assess the map of their organizational structure. Leaders should begin marking the map from top to bottom and bottom to top (including customers) and visually illustrate interconnecting triangles.

III. The Results of Change

A. Relief – When a group of people solve a problem and solidify hierarchy the group feels a sense of relief. The old anxiety that was at the beginning of the conflict is resolved and controlled.

B. Insight – Although insight is not necessary for change, employees will begin to understand the reasons behind the behaviors of themselves and others. It may relate to an understanding about the company such as a generational conflict or a personal understanding like one’s own relational shortcomings or family influence.

C. Productivity – Proper management of roles creates an appropriate boundary for relationships and tasks. When people operate in a system that is proper for them, this facilitates optimal professional growth.

D. Resistance – If someone has been given inappropriate power through triangulation, the problem solving process creates a loss for them. Although this is no reason to keep from resolution, it is important that leaders understand this possibility.

E. Needs –Often times needs will be apparent as one shifts to a position of responsibility. This is often the case if a leader is under functioning within a stressed triangle. After problem solving he will be confronted with higher expectations which may require training or counsel

F. More change – As a company problem solves, the people in contact with them will recognize change and will be influenced by this. This is especially true with three generation triangles as the reorganization of power and communication impacts several different areas. Also, change occurs as one ends projecting behavior that tends to have a far reaching level of negative reaction and impact.

Jeff Dwarshuis LMSW, ACSW is a psychotherapist in private practice in Grand Rapids Mi. He specializes in the use of EMDR for traumatic memories, anxiety, depression and performance. Contact Dwarshuis by calling (616) 443-1425 or sending an email to jeffsemdr@tds.net

What Is Integrated EMDR?

By Jeff Dwarshuis LMSW ACSW

When Eye Movement Desensitization and Reprocessing (EMDR) was developed by Francine Shapiro in 1989 it was used as a method of treatment for Posttraumatic Stress Disorder (PTSD). EMDR dramatically reduced or eliminated the negative impacts of traumatic memory leading to PTDS. Today it is recognized as the treatment of choice for PTSD and thousands of people have benefited from its use. (See blog article “What is EMDR?”)

Since that time, researchers and therapists have expanded the use of EMDR to include a number of other mental health diagnoses besides PTSD. It was discovered that not only did EMDR eliminate the impacts of acute memories leading to PTDS but it also eliminated the negative impacts and irrational self perceptions caused by bad memories and bad experiences in general. With this discovery, EMDR treatment could be applied to depression, anxiety, relational problems, performance problems or any problem or mental health diagnosis that was caused by negative life experiences. Due to the complexities of many of these problems, treatment needed to include other suggestions besides EMDR Therapy such as cognitive therapy, psychoeducational reading or communication exercises. This multifaceted approach to treatment is called “Integrated EMDR”.

The Two Primary Responses

When using Integrated EMDR it is important that the therapist be able to predict how EMDR will impact a particular client. Having this understanding, the therapist can determine if other treatment suggestions are necessary.

With each EMDR session there are two primary responses by the client. First, the client experiences a distancing from the negative memory and a decrease in related negative emotions, body reactions and negative cognitions that accompany the memory. These changes are permanent and the therapist can expect the client be able to discuss, investigate, and revisit any part of the negative experience with an objective view. Also, the decrease in negative reaction quickly eliminates PTSD symptoms as well as related symptoms of depression and anxiety.

The second distinct response to EMDR is Accelerated Information Processing (AIP). AIP is best described as a fast cognitive restructuring of the irrational thoughts that occur with the recall of negative memory. During EMDR the client has an acceleration of reasonable thoughts, perceptions and considerations related to the event and sees the memory (and sometimes related memories) in a reasonable, rational manner.

AIP is what allows the traumatized war veteran, who once felt helpless during memory recall, to say “I did the best I could and I am a good soldier” and the sexual assault victim who experiences intrusive flashbacks to say “It is over and I am OK”.

AIP is found to work also on future pictures that cause negative reactions such as performance topics, workplace assignments, athletic competitions or personal assertions. AIP, in these cases, allows the client to look ahead to the future performance picture with a rational and reasonable perspective on their ability to successfully complete the task.

The distancing from traumatic memory and AIP are both an expected result of each successful EMDR session. Knowing that these responses occur allows the therapist to predict how a client will think, feel and act after EMDR is completed and this can aid the therapist in considering other client needs.

The Best Expected Level

In addition to knowing the responses to EMDR, it is also helpful to know that EMDR will bring a client to what is known as their “best expected level”. For example, a client who was abused at a young age may have carried negative memories and related complications for a lifetime. EMDR will bring this person to their “best expected level” which means all symptoms and negative physical, emotional and cognitive reactions should be reduced or eliminated. The client is likely to feel better than they ever have felt before. However, if that person was raised in an environment of conflict, they may not have the skills to communicate their needs or their progress. For this client the treatment plan would require added suggestions for communication skills. A similar client may experience all of the benefits listed above. However, if that client has a history of neglect, the client may not be able to explain their internal changes. This client would benefit from cognitive therapy exercises designed to help one pay attention to specific changes in thoughts and feelings. In general, EMDR will bring someone to their “best expected level” but will not teach things that have not been learned. Recognizing this specific quality of EMDR, the therapist and client can address additional needs and the treatment objectives can be suggested as necessary.

Therapeutic Considerations

Integrated EMDR is a highly effective method of treatment for most all mental health diagnoses and can be used often. Clients who use Integrated EMDR complete treatment more quickly than traditional therapy (3-4 times more quickly) and are in a better position to not have to return to therapy.

Many therapists will find that Integrated EMDR is different from traditional therapy. With EMDR, the therapist acts as a “technical manager” over a treatment process and offers little feedback or interpretation. In this way, the therapist’s role is diminished and there is more reliance on a treatment method and client participation. Also, therapists traditionally make suggestions and interpretations to clients. However, with EMDR and the impact of AIP, the best interpretations are done by the client. Therapeutic interpretations are best done during times of review.

Also, the process of evaluation for positive change in Integrated EMDR can be difficult. Often times the client experiences a dramatic shift in their life. However, since EMDR will bring someone to their “best expected level” the client experiences life as they should and at times will not recognize the differences. Successful EMDR is a comparable to the person who has felt the pain of a sore foot for weeks and wakes one morning with no pain and not recognizing that anything is different. EMDR is the same. Often times the client is unaware of changes until the therapist reviews symptoms and cognitive self beliefs.

Jeff Dwarshuis LMSW, ACSW is a licensed psychotherapist in private practice specializing in EMDR therapy. For contact call (616) 443-1425 or send an email to jeffsemdr@gmail.com.

Also see Dwarshuis’ webpage at http://www.jeffdwarshuis.com/ for free clinical information and blog entries on EMDR, performance strategies, upcoming presentations and family health.

EMDR For Performance Enhancement

By Jeff Dwarshuis LMSW, ACSW

All people have difficult times and employees at all levels of leadership will carry stress to the workplace. The result can be a less than optimal performance. Employees can be stressed by financial hardship, marital discord, parenting or past issues of divorce, family loss, bereavement or child abuse. All can dramatically impact an employee’s work performance.

Eye Movement Desensitization and Reprocessing (EMDR) is a treatment that can quickly and effectively assist with workplace stress. EMDR has its beginnings as a treatment for Posttraumatic Stress Disorder and has been very effective with performance, depression and anxiety as well. Created by psychologist Francine Shapiro PhD, EMDR uses a blend of cognitive, emotive and client centered therapies in combination with neurobiological interventions. Since its beginning in 1995, EMDR has dramatically changed the lives of thousands of people.

EMDR, REM and Memory Reprocessing

To understand EMDR it is helpful to first know about the impact of Rapid Eye Movement (REM). After 30-60 minutes of sleep an individual begins REM sleep. During REM, one involuntarily moves their eyes back and forth. The eye movements cause a neurobiological reaction which stimulates a reprocessing of the day’s memories and makes recent memories into old memories. If someone has a negative memory in their day, the REM process facilities making this recent bad memory no longer bothersome.

REM and Posttraumatic Stress Disorder

Traumatic memories occur when one is overwhelmed by either witnessing or enduring something that is horrific beyond the typical human experience. This might include combat, child abuse, domestic violence, personal assault, traffic accidents or traumatic medical procedures. Because of the severity of these memories, the REM mechanism described does not work. In these cases, the individual remains aware of the memory and continues to experience its negative impacts. The memory is not reprocessed and the individual could go on for decades terrorized by their own memory. This is called Posttraumatic Stress Disorder.

Negative Memories and the “Three Point Power Supply”

All negative memories create three things which exist interdependently and make a memory seem unpleasant. These three things are a negative emotion, an unpleasant body sensation and a negative self belief. Say for example someone went to a social gathering and said something foolish in front of a group of people. When thinking about this memory, the person would experience embarrassment, flushing and a self belief of “I am so stupid!” During REM, eye movements create an even stimulation of the right and left hemispheres of the brain and cause a tremendous and fixated calm in the body. Since the body is so relaxed, it does not react during the subconscious reprocessing of daily negative memories. The body reaction is separated from the two other interdependent “power supplies’ and the negative impacts of the memory fade. The individual can recall the event but no longer experiences embarrassment, flushing or a negative self belief.

EMDR Procedure as REM Simulation

EMDR is a simulation of REM used in a therapeutic setting and applied to a traumatic memory. During an EMDR session, a client visualizes a trauma while recognizing the negative emotion, body sensation and self belief. The therapist measures the negative response levels and leads the client through sets of eye movements by use of a light bar or “eye scan”. After 45-60 minutes, the negative impacts of the trauma are gone…permanently.

EMDR, Performance Enhancement and the Workplace

All individuals are functioning below their potential because of a history of mistakes, criticisms, self questioning or relational abuse. A therapist can uncover these performance interferences by asking someone a detailed list of questions to help the person visualize an ideal state. The ideal state may have to do with performance in school, the performing arts, sports, relationships or in the workplace. The therapist asks what memories or experiences get in the way of the individual being able to live up to their ideal. Those memories are then treated as EMDR memory targets, the EMDR procedure is done in the office and the client is free to return to their goals without the interference of negative memories.

For example, imagine an employee who is highly skilled and committed and his boss wants to promote him to a manager position. The employee, however, has a number of problems relating to employees including having a temper and not listening. The CEO very much wants to promote him but without the necessary relational skills, the CEO would have to hire from outside the company.

Using the EMDR performance protocol, that potential manager would be asked a series of questions to assist him in seeing his ideal work state. For example…”In the ideal state what are you doing that you are not doing now?” “What personal characteristics or qualities are improved?” “What are you feeling in the ideal picture?” “What do you believe about yourself?” After the potential manager sees this ideal picture of himself interacting with his employees he then is asked to identify a memory that interferes with his being able to live the ideal picture. Most of the time the employee will describe negative memories related to their relationship with their parents. This may be in the form of criticism, neglect or abuse. Most all stated and volunteered answers regarding interfering memories are from childhood. Then the employee would be asked to visualize the bothersome memory and do the set up for the EMDR procedure. The person follows the EMDR procedure described above, eliminates the negativity of the old memory and visualizes himself in the ideal state. Simply doing this one procedure, the employee returns to work that day and begins to improve and act differently.

The employee may have a series of memories that interfere with the ideal performance picture and each memory is reprocessed using the EMDR procedure. Each one hour session will cover 1-2 memories. The treatment processes is brief and intense lasting 8-12 sessions. Unlike traditional therapy that requires time between sessions, EMDR can be completed as quickly as one would like.

What are some typical work performance problems addressed by EMDR?

1. Public speaking

2. Managing difficult people

3. Increased effectiveness in sales

4. Increased believably in short and long-term success goals

5. Increased ability to communicate with potential business partners

6. Increased success in working on a team

7. Increased ability to manage time

8. Increased ability to manage workplace crisis

9. Increased ability to manage job stress

10. Increased physical health due to fewer symptoms of stress

The EMDR performance enhancement procedure has allowed employees to get past personal issues, better use their skills and knowledge and be promoted. Also, employers have been able to retain valued employees who otherwise would have been terminated because of ongoing behavioral and emotional problems carried to the workplace.

Jeff Dwarshuis LMSW, ACSW is a licensed psychotherapist in private practice specializing in EMDR therapy. For contact call (616) 443-1425 or send an email to jeffsemdr@tds.net.

Also see Dwarshuis’ webpage at http://www.jeffdwarshuis.com/ for free clinical information and blog entries on EMDR, performance strategies, upcoming presentations and family health.