Complex Posttraumatic Stress Disorder – Page 2

EMDR for Complex Posttraumatic Stress Disorder and Addictions

By Jeff Dwarshuis LMSW ACSW

EMDR and Brain Functioning

Eye Movement Desensitization and Reprocessing (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.

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 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.

EMDR and Two Primary Reactions

During the EMDR procedure, 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

Addictive Behavior and Irrational Thinking

All addictive behavior leads to hardship, loss and misery. While experiencing these negative things the addicted individual continues the behavior and maintains the irrational view that the addictive behavior, within the context of the person’s life, is a pleasurable thing. The individual is caught up in a physical, emotional and thought cycle which continues to perpetuate the idea that the behavior is okay. However, this perception is irrational, incomplete and cut off from the person’s actual capacities to both do and see things differently. This is also true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Disorder. However, in these cases there can be additional patterns of using the addiction as a means of avoidance which will diminish through this protocol.

Using EMDR for addictions targets memories of addictive behavior to create more distance from the memory and to see it more rationally. Using EMDR for addictions assumes that EMDR will work not only with traumatic memories but also with memories that are pleasurable but, are both irrational and destructive. To do this procedure the therapist and client list what is known as The Feeling-State (FS) or that exact time the individual feels the greatest emotional, physical, and cognitive pleasure from the addictive behavior. Then the positive emotional, physical and thinking reactions generated by visualizing the FS are recorded and measured by the therapist. The client uses the EMDR protocol applied to this FS and does eye movements while noticing all levels of pleasure from the imagery. As the client progresses through the EMDR procedure he will begin to respond with the two primary reactions described above. First, there will be more distance from the pleasure. Second, the EMDR protocol activates the AIP and the client more rationally recognizes the negative impacts of the addictive behavior such as cost, impacts on relationships, health and career. As the recognition of the reality of the hardship of the additive behavior increases, the physical, emotional and cognitive pleasure response decreases.

The Cognitive Replay and Preparing for the Future

During the listing, recording and measurement of the FS, the therapist also records the client’s negative cognitions, or self beliefs, that lead to or cause the addictive behavior leading to the FS. Also, the therapist records the negative cognitions that result from participating in the addictive behavior. For example, a person might have a bad day at work and falsely believe “I am a failure”. The emotional discomfort from this negative self talk might cause the person to want to drink to decrease the pain.

After drinking the client might then falsely believe “I am a bad person” since he drank.

Following the collection of the two negative cognitions, the therapist then asks what positive cognitions the client would rather believe than the two negative ones. After the client’s FS level decreases as illustrated above, the therapist instructs the client to imagine himself fully believing the first positive cognition and then visually reenact the beginning of the addictive behavior using the positive cognition. The client then imagines how he might respond differently to the temptation of the addiction. The client does eye movements both during the positive self talk as well as during the visualization of change. The therapist then instructs the client to repeat the same process but this time using the second positive cognition to see how he might handle the results of his addictive behavior differently. Again, eye movements are done at the therapist’s instruction. The use of reimagining the before and after behaviors using positive cognitions provides insights to the client that he has never considered within this context since his previous thinking, feeling and physical reactions were dominated by the cycle of the FS and seeing himself as unable to manage his temptation or negative results of his behavior.

A Different Kind of Therapy

EMDR is a neurobiological method of treatment that allows intense, effective and permanent change to occur. These changes are emotional, physical, and cognitive. Applied to addictions, EMDR will assist one to be more emotionally distant from a memory, see the realistic level of destruction of their own behavior and create an increased recognition of one’s abilities to act differently. All known addictions can be treated with this protocol including substance abuse, sexual addiction, gambling, alcoholism and compulsive eating. Additionally, this protocol can be used in combination with other treatment objectives and EMDR protocols to treat codependency, self-harm and Complex Posttraumatic Stress Disorder.

For more information on EMDR for addictions see Robert Miller’s “Treatment of Behavioral Addictions Utilizing the Feeling State Protocol: A Multiple Baseline Study”. This study, as well as the concepts of Adaptive Information Processing of Francine Shapiro PhD and Resource Installation by Andrew Leeds PhD influenced and directed many of the concepts in this article.

Resources

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

Cognitive Therapy for Challenging Problems by Judith Beck (2005)

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)

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.

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

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

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.

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

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)