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|"Post traumatic stress disorder: cognitive therapy with children and young people, Patrick Smith, Sean Perrin, William Yule and David M Clark, Routledge 2009, £19.99, ISBN 978-0415391641" |
|"Eye movement desensitisation and reprocessing (EMDR) is now well established as an effective way to treat post-traumatic stress disorder (PTSD). Robin Logie reviews the evidence for this approach, and explains how bilateral stimulation of the right and left sides of the brain enables traumatic experiences to be ‘metabolised’, learned from and stored safely away for reference. However, increasingly, practitioners are successfully using these same techniques with a range of other mental health conditions that are trauma-related, from depression to obsessive compulsive disorder, and in pain management"|
It may come as a surprise to discover that Europe is leading the way in the development of Eye Movement Desensitisation and Reprocessing (EMDR) psychotherapy for children and adolescents, and in teaching therapists how to adapt the adult protocol1 for the developmental needs of childhood. How has this been achieved?
EMDR and children: Europe leads the way
A landmark conference held in London in 2000 by the Association for Child Psychology and Psychiatry2 provided the initial forum for child and adolescent clinicians from Europe to share their EMDR work with others, and brought them together with two American pioneers in this field, Robert Tinker3 and Ricky Greenwald4. Other American pioneers who had helped to shape the early thinking of the Europeans in this field included Joan Lovett5 and Carol York.
However, a year after this conference, the European group itself commissioned Robert and Sandra Tinker- Wilson to run their first residential five-day training for child and adolescent trainers, and since then a further two child trainers’ trainings have been held – with the next planned for 2008. Similar trainings have yet to be developed elsewhere in the world. The goal is to develop trainers for each European country, able to train in their own language using videos of their own children and thus developing Europe-wide gold standards for good practice in EMDR therapy, and then for research to blossom. A waterfall model has been adopted for training, as Bob Tinker has reflected: ‘If you teach 10 and those 10 then teach 10… how many can we reach?’
In 2003 the European Child and Adolescent EMDR Committee gained accreditation from the EMDR Europe Association for its trainers, its standardised manual and its course standards. After this successful effort to get the child’s voice heard in an essentially adult EMDR world, our positive cognition is now ‘We are wonderful’! (The EMDR process elicits positive cognitions.) To date, there are 13 EMDR Europe accredited child and adolescent trainers from Denmark, Germany, Israel, The Netherlands, Sweden and the UK, and more in training. Over 3,000 clinicians across Europe have been trained on the Child Level I training and over 100 trainings have taken place. Child Level II training is now being piloted in Europe and is likely to be running in the UK in 2007. So the ball has gained an unstoppable momentum.
Of course EMDR is a relatively new psychotherapy – serendipitously discovered by Francine Shapiro, who published her original work with adults in 19896. Since then, EMDR has been revolutionising psychotherapeutic practices around the world. It is an integrative psychotherapy that utilises an adaptive information-processing model to help the client process previously indigestible emotions, thoughts and behaviours, and helps to regulate the underlying dys-regulated emotional and physiological systems. It also provides a new perspective on assessment of a client’s problems and offers explanations about the development of the pathology, guiding case conceptualisation and treatment. EMDR is now a recognised and proven form of psychotherapy for posttraumatic stress disorders in adults and has been recommended as a treatment of choice for adults by NICE7.
Working with young people
In this new field, however, no clear recommendation can be made for its use with children and adolescents as, to date, there are no large randomised controlled trials validating its use with this population and only a few small sample studies showing EMDR’s efficacy with children and young people2,8-13.
A primary goal of the EMDR Europe Child and Adolescent Committee (of which there are currently members from 14 different countries) is now the development of high-quality multi-site research projects to address this deficit. But encouragingly, clinical reports of EMDR’s efficacy in individual child and adolescent cases and small samples continue to abound at every EMDR Europe and International Association conference.
Why, when and how it works
EMDR is a particularly powerful psychotherapy and can bring very rapid and substantial changes for children and adolescents. One of the main things is that children find it easy to relate to the structured nature of the protocol1 – which is adapted to meet their developmental needs – and the use of the alternating bilateral stimulation. This protocol enables them to become proactive in their own treatment because it focuses on issues that are of concern to them rather than issues about them that are of concern to the adults in their world. I find that, once children have experienced the relief that EMDR therapy brings for one problem, they are more than willing to take ownership of the process. It is not uncommon to find children as young as five years coming into the next EMDR session, sitting down and stating what they want to work on. The nature of the therapy enables their problems to be unfolded at the pace of the child and to be processed uniquely for their own needs. I am often struck by the amazing things that children invent for themselves in processing to help with their own problems. For example, one child conjured up a machine that could destroy flashbacks by systematically blasting each picture, frame by frame.
EMDR is being used in Europe to help children and adolescents with a wide range of anxiety-related problems, including single trauma, phobias, nightmares, school-related anxieties, bullying, medical problems, enuresis, social anxieties and fears, attachment problems, sexual and physical abuse, rape, bonding, bereavement and depression. It is also being found to be effective with children who have learning difficulties and also for some children on the autistic spectrum. In one case, a child with clinical depression following a traumatic bereavement recovered in just three sessions of EMDR given once a week.
The number of sessions required to treat children and adolescents varies considerably and depends on the severity of the problem, the age at which it occurred, the number of problems they have, how long the problems have persisted and the child’s attachment patterns and sense of safety in the world. The younger the child is, and the more pervasive the traumas, the more devastating the consequences are likely to be for a child in the longer term, in terms of their attachment capacities and vulnerability to pathology in adulthood.
Clinical observations indicate that EMDR therapy seems to be particularly helpful in working with early pre-verbal memories2 and linking sensorily-stored memory to language for integration during the processing. EMDR therapy also seems to facilitate communicative intent in non-verbal ways, as it appears to be attuning the therapist to the client’s nonverbal cues and attuning the client to the therapist’s14.
This non-verbal attunement, which seems to be achieved by the EMDR protocol, might also be facilitating in children a sensitivity to another’s affect cues, which may lead to increased emotional awareness, connectivity and motivation to communicate and hence further joint attention. This may be why EMDR therapy is proving so beneficial to some children on the autistic spectrum14. Certainly, when newcomers to the therapy observe videos of children undertaking the desensitisation, they are amazed at the intensity of the children’s concentration, focus and ability to sustain the tasks. There is often a sense of disbelief – the children they work with would not be capable of achieving this degree of ‘goodness’. But of course they are.
With careful preparation, parents can be included in many EMDR sessions as cotherapists and this helps to keep the child feeling safe while processing difficult material. Witnessing the EMDR processing seems to sensitise parents to what the child has actually experienced, and helps the parent to map onto their child’s somato-sensory and frightening experiences from the child’s perspective and understandings. Often, too, the parents can read their child’s own idiosyncratic non-verbal messages and are able to signal things to the clinician about this. They can also be surprised at how well their child does in this treatment and the things that they are able to demonstrate. For example, one child with an autistic spectrum disorder, aged 12 years, for the first time outside of school started to write spontaneously – something her parent had never seen. Another, also on the autistic spectrum, was able to show an awareness of role play and others’ perspectives14.
EMDR therapy is also proving helpful clinically with attachment for children who have been placed for adoption after chronic abuse and neglect – some of our most damaged children. In the work done with the parents and the child, the EMDR therapy proactively works in helping them to attune to each other, and it is often used together with claiming and healing narratives15. Some of the most exciting work is being done in this area, and nothing can replace the sense of thrill, wonder, awe and humility at witnessing attachment and bonding behaviours occurring in the office right in front of you.
Following the EMDR therapy, many parents report that they discuss and build narratives, as they now understand more about their child’s inner world. They report that they are more able to notice the environment from their child’s perspectives and anticipate things better for them. Another side effect of the parent being participant in the EMDR process is that, often, they too then want therapy for themselves. Indeed, sometimes it is important for the parent to have EMDR therapy before the work with their child can begin, in order for them to be as emotionally available to the child as possible during the processing. Collecting a detailed family trauma history and building a trauma timeline is helpful in the earliest stages of the work, as this identifies areas and issues that need to be worked on. In Europe, EMDR therapy is also being integrated into family therapy16.
This is often produced by following the therapist’s fingers to stimulate brain activity, but therapists also use alternative methods such as light bars, tactile devices or pulsars, hand tapping, drumming, and audio stimulation via beeps, clicks etc. Some of these appeal specially to children, and play therapists have often used the child’s favourite toy to lead their eye movements.
It seems that, no matter what your theoretical and professional orientation may be, EMDR psychotherapy can be integrated into your existing framework. However, EMDR therapy should only be used by the clinician in those areas in which they already have clinical expertise, and the Europe EMDR child trainings are designed for those clinicians who are already child and family therapists. Undertaking EMDR Europe approved trainings for both adults and children is essential to ensure your trainings are of a high standard. And seeking regular supervision afterwards is also essential. EMDR therapy fails when the clinician does not understand or utilise the protocol sufficiently well or meets a problem and then stops using it. It appears a simple technique but is actually complex – it takes about three years to achieve good competency. Information on the training courses can be found on the EMDR Europe and UK and Ireland websites17. One of the most delightful aspects of using EMDR therapy with children and adolescents is watching the post-traumatic growth that occurs once the maladaptive emotions, memories and behaviours have been resolved. What one sees clinically is accelerated developmental progress, with the children seeming to be in a phase of ‘developmental catch-up’ emotionally and socially, and also in their moral development and, in younger children, sometimes also a physical growth.
EMDR and trauma
When a person is traumatised, the brain’s healing process may become overloaded, leaving the original disturbing experiences unprocessed. These ‘raw’ memories are stored in the brain and can continue to cause trouble when similar events are experienced. EMDR is a complex method of psychotherapy that integrates many of the successful elements of a range of therapeutic approaches, and combines them with eye movements or other forms of bilateral stimulation in ways that stimulate the brain’s information processing system to do what it failed to do earlier – desensitising and reprocessing the traumatic material.
Joanne Morris-Smith is an EMDR Europe accredited child trainer and EMDR Institute facilitator who organises specialist EMDR with children trainings. She is a consultant psychologist with 27 years’ NHS experience and works with Blackwater Valley and Hart PCT and Great Ormond Street Hospital. Email firstname.lastname@example.org
This article was first published in December 2006 CCYP journal, the quarterly journal of CCYP (Counselling Children and Young People). For more information about this division of BACP visit www.ccyp.co.uk
1. Shapiro F. Eye Movement Desensitization and Reprocessing: basic principles, protocols and procedures. New York: Guilford Press; 1995.
2. Morris-Smith J. (ed) EMDR: clinical application with children. Association of Child Psychology and Psychiatry. Occasional paper 19; 2002.
3. Tinker R, Wilson S. Through the eyes of a child: EMDR with children. New York and London: WW Norton & Co; 1999. 4. Greenwald R. Eye Movement Desensitization and Reprocessing (EMDR) in child and adolescent psychotherapy.
Northvale, New Jersey: Jason Aronson; 1999. 5. Lovett J. Small wonders: healing childhood trauma with EMDR. New York: The Free Press; 1999.
6. Shapiro F. Efficacy of the Eye Movement Desensitisation procedure in the treatment of traumatic memories. Journal of Traumatic Stress Studies. 1989; 2:199-223.
7. National Institute for Health and Clinical Excellence. Anxiety: management of post-traumatic stress disorder in adults in primary, secondary and community care. DOH; 2005.
8. Chemtob CM, Nakashima J, Carlson JG. Brief-treatment for elementary school children with disaster-related PTSD: a field study. Journal of Clinical Psychology. 2002; 58:99-112.
9. Fernandez I, Gallinari E, Lorenzetti A. A school-based EMDR intervention for children who witnessed the Pirelli building airplane crash in Milan, Italy. Journal of Brief Therapy. 2004; 2:129-136.
10. Jaberghaderi N, Greenwald R, Rubin A, Dolatabadim S, Zand SO. A comparison of CBT and EMDR for sexually abused Iranian girls. Clinical Psychology and Psychotherapy. In press.
11. Scheck M, Schaeffer JA, Gillette C. Brief psychological intervention with traumatized young women: the efficacy of Eye Movement Desensitization and Reprocessing. Journal of Traumatic Stress. 1998; 11:25-44.
12. Soberman GB, Greenwald R, Rule DL. A controlled study of Eye Movement Desensitization and Reprocessing (EMDR) for boys with conduct problems. Journal of Aggression, Maltreatment and Trauma. 2002; 6:217-236.
13. De Roos C, Greenwald R, De Jongh A, Noorthoorn EO. EMDR versus CBT: EMDR (Eye Movement Desensitisation and Reprocessing) versus CBT (Cognitive Behavioural Therapy) for disaster-exposed children: a controlled study. Poster presented at ISTSS Conference 2004. New Orleans, USA.
14. Morris-Smith J. Can EMDR be used with children suffering from autistic spectrum disorders? Paper presented at EMDR Europe Conference 2006. Istanbul, Turkey.
15. Morrris-Smith J. Helping children and families recover: the role of EMDR therapy in the aftermath of disaster and traumatic events. Paper presented at UK & Ireland Conference March 2006. London.
16. Silvestre M. Integrating EMDR into family therapy: the way forward following the death of a sibling. Paper presented at EMDR Europe Conference 2006. Istanbul, Turkey.
17. The EMDR UK & Ireland Association is at www.emdr-uki.org (PO Box 32283, London W5 3YB).
The EMDR Europe Association is at www.emdr-europe.org (PO
Box 784, Herts AL2 3WY).