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Update on Treating Addictions with EMDR

Gabor Maté says that “the root cause of addiction is trauma” (Maté, 2010) but I think we need to add dissociation to that sentence because addiction is a dissociative process caused by trauma. I do not think that he would disagree considering that he wrote a book called Scattered (1999), which talks about the roots of ADD/ADHD as emotional dissociation.

You will have to reference my previous blog on this subject (HERE) to have more of the backdrop of what I am presenting here. This is intended for EMDR/trauma resolution clinicians but believe that anyone would benefit from exploring. Also, before I can give you this update, I will briefly make sense of how addiction, trauma, and dissociation interplay.

“Addiction as Dissociation Model” is what I have been working on for the past year (along with my mentor Dr. Jamie Marich) and have submitted it as a position paper and is currently under review. HERE is a recent blog that we did to highlight some of the main points (O’Brien & Marich, 2019). I believe that this model’s importance is critical to the treatment of addiction because it highlights where addictions fit into the mental health “disorder” paradigm but also because addiction symptomatology can hide in other mental health presentations.

I put “disorder” in quotations because specifically addiction, trauma, and dissociation are normed experiences, meaning that they are supposed to happen given certain conditions and for this reason they are interrelated. Addiction, trauma, and dissociation are inseparable forces of nature because like a stone into a pond (trauma) there going to be ripples (dissociation and potentially addiction). I believe that addiction and dissociation are the same process and that it is the impact of trauma that creates the extremes. Because of this, the root of addiction is untreated dissociation caused by trauma and untreated trauma. We use the definition of “dissociation in trauma” as the operational definition for dissociation (Nijenhuis & Van der Hart, 2011). For addiction, I will use our working definition of addiction as “a manifestation of untreated dissociation and trauma.”

When looking at these three experiences and how they overlay, we have to recognize 3 things.

1) Any life-threatening or adverse life experience, perceived or real, can produce the same symptomatology i.e., trauma and stress symptomatology, 2) that dissociative/addictive states create traumas, 3) and that dissociation always accompanies trauma due to the law of cause and effect.

So I ask, can you have trauma without dissociation? Can you have trauma without addiction? Can you have addiction without trauma and dissociation? Can you have dissociation without addiction?

Here are my answers and rationale for what I am suggesting.

Can you have trauma without some form of dissociation? No, i.e., a stone thrown in a pond is going to create a ripple. It was brought to my attention in a FB group, basically warning me against absolutes, that dissociation does not always happen during a traumatic event because people can consciously experience a traumatic event. I agree that people can be conscious during a traumatic event but this does not mean that a form of dissociation is not present because we can be consciously dissociated. This viewing of an experience sounds more like depersonalization, which is a form of dissociation. Furthermore, there is the concept of co-consciousness that suggests that both can be happening at the same time. Dissociation is not just about checking out momentarily; we can be consciously living dissociated, which can be considered dual attention. This is paradoxical but is essential to understanding dissociation and addiction and this is why parts work is essential to treating addictions.

Can you have trauma without addiction? Yes, you can have trauma without addiction but the trauma is most likely from a natural disaster i.e., an “act of God” as insurance companies call them but ultimately, “God” gives enough warnings before a natural disasters. Staying and not heeding the warnings is a sign of being addicted. “Addiction as Dissociation” explores when we are living dissociatively we are in a state of being addicted. All other traumas that I can think of happen as a result of someone else trying to get their needs met in excessive or maladaptive ways while under the influence of this unmet need (not just a drug).

Can you have addiction without trauma (and dissociation)? No, because addictive behaviors are traumatic/life threatening to the survival reptilian brain and this would produce dissociation as a response. Addictive Memory (Boening, 2001) is traumatic memory and so would produce the same symptoms. Addictions are on the spectrum of trauma and dissociation and what can be inferred is that since dissociation has a normal range of presentations so do addictions and trauma.

Can you have dissociation without addiction? Yes, because there is a normal range of dissociative experiences, however, outside the normal range is where pathological dissociation (Waller, Putnam, & Carlson, 1996) begins and this can be considered an addicted state. Interestingly enough, dissociation is produced by the endogenous opiate and cannabinoid systems in the brain (Lanius, 2014), which suggests that we can become addicted to the processes produced by dissociation and the traumas that cause them (Van der Kolk, 1989).

When conceptualizing “Addiction as Dissociation” we must see that the addictive behaviors are a manifestation of a previous dissociative experience that is manifesting as a re-enactment and/or creating a feedback loop. So, to explore this connection comprehensively with EMDR, by performing a floatback from the first time the client fell in love with the drug or bonded with their dissociation, will produce their dissociation history.

When doing this, what I have found is that clients floatback to early childhood experiences of excessively watching TV, playing video games or sports, eating sugar/food, studying/school, fighting, stealing, or extra-circular activities. Again, these are all done excessively suggesting that they were compensating for emotional abuse or neglect. We can conceptualize these as “small d” dissociations. Also, and more obviously, previous dissociative experiences as a result of traumas or adverse life events. These would be “big D” dissociations which would include any (real, potential, or perceived) medical procedure/illness of the individual or family member or hearing age-inappropriate stories with adult themes or death. More on this last point in the conclusion.

Here is the update… The Set-up

The dissociative response produces a felt experience of numb (the relief moment) that would emotionally be interpreted as safety, stillness, peace, and comfort. Some dissociative responses like fighting and stealing produced a high as well and if that still stays with them then it is a target. Even though it may be in the absence of conscious presence, it is still real to the person experiencing the immediate effects of relief from the subjective experience. Our survival brain would retain these experiences for future survival needs and would reproduce/reenact it as a way of communicating this need to the conscious self.

Temporally, there is a before, during, and after any given trauma. However, I contend that there are really two memories created in the “during phase” i.e., the stone and the ripple. First, is the inescapable shock moment (trauma) and then second is the dissociative response (safety/relief moment). If the dissociative response registers on the Positive Feeling State Scale (PFS) or even if it registers on the SUD scale, then it is the target. If it doesn’t register then it may have been processed naturally or is dissociated suggesting that it is unresolved. It is essential to target this because this is what is being re-enacted or caught in the feedback loop. We can target it by switching the NC and the PC as I suggested in my previous writing.

What we are doing as EMDR therapist is treating the “during” part of the memory when we are reprocessing a traumatic memory (Phases 4 and 5). Typically, when reprocessing the trauma you can get the dissociative moment (the safety/relief moment) as well - but not always. Taking a dissociative history like we do a trauma history is probably not something that most clinicians do regularly so this relief moment is often missed as a component of the client’s treatment. By doing the dissociative floatback it will provide more access to their dissociative profile, provide targets, and provide comprehensive treatment.

We can treat dissociation by targeting the dissociative moment and/or the safety that it provides. This is the memory that we need to target when treating dissociation and also addiction. In reference to my previous blog, how we set this up with our clients is by asking, “Do you remember that moment that checking out felt good or right?” This is the same question for addiction “Do you remember when you fell in love with the addictive behavior or that feeling of numb?” PC: “What does that make you believe about yourself or this situation?” (You will need a greatest hits list for this purpose. Click HERE for Dr. Marich or HERE for mine.) “What do you need to believe about this now (as the adult you)? Then get a PFS (Positive Feeling State) or SUD, feeling, and body sensation i.e., standard protocol.

Conclusion

Addictions can form as a response to trauma but often times linking the addictive behavior to the consequences or treating the trauma does not eliminate the addiction. In cases where addictions are present, we need to treat both the trauma and dissociative response from the earliest ages (even pre-verbal or inter-generationally) and for that we need the Addiction as Dissociation conceptualization. Once that is in place, then we can use trauma resolution methods to treat it. This is what Dr. Marich and I providing. Treating the cravings or triggers is really treating the symptoms of addiction. Often times this leads to the underlying mechanisms of dissociation but to securely say that we have treated an addiction therapeutically we have to resolve both the trauma and the dissociative response.

To me the dissociative response of living dissociatively (this includes re-enactments and feedback looping in the memory system) is what defines active addiction. We cannot separate from trauma from dissociation anymore then we can separate water from the wave. Someone who is addicted (to be fair I believe that bonded is a better word for addiction) to his or her dissociation is going to produce reenactments that are based on emotional logic. See my most recent blog HERE on the subject.

Often times addiction is seen an avoidance tactic. What is the difference between avoidance and keeping one safe? For me, it is our cultural stigma, which inform our negative beliefs. With “Addiction as Dissociation” conceptualization, addictions are more of a survival need for securing a feeling of safety. Clients respond better to this more humanistic approach rather than being told that they are doing something wrong.

Lastly, the power of story cannot be denied or dissociated from. Stories are often our first highs in life. A good story hooks us in and it is that hook that gets us before any addictive behaviors sets in. Our stories are what our survival brains eat for food. It gobbles up the information as facts because it might have to use this knowledge in the future in order to survive but also in order to thrive. I write this last part because you may have to address the glorifying stories that the client has heard or seen from their childhood or saw in media. For example, I have targeted characters from “Dazed and Confused” and “Hunter S. Thompson,” however, more often I have targeted familial stories. Hearing that mom or dad did this or that when s/he was younger suggests to the child listening that this is what s/he has to do in order to be a wo/man or adult. Following in the footsteps of our parents is inevitable but it does not have to be so literally. Ultimately, this is breaking the cycle of addiction, which is essential to truly treating addictions. Stories are our reference material for life, so be mindful of what and how you share.

References

Boening, J. (2001). Neurobiology of addiction memory. Journal of Neural Transmission, 108, 755-765.

Lanius, U. (2014). Dissociation and endogenous opioids: A foundational role. In U. Lanis, S. Paulsen, and F. Corrigan (Eds.), Neurobiology and treatment of traumatic dissociation: Toward an embodied self. (pp. 81-104). New York: Springer Publishing Company.

Maté, G. (1999). Scattered: How attention deficit disorder originates and what can you do about it. New York, NY: Plume.

Maté, G. (2010). In the realm of hungry ghosts: Close encounters with addiction. Berkeley, CA: North Atlantic Books.

Nijenhuis, E.R.S., & van der Hart, O. (2011). Dissociation in trauma: A new definition and comparison with previous formulations. Journal of Trauma and Dissociation. 12:4 (pp. 416-445). DOI: 10.1080/15299732.2011.570592

O’Brien, A., & Marich, J. (2019). Addiction as Dissociation Model by Adam O'Brien and Dr. Jamie Marich. Retrieve https://www.instituteforcreativemindfulness.com/icm-blog-redefine-therapy/addiction-as-dissociation-model-by-adam-obrien-dr-jamie-marich

Van der Kolk, B.A. (1989). The compulsion to repeat the trauma: Re-enactment, revictimization, and masochism. Psychiatric Clinics of North America, 12, 389-411.

Waller, N., Putnam, F.W., & Carlson, E.B. (1996). Types of dissociation and dissociative types: A taxmetric analysis of dissociative experience. Psychological Methods, 1(3). 300-321.

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Addressing Shame: The Color and Shape Set-up for EMDR Therapy

When I first started to use EMDR with my clients, particularly with more complex cases, there seemed to be more that needed to get done before trauma processing. There needed to be more resourcing but also something that is able to touch a deeper trauma that is inside of our clients. Shame is usually the culprit.

Mason (2013) stated that, “shame safeguards the spirit.”  When shame is our reality, we don’t feel good about ourselves.  Shame is generally learned from experiences in our most vulnerable developmental years. However, since memories can be moved/restored through the process of memory reconsolidation (Ecker, Ticic, & Hulley, 2012), our reality is subjective to the meaning we give it. This teaching may question our foundation of what composes our reality. Even more to the point, it calls into question the very essence of who we are.

In the Institute for Creative Mindfulness EMDR therapy training, we explore the client’s trauma targets using a thematic approach. Addressing traumas in a thematic way allows the client to address what they believe and how they feel about themselves in order to rewrite, renew, or own their story. Because of this, anything can be targeted with EMDR, if it holds adaptive or maladaptive value and the client can emotionally access it. However, what about the experiences that are there but not recognized consciously or that started before narrative or declarative memory developed in the brain?

Let me first acknowledge the difference between what I am presenting and Paulsen and O’Shea’s (2017) “When There Are No Words” protocol. Paulsen and O’Shea’s stance is that their protocol “reset the hardwired neuro-affect circuits” and this is done in Phase 2 Preparation. What I am presenting here is an option for clinicians who are not trained to do “When There Are No Words” (or are having difficulty following the nuances of protocol they downloaded off the web). Paulsen and O’Shea’s protocol can be helpful for clients; however, I also believe that accessing implicit memories through what I am suggesting holds additional value on two levels. One, it is a good and safer place to get “buy-in” from a client, and two, if it does not go as we would hope, it can be “diagnostic.” I want to gain access to my client’s earliest wounds. What I am proposing is more of a “Phase 2.5” intervention that links Phase 2 and the reprocessing Phases 3-6 (Marich, 2019). This intervention allows clinicians to address our client's preverbal schemas with any and all thematically shame-based core belief clusters because this is actually where the cluster begins.

Shape and Color Set-up:  While taking clients trauma history (Phase 1) and assessing core beliefs (Phase 3), I am looking to put their core beliefs in two categories: shame-based (i.e., I am bad, I am worthless) and fear-based (i.e., I am in danger, I am powerless) core beliefs. Before floating back on a core belief I will ask, “Do any of these shame-based beliefs just feel like they have always been there?” (I will either ask this during Phase 1, Client History or Phase 3 Assessment.) Nine times out of ten, clients will identify a shame-based negative cognition. If the clients pick a fear-based cognition like “I am in danger,” I stay away from it because it is most likely linked directly to an event that can be directly recalled and I am not trying to have them start reprocessing a direct memory. If this happens, I will guide them towards a shame-based core belief.

After resourcing in Preparation (Phase 2), assessing targets (Phase 3), and establishing some kind of stop signal, I then have the client create a target of the core belief felt-sense by asking, “What shape and color would represent this ‘has always been there’ belief?” Once the client has the image (and negative cognition) then it is standard protocol time (i.e., Phases 4-7 and Phase 8 in the next session). Future template can be done but I feel that because I am priming the pump and that there are declarative memories still to go, I wait until I see how the client responses to the process and do future templates with memories that are able to be recalled.

Rationale: I am trying to see what is going on under the hood and also preparing their memory system for reprocessing shifts. My reference to the shape and color or image comes from Mark Grant’s work on pain management (1995) and so any strong preverbal emotion can be targeted in this way. Paulsen and O’Shea also use this strategy; they do not, however, want you to activate the client. My position is that if we are addressing the client’s schema, that they are feeling all the time, they are already activated. Again, I suggest doing this on shame-based themes and not fear-based ones because I believe it is safer and the client is less likely to activate actual memories. However, activating shame-based memories does happen. In this case, I will guide them back to target or go back to resourcing. If the client has too much shame then the standard practices of creating some distance between the client and image, having the client pendulate, or taking only doing a fragment is advised. To further support my position, if the theme carries a high SUDs, which it normally does, Shapiro (2018) suggests doing a more intense early memory first because if they can do this, then they can handle whatever else is to come. Lastly, and for obvious reasons, this is actually the start of the cluster.

Buy In: Starting with a shape and a color allows the client to test-drive reprocessing. When clients open up to reprocessing they are opening themselves to their own healing. When that positive shift happens, they have experienced something that is effective and they will have more buy-in into their treatment. When, as the clinician, we express that it is a more indirect way of reprocessing EMDR, it implies that we are starting someplace safer. Clients appreciate this. Also, since their core beliefs are something that they already feel and live with on a daily basis they are familiar with it and okay talking about this more than their traumas. Once they have seen a shift in this, then now know and have direct experience that EMDR therapy works for them.

Diagnostic: Doing this is also a good test run to see if the person is able to do the deeper work and can be diagnostic in the sense that you get a feel for the clients protective/dissociative system and their level of preparedness on an unconscious level. Ideally, this is assessed in Phases 1-3 of EMDR but it is not always apparent on an unconscious level. Obviously, we need to have rapport, do assessments like the DES (at a bare minimum), and use our clinical judgment but it is not always obvious how someone’s unconscious will respond. If the client picks a shape and a color that goes from dark to something light and has freed something in them or they feel lighter, then chances are they are ready to do the deeper work that they are coming to us for. Additionally, they now have direct experience with feeling a shift in their emotional body, particularly with something that feels like it has always been there, again, we get a lot of buy-in.

As clinicians, we also get a lot of information regarding diagnostics if the client cannot remember their early childhood and/or by seeing if the client can do calm/safe place or container. If they cannot do this effectively then there is more going on in their dissociative process that is worth discussing with them (Paulsen, 2009). I started doing the Color and Shape Set-up before having the Dissociative Table (Paulsen, 2009) as a tool in my EMDR toolbox. I now will start with the dissociative table, O’Shea and Paulsen’s “When There Are No Words,” and then this Color and Shape Set-up, when appropriate.

Observations: The shame color/shape/image is usually dark. When reprocessing goes well, people get to a bright and lively color and/or translucent image. Sometimes, it just disappears. When it does not go “right” the image usually stays the same and clients will say, “it does not feel like it is going to move.” This is clinically telling and potentially diagnostic so more psycho-education and resourcing may be needed. Yes, some clients will have the wherewithal to identify that “it has always been there” or “I just feel it.” This insight may indicate where they are at in their readiness to do deeper reprocessing. This suggests to me that they are highly attuned to their body and are already primed to do EMDR or trauma reprocessing.

Generalization: Generalization is when the client starts to reprocess all of the thematic memories in a cluster (Ecker, Ticic, & Hulley, 2012). This happens because once a core belief is resolved in an earlier memory the lesson learned is applied to other similar situations. Since the brain works through making associations, any association can connect to the neuro-network that rides this theme is going to be impacted, hence has the opportunity to be reprocessed. If the client is consciously and unconsciously open to healing then they are going to do a great deal of work starting in this way.

Populations: I particularly love doing this with people are addressing their addictions because they are usually living in their right-brain processes. This also goes for people who are creative and children between the ages of 2-12 respectfully. Highly motivated adolescents respond well but other adolescents find it weird. Similarly, I like doing this with personality disorders as well because it gives them the opportunity to allow shifts to happen, and/or challenges them if it does not. It provides experiential material to work on. For more left-brained people, it can be a challenge but it gives them the opportunity to connect to their more emotional side.

Healing Light: Also, consider that this can be done in combination with healing light. I will have clients get their SUDS down to a like 2-3 and then I will perform the healing light or Light Stream on the remainder. I have witnessed some very spiritual and religious experiences by doing this.

Target Order: When I do a floatback and get the earliest memory if it is not between the ages of 2-5, I have my client’s try and float further back. Because of what I am purposing, with regard to schemas and shame-based beliefs, it is implied that the earliest recall memories are going to be represented around the chronological ages of 2 to 5. Our expertise that tells us that the schemas started before the age of 2 so we would be better to start there.

Clients are coming to us for our expertise on the therapeutic process and trauma etiology, which can conflict with letting the client lead or decide what memory to do first. If I have a client who wants to address something more recent or only one specific memory then I will have them try the Color and Shape Set-up first as a test run. Similarly, if there is no discrete memory (Greenwald, 2007) or test run memory to do, I do this set-up. There are times when having the client lead or pick a memory that they want to work on can be effective.  Allowing the client to lead the selection of targets without any guidance, however, can be what creates more work later. So, we have to have a good case conceptualization in order to maximize the outcomes of healing and our conceptualization has to be based on trauma-informed care, which means to me, safety first. What this writing ultimately comes down to is that traumas are compounded in the memory network because our neuro-networks are associative and by previous traumas so starting off at the earliest is the safest and will be more likely going to produce better outcomes (Greenwald, 2007).

Feel free to contact me for individual consultation or attend my weekly group on Friday’s 12-2pm EST.

References

Ecker, B., Ticic, R., & Hulley, L. (2012). Unlocking the emotional brain: Eliminating symptoms at their roots using memory reconsolidation. New York, NY: Routledge.

Grant, M. (1995). From https://emdrtherapyvolusia.com/wp-content/uploads/2016/12/Mark_Grants_Pain_Protocol.pdf Retrieved on 2/8/19

Greenwald, R. (2007). EMDR: Within a phase model of trauma-informed treatment. Binghamton, NY: Haworth Press, Inc.

Marich, J. (2019). EMDR Therapy Phase 2.5: Honoring a Wider Context for Cnhanced Preparation. [Blog Post]  Retrieved from https://www.instituteforcreativemindfulness.com/icm-blog-redefine-therapy/emdr-therapy-phase-25-honoring-a-wider-context-for-enhanced-preparation-by-jamie-marich-phd-lpcc-s-licdc-cs-reat-ryt-200

Mason, M. (2013). Women and shame: Kin and Culture. In. Claudia Bepko (Ed.), Feminism and addiction (pp. 175-194). New York, NY: Routledge

Paulsen, S. (2009). Looking through the eyes of trauma and dissociation: An illustrated guide for EMDR therapists and clients. Bainbridge Island, WA: A Bainbridge Institute for Integrative Psychology Publication.

Paulsen, S., & O’Shea, K. (2017). When there are no words: Repairing early trauma and neglect from the attachment period with EMDR Therapy. Bainbridge Island, WA: A Bainbridge Institute for Integrative Psychology Publication.

Shapiro, F. (2018). Eye movement desensitization and reprocessing (EMDR): Basic principles, protocols, and procedures (3rd ed). New York, NY: Guilford Press.