Author: Cecilia Clementi, Ph.D., Psy.D
“Trauma victims cannot recover until they become familiar with and befriend the sensations in their bodies…
Physical self-awareness is the first step in realizing the tyranny of the past.”-Bessel Van der Kolk-
… and this is where Mindfulness and EMDR approaches meet.
What are PTSD and Complex PTSD?
Many people experience traumatic events in their life span. However, to develop a Post-traumatic stress disorder (PTSD), a person must have experienced or witnessed a traumatic event that involves actual or threatened death, serious injury, or sexual violence”. (1)
The core aspects of PTSD’s symptoms are the following:
intrusions or re-experiencing the events
avoidance and detachment from people, events, and environmental triggers of trauma
arousal or reactivity or hyper-vigilance as a sense of current threat
An additional feature of PTSD is related to changes in cognition and mood, such as:
exaggerated negative beliefs about themselves, the world, or other people
having distorted thoughts about what caused the event and the consequences
persistent negative emotions
less interest in significant events
feeling detached or estranged from others and finding it impossible to experience positive emotions
Only if symptoms last more than one month can a PTSD diagnosis be made. Complex post-traumatic stress disorder (C-PTSD) might be caused by recurrent and long-term traumatic events, starting in childhood or at a young age.
People with C-PTSD not only have PTSD symptoms such as flashbacks, insomnia, or hyper-arousal but also have problems in:
Emotions regulation (difficulty in managing their feelings). They can also experience feelings of worthlessness, shame, and guilt.
Self-image (feeling different from others or having a negative view of themselves).
Interpersonal relationships (difficulty in trusting others or managing or maintaining relationships).
C-PTSD is often associated with dissociation, a mechanism of the mind that separates fragmented traumatic memories from daily life experiences. Dissociation can be seen as a way to protect from the intense pain and suffering of traumatic memories, helping people to go on with their lives. Unfortunately, traumatic memories can be suddenly sparked by different kinds of triggers, bringing emotional activation or arousal.
Trauma survivors can alternate between states of intense agitation and numbness. They can often develop mood or anxiety disorders, eating disorders, addictions, and personality disorders. (2)
Trauma and mindfulness
Mindfulness represents a fundamental tool in the process of healing from trauma. It helps to intentionally bring the attention back to the present experience with grounding, centering, and the attitude of openness, curiosity, acceptance, non-judgment, kindness, and letting go.
Mindfulness-based programs such as MBSR have effectively treated PTSD as well. (3) However, in some cases, mindfulness practice can also cause more dysregulation and distress in people with significant traumatic experiences when they do not feel safe while practicing. Therefore, a trauma-sensitive mindfulness approach, as described by David Treleaven (4), implements safety strategies in meditation. This can help trauma survivors to be present in the discomfort without getting overwhelmed. In other words, they must stay within “their window of tolerance,” which, according to Dan Siegel (5), represents the optimal zone between hyper and hypo-arousal states, where people can be present, stable, and regulated.
Trauma-sensitive mindfulness (TSM) (4) is based on some important principles :
Stay within the window of tolerance.
Maintain presence and safety.
Realize.
Recognize the trauma signals.
Respond.
Avoid Re-traumatization.
Trauma and psychotherapy
Sometimes, talk therapy can further traumatize those who already have PTSD or complex PTSD. According to Bruce Perry, 6 R’s need to be considered in the process of healing trauma: (6)
Rhythmic: regulation of the arousal that can easily get too extreme using different tools such as dancing, walking, playing, etc.
Repetitive: repetition of positive experiences that help to feel safe and facilitate the process of healing from a trauma
Rewarding by creating moments where the person can overcome challenges, increasing his self-confidence
Relational: related to the impact of a strong, trusting relationship and a safe environment in processing a traumatic experience.
Relevant treatment is developmentally matched to the individual according to age, needs, wants, and past traumas.
Respectful: Not all psychotherapeutic approaches are effective in treating traumas.
What is EMDR?
Eye Movement de-sensibilization and reprocessing (EMDR), developed by Francine Shapiro in 1989, (7,8), is considered one of the most effective evidence-based psychotherapies to treat traumas and PTSD symptoms (9), and it is recognized as the psychotherapy of choice for PTSD by the World Health Organization.
EMDR has also been found to be an effective treatment for other psychiatric disorders, mental health problems, and somatic symptoms (10). EMDR is based on the Adaptive Information Processing (AIP) model. It considers the maladaptive encoding and/or incomplete processing of traumatic and disturbing adverse life experiences as the main factor for the development of psychopathology. And causes an impairment in the ability to integrate these experiences in an adaptive way. EMDR enables the resumption of normal information processing and integration.
EMDR is a structured and integrative psychotherapy that encourages the patient to focus briefly on the trauma memory while simultaneously experiencing bilateral stimulations (right/left eye movement, tapping, sounds). This bilateral brain hemisphere stimulation, similar to the pre-REM sleep state, reduces vividness, emotion, and physiological reactions in the present associated with trauma memory.
EMDR addresses past, present, and future issues by targeting past experiences, current triggers, and potential challenges.
EMDR reduces or eliminates the distress of the disturbing memories and present/future triggers by addressing the three levels of experience (sensations, emotions, and cognitions).
At the same time, EMDR improves the view of the self and stimulates and reinforces inner resources (post-traumatic resources).
A clinical case
The clinical treatment of complex cases related to clients with multiple mental disorders, such as eating disorders or other psychological distress (anxiety, depression, addiction, etc.), is associated with C-PTSD and personality disorders. In this kind of complexity, an integrated and tailored approach is needed.
As an EMDR psychotherapist and Mindfulness / Mindful eating teacher, I found the integration of these approaches particularly effective, as the following clinical case shows.
Sarah is a 25-year-old woman with C-PTSD, Bulimia nervosa (BN), low self-esteem, mood swings, and neglect issues.
During childhood, she was sexually abused by her older brother many times, but her parents did not take it seriously and avoided protecting her. She also had many partners who were verbally and physically abusive, and she always felt used and not seen by them.
She started to use binging and purging behavior during adolescence as a coping strategy to deal with difficult emotions and to punish herself by destroying her body. When triggered by past traumatic memories, she often gets dissociated and sometimes uses self-harm. This dysfunctional mechanism reinforces her negative cognitions about herself. Binging and purging after it, or self-harming, are her dysfunctional coping strategies to reduce emotional pain.
The first goal of psychotherapy was stabilization: mindfulness was used as a tool to reconnect to the present moment awareness, observing sensations, emotions, and thoughts without judgment and not getting identified. Distress tolerance and emotion regulation coping skills were implemented.
A trauma-sensitive mindfulness approach was used to avoid re-traumatization, helping her not to dissociate.
Mindful eating approach and practice were used to treat bulimia nervosa symptoms and to cultivate a joyful and more balanced relationship with food and body.
Then EMDR enhanced positive resources (e.g., safe place) and elaborated past traumas, present triggers, and future challenges.
Sarah also had psychiatric and nutritional consultations.
At the end of psychotherapy, Sarah had no binging and purging episodes. She was also more confident in herself and able to better manage her difficult emotions and mood swings by validating and self-soothing instead of self-harming or binging. Traumatic memories no longer triggered her, and she was more able to have healthy sentimental relationships.
About the Author
Cecilia Clementi, Ph.D., Psy.D is a clinical and health psychologist, EMDR, CBT, and DBT psychotherapist, and certified mindfulness and mindful eating teacher. She works in her private clinic and at San Nicola Addiction Rehabilitation Centre in Italy. Her areas of expertise are eating disorders, addiction, and trauma. Cecilia has been a TCME Board member since 2015.
References
American Psychiatric Association (2013).Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, DSM-5. Arlington, VA.
Qassem, T., Aly-ElGabry, D., Alzarouni, A., Abdel-Aziz, K., and Arnone, D. (2012) Psychiatric Co-Morbidities in Post-Traumatic Stress Disorder: Detailed Findings from the Adult Psychiatric Morbidity Survey in the English Population. Psychiatr Q, 92,1, 321-330. doi: 10.1007/s11126-020-09797-4.
Boyd, J.E., Lanius, R.A., and McKinnon, M.C. (2018) Mindfulness-based treatments for posttraumatic stress disorder: a review of the treatment literature and neurobiological evidence. J Psychiatry Neurosci. 43,1,7-25. doi: 10.1503/jpn.170021
Treleaven, D. (2018). Trauma sensitive mindfulness: Practices for safe and Transformative Healing. W.W. Norton and Company, New York.
Siegel, D.J.(1999). The developing mind: Toward a neurobiology of interpersonal experience.Guilford Press, New York.
Douglas, A. (2021). Meeting children where they are: the neurosequential model of therapeutics. Adoption advocate, 160, 1-10
Shapiro, F. (1989). Eye Movement desensibilization, Journal of Behavioral therapy and Esperimental Psychiatry,20, 211-217
Shapiro, F. (2001). Eye Movement desensibilization and reprocessing: basic principles, protocols and procedures. 2nd Ed., Guilford Press, New York.
Chen, Y.R., Hung, K.W., Tsai, J.C., Chu, H., Chung, M.H., et al. (2014) Efficacy of eye-movement desensibilization and reprocessing for patients with posttraumatic-stress disorder: a meta-analysis of randomized controlled trials. PLoS One.9,8, e103676. doi: 10.1371/journal.pone.0103676
Maxfield, L. (2019). A clinician’s guide to the efficacy of EMDR therapy. Journal of EMDR Practice and Research. 13,4, 239-246. Doi: 10.1891/1933-3196.13.4.239.