PTSD research paper

Deactivating the Buttons: Integrating

Radical Exposure Tapping with a Family

Therapy Framework

Laurie MacKinnon Private Practice, Insite Therapy and Consulting, Lane Cove, New South Wales

The purpose of this paper is to describe and illustrate with case examples a brief intervention termed Radical Exposure Tapping (RET). RET can be integrated with family therapy to address stuck points where the therapy is hindered by a family member’s affective block, an intense and unchangeable emotional reactivity to a specific trig- ger. RET draws from the methodology of Eye Movement Desensitization and Reprocessing (EMDR) and com- bines it with the tapping sequence of the Emotional Freedom Technique (EFT) to produce an intervention that is more flexible than EMDR, provides greater rigor than using the EFT technique alone and can be effective in a sin- gle session within the context of family therapy. The paper puts this work into context by first over viewing defi- nitions of trauma and Post-Traumatic Stress Disorder, arguing that family members’ emotional reactivity may be a symptom of PTSD even when they would not qualify for the diagnosis because they had not experienced a life threatening event.

Keywords: Trauma, Post-Traumatic Stress Disorder, Criterion A, emotional reactivity, emotional trigger, Radical Exposure Tapping, Eye Movement Desensitization and Reprocessing, Emotional Freedom Technique, single session, brief intervention, family therapy

Key Points

1 A family member’s emotional reactivity to a specific trigger, an affective block, may reflect symptoms of Post- Traumatic Stress Disorder (PTSD).

2 Techniques for treating PTSD can be used with people who have symptoms of PTSD even if they do not qualify for the diagnosis because they do not meet Criterion A.

3 In terms of viability for integrating with family therapy, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is too time consuming, Eye Movement Desensitization and Reprocessing (EMDR) lacks flexibility, and Emo- tional Freedom Technique (EFT) lacks rigour and theory.

4 Radical Exposure Tapping (RET) is a brief intervention that combines Eye Movement Desensitization and the Emotional Freedom Technique. RET can be integrated with family therapy to address family members’ emo- tional reactivity to a specific triggers.

Introduction

Three decades ago, when I worked within a family therapy approach that coached family members to break free of repetitive cycles of interaction, I would sometimes hit a stumbling block. I would identify a circular pattern and coach family members to behave differently. When they returned for the next session, sometimes a parent would say: ‘Sorry I really tried, but I just couldn’t do it. That kid just pushes my but- tons’. We would track the history of that button, tracing its roots into relationships or

Address for correspondence: [email protected]

Australian and New Zealand Journal of Family Therapy 2014, 35, 244–260 doi: 10.1002/anzf.1070

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events in the parent’s family of origin. Sometimes this insight made a difference and parents became less reactive. And sometimes, the parents just remained stuck.

In those days, we conceptualized the stuckness as an affective block, emotional reactivity to a specific trigger that only many sessions of family of origin work or years of individual therapy could ever shift. But those were unlikely solutions for parents engaged in short-term therapy focused on the child’s behaviour. Even if parents could be convinced to undergo individual therapy, there was no guarantee the therapy would change that particular affective block or that it would work quickly enough to benefit the child. If only there was a silver bullet, a brief inter- vention to address affective blocks without disrupting the overall flow of family or couple therapy.

Over the last decade, therapists of all persuasions became interested in the fields of neurobiology and trauma. As I learned more about these areas, I began to wonder:

1. Are affective blocks really an indication of unresolved trauma? 2. Could therapeutic interventions for unresolved trauma prove helpful? 3. If the answer was yes, could these interventions be brief and practical enough to

be viable in a family therapy context?

This paper recounts the journey I have travelled in answering these questions. First I outline definitions of trauma and memory processing, identifying the benefits and constraints of current treatment approaches. I then propose an integration of approaches that contributes a parsimonious theory and practice that is teachable and brief enough to be incorporated into family therapy practice.

What is Trauma?

In common discourse, trauma refers to a deeply distressing or disturbing reaction to experiencing a terrible event. Although most people recover from such experiences, a small percentage go on to develop symptoms that do not remit even months or years after the event. In 1980, The American Psychiatric Association created the diagnosis of post-traumatic stress disorder (PTSD) and revised it in 2013 (American Psychiatric Association, 2013). To qualify for this diagnosis, people must meet Criterion A – they must have been exposed to actual or threatened death, serious injury or sexual vio- lence. The exposure may be first hand, or as a witness, or vicarious, as in hearing about the event through a close relative or friend who experienced the event first hand.

There are four main clusters of symptoms associated with PTSD. These are: re- experiencing the event (often as intrusive flashbacks or nightmares); heightened physi- ological arousal; avoidance of the memories, thoughts, feelings or reminders of the event; and negatively altered beliefs, thoughts, moods and feelings. The person may have a distorted sense of blame for causing the traumatic event and continue to feel anger, horror, fear, guilt or shame and be unable to experience positive feelings (American Psychiatric Association, 2013).

Although many facets of the DSM definition of PTSD are contentious, of rele- vance to this paper is Criterion A: the person must have experienced or been exposed to a life-threatening event. A person who experiences a severe life stress not life-threat- ening but that nevertheless, results in the same four symptom clusters of PTSD, does not qualify for a PTSD diagnosis.

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Ironically, studies have shown that severe life stresses are much more likely to result in greater levels of PTSD symptoms than those events that do meet the criteria for trauma in accordance with Criterion A (Gold, Marx, Soler-Baillo & Sloan, 2005; Mol, et al., 2005; Van Hooff et al., 2009). Interpersonal events are known to result in more severe PTSD symptoms than other events such as natural disasters (Lancaster, Melka & Rodriguez, 2009).

PTSD symptoms may be precipitated in people who have experienced workplace bullying (Matthiesen & Einarsen, 2004) or sudden, severe emotional loss (Carlson, Smith & Dalenberg, 2013). In studying gay and lesbian youth Alessi, Meyer and Martin (2013) found that unemployment, homelessness, separation from parents and, of more – significance, ending a relationship were non-life-threatening events fre- quently associated with PTSD symptoms. Individuals with social phobia have a nega- tive self-image linked to memories of socially embarrassing or humiliating events (Erwin, Heimberg, Marx & Franklin, 2006; Wild, Hackmann & Clark, 2008). Simi- larly, people suffering from agoraphobia experience distressing sensory and somatic imagery in situations that elicit their anxiety, imagery associated with memories of disturbing events, often events that occurred during adolescence (Day, Holmes & Hackmann, 2004).

In short, to qualify for a diagnosis of PTSD, an individual must have experienced or witnessed or been exposed to a life-threatening event. Those who have all the symptoms of PTSD, however severe, but who have not been exposed to a life-threaten- ing event, do not technically have PTSD. This is the case even though those who have experienced stressful life events such as losses, rejections, humiliations, bullying may have even greater symptomatology than someone who qualifies for PTSD diag- nosis.

Why is this distinction important? It was important to me because as a family therapist I had always thought that I did not need training in working with trauma- tized people. My clients were not war veterans or victims of accidents and I had not specialized in sexual abuse – few of my clients would have received a PTSD diagnosis. However, many, many of my clients suffered from experiences of loss, rejection, humiliation, bullying, and had symptoms of hyper arousal, emotional reactivity and intrusive memories. They had symptoms of PTSD.

This distinction is important to the field of therapy, because noteworthy break- throughs have been made in recent years in techniques for treating PTSD, techniques that can also be used with people who have symptoms of PTSD even if they do not qualify for the diagnosis.

What Treatments Work for PTSD?

A meta-analysis of the research in the Cochrane Library, (Bisson & Andrew, 2009) concluded that the two most effective treatments for PTSD are Trauma-Focused Cog- nitive Behavioral Therapy (TF-CBT) and Eye Movement Desensitization and Reprocess- ing (EMDR). Although there are debates between the proponents of TF-CBT and EMDR as to which is most effective, a meta-analysis of the research does not establish one to be superior to the other (Seidler & Wagner, 2006). Other meta-analyses of PTSD treatments have not resulted in TF-CBT and EMDR being clear-cut winners but show contradictory results, possibly because treatment approaches are sometimes compared with supportive therapy, a kind of sham therapy, something not intended to

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be therapeutic that stops the patient from even talking about the traumatic event (Benish, Imel & Wampold, 2008). Benish et al. (2008) argued that given that the biggest problem with PTSD treatment is that patients drop out, there should be a variety of treatment options so patients can choose the therapy that fits their world- view and is tolerable to them.

Therapies designed to target trauma have several parts in common. The therapist first ensures that the client is safe in their current environment and feels safe in the therapy room. The therapist then introduces a method that helps the client face, or be exposed to, the disturbing memories until they are no longer disturbing, a process termed memory processing. Instead of avoiding the memory (a symptom of PTSD), the client encounters it, re-experiencing its emotional and physical affect. Using numerical scaling questions, often termed the subjective unit of disturbance scale (SUDS), the therapist tracks the client’s level of disturbance as a way of keeping the client within a window of tolerance. The client must stay in contact strongly with the memory but not be so overwhelmed that he or she loses touch with present reality. When processed, the memory changes into a more coherent, narrative form that no longer evokes negative cognitions and painful affect and, therefore, no longer has to be avoided (Foa, Hembree & Rothbaum, 2007; Zayfert & Becker, 2006).

The most widely practiced form of memory processing is a combination of cogni- tive behavioural therapy, behavioural therapy and principles of systemic systematic desensitization, as exemplified in Prolonged Exposure, developed by Edna Foa (Foa et al., 2007). Through imaginal exposure, the client faces the frightening memory repeatedly until habituation to the distressing affect occurs. The client typically recalls the memory in detail, aloud, first with eyes open and in the past tense, then increas- ing the intensity by recalling the memory in detail, aloud with eyes closed and in the present tense. In between sessions, the client is required to undertake daily homework such as listening to the audio taped narrative of the therapy session. The treatment of a single traumatic memory typically takes several sessions.

This approach has been practiced widely for more than 20 years and is empirically validated as highly effective for PTSD (Powers, Halpern, Ferenschak, Gillihan & Foa, 2010). Although this approach works, as a family therapist my first question was: Does it really take that many sessions and homework to process a single traumatic memory? If so the approach has little chance of ever being integrated with couple and family therapy. My answer to this question was no because research has shown that EMDR has been shown to work in about a third of that time, with fewer dropouts from treatment, with no homework (Ironson, Freund, Strauss & Williams, 2002) and cli- ents do not need to tell the whole story aloud.

What is Eye Movement Desensitization and Reprocessing (EMDR)?

EMDR was named after and is most widely known for the technique of having the client focus on a disturbing memory while using their eyes to follow the therapist’s back-and-forth hand movements. EMDR researchers have argued it is more than just exposure therapy and demonstrated that the eye movements make a considerable contribution to the rapid reduction in the intensity of disturbing mental imagery (Lee & Cuijpers, 2013). Francine Shapiro, the originator of the model, emphasized that EMDR is not merely an eye movement technique but a method of psychother- apy that happens in eight phases over several sessions (Solomon & Shapiro, 2008).

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During these sessions the therapist will typically address several traumatic memories because free association to other memories is encouraged, not restricted as it is with CBT Trauma Focused Therapy.One reason EMDR may be more efficient than exposure therapies is because it provides a method for unpacking the memory and heightening the client’s contact with the memory by asking questions to elicit:

� the picture or other sensory information � the affect felt as somatic sensations � the negative cognition � a desired positive cognition � and a SUDS rating level.

Processing involves the client holding a disturbing part of the memory in mind while watching the therapist’s hand moving in front of their eyes in a series of sets of about 25 back-and-forth movements. Unlike exposure based therapy, clients are encouraged to free associate to other thoughts and memories and typically process sev- eral traumatic memories in the course of therapy.

Over the last two decades, there has been noteworthy interest in understanding how EMDR works neurobiologically. Although much of the literature has been spec- ulative and theoretically driven, brain imaging studies have demonstrated that EMDR subjects show changes that correlate with decreased limbic activity and greater emo- tional regulation (Bergmann, 2010). Although most EMDR research has focused on the effect of bilateral eye movements, in practice, EMDR therapists also use hand or arm tapping or auditory tones (Shapiro 2001; Solomon & Shapiro, 2008). Despite the type of sensory input, the distinguishing feature of EMDR theory and practice is that it involves bilateral – alternating each side of the body – sensory stimulation. This raised the question for me: Does sensory stimulation have to be bilateral to have a beneficial effect?

My answer to that question was no because my knowledge and experience of the Emotional Freedom Technique showed me that tapping on only one side of the body, can also be effective in reducing symptoms of PTSD.

What is the Emotional Freedom Technique?

The Emotional Freedom Technique (EFT) was developed by Gary Craig (2008, 2010) who derived it from aspects of Thought Field Therapy (Callahan & Trubo, 2002), then made the method freely available as a self-help and a therapist directed therapy. In this technique, the client focuses on whatever is disturbing, then begins tapping on the hands while repeating a statement of self-acceptance. This is followed by a few minutes of tapping in a particular sequence on particular acupressure points on the hands, head, face and trunk. Proponents describe the process as tapping into the body’s energy field.

In a randomized controlled study using EFT with Iraq war veterans in the USA, veterans reduced PTSD symptoms and ratings of anxiety, depression and insomnia in six, hour-long sessions (Church et al., 2013). Another randomized controlled study (Church, Pi~na, Reategui & Brooks, 2012) demonstrated the effectiveness of a single session of EFT in reducing the intensity of PTSD symptoms in adolescents who had been abused. In a preliminary report not published in an English journal, Andrade and Feinstein (2003) described a randomized double-blind pilot study of more than

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5000 patients in allied health treatment in South America that showed the superiority of tapping over CBT and medication for clients with anxiety disorders.

In reviewing the research for energy psychology, including EFT, Feinstein (2008) concluded that scientific evidence and extensive clinical reports suggest that it can be effective for a range of psychological problems. The mechanism of action proposed by Feinstein is that tapping on acupuncture points stimulates or sends signals to the amygdala.

In disputing Feinstein’s claims, however, McCaslin (2009) argued the research is poor and that the changes described can be attributed to cognitive and behavioural techniques already well-known. He challenged Feinstein’s proposition that tapping works like acupuncture in directly reducing activity in the amygdala, arguing that the same changes in the amygdala occur after cognitive or exposure therapy.

However, EFT compared favourably to EMDR in a randomized controlled study, (Karatzias et al., 2011). Both were found efficient and effective, producing significant therapeutic gains by the end of treatment and at follow-up. The authors concluded that the problem with EFT was the speculative nature of its underlying theory and they called for a dismantling of the approach to understand its effectiveness.

Proponents of EFT maintain that it is the tapping on particular acupressure points on the body, in a particular sequence that creates change. However, with so little sci- ence behind that theory, I asked the question:

Does the client actually have to tap on those particular points? The answer I found to that question was no. Research has shown that subjects

who tapped a few inches away from those points and even clients who tapped on a doll, rather than their own bodies, all improved equally (Waite & Holder, 2003). It is unlikely that the particular points are responsible for the change; it is unlikely to even be the sensation of tapping at all. A form of therapy where clients concentrate simultaneously on the disturbing memory and the sound of the therapist counting aloud has been shown to be as effective as EMDR (Greenwald, McClintock & Bailey, 2013).

Why is it, then, that concentrating on a distracting sensory input, while simulta- neously keeping in mind the traumatic memory, results in faster resolution of trau- matic memories than imaginal exposure alone? Research into the neurobiology of memory reconsolidation reveals that memories are not like videos or photographs, but are created and brought into working memory each time they are accessed. In that activated state, they are, for a short while, unstable and to persist must be restabilised. What is most likely to erode the memory during that state is the overloading of work- ing memory. Sensory inputs that require the most from working memory are those that are most likely to result in an erosion of the clarity and intensity of the accessed memory. This is true for eye movements, tapping sequences and drawing complicated pictures (Gunter & Bodner, 2008), and many other therapeutic interventions (Ticic, Ecker, Hulley & Neimeyer, 2012).

In my silver bullet quest, I received advanced training in EMDR and EFT, both of which offered to deliver more, in fewer sessions, than TF-CBT. Although EMDR held some promise for me, I experienced two big drawbacks. The first, ironically, was also its greatest asset: its rigorous protocol. To follow that protocol still entailed too many sessions away from family therapy. EMDR sees itself as a form of psychother- apy and it lacks the flexibility to be integrated with family therapy as a stand-alone technique. Although it is technically possible for a therapist to conduct single sessions

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using the eye movement technique only, this breaches EMDR protocol. The second drawback was that EMDR internationally is restrictive about who can teach and who can attend training.

The Emotional Freedom Technique had neither of these drawbacks. EFT can be used as single session therapy, something easily integrated with family therapy. The other advantage of EFT over EMDR is its immense flexibility: anyone can teach it, anyone can learn it and there is no protocol prohibiting one from doing it in a single session. It is the lack of a rigorous protocol that is its biggest drawback. In viewing videotapes of EFT therapists working with war veterans using multiple therapists, one is struck by the range of practices in which they engage all under the banner of EFT (http://www.eftmastersworldwide.com/PTSD/).

As someone who trains therapists, I needed a more rigorous protocol. I began to experiment in my practice with clients by combining the EMDR procedure for elicit- ing recall of the traumatic memory with the EFT self-acceptance statement and tap- ping sequence. This allowed me the flexibility of doing single sessions within the context of family therapy but it also provided much greater rigor than using the EFT technique alone. The rapid changes I saw clients make were so surprising to me that I decided to study the process more rigorously. I offered up to three sessions free to parents who were in family therapy with other therapists with the understanding that the sessions would be video recorded.

In the next year I worked with over a dozen parents and have now edited and reviewed the videos from over one hundred sessions, a process that has helped me refine the technique. I began teaching other therapists. To differentiate what we were doing from both EMDR and EFT, we called it Radical Exposure Tapping: radical, because compared with traditional exposure therapy it works fast and often results in a sense of radical acceptance; exposure, because it acknowledges that, like all other memory processing therapies, imaginal exposure to the disturbing event is key; tapping because the ingredient that differentiates it from exposure therapy and EMDR is the EFT tapping sequence.

What is Radical Exposure Tapping?

Radical Exposure Tapping (RET) combines elements of EMDR and EFT to create a memory processing intervention that works quickly in resolving the disturbing affect that goes with distressing or traumatic memories. First, the therapist interviews the client and elicits the story that contains the sequence of behaviour the client wishes to change. Sometimes the client is clear about the original traumatic memory connected to the sequence of behaviour and other times the therapist must elicit it by asking the client to close their eyes and float back to the earliest time they have felt something like this before. The therapist then uses the EMDR procedure to activate the disturb- ing memory neurologically by asking the client to bring the memory to mind while answering the following questions:

1. What do you see? What is the image or picture that is most disturbing? (Sensory) 2. What is the disturbing or negative feeling and where in your body do you feel it?

(Somatic) 3. What is the negative thought about yourself that goes with that? (Negative cogni-

tion)

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4. How disturbing is that right now on a scale of 10? (SUDS)

The therapist notes the keywords that the client uses in answering the above ques- tions. The client is then asked to copy the therapist actions and words while the ther- apist taps using the EFT tapping sequence. The tapping begins by saying, three times, a self-acceptance statement while tapping both hands together in karate chop fashion. After this, the therapist taps two rounds on eight points on the face and trunk while repeating aloud the client’s keywords. The tapping takes about 3 minutes in total. After the second round, the therapist then tells the client to breathe in and out, then asks what comes up?, asking the client to report on whatever he or she now experiences.

Change in the level of disturbance is tracked by asking for a SUDS rating: what number are you now? If the client is still feeling some disturbance, the therapist incor- porates any new keywords and resumes another round of tapping. When the client reports zero, which equates with no remaining disturbing affect in the body, the memory is considered resolved. At that point, the therapist asks the client what they would like to think instead of the earlier negative cognition and one last round of tapping incorporates the positive cognition.

In the following case examples, a single session of RET worked as a silver bullet in transforming the client’s affective block, thus enabling family therapy to continue effectively. In both cases, the ongoing family therapist referred the clients to me for a one or two session consultation and this was my first meeting with the client.

Case Example 1: Mother, ‘They Took My Baby’

When Nicole entered the room and sat down, she reached for the tissue box. Her family therapist had requested that I have a meeting with Nicole because the family therapy sessions were dominated by Nicole’s tears and persistence in talking about how she could not get over having had her son removed by protection services when he was only 3 days old. Although he was now 2 years old and had been back in her care since he was 8 months old, each time she looked at him or talked about him, she cried.

Nicole and her husband had attended family therapy for 2 years after child protec- tion services had ordered them to attend therapy and removed their children. The couple engaged well with the therapist and worked hard over several months to become less chaotic and more authoritative in their parenting, changes that protection services had acknowledged. A plan was in place to restore the children. During that time Nicole had become pregnant again and she believed child protective services would let her keep the baby. She was shocked when 3 days after the baby was born, a young worker came into the hospital and took the baby from her arms. Although Nicole had visited the baby in the foster home twice a week over the next ensuing 8 months, she felt her bond with the baby had been damaged, damage that would not heal when he was returned to her.

Therapist: What is the most painful part of the memory?

Nicole: (Tears rolling down her face.): Them taking him away. I had to sit there like it was okay, like I didn’t care. But I did care.

Therapist: What do you see in the most disturbing scene?

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Nicole: Me standing there alone in shock. The baby’s already gone.

Therapist: What you feel in your body now?

Nicole: A lump in my throat. My arms are numb. Emptiness in my heart.

Therapist: What is the negative thought about yourself that goes with that? I am. . .

Nicole: (crying). . .a bad mother. I thought I was a bad mother cause he’s gone.

Therapist: On a scale of 0 to 10, how disturbing is the memory to you now as you sit here with me?

Nicole: Ten

After describing the tapping process, I asked Nicole to copy everything I said and did.

Therapist: (tapping on the karate chop point) Even though I have a lump in my throat and my arms are numb, my heart is empty, and I am alone in my room, they have taken my baby, I deeply and completely accept myself.

This was followed by two rounds of tapping the eight points while incorporating the client’s words: my baby is gone, my heart is empty, all alone, lump in throat, arms numb, feel like I am bad mother, baby gone, my baby, baby Timmy, they took my baby. All alone. Through her sobs, Nicole repeated the therapist’s words.

Therapist: Big breath in and out. . . What comes up?

Nicole: Now I have a headache. My arms are still numb but I don’t have a lump in my throat.

The therapist repeated the tapping sequence incorporating the new words: head- ache, arms are numb.

Therapist: Big breath in and out. . . What comes up?

Nicole: I see Timmy smiling at me

The therapist repeats the tapping sequence incorporating the new words: Timmy smiling at me.

Therapist: Big breath in and out. . . What comes up?

Nicole: I see Timmy smiling at me. (She looks down, smiling and crying). I see him playing outside with the kids. It’s a nice picture. I know I am doing something right.

Therapist: Go back to the memory we started with. . .and tell me what happens.

Nicole: I’m not thinking about it. (She hesitates, looks down as if searching). Sorry. The picture of Timmy smiling at me is overriding it.

Therapist: Try to bring it back so that you know when you leave here. . .

Nicole: It’s like my mind is hesitating to bring it back. Like my mind doesn’t want to bring that bad memory back. It doesn’t seem as bad because all I can see is his smiling face telling me I am a good mother. Like he’s saying Mummy it’s OK.

Therapist: How disturbing is it to you now out of 10?

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Nicole: About a 5.

Therapist: And what is still disturbing?

Nicole: Not saying goodbye to him. They just took him out of the room. (She pauses). But now even that doesn’t seem like such a big deal. Cause I got him back.

Therapist: Just scan through your body and see if there is any part that still feels upset or disturbed.

Nicole: There’s just little of things they did with him, but all I can see is him smiling at me.

Therapist: Is there any part of your body that feels tight or tense or heavy?

Nicole: No! I don’t have a lump in my heart! I don’t have a lump! (Rubs her hand on her chest as if searching). Every time I talked about it, I would feel like I was just going to swell up and choke myself.

Therapist: So is there any disturbance left in your body?

Nicole: No. There’s nothing. It’s zero. All I can see now is his little face smiling at me. (She looks at the therapist, as if puzzled). What did you do?

Therapist: So when you bring back that memory, what do you want to think instead of I am a bad mother?

Nicole: I am a good mother. Timmy tells me that with his beautiful smile.

The therapist begins a final round of tapping: Even though they took Timmy away from me, I choose to know that Timmy loves me and I am a good mother, then taps two rounds using the Nicole’s words: I got Timmy back and he loves me. He smiles at me. He tells me he loves me. He tells me I am a good mother. With his beautiful smile. I got him back.

Therapist: How are you doing now?

Nicole: Good. Like a big brick’s been lifted from me.

This initial session lasted fewer than 28 minutes. Nicole returned after 2 weeks, reporting, ‘I haven’t thought about those bad feel-

ings since I was here. Having those memories before I couldn’t think about them without crying. Now I am at peace with myself. I have this beautiful little boy and I am his world’.

When I asked Nicole to bring back the memory we had worked on in the first session, she calmly and without emotion told the story concluding: ‘It doesn’t bother me now, cause I got him back. My eyes have been opened up. Instead of dwelling on what was, I am focusing on what is’.

Nicole described other changes. She felt closer to her husband. After the session, she had reached out to him and apologised to him for pressuring him to have another baby. She said that she realized that ‘I don’t need another baby to prove that I am a good mother’.

She said she was no longer shaking and getting upset when driving by the house where she had grown up, the house in which her father had beaten her:

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‘I’m using what happened with Timmy as the role model for dealing with things. Just like I wasn’t a bad mother, I wasn’t a bad daughter. I am not a bad person. I know that he was a bad father and it’s not my fault’.

Her family therapist reported that Nicole no longer cried in sessions and family therapy could move forward.

Case Example 2: Stepfather, ‘Anything to do with Him Just Pushes My Buttons’

Joe, a blue-collar worker in his early 50s, in his own words looked tough. ‘And maybe I am tough but I have a heart of gold’, he said. His wife asked Joe to come to family therapy after she tired of being caught in the middle of escalating arguments between Joe and her 17-year-old daughter, Susie. The family therapist invited Joe to attend a session with me with the goal of becoming less reactive to his stepdaughter. Unbe- known to me, just prior to my interview with him, Joe and his family had spent more than an hour in family therapy arguing over whether Susie and her sister should be allowed to phone the biological father, Peter, using the family home phone. In that session, Joe had been adamant that as long as he was paying the bills, that was never going to happen.

In the first part of my interview with him alone, Joe described Susie as lazy and messy around the house. I elicited a sequence: Susie would leave a mess, Joe would criticize her, she would argue back, and in the resulting escalation, pick up the phone to ring her biological father and complain about Joe. This infuriated Joe and made him even more irritated with her messiness. Anything to do with the biological father, said Joe, really pushed his buttons.

Joe then recounted the story of the Family Court disputes which had resulted in Joe and his wife spending tens of thousands of dollars, losing time from work, never having a holiday, having to sell the family car, and for 2 years having to fight the bio- logical father’s allegations that Joe was a paedophile, allegations that the father ulti- mately withdrew but that had caused Joe humiliation and problems at work. To top it off, although the children had run away from living with their father, Joe and the mother were still legally required to pay child support to him.

When I asked Joe what would be different if we could inoculate him so his step- daughter could not push his buttons, he said that he would be less reactive to triggers about the biological father. ‘So that every time Susie mentioned his name or defended him, I wouldn’t feel like driving across the city to strangle him’. I asked him to bring back the worst memory he had about these events. He had a picture of Peter’s face, tightness in his chest and his negative cognition was I am powerless. We tapped using his keywords: powerless, his face, Family Court, paedophile, ruined my reputation, all that money.

Therapist: Big breath in and out. What happens now?

Joe: I just saw a picture of his face and nothing else. (He holds out his hands as if holding a face in front of him). Just a vision, and then it went away. Wow. How freaky! Something happened!

Therapist: When I ask you how disturbing it is now on a scale of 10?

Joe: It’s gone. He went away. Man! That’s head spin! I can’t say nothing happened. Here – look at the tears. (He points to tears welling up in his eyes). And they aren’t

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tears of sadness. Maybe tears of relief. I’ve got tingling up and down in my spine. I’ve got goose bumps. (He rubs his hands up and down his arms). I am a hard-assed bloke! This kind of thing isn’t supposed to happen to me!

Therapist: What happens when you bring back the thought of Peter?

Joe: I don’t bring back the thought of Peter. It’s just not there. That’s freaky in itself!

Therapist: So if you go home and see Susie picked up the phone to phone her father. . .

Joe: (Calmly). She can do whatever she likes. It’s her father.

Therapist: It doesn’t trigger you?

Joe: No, not at all. (He shrugs and rolls his shoulders). I feel like a whole weight has just been lifted off me.

I spent a few more minutes with Joe, tapping a positive cognition, before ending. The session lasted 33 minutes. Joe walked from the interview room into the waiting room, where his family sat waiting for him. There he announced calmly to Susie and her sister, ‘You can use the home phone to call your father twice a week’.

These two case examples demonstrate how a single session of RET can be inte- grated with ongoing family therapy to deactivate family members from what I have called affective blocks, allowing them to respond more openly and flexibly to other family members.

Integrating Radical Exposure Tapping with Couple and Family Therapy

RET is not a replacement for family therapy, but, an additional component that allows it to take place more efficiently and effectively. Opportunities to undertake RET are most likely to emerge when family therapists are using a trauma lens. As dis- cussed in a previous paper, some elements of this include, getting a trauma focused genogram and trauma list and routinely using tools to screen for symptoms of PTSD. Clues to the existence of unresolved memories of past trauma may also be in interac- tional processes in the therapy room in crucial sequences, in which one person is affectively triggered by the words, the look, the tone, or the body language of another family member (James & MacKinnon, 2012).

In the two case examples described above, I was a consultant to the ongoing primary family therapist, providing only one or two RET sessions before the client resumed family therapy. As a consultant, I had a particular advantage. RET requires the therapist to closely track the client’s process and this means that the therapist can remain neutral rather than being committed to a particular outcome. The more the therapist tries to manipulate the process to accomplish a particular outcome, the less neutral the therapist will be. Neutrality is easier from the vantage point of a consultant than from that of the family therapist, especially for family therapists working in services where clients are required to attend, such as, in court-ordered post separation work or probation.

It is possible, nevertheless, for couple and family therapists to provide a session of RET and in fact, there are situations that demand it. For example, a couple returned to me for their second session and the woman was angry and agitated. The day before, her husband had announced he was having an affair and was considering leav-

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ing her. I found it difficult to conduct the session because anything the husband said resulted in the wife erupting into an angry tirade and verbally abusing him. I asked the husband to step out and I spent half an hour with the wife. In the RET session that ensued, the wife reduced her reactivity to the husband’s news after unearthing and resolving an overwhelming and painful memory of the day her own father announced he was leaving her family. When the husband came back into the room, the wife remained calm during the session.

In another case, in an initial session, a teenage girl became uncontrollably upset when I asked her parents about her estranged brother. Although he now lived far away, the daughter said he had sexually abused her and she was in constant fear of seeing his face in the neighbourhood shopping centre. The intensity of her distress made it impossible to continue the family session with her in the room yet it seemed unwise to continue without her. I asked the parents and siblings to wait outside while I had a meeting with the daughter. In a half hour session using RET, the daughter went from a frenzied state to feeling calm, strong and no longer fearful. We resumed the family session. The daughter announced to her parents that she felt her mind was now clear and that she was looking forward to going back to school because she now felt she could concentrate.

When conducting an RET individual session within a context of continuing couple and family therapy, the family therapist needs to manage issues of confidentiality and communication. How will the transformative changes that take place within the individual RET session be communicated or understood by others in the family? It is preferable to dis- cuss these issues before the RET session. In the example above, I had no time to explain RET to the family because I decided to use it in the individual meeting with the daugh- ter when talking to her only made her more upset. Nor could I have predicted her changes. But when the daughter returned to the family session transformed, the parents were confused and found it difficult to understand how their daughter could have chan- ged so quickly in only half an hour after several months of frenzied outbursts.

Is it possible to use RET with everyone in the family simultaneously when they have all experienced the same traumatic event such as a fire or a car accident? The answer to that question has to be no because even in those instances where family members have gone through the same event, the meaning of that event and the most disturbing fac- ets of it will be different for each family member. The worst part of it for a child, for example, might be the memory of screaming and the terrified look on her parents’ faces, and for the mother it might be the moment she thought that they were all going to die.

Can RET be conducted with other family members present? Occasionally, it is sensi- ble to have a caring family member present, especially if it is a helpful parent while working with a child. When a family member is in the session while the therapist conducts RET, that person is there as an observer only. Their presence can be made less intrusive and more helpful by asking them to tap wordlessly on themselves during the tapping sequences. Therapists must also consider, however, whether the observing person will have an inhibiting effect on what the client is willing to say and, con- versely, whether the observing person will be negatively affected by what they hear. Because the process may uncover memories that have not yet been discussed in ther- apy, the therapist cannot predict what may emerge during the session.

For example, a 30-year old woman, a single mother with a brain injury, and her 60-year old mother were seen in family therapy to strengthen their ability to work as

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a parenting team in raising the mother’s children. In the family session, I witnessed a repetitive sequence in which the grandmother, unprovoked, would criticise her daugh- ter who would burst into tears and fly out of the room. During one of these exits, when I enquired, the grandmother said she had no explanation about the anger behind her verbal attacks. I asked her to close her eyes and float back to the earliest time she felt that same anger. After a moment, her eyes popped open and tears streamed down her face. She said she recalled a memory of her daughter coming up behind her and, in a surprise attack, punching her in the head. She had never dis- cussed that incident with the daughter because, at the time, she believed the daughter could not be held responsible for her behaviour because of her head injury. Since then, she had been on the offensive with her daughter. Using RET, I helped the grandmother resolve the traumatic memory.

When her daughter returned to the room, the grandmother, in an assertive but loving tone, spoke about the incident and told the daughter that she must never hit her again. This time the daughter remained in the room and listened. In this case, it is unlikely that the grandmother would have disclosed the memory of this incident had the daughter remained in the room. If the daughter had remained, it is likely that she would have felt more criticized and become even angrier and defensive, prohibit- ing any likelihood of me conducting RET with her mother.

It is important to consider the effect of offering an RET session to only one part- ner, or family member because doing so my inadvertently frame that person as the cause of the problem or pathologise them in the eyes of their partner or other family members. For example, if in couple therapy, the therapist learns that a woman feared her husband’s angry outbursts during which he yells and throws chairs, it would be inappropriate for the therapist to offer RET to the woman, without first addressing and requiring change from the husband.

There are many situations where fear is a useful and appropriate response. The first principle of working in a trauma focused approach is to address safety. Thus if someone is in an unsafe situation the therapist’s energy should be directed to creating a safety plan and helping the client carry it out.

Could RET inadvertently make a client become less vigilant in an unsafe situation? In working with women who have experienced domestic violence, I do not find this to be the case. When earlier memories of suffering abuse are resolved, these women are more able to cognitively assess situations and decide how best to act to protect themselves. They continue to feel an appropriate amount of fear but they are no longer paralysed.

RET is not a substitute for the therapist addressing the negative dynamic within a relationship and is unlikely to change a behaviour that is functional within the sys- tem. Sometimes children present with symptoms that may appear trauma-based but that are functional in maintaining the relationship between the parents who join to deal with their problem child.

When a child has experienced a traumatic event and has symptoms as a result, possibly RET may help. However, before considering RET, the therapist should first discover whether the child’s symptoms reflect the parents’ symptoms or whether the child’s behaviour is somehow functional within the family relationship system. For example, a 10-year-old girl presented with severe anxiety, nightmares, and inability to concentrate at school. Her symptoms began 2 years earlier after the she had witnessed her father brutally attack her mother. Although she had not seen the father since that incident, the daughter had clear traumatic memories and described the events as

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though they had happened yesterday. The mother herself, however, also had the same symptoms, scoring in the severe range for depression, anxiety and symptoms of PTSD and it was necessary to help the mother with her traumatic memories before the child’s symptoms could be addressed.

Conclusion

So here ends the story of my quest for the silver bullet, a brief intervention that can address affective blocks without disrupting the overall flow of family or couple therapy. The quest took me on a journey through understanding the nature of trauma and the neurobiology of memory through to exploring the sometimes surprising ways how memory can be disrupted and reconsolidated. Now, instead of having that sinking feeling when a client complains that someone or something just pushes my buttons, I look for opportunities for asking: Would you like to feel differently about that?

RET seems most useful for clients who answer yes to that question, those who are distressed by their feelings, want to feel or act differently but feel helpless to change. Clients who do not want to feel differently but are coerced by others to change their behaviour are less suitable candidates as are those who has a vested interest in main- taining their reactivity. A 16-year-old girl once answered that question with, ‘No, I don’t want to feel differently. I want to stay angry. I want to punish my parents’.

RET as described in this paper and practiced by me or by other therapists has been surprisingly effective in addressing distressing life events that commonly emerge in couple and family therapy. This ranges from the mundane – parents who are reac- tive to their teenagers who have a messy room or spend too much time on the com- puter – to the intensely disturbing – bullying, broken hearts, learning about an affair, intrusive flashbacks to physical or sexual abuse, distressing medical intervention and facing the death of loved ones. Results are not dependent on the client believing in the intervention or knowing anything about it, only on their willingness to cooperate with the process.

Even so, the RET as described in this paper is not effective with everyone. For some clients, arousal levels soar too high, exceeding their window of tolerance, and the process requires modification. For others, arousal levels are too low and other techniques must be integrated to increase the affective intensity. Although on the sur- face, RET may appear straightforward, therapists describe it as more difficult to learn than they expect. Considerable skill is require in interviewing the client to elicit the underlying memory and create a focus for memory processing. The therapist must be also be able to tolerate and stay with intense affect and be able to remember the tap- ping sequence and the client’s exact words.

Where to from here? My next step is to document more systematically and quanti- tatively the changes clients experience after one or two sessions of RET and to iden- tify those clients for whom it is more or is less effective. To this end, over the last 2 years, I have worked with a team in providing an RET clinic for clients in a post- separation counselling program. Clients are invited to attend two sessions to work on issues related to post separation and disputes about contact and residence of their children. We are asking: Are some high conflict separated parents actually traumatized? Could therapeutic interventions for unresolved trauma prove helpful?

Answers to these questions and the results from this work will be presented in a paper to follow.

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References Alessi, E.J., Meyer, I.H., & Martin, J.I. (2013). PTSD and sexual orientation: An examination

of criterion A1 and non-criterion A1 events. Psychological Trauma: Theory, Research, Prac- tice, and Policy, 5(2), 149.

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Andrade, J., & Feinstein, D. (2003). Preliminary Report of the First Large Scale Study of Energy Psychology. Energy Psychology Interactive: An Integrated Book and CD Program for Learning the Fundamentals of Energy Psychology. Ashland, OR: Norton Professional Books.

Benish, S.G., Imel, Z.E., & Wampold, B.E. (2008). The relative efficacy of bona fide psycho- therapies for treating post-traumatic stress disorder: A meta-analysis of direct comparisons. Clinical Psychology Review, 28(5), 746–758.

Bergmann, U. (2010). EMDR’s neurobiological mechanisms of action: A survey of 20 years of searching. Journal of EMDR Practice and Research, 4(1), 22–42.

Bisson, J., & Andrew, M. (2009). “Psychological treatment of post-traumatic stress disorder (PTSD)(Review).” The cochrane library 1.

Callahan, R., & Trubo, R. (2002). Tapping the Healer Within: Using Thought-Field Therapy to Instantly Conquer Your Fears, Anxieties, and Emotional Distress. New York: McGraw Hill Professional.

Carlson, E.B., Smith, S.R., & Dalenberg, C.J. (2013). Can sudden, severe emotional loss be a traumatic stressor? Journal of Trauma & Dissociation, 14(5), 519–528.

Church, D., Pi~na, O., Reategui, C., & Brooks, A. (2012). Single-session reduction of the intensity of traumatic memories in abused adolescents after EFT: A randomized controlled pilot study. Traumatology: An International Journal, 18(3), 73–79.

Church, D., Hawk, C., Brooks, A.J., Toukolehto, O., Wren, M., Dinter, I. et al. (2013). Psy- chological trauma symptom improvement in veterans using emotional freedom techniques: A randomized controlled trial. The Journal of Nervous and Mental Disease, 201(2), 153– 160.

Craig, G. (2008). The EFT Manual. Fulton, CA: Energy Psychology Press.

Craig, G. (2010). Emotional Freedom Techniques: The Manual (2nd ed.). Santa Rosa, CA: Energy Psychology Press.

Day, S., Holmes, E., & Hackmann, A. (2004). Occurrence of imagery and its link with early memories in agoraphobia. Memory, 12(4), 416–427.

Engelhard, I.M., van Uijen, S.L., & Van den Hout, M.A. (2010). The impact of taxing work- ing memory on negative and positive memories. European Journal of Psychotraumatology, 1, pp. 5623/1–5623/8.

Erwin, B.A., Heimberg, R.G., Marx, B.P., & Franklin, M.E. (2006). Traumatic and socially stressful life events among persons with social anxiety disorder. Journal of Anxiety Disorders, 20(7), 896–914.

Feinstein, D. (2008). Energy psychology: A review of the preliminary evidence. Psychotherapy: Theory, Research, Practice, Training, 45(2), 199.

Foa, E., Hembree, E., & Rothbaum, B.O. (2007). Prolonged Exposure Therapy for PTSD: Emo- tional Processing of Traumatic Experiences Therapist Guide. New York, NY: Oxford Univer- sity Press.

Gold, S.D., Marx, B.P., Soler-Baillo, J.M., & Sloan, D.M. (2005). Is life stress more traumatic than traumatic stress? Journal of Anxiety Disorders, 19(6), 687–698.

Greenwald, R., McClintock, S.D., & Bailey, T.D. (2013). A controlled comparison of eye movement desensitization & reprocessing and progressive counting. Journal of Aggression, Maltreatment & Trauma, 22(9), 981–996.

Deactivating the Buttons

ª 2014 Australian Association of Family Therapy 259

Gunter, R.W., & Bodner, G.E. (2008). How eye movements affect unpleasant memories: Sup- port for a working-memory account. Behaviour Research and Therapy, 46(8), 913–931.

Ironson, G., Freund, B., Strauss, J.L., & Williams, J. (2002). Comparison of two treatments for traumatic stress: A community-based study of EMDR and prolonged exposure. Journal of Clinical Psychology, 58(1), 113–128.

James, K., & MacKinnon, L. (2012). Integrating a trauma lens into a family therapy frame- work: Ten principles for family therapists. Australian and New Zealand Journal of Family Therapy, 33, 189–209.

Karatzias, T., Power, K., Brown, K., McGoldrick, T., Begum, M., Young, J. et al. (2011). A controlled comparison of the effectiveness and efficiency of two psychological therapies for posttraumatic stress disorder: Eye movement desensitization and reprocessing vs. emotional freedom techniques. The Journal of Nervous and Mental Disease, 199(6), 372–378.

Lancaster, S.L., Melka, S.E., & Rodriguez, B.F. (2009). An examination of the differential effects of the experience of DSM–IV defined traumatic events and life stressors. Journal of Anxiety Disorders, 23(5), 711–717.

Lee, C.W., & Cuijpers, P. (2013). A metaanalysis of the contribution of eye movements in processing emotional memories. Journal of Behavior Therapy and Experimental Psychiatry, 44(2), 231–239.

Matthiesen, S.B., & Einarsen, S. (2004). Psychiatric distress and symptoms of PTSD among victims of bullying at work. British Journal of Guidance & Counselling, 32(3), 335–356.

McCaslin, D.L. (2009). A review of efficacy claims in energy psychology. A review of efficacy claims in energy psychology. Psychotherapy: Theory, Research, Practice, Training, 46(2), 249– 256. doi:10.1037/a0016025

Mol, S.S., Arntz, A., Metsemakers, J.F., Dinant, G.J., Vilters-van Montfort, P.A., & Knottne- rus, J.A. (2005). Symptoms of post-traumatic stress disorder after non-traumatic events: Evidence from an open population study. The British Journal of Psychiatry, 186(6), 494– 499.

Powers, M.B., Halpern, J.M., Ferenschak, M.P., Gillihan, S.J. & Foa, E.B. (2010). A meta- analytic review of prolonged exposure for posttraumatic stress disorder. Clinical psychology review, 30(6), 635–641.

Seidler, G.H., & Wagner, F.E. (2006). Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: A meta-analytic study. Psychological Medicine, 36(11), 1515–1522.

Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures (Second Edition). New York, NY: Guilford Press.

Solomon, R.M., & Shapiro, F. (2008). EMDR and the adaptive information processing mod- elpotential mechanisms of change. Journal of EMDR Practice and Research, 2(4), 315–325.

Ticic, R., Ecker, B., Hulley, L., & Neimeyer, R. (2012). Unlocking the Emotional Brain: Elimi- nating Symptoms at their Roots Using Memory Reconsolidation. New York, NY: Routledge.

Van Hooff, M., McFarlane, A.C., Baur, J., Abraham, M., & Barnes, D.J. (2009). The stressor Criterion-A1 and PTSD: A matter of opinion? Journal of Anxiety Disorders, 23(1), 77–86.

Waite, W.L., & Holder, M.D. (2003). Assessment of the emotional freedom technique. The Scientific Review of Mental Health Practice, 2(1), 1–10.

Wild, J., Hackmann, A., & Clark, D.M. (2008). Rescripting early memories linked to negative images in social phobia: A pilot study. Behavior Therapy, 39(1), 47–56.

Zayfert, C., & Becker, C.B. (2006). Cognitive-Behavioral Therapy for PTSD: A Case Formula- tion Approach. Guilford Press. http://www.eftmastersworldwide.com/PTSD

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