The Process of EMDR Therapy with Addictions
EMDR & Beyond Team members Alicia Rowley LMHC, CADC,Approved Consultant, and Katrina Serfling LMHC, NCC, Approved Consultant provide sound practice wisdom and expert resources for addressing addictions with EMDR Therapy. Here is what they have to share with us:
Introduction
When we decided to write a post about addictions work and EMDR, it was difficult to decide where to start. There is so much to consider! All our clients likely have an addiction to something, whether it’s eating, smoking cigarettes, staring at their phone, watching TV; the list goes on. All of these behaviors our clients report started as a solution from something much bigger. In the process of using their new solution, some behaviors and substances became the problem they struggled with in their own right.
We would like to assist our colleagues in using EMDR and addictions protocols and interventions regardless of specializing in addictions work. We‘re all capable of meeting and doing EMDR with our drug or other addicted clients. Areas this post will cover include: where to start, stages of change, useful tools for each stage of change, two handed interweave with addiction, Internal Family Systems (IFS) & Ego State work, and brief coverage of our experience with the DeTur protocol for addiction.
History taking: Flagging Behaviors
After taking a thorough assessment history, one of the unique challenges in working with substance use disorder clients is trying to figure out where to begin. Do I address the underlying trauma? The triggers to use? Can my client stay sober when their living situation is unsafe?
Guidance was offered by Hope Payson’s Treating Substance Abuse and Compulsive Behavior with EMDR Therapy* training, presented recentlly in our area. They shared red, yellow, and green flag behaviors to utilize during the assessment phase. A client showing red flags relates to suicidal and homicidal thoughts, dissociation, lethal drug/alcohol use, or pressing medical and safety concerns. Sometimes when noticing red flags,a ‘case manager hat’ is required in reconnecting the client with sober or safe supports or referring to a higher level of care offered by residential or outpatient substance abuse treatment programs.
Yellow flags might mean the opportunity to ‘proceed with caution’ with clients in testing affect tolerance, ability to discuss trauma, learning new coping skills to replace compulsive/addictive behavior, and ability to stay in the present. These are essential steps in the preparation phase of EMDR therapy.
Some green flags with a client might be being able to utilize the tools and resources practiced in session, tolerate feelings, and exhibiting more stability. When noticing green flags, this might be an opportunity to move forward with EMDR reprocessing of trauma. Assessing readiness for processing typically includes the client being able to stay within their window of tolerance.
Preparation: Popky’s DeTur & Kiessling’s Extended Resourcing
If you are still concerned on where to start, creating calm place, container, and practicing Aj. J. Popky’s DeTur Protocol for triggers and cravings are useful during the assessment phase.
The other key tool to utilize is Extended Resourcing from Roy Kiessling’s EMDR Consulting’s EMDR Basic training. This protocol highlights and reinforces skills our clients use to abstain from use or make it through a triggering event. Clients often carry the weight of those negative core beliefs about self, so it can often be difficult to notice the positive. When a client chooses not to go to the liquor store or engages in safe coping, it’s important for them to recognize that part of self (sober self) or the skill (resilience) within him or her, and where they utilized this skill from the healthy part of self.
We access the positive emotions and sensations and further enhance this experience through tapping in with BLS. Although extended resourcing is supposed to enhance all the “feel goods,” we found substance abusing clients require a lot of guidance and support to notice the positive feelings about themselves and where in their bodies they notice that good feeling. They are frequently not used to feeling the ‘good stuff ‘ without the substance. Do make note of the pesky inner critics or difficulty feeling positive about self that come up for later addition to their target sequence planning. Remind clients that it is also our job to help them recognize the ‘good stuff’ along with reprocessing the ‘bad stuff.’
Stages of Change Model
Another way to assess where to begin is by using the stages of change model by Prochaska and DiClemente as this is a piece you are continually reassessing with substance use disorders. It’s not uncommon for clients to vacillate between stages of change,sometimes taking two steps forward and one step back. We often meet clients at various stages of change and it’s important we are using the tools that fit the stage of change a client is currently experiencing. For pre-contemplation and contemplation, we use Jim Knipe’s maladaptive positive feeling state protocol from his book EMDR Toolbox: Theory and Treatment of Complex Trauma and
Dissociation, which investigates what’s the best part about continuing to [insert addictive or compulsive behavior here]. These protocols help establish the relationship between a client and their substance use or compulsive behavior has developed as a solution to their trauma in a nonjudgmental way.
FSAP & Two Hand Interweave
The better we understand this relationship between positive feeling state achieved and compulsive/addictive behavior, the more effective we can be in assisting clients in finding healing. It’s also important to validate and normalize the discussion around their substance use or compulsive behavior by asking ‘what’s the best part about it’? This opens the discussion up for exploring the advantages of substance use. As we were talking about our experiences with maladaptive positive feeling state protocol (FSAP by Robert Miller), we both expressed having inconsistent success in unlinking the positive feeling state from the compulsive behavior. We still found it to be valuable as a psychoeducational piece. It brings the client’s ambivalence about change into the room so it can be addressed.
When the client is in the contemplative stage of change (weighing the pros and cons of substance use), there are some great interweaves or interventions that many of us know which fit easily into addictions work. One intervention we use frequently with our clients is the Two Handed Interweave developed by Robin Shapiro. It works in so many ways!
Typically, you have clients imagine in each hand their black and white thoughts (e.g. a part that wants to be sober versus part that says, “Screw it! Why shouldn’t I use?!”). Then, engage in fast processing speed for roughly 60 seconds and check in; each client is different and will need different lengths of time for this, but start with 60.
This interweave can be used as part of regular reprocessing or as a stand alone. Another way to use the two handed interweave would be to put a positive feeling state of a substance in one hand and negative consequences in the other. We found many clients have also benefited from putting the version of themselves they want to be in one hand and the place on their journey where they actively are in the other. It helps them to identify how far they have come and be more gentle with themselves in their process. The two handed interweave can assist clients in moving into the preparation and action stages of change by allowing them to increase hope and have stronger personal insights about their use.
Processing: Integrating Ego States and IFS
Additionally, we found a lot of meaningful progress in our integration of ego states and IFS (Internal Family Systems). Although they appear to blend very easily, we know they are definitely not the same. When began using these interventions with clients, we saw an extreme shift in their progress. Many who struggled with experiencing emotions were suddenly filled with tears that they could now tolerate and could connect with struggling parts of themselves. Then the work can begin!
It’s a subtle method to externalizing the addiction or compulsion, as separate from the self; however, it also communicates that the addiction is part of them, but not “who” they are in totality... it is also not something that can be dismembered or forgotten. Ego State and Internal Family Systems theories (IFS (Richard Schwartz: Internal Family Systems) encourage addicted clients to accept and work with every aspect of themselves. These interventions add curiosity about those aspects of self and fosters communication internally. Many of our addicted clients are not familiar with empowering internal dialogue as they have hated themselves for so long.
IFS in particular highlights the role of the fire fighter which is the addictive behavior; or, as IFS explains, is actually the defense system. IFS encourages curiosity by helping the client be interested in what is making the firefighter/defense system engage. As you discuss with your client and they become curious, this is the opportunity to write down areas for the future target sequence development. To learn more, please check out Robin Shapiro’s book Easy Ego State Interventions which we both highly recommend. Another good read is Self Therapy by Jay Earley, which provides a nice ‘step by step’ approach to IFS, as well as language to use in session. The Internal Family Systems Skills Training Manual by Frank G. Anderson, Martha’s Sweezy, and Richard Schwartz is also a great resource. Overall, these methods do a great job of reducing shame and encouraging clients to accept their “firefighters” (IFS) as parts of self that are there to assist them. Even though they can recognize how that help is now maladaptive it was helpful at some point!
Utilizing DeTur
Lastly, DeTur is something with which we both have had experience after attending Hope Payson and Kate Becker’s EMDR and Addictions workshop. We initially had some concerns around doing DeTur with a client. After all, we are purposefully activating the addicted part of the brain to work with in our office. We wondered, “Am I going to cause my client to relapse? What if I can’t help my client ease their urge?” But, if you really think about it...what better place for a client to get activated than in your office rather than triggered by their daily life events they must address on their own?
This was a shift in some of the CBT-based addiction training we had received when beginning our careers, where we teach clients to avoid substance using thoughts versus asking them to notice or get curious about their thoughts. Learning to accept and get curious about substance abuse thoughts, urges and cravings rather than experiencing them as something to be ashamed of is extremely powerful. Although we would recommend familiarizing yourself with the full DeTur protocol first, it is very effective.
Desensitizing Triggers
There is one portion of this protocol we want to highlight, learned from Kate Becker and Hope Payson’s training, in which you work on desensitizing a trigger. What you do is ask your client to notice all the words, tastes, smells, emotions, and body sensations related to the trigger and how intense that is on the 0-10 scale. then, you have the client notice where s/he feels these urges in their body and focus on the trigger while doing long, fast sets of BLS until level of urge (LOU) is a 0.
Helping a client get to 0 has been transformative to watch! It is amazing to see, in a short amount of time, a client having the power to notice the intensity of a trigger reduce is most encouraging! As with most substance abusing clients, they are worried the feeling will last forever. When they notice the shift within their bodies and minds, as the intensity passes, it is very hopeful and healing. Additionally, DeTur encourages us to utilize a future script for encountering a trigger, once level of urge (LOU) has been brought down to 0. Since our imagination is so strong, this can really support and encourage clients who may typically live in fear of triggers.
Summary
There is just so much fun and interesting EMDR related addictions material out there and we continue to learn. As our clients progress through their stages of change, there are multiple options for doing standard EMDR with addictions interweaves you can implement. There are also many options for adaptive information to be developed and enhanced as resources going forward. Additionally, ending a session with ‘future healthy self’ (an adaption of DeTur’s Future Template) is very effective. This involves tapping into that good self love as encouraged with ego state or IFS, or simply tapping in strides they have made, assisting them in their end of session experience.
To Learn More
EMDR & Beyond highly recommends Hope Payson’s training on EMDR and Addictions. Listen to Elyse Harper’s excellent discussion with Hope on the latest understanding of addictions and treatment on her podcast Healing Confessionals: Understanding the Multiple Roots of Addiction* As we were writing this post, Katrina reached out to Hope Payson about a very timely addictions documentary, Recovering Community: A Documentary of Hope, that she is releasing. This excellent addictions and recovery documentary is now available by request for virtual distance viewing from Hope, for clinicians and community members.
We hope this post encourages you to take a further step into EMDR and Addictions work in your EMDR clinical practice!
Alicia Rowley, LMHC, CADC EMDR Therapist,, Approved Consultant & Substance Abuse Specialist alicia@aliciarowleycounseling.com
Katriine Serfling LMHC, CADC Certified EMDR Therapist, Approved Consultant & Substance Abuse Specialist kmserfling@gmail.com
*additional resources about addictions with Hope Payson