OEI Observed Experiential Integration for Trauma A New

OEI: Observed & Experiential Integration for Trauma: A New Trauma Therapy Rick Bradshaw, Ph. D, RPsych Trinity Western University rickphyl@telus. net Laurie Detwiler, M. A. , C. C. C. Kwantlen Polytechnic University (laurie. detwiler@kwantlen. ca) CCPA Annual Conference Ottawa, ON May 18, 2011

Polyvagal Theory & Co-Activation of Sympathetic & Parasympathetic • Stephen Porges (2001, 2007) Polyvagal Theory – Social Connection – Ventral Vagal Complex (VVC) – Brake = On – Fight or Flight – Sympathetic Nervous System – VVC Brake = Off – Freeze – Dorsal Vagal Complex • OEI – Neuro-Activation & Micro-Attunement together – Mirror Neurons, Embodied Simulation, Intentional Attunement • OEI – Switching for Titration, Glitch Massaging, Transference – Extraocular muscles, Intraocular muscles, and Proprioception • OEI – Switching for Artifacts, Release Points, Sweeping – Feigned Death (Freeze) responses – Chest, Airway, Stomach

Observed & Experiential Integration (OEI): What is it? • • • SWITCH – Alternately covering & uncovering the eyes SWEEP – Covering one eye, guiding other eye across TRACK – Guiding one or both eyes, watching for glitches GLITCH MASSAGE – Guiding eye(s) over/out of glitches GLITCH HOLD – Bilaterally stimulating, holding in glitches RELEASE POINTS – Places to guide eyes for release of: * Hyperventilation & temporary cessation of breathing * Chest compression & throat constriction (LR & Abducens) * Nausea, queasiness, abdominal cramping (SO & Trochlear) * Jaw tension and tooth grinding

OEI: What is it used for? • Rapid de-escalation of affective & somatic intensity • Assessment & treatment of negative transference • Avoidance of, and relief from, panic attacks • Overcoming addictions, including self-harm • Dissolving barriers to performance

The Self-Trauma Model: Briere • Flashbacks constitute natural attempts of the human brain to desensitize traumatic material, but… • In those with severe, prolonged childhood trauma there is often a developed capacity to dissociate when overwhelmed (Lanius) • This leads to cycles of abreaction and dissociation (PTSD, CPTSD, DDs)

OEI & the Abreaction-Dissociation Cycle Dissociation …Therapeutic Window Staying within the… Abreaction

Once upon a time…. Two psychotherapists in Vancouver Canada (Audrey Cook & Rick Bradshaw) • Working with abuse, neglect and other trauma • Finding ‘talk therapies’ ineffective for PTSD, Complex PTSD, and Dissociative Disorders likely because… • Psychological trauma affects different areas of the brain than speaking and listening….

1994 & ‘ 95 Audrey Cook found that: EMDR wasn’t working with some CPTSD/DD clients: – Those with ‘lazy eyes’ couldn’t track their therapist’s fingers with both eyes at the same time – Some clients were too dissociated & disconnected – Some clients were overwhelmed by intense abreactions • Thought: “I wonder if it would work one eye at a time” - Led to OEI ‘Switching’ (alt covering eyes) SWITCHING VIDEO DEMO

OEI and EMDR: Differences EMDR Doesn’t address negative transference between therapist & patient No acknowledgement of tiny halts or hesitations in eye movements OEI Includes transference checks & clearances for individuals & groups Involves identification and resolution of tiny halts or hesitations-eye movement No recognition of “side effects” of trauma processing on additional aspects of the past Techniques for resolving “artifacts” like headaches, dizziness/drowsiness, and visual distortions

OEI and EMDR: Differences EMDR Mechanism = eye saccades and rhythmic sounds or taps (PGO region of the brain) OEI Mechanism = different than eye saccades and rhythmic sounds / taps; Can involve simple covering of eyes Cognitions are essential in protocol – Negative Cognition, Positive Cognition, SUDS, Vo. C Cognitions not in protocol. Numbers optional rather than required. Observe Intensity & Conflict Markers

OEI and EMDR: Differences EMDR OEI Requires use of both eyes One eye at a time or two simultaneously eyes Vision not required. Can use sound or touch to stimulate the brain mechanism Requires vision to sense light & track movement across both visual fields Does not acknowledge or address nausea, hyperventilation & cessation of breathing, chest tightening, or jaw clamping Includes “release points” for nausea, hyperventilation & cessation of breathing, chest tightening, and jaw clamping

OEI and EMDR: Similarities Can be performed using both eyes. Procedures in both therapies involve the tracking of a moving object (therapist finger, wand, etc. ) Involves focusing on trauma in multi-sensory fashion to expose individual to the intensity of past experiences Involves arousal of fight-or-flight response and/or freeze response via midbrain & forebrain.

Speech Area: Speech Production

Listening Area – Understanding Speech

Limbic & Paralimbic Structures • The parts of the brain most involved in producing intense symptoms, like: • Panic, flashbacks, startle response, nausea, and throat or chest constriction • Are not directly affected by talking or listening

Limbic System: Midbrain

Anterior Cingulate Gyrus

Eye & Brain Connections • Both eyes have connections to both halves of the brain • Half of each visual field in each eye is associated with half of the brain, and the other half of each visual field is associated with the other side of the brain. Integration can occur with one eye at a time or both eyes

OEI TECHNIQUES & APPLICATIONS An Overview of OEI Procedures with Treatment Targets by Dr. Rick Bradshaw

5 Building Blocks of OEI Level I Techniques Switch Sweep Release Points Level II Techniques Glitch Hold Glitch Massage

OBSERVATIONS & DISCOVERIES 1 Core Trauma Symptoms: • Encountered during processing of traumatic material • In the center or ‘core’ of the body. Symptoms include: • • • Hyperventilation temporary cessation of breathing chest compression throat constriction nausea • OEI switching reduce & glitch work dissipates intensity • Intensity, type of emotion, & location of body sensation usually differs, depending on which eye is covered

Core Trauma vs Artifacts p. 30

OBSERVATIONS & DISCOVERIES 2 Dissociative Artifacts: • In response to intensity of trauma processing • Outside (peripheral to) the core of the body • Symptoms include: • • • visual blurring & occlusions headaches & pressures tingling & numbness (hands, face, feet) Dizziness, lightheadedness, loss of balance drowsiness • Usually dissipated quickly with switching & sweeping • Balance boards to assess & minimize dissociation

OBSERVATIONS & DISCOVERIES 3 Shock: “Can you believe it…. ? ” • Incongruence: Severity of incident not accompanied by expected emotional & physical intensity markers • Process seems blocked by shock • Switching and asking the questions: • • “Can you believe __(name)__ did that to you? ” “Can you believe ___(name)___ was killed? ” “Can you believe you can’t believe it? ” “Can you believe any man would do that to anyone? ” • Shifts clients out of disconnected states • Not unusual for clients to be connected to the reality of an event with one eye open but not with the other open

OBSERVATIONS & DISCOVERIES 5 Eye Dom. & Affective/Somatic Differences • Dominance check: The Dominance Factor (Carla Hannaford) • Majority of clients = more fear & anxiety w dominant eye = sadness & despair w non-dominant • If much early onset abandonment/abuse, less predictable Often ‘sad & mad’ or ‘sad & afraid’ • Difficulty holding gaze: shame or fear of disapproval

OBSERVATIONS & DISCOVERIES 4 Transference Checking & Clearing • During switching for core trauma symptoms and dissociative artifacts, clients disclose differences in perceptions of therapists, depending on which eye is covered, including differences in: • • • Perceived proximity of person (close, distant) Color (green or gray to red or yellow) Perceived age or facial expression (angry, caring) Perceived proportions of head & body Perceived attitude or mood of therapist • Switching dissolves these perceptual distortions • Sometimes add glitch work for resistant distortions • Extended to: • • Mirror work - body/facial dysmorphic disorder Body image perceptions – eating disorders Families & groups (couples/parenting/attachment) Substitutions (photos, videos, symbols & objects)

OBSERVATIONS & DISCOVERIES 6 Release Points: P. 27 • Glitches = most intense place in most intense eye • Release = least intense place in least intense eye • Respiratory system: cover Dom eye, lowest rib, ND side • Gastrointestinal: cover Dom eye, lowest rib, Dom side • Jaw Tension: alt cover eyes, level of lips, 180º to 90º VIDEO OF RELEASE POINTS

Release Points P. 27

Technique Release Points Application Target Respiratory (Chest) Breathing Gastrointestinal (Throat) (Stomach) Jaw Compression Constriction Nausea Tension

Key External Events 1 1999: Audrey has discovered use of both objective and subjective applications for glitch resolution EMDR International Association Conference, Las Vegas: First Clinician Manual, First Video* Audrey demonstrating subjective glitch track & hold w bilateral audio stimulation in Las Vegas (video) 2002: 2 nd ed. of OEI Clinician Manual: Hi’s, Lo’s, I/O, H/V/D 2003: OEI Training DVD, first OEI RCT (delayed C)

Key External Events 2 2004: Combine OEI with body therapies (massage) Start arc patterns to reduce lens refocusing 2005 -6: Comparative experimental RCT (18 -mo RCT) Titrate with therapist body & face, postures 2007 -8: 20+ conference papers, OEI Client Handbook Glitch massage: proximal-distal movements

Technique Application Target Partners Transference Mirrors Switch Titration Intensity Clearing Artifact

Technique Sweep Application Clearing Target Artifact

New Applications & Combinations • Process & chemical addictions, eating disorders (urges) • Inner voices, self-loathing, and self-harming behaviours • Peak performance (focus on goals, target interferences) • Dissociative disorders & attachment difficulties (states) • Somatic symptoms (fibromyalgia, MS, PNES, chronic pain) • Combined w language acquisition & accent reduction • Combined w systematic desensitization & psychodrama

Cross-cultural applications Indonesia: • GAM vs Military conflict & Tsunami expatriates vs locals • “Massage your brain using your eyes to lift your heavy heart” • Gender differences (vulnerable vs guarded emotions) Korea: • ‘Expert’ professionals ‘fix’ problems • Somatic symptoms = less loss of face • Medical procedures to treat symptoms 1 st Nations: • Family members & community share • Attending to quality of relationships • Healing broken attachments (RHAP)

Glitch Tracking & Massaging Saw note (EMDR listserve): skips/halts in eye movement • Resolution of intensity & dissociation with ‘massage’ • Patterns were associated with different targets/events • ‘Glitches’ seem to clear after massaging ‘stuck points’ • Thought: “I wonder if continued work will bring healing? ” Led to OEI Tracking & Glitch Work/Massage TRACKING & GLITCH MASSAGE VIDEO DEMO

Technique Application Target Partners Transference Glitch Massage Mirrors Titration Intensity Clearing Artifact

Technique Application Glitch Hold with Restoration Bilateral Stimulation Target Visual Splitting Titration Intensity Clearing Artifact

The Future of OEI - Part I Unique Contributions of OEI: • Easily & quickly integrated with otherapies • Reduces interference with cognition & speech (top down) • Psychological “Emergency Room” procedures • Self-help procedures facilitate affect regulation • Increases midbrain-to-prefrontal integration (bottom up) • Reduces addictive & self-harming urges

Complex PTSD Symptoms & OEI (CPTSD was defined by Herman, elaborated by Curtois) There are OEI techniques that address these: • Affect Dysregulation See one-page handout for details • Dissociation/Numbing • Negative Self-Perceptions • Internalized Perpetrator Beliefs • Difficulties in Relationships with Others • Somatic Symptoms – Abuse-Specific, Other • Despair & Shattered Assumptions of Hope

Observed: Therapist watches for glitches while tracking Therapist watches for conflict & intensity markers Therapist watches for visual splitting/dilation Experienced: Client cues therapist during tracking (Track-to-Target) Client notices & reports all artifacts Client notices & reports level of intensity

Equalization: intensity, colour, light, body tension Combination: emotions (mad & sad) blend or dissolve Joining: alters (infant, child, teen, adult) merge Sensory: double vision clears, pains resolve Dissolution: visual distortions clear Resolution: objects that were invisible materialize

First Study of OEI with PTSD • Mixed Traumas (witnessing suicides, MVAs, assaults, accidental deaths) and mixed gender • Random Assignment to OEI or delayed treatment control group, only switching • Script-driven symptom provocation, C = +2 Exp • CAPS and IES-R

Treatment vs Control: CAPS Clinician-Administered PTSD Scale (CAPS) scores from Time 1 to Time 2 for control group (n = 5) and treatment group (n = 5). The dashed horizontal line reflects a threshold for clinically significant levels of PTSD symptoms (Orr, 1997).

IES-R Avoidance/Numbing Impact of Event Scale-Revised (IES-R) Avoidance & Numbing subscale scores, Time 1 to Time 2 for control group (N = 5) and treatment group (N = 5).

Presentation by Laurie Detwiler, Faculty Member,

The Place of Trauma Therapy in the Process of Recovery from PTSD CCPA Annual Conference May 18, 2011

Research Questions • What critical incident helped or hindered your process of recovery from PTSD? • What event or experience helped or hindered your process of recovery from PTSD? • Follow up questions fit well with the method.

Validity • Careful definition of the purpose of the research • Qualified observers • Final follow up Reliability • Independent judge sorted 25 incidents into helping and hindering categories • Interpreter reliability: 92% inter-rater agreement between judge and primary rater

Interpret and Report • 8 people, 6 women and 2 men, aged 28 to 54 yrs (average = 45 yrs) • 6 Caucasian, 2 Caucasian & First Nations • Diagnosed with PTSD in 2003 during a trauma therapy study • Traumatic incidents ranged from sexual assault, emotional abuse, witnessing a death and car accidents • Range of events & time since traumatic event

Categorical Descriptions (helping) 1. Awareness of Recovery Coming From Involvement in Trauma Therapy Study 2. Resources, including Spirituality, Marital/Family, Financial, & Physical 3. Coping Strategies 4. Developing New & Positive Relationship With Self

Categorical Descriptions (helping) 5. Growth From Trauma 6. Understanding Your Own Life Experience 7. The Importance of Being Listened to, Cared For, Validated and Accepted For Who You Are by a Professional Helper 8. Making Personal Choices to Lead a Healthy Life

Categorical Descriptions (helping) 9. 10. 11. 12. Unexpected Positive Circumstances Knowing That You Are Not Alone Talking Today Was Impactful Forgiveness

Categorical Descriptions (hindering) 1. 2. 3. 4. Limitations in Resources ICBC Is An Unhelpful System When Boundaries Fall Difficulty Coping

Categorical Descriptions (hindering) 5. 6. 7. 8. Fear Magnification The Physical Pain Cycle Harmful Healers Being In Situations Similar to the Original Trauma

Categorical Descriptions (hindering) 9. Unexpected Negative Circumstances 10. Can Not Forgive Self 11. Sexual Difficulties

Follow Up Themes 1. Recovery is a process which includes more than therapy, and all categories are important 2. However, OEI was very important in recovery for all 8 (two said 10/10, average score = 8/10) 3. Lack of Social Support as a theme was big, in particular Brewin’s (2003) “Other as Betraying” 4. Also: “Other as Abandoning” Brewin (2003)

Latest Sexual Assault & PTSD Study • Comparative Experimental Treatment Outcome • 1 year to recruit 137 women, screened to 33, 18 Months from Start to Finish, Participants • Quantitative, Qualitative & Psychophysiological Measures in cross-over design

Research Design I • Selected Trauma of Interest: 20% of women sexually assaulted in lifetimes and almost 50% of those develop PTSD • Script-Driven Symptom Provocation: 50 second audiotape of most intense portion of trauma played on 4 occasions + TMI-PS • Cross-Over Design: CPT-R in phase I gets OEI in phase II, OEI in phase I to CPT-R

Research Design II • Controls: Random (Wave) Assignment to Groups and Therapists within Groups • Assessors Blind to Group Assignments • All Participants Receive Control Condition (B. R. A. I. N. ) and Active Therapy Participants Receive 3 sessions of OEI or CPT plus 4 hours of Psychoed (sessions & groups videotaped) • Credibility Checks for all Interventions (COTQ) • Manualized Treatments

Results - CAPS Time: F(2, 21) = 49. 62, p =. 04, η 2 =. 83 Time*Group: F(4, 42) = 2. 96, p =. 03, η 2 =. 22 Group: F(2, 22) = 1. 32, p =. . 29, η 2 =. 11

Results – IES-R Numb/Avoid ▲ Control Group ↑ Cognitive Processing Therapy * One Eye Integration

Qualitative Interview Findings • Randomly selected cases from OEI & CPTSD groups, interviewed at 3 -month follow up: – OEI: More profound reduction of PTSD symptoms – CPT-R: Improved ‘coping’ & self-referencing beliefs • When participants interviewed after cross-over: – Majority of participants (~ 75%) chose OEI as ‘most beneficial’ of the two therapies after having both – Therapy preference: Interesting trend by MBTIThinkers to prefer CPT-R (“makes sense”, “logical”)

Limitations • • • Small N & significant screening process Females, mainly Caucasian, sexual assault Manualization may have affected bond – OEI Script-driven symptom provocation – 1 trauma Small treatment doses (3 hrs. individual plus 4 hours group per therapy, along with exposure & psychoeducation components) • Extended periods with no active treatment: (3 months + 3 months), additional traumas

The Future of OEI - Part II (You) Diffusion of Innovation Theory Diffusion of Innovations 5 th ed. (Rogers, 2003) Lovejoy, Demireva, Grayson, & Mc. Namara (2009) • Relative Advantage: better job performance & $’s • Compatibility: congruence with existing frames • Complexity: difficulty in learning, comprehending • Trialability: pilot testability on small scale • Observability: visibility of positive outcomes

Acknowledgements Fahs-Beck Foundation for Experimental Research New York Community Trust Dr. Marvin Mc. Donald, Dr. Paul Swingle, Dr. Jose Domene, Kristelle Heinrichs, Dave Grice, Marie Amos, Karen Williams, Kiloko Ndunda, Jessica Houghton, Jake Khym, Becky Stewart, Jen Mc. Innes, Darlene Allard, Tanya Bedford, Heather Bowden, Gillian Drader, Brenda De. Vries, Danielle Duplassie, Sandra Dykstra, Ida Fan, Esther Graham, Maren Heldberg, Nadia Larsen, Michael Mariano, Beverly Ogden, Steivan Pinoesch, Mandana Sharifi, Nidhi Sharma, Chris Tse, Dana Vanderwiel, Dawne Visbeek, Melissa Warren, Linda Gibson, Andrea Busby, Melissa Ducklow, Kwantlen nurses, TWU UG Psych students.