Trauma – Bessel van der Kolk -The road to recovery - Letting Go of the Past: Emdr - The Rike

Is this delusional, or just sleepwalking? Is that music? Am I awake or sleeping?

– John Keats

David is a middle-aged contractor who came to see me because his violent temper was turning his family into a living hell.

When we first met, David told me what happened in the summer when he was 22, when he was working as a pool lifeguard. One afternoon, there was a group of teenagers playing loudly in the pool and drinking beer, and David said they weren't allowed to drink. The group attacked him, one of whom stabbed him in the left eye with beer bottle fragments. 30 years later, he still has nightmares and is haunted by the horrific attack.

He does not show affection for his wife, he is harshly critical and often shouts at his teenage son for small mistakes. On some level, he felt that losing one eye gave him the right to mistreat others, but he also hated the angry, hateful person he had become. He realized his efforts to manage his rage had kept him stressed and wondered if it was his fear of losing control of things that kept him from feeling love and friendship.

When David came to see me for the second time, I introduced him to Eye Movement Desensitization and Reprocessing (EMDR). I asked David to reminisce about the time he was attacked, to recall the images he saw, the sounds he heard, the things he was thinking at the time. I told him, "Let those moments come back." Then I asked him to follow my index finger as I held my finger about 30.5 cm from his right eye and moved it back and forth slowly. Within seconds, he recalled a rage and terror, painful sensations, blood dripping down his cheeks and he found himself unable to see anything more. As he recounted these feelings, I occasionally said words of encouragement and continued to move my fingers back and forth.

Every few minutes, I stopped and asked him to take a deep breath. Then I asked him to pay attention to what was going on in his mind, which was a brawl at school. I asked him to pay attention and keep himself in that memory. Other memories come up, seemingly randomly: He searches everywhere for his attackers, wants to hurt them, fights at bars. Each time he recounted a new memory or a new feeling, I urged him to pay attention to what was going on in his mind and I continued to move my fingers.

At the end of that meeting, David looked much calmer. He told me the memory of the wounding had lost its formidability, now it was something unpleasant that happened a long time ago. He said wistfully, "It's boring, and yet it has confused me for years, but I'm amazed that I've finally built such a beautiful life on my own."

Our third session the following week was dealing with the aftermath of the trauma: David had been using drugs and alcohol for years to cope with his rage. When we repeat the EMDR sequence, many memories still arise. David remembers talking to a prison guard he knew about wanting to kill his attacker, and then he changed his mind. Remembering this memory was a profound release: He came to me thinking he was an almost irrepressible monster, but then he realized that he had turned his back on hatred, bringing him back to his own caring and generous personality.

Then he spontaneously realized he was treating his child the way his attacker used to treat him. When the session was over, he asked if I could meet with him and his family so he could tell his son what had happened and ask for his forgiveness.

At our fifth and final session, he reported that he had slept better and that for the first time in his life he felt inner peace.

A year later, he called to inform me that he and his wife had grown closer, that they had both started practicing yoga together, that he was laughing more and that he really enjoyed gardening and carpentry.

UNDERSTAND MORE ABOUT EMDR

My experience with David is one I've experienced in my two decades of using EMDR to reconstruct traumatic events that happened in the past. I learned of this method through the case of Maggie, a young and brave psychologist who ran a shelter for sexually abused girls. Maggie faces constant confrontations, conflicts with almost everyone, except for the 13-14 year old girls she cares for. Maggie is on drugs, has a dangerous and violent boyfriend, she often quarrels with her superiors and also frequently moves from place to place because she can't stand her roommates (and they can't stand her either). I didn't understand how she had the stability and focus to earn a PhD in psychology from a prestigious university.

Maggie was referred to a therapy group I organized for women with similar problems to her. During the second meeting, she told us that her father raped her twice, once when she was 5, once when she was 7. She had thought this was her fault. She explained that she loved her father so much, and that she was probably so charming that he couldn't control himself.

Listening to her, I thought, "She may not blame her dad, but she'll definitely blame everyone else," including her previous therapists for not helping her get better. Like many trauma survivors, she tells one story in words but her actions tell another.

One day, Maggie eagerly came to the group to discuss a remarkable experience she had this past weekend at an EMDR training session for professionals. At the time, I had only fleetingly heard that EMDR was a new trend of therapists in which they swung their fingers in front of patients. To me and my colleagues in academia, it seemed like a new one of the crazes that had always plagued psychiatry, and I firmly believe this also became one of the obstacles for Maggie.

Maggie told us that during the EMDR session, she vividly recalled how her father raped her when she was 7 years old, she recalled from inside the baby's body that she was. She could feel how small her body was, could feel her father's large body pressed against hers, could smell alcohol in his breath. However, she told us that, even if she relives the event, she can see it from the perspective of someone who is already 29 years old. She burst into sobs, "I'm just a little girl. How could someone so big do that to a baby?" She cried for a long time before saying, "It's over. Now I know what happened. It's not my fault. I was just a baby and there was nothing I could do to stop him from abusing me."

I was stunned. For a long time, I've been looking for ways to help people relive their traumatic past without causing them to re-traumatize. It seems that Maggie had a flashback-like experience without being attacked by it. Can EMDR help people safely access the footprint of trauma? Can EMDR turn that trauma into a memory of an event that happened a long time ago?

Maggie had a few more EMDR therapy sessions and remained on our team long enough for us to see how she changed. She was less angry and retained the sense of enthusiasm that I enjoyed so much. A few months later, she met someone of the type of man she had never been attracted to before. She left the group, announcing that she had dealt with her trauma. And I decided it was time for me to learn this method of EMDR therapy.

EMDR: FIRST APPROACHES

Like many scientific advances, EMDR is derived from a random observation. One day in 1987, psychologist Francine Shapiro was walking through a park, absorbed in thinking about some painful memories, when she realized that rapid eye movements had greatly alleviated her pain. How can a treatment modality develop from such a short experience? How could such a simple process not be documented beforehand? Initially skeptical of her observations, she applied her method to years of experimentation and research, gradually building it into a standard procedure that could be taught and verified in controlled studies.

I went to my first EMDR training session while I was dealing with some of my own trauma. A few weeks ago, my Trauma Clinic at Massachusetts General Hospital was closed, so I urgently needed to find new locations and new funds to treat patients, train students, and conduct our research. Coincidentally, around that time, my friend Frank Putnam, who was researching the sexually abused girls I mentioned in chapter 10, was fired from the National Institutes of Health; Rick Kluft, the leading expert on dissociation, also lost his research team at the Pennsylvania Hospital's Research Institute. It may all be just coincidence, but it still makes me feel as if my whole world is under attack.

My sadness about the Trauma Treatment Clinic can be a good test for my EMDR testing. As I watched my partner's fingers, I thought of a series of blurred childhood scenes: tense family conversations at the dinner table, conversations with classmates during recess, throwing pebbles at the window with my brother — all vivid images, floating, "a state of hypnosis" that we experience when we sleep late on Sunday mornings, and then forget when we are fully real.

After about half an hour, my partner and I recalled when my boss told me my clinic was closed. Now I feel very calm: "Okay, it's happened, it's time to put the past behind." I wasn't stuck in the past, the clinic was later rebuilt and has been thriving ever since. Is EMDR the only reason I can let go of my anger and suffering? Of course I'll never know for sure, but the developments in my mind — from childhood scenes that don't involve leaving things behind — are unlike anything I've experienced in talk therapy.

What happened next, when it was my turn to do EMDR, was even more interesting. We moved on to another group, and my new graduate student, whom I had never met before, told me that he wanted to address some painful childhood incidents involving his father, but he didn't want to discuss them. I've never worked with anyone who refuses to tell my "story," so I was annoyed and confused when he refused to share any details. While I was moving my fingers in front of his eyes, in great distress, he began to sob, his breathing became fast and shallow. But every time I asked, he refused to tell me what was on his mind.

At the end of our 45-minute session, the first thing this guy said was that he found me so uncomfortable that he would never refer a single patient to me. In addition, he commented the EMDR session addressed his father's abuse. While I suspect that his rudeness to me was a transfer of his unresolved feelings toward his father, he clearly looked much more relaxed.

I turned to Gerald Puk, my EMDR coach, to say I was so confused. This guy obviously didn't like me, he looked extremely distressed during the EMDR session, but now he tells me that his lingering pain is gone. How can I tell if he solved it or can't if he doesn't want to tell me what happened?

Gerald smiled and asked if I had stumbled upon becoming a mental health professional to solve some of my own personal issues. I agree that most people who know me would think so. He then asked if I found it meaningful for people to tell me their trauma stories. Again, I have to agree with him. He said, "You know, Bessel, maybe you need to learn to suppress your curiosity. If it's important for you to hear stories of trauma, why not go to the pub, put a few dollars on the table and say to your surroundings, "I'll buy you a drink if you tell me your trauma story? But what you really need to know is the difference between a patient's desire to hear a story and his inner self-healing."

I knew Gerald's rebuke by heart and ever since then I have enjoyed repeating it to my students.

After leaving the EMDR course, I still can't stop thinking about three issues I'm still very impressed with to this day:

EMDR loosens something in the mind/brain, giving people quick access to memories and images related to their past. This seems to help them put the traumatic experience into a larger context or perspective.

One can recover from trauma without having to talk about it. EMDR allows them to observe their experience in a new perspective, without having to exchange back and forth with others.

• EMDR is effective even when the patient and therapist do not have a trusting relationship. This is especially fascinating because when traumatized, people are rarely able to open their hearts and trust others.

For many years afterward, I performed EMDR with patients who spoke many different languages, languages where I could only speak, "Pay attention here," the most important guideline of EMDR therapy. (I always have an interpreter with me, but mostly to explain the steps of the procedure to the patient). Since EMDR doesn't ask patients to talk about things they can't stand or to explain to a therapist why they're feeling sad, it allows them to focus fully on their inner experiences, and sometimes they produce extraordinary results.

EMDR METHOD RESEARCH

My colleagues and I showed everyone other videotapes documenting our EMDR sessions with PTSD patients, allowing us to track patient improvements week by week. We then began formally measuring their progress on the standard PTSD rating scale.

We also arranged with Elizabeth Matthew, a specialist in neuroimaging at New England Deaconess Hospital, to scan the brains of 12 patients before and after treatment. After undergoing three EMDR sessions, 8 out of 12 had significantly reduced PTSD scores. During brain scans, we were able to see a sharp increase in frontal lobe activity after treatment, as well as a stronger anterior region of the colon and basal ganglia. This change may explain the difference in how they experience their trauma.

One man recounted: "I remember it as if it was a real memory, but it was more distant. Normally, I would be drowned out in that memory, but this time I managed to emerge. I feel like I'm in control." One woman told us: "Before, I felt every piece of it. It's more complete now, it's no longer fragmented and so it's easier for me to control it." Leg shifting is no longer something that just happened but has become something that happened a long time ago.

We then received funding from the National Institute of Mental Health to compare the effects of EMDR with either a standard dose of Prozac or a placebo." Of the 88 study participants, 30 were treated with EMDR, 28 took Prozac, and the rest were given a placebo. As usual, people who take a placebo have very good results. After eight weeks, 42% of the placebo group had marked improvement, a larger proportion than many other treatments advertised as "evidence-based."

The Prozac group fared slightly better than the placebo group, but almost nothing changed. This is characteristic of most studies on medication for PTSD: Patients improved by 30% to 42% by participating in the study; When the drug took effect, they improved by another 5% to 15%. However, patients who received EMDR actually fared much better than those who received Prozac or a placebo: After eight sessions of EMDR, 4 in 1 people received complete treatment (their PTSD scores dropped to levels considered negligible), compared to 1 in 10 people of the Prozac drinking group.

But the real difference occurred over time: When we interviewed our patients eight months later, 60% of those treated with EMDR reported that they were almost completely cured. As the great psychologist Milton Erickson said, once you kick off the log, the river will start flowing. Once people begin to integrate their traumatic memories, they naturally continue to improve. In contrast, all those who took Prozac experienced a relapse upon discontinuation of the drug.

This study is important because it demonstrates that specific therapies for PTSD such as EMDR can be much more effective than medications. Other studies have confirmed that if patients take Prozac or related medications such as Celexa, Paxil and Zoloft, their PTSD symptoms usually improve, but only if they continue to take the medication. This makes drug treatment more expensive in the long run (Interestingly, although Prozac is seen as a major drug for fighting depression, in our study, EMDR reduced depression even more than taking antidepressants).

Another important finding of our study is that adults with a history of trauma as children respond to EMDR very differently than those who have suffered trauma as adults. By the end of week eight, nearly half of the adult-onset group treated with EMDR had completely recovered from the disease, while only 9% of the group abused as children showed such marked improvement. Eight months later, the cure rate was 73% for the adult-onset group, compared with 25% for the group with a history of abuse as a child. The group that was abused as children had small but positive and lasting reactions to Prozac.

These results reinforce the findings I outlined in Chapter 9: Long-term abuse as a child causes mental and biological changes that are very different from silent traumatic events in adulthood. EMDR is an effective treatment for traumatic memories, but it is ineffective with the effects of betrayal and neglect along with physical or sexual abuse in children. Eight weeks of treatment with any type of approach are rarely enough to resolve the sequelae of prolonged trauma.

In 2014, of the studies conducted on people with PTSD due to trauma reactions in adulthood, our EMDR study had the most positive results. But despite the results of this study and that of dozens of others, many of my colleagues continue to be skeptical about EMDR — perhaps because its effectiveness is incredible, and it's so simplistic. I can certainly understand these skepticisms — EMDR is an unusual procedure. Interestingly, in the first scientific study on the application of EMDR to veterans with PTSD, EMDR is expected to perform so badly that it is listed as a control condition comparable to biofeedbackassisted relaxation therapy. To the researchers' surprise, 12 sessions of treatment with EMDR turned out to be the most effective. Since then, EMDR has become one of the PTSD therapies authorized by the Department of Veterans Affairs.

IS EMDR A FORM OF EXPOSURE THERAPY?

Some psychologists have theorized that EMDR caused patients to lose sense of traumatic events, and thus involved exposure therapy. A more accurate description would be that it systematizes traumatic memory fragments. Our research shows that after being treated with EMDR, patients think of trauma as a coherent event in the past, rather than experiencing disjointed sensations and images from any context.

Memories have expansion and transformation. As soon as a memory is recorded, it goes through a long process of association and reinterpretation – an automatic process that occurs in the mind/brain without any input from the conscious ego. When this process is completed, the experience is integrated into other life events and no longer takes on a life of its own. As we have seen, in PTSD this process fails and memory gets stuck.

Unfortunately, few psychologists, during training, are taught about how the memory processing system in the brain works. This deficiency can lead to the wrong treatments. In contrast to phobias (such as spider phobias, which are based on a specific irrational fear), post-traumatic stress is the result of a fundamental rearrangement of the central nervous system based on experiencing a real death threat (or seeing someone die), That experience rearranged the process of self-experience (such as helplessness) and the process of explaining things in reality (the whole world is dangerous).

During exposure, the patient initially becomes extremely uncomfortable. When they recalled traumatic experiences, they had sharp increases in heart rate, blood pressure, and stress hormones. But if they try to keep the treatment going and continue to re-experience the trauma, they gradually become less reactive and less likely to break down when recalling the event. As a result, their PTSD scores were lower. However, as far as we know, simply exposing someone to old trauma does not help them integrate that memory into the overall context of their lives, and rarely do they recover to the point where they can happily connect with people and participate in activities they had before the trauma.

In contrast, EMDR, as well as the treatments discussed in later chapters — intra-family therapeutic systems, yoga, neurofeedback, psychomotor therapy, and drama — focus not only on regulating intense memories triggered by trauma but also restoring a sense of awareness, mutual aid and commitment through mastery of one's own body and spirit.

DEALING WITH TRAUMA WITH EMDR

Kathy is a 21-year-old student. When I first met her, she looked terrified. She went into psychotherapy with a therapist she trusted and felt understood but she didn't improve. After her third suicide attempt, she was referred to me, hoping that the new technique I had told them could help her.

Like many of my trauma patients, Kathy is focused wholeheartedly on her studies: When she reads a book or writes an essay, she can prevent everything else from leaving her life. This made her a capable student, even if she had no idea of establishing a loving relationship with herself, let alone building a loving relationship with another person.

Kathy told me that her father had abused HER, pushing her into child prostitution for years. This information made me think of using EMDR as an adjuvant therapy.

Fortunately, Kathy responded excellently to EMDR therapy and fully recovered after only eight courses, the shortest time in my experience for someone with a history of severe abuse as a child. The therapy took place 15 years ago, and I recently met with her again to discuss the pros and cons of adopting her third child. She was amazing: intelligent, funny, happy to mingle with her family, and has now been a teaching assistant on the subject of child development.

I wanted to share my notes from Kathy's fourth EMDR session, not only to demonstrate what happens during a session, but also to show you how the human mind works when it integrates a traumatic experience. Brain tests, blood tests, or rating scales can't measure this, and even a video can only faintly convey how EMDR can unleash the mind's imaginative powers.

Kathy was sitting in a chair more than half a meter away, slanted at a 45-degree angle. I asked her to recall a particularly painful memory and encouraged her to recall what she heard, saw, thought, and felt in her body when the event unfolded (my records don't record whether she spoke or not, I guess not because I didn't take notes).

I asked her if she was "present in the memory" and when she said yes, I asked her how "real" it felt on a scale of 1 to 10. She said it sits at about 9. Then I asked her to follow my moving finger. After every 25 or so of her eye movements, I said, "Take a deep breath," then I said, "How do you feel now?" or "What are you thinking now?" Kathy would tell me what she was thinking. Whenever her tone, facial expressions, body movements, or breathing indicated that this was an emotionally important topic, I would say, "Be mindful of that," and initiate another wave of eye movements, while Kathy remained silent. Except for those words, I remained silent for the next 45 minutes.

Here's a summary of what Kathy recounted after the first round of eye movements: "I realised I had scars when my dad tied my hands behind my back. The other was from my father marking me as if claiming I was his, and the other [she pointed] were bite marks." She looked stunned but was unbelievably calm as she recalled: "I remember being petroled on me, my dad used a Polaroid camera to take a picture of me, and then I was drowned in the water. I was gang-raped by my father and two of his friends. I was tied to a table. I remember them using beer bottles to assault me."

My stomach tightened when I heard Kathy share, but I said nothing more than to ask Kathy to keep those memories in my mind. After about 30 more eye movements, I stopped when I saw her smiling. When I asked her what she was thinking, she replied, "I'm in Karate class! That's great! I'm disgusted! I watched them back off. I shouted, "Don't you guys see you're hurting me? I'm not your girlfriend." I said, "Keep that memory," and began the next series of eye movements.

After finishing the series of eye movements, Kathy said: "I saw two images of me, a smart, lovely little girl, and a lecherous girl. Women who can't take care of themselves, can't take care of me, can't take care of their husbands — these things make me serve these men." She began to sob during the next process and when she finished, she said: "I see how small I am, how brutal these crimes are for a little girl. It's not my fault." I nodded and replied, "Yes, keep that memory." The next wave of eye movements ends with Kathy saying, "I'm imagining my life right now, I'm growing up, holding me as a kid and saying, 'You're safe.'" I nodded encouragingly and continued to encourage Kathy to reminisce.

The images continue to flood in: "I saw a bulldozer flattening the house I grew up in. It's over!" Kathy then started with a different line of thought: "I'm thinking about how much I like Jeffrey. I thought maybe he wouldn't want to hang out with me. I think I can't stand that. I've never been anyone's girlfriend and I don't know how to do it." I asked her what she thought she needed to know and started the next wave of eye movements. "Now there's someone who just wants to be with me, how simple it is. I don't know what it's like to be myself around men. I was petrified."

As she watched my fingers, Kathy started crying. When I stopped, she told me, "I saw Jeffrey and I sitting in a café. My father walked in. He began to scream, fifteen axe in hand. He shouted, "I said you were mine. He put me on the table, then raped me, then raped Jeffrey." She burst into tears. "How can you open up to anyone else when you have pictures of your father raping both you and your friend?" I wanted to comfort her, but I knew it was more important to keep her associations going.

I asked her to focus on what she felt in her body: "I felt it on my arm, on my shoulder, and on my right chest. I just want to be hugged." We continued EMDR therapy and when it stopped, Kathy looked more relaxed. "I heard Jeffrey say it's okay, that he was brought here to take care of me. He said it wasn't about me and that he just wanted to be with me for myself." Again, I asked her how she felt in her body. "I feel very peaceful. A little shaky, like when using new muscle fibers. I was relieved too. Jeffrey knew everything. I felt alive and that it was over. But I was afraid my father was abusing another little girl, and it made me so sad, I wanted to save her."

But as we continued, the trauma came back along with other thoughts and images: "I'm so nauseous... I had a lot of smells, cheap perfumes, alcohol, vomit." A few minutes later, Kathy burst into tears: "I really feel like my mum is here. I felt as if she wanted me to forgive her. I think the same thing happened to her, she was apologizing to me endlessly. She was telling me that the same thing happened to her — that the culprit was my grandfather. She said my grandmother was heartbroken that she couldn't be there to protect me." I kept asking her to take a deep breath and stay with whatever was rising.

At the end of the next round of eye movements, Kathy said: "I feel like it's over. I felt my grandmother hugging my grown-up, telling me she was deeply sorry for marrying my grandfather. That you and your mother guarantee this will end here." After her last round of EMDR, Kathy smiled, "I saw me pushing my dad out of the café, and Jeffrey locking the door. He stood there. You can see him through the glass, people are mocking him."

Thanks to EMDR, Kathy was able to combine her traumatic memories and appeal to her imagination to help her stop the memories and achieve a sense of wholeness and autonomy. She achieved that with my few questions and without discussing the details of the experience (I found it unnecessary to question their accuracy, her experiences were real to her, and my job was to help her deal with them in the present). This process releases something in Kathy's mind/brain to trigger new images, feelings, and thoughts; as if her vitality emerged, creating new possibilities for her future

As we have seen, traumatic memories persist as detached, unrenewed images, feelings, and emotions. In my opinion, the most notable feature of EMDR is its ability to display a wide range of sensations, emotions, images, and thoughts unrelated to the original memory. Assembling this old information into new memory is a way for us to integrate these experiences into the daily memory of the non-traumatic present.

EXPLORING THE RELATIONSHIP WITH SLEEP

Not long after learning about EMDR, I was invited to talk about my work at the sleep lab headed by Allan Hobson at the Massachusetts Center for Mental Health. Hobson (along with his mentor, Michel Jouvet) was famous for discovering that dreams are created by the brain, and one of his research assistants, Robert Stickgold, was exploring the function of dreams. I showed them a videobook of a patient who suffered from severe depression for 13 years after a horrific car accident and after just two EMDR sessions, she went from a panic victim to a confident, determined woman. Robert was impressed.

A few weeks later, a friend of the Stickgold family became so depressed after the cat's death that she was hospitalized.

The psychiatrist involved in treating her concluded that the cat's death triggered unresolved memories of her mother's death when she was just twelve years old and that he connected her with Roger Solomon, a well-known EMDR trainer, who successfully treated her. Then she called Stickgold and said, "Bob, you have to research this. It's really weird — it has to do with your brain, not your mind."

Not long after, an article appeared in the journal Dreaming showing that EMDR is associated with rapid eye movement (REM) sleep — when dreams begin to occur. Research shows that sleep and especially dream sleep play an important role in mood regulation. As the article in Dreaming states, the eyes move rapidly back and forth during REM sleep identical to the eye movement in EMDR. Increasing REM sleep time helps reduce depression, while reducing REM sleep time will make us even more depressed.

Of course, PTSD has a reputation for being associated with unstable sleep, and drinking alcohol or taking drugs will disrupt REM sleep. During my time at the Department of Veterans Affairs, my colleagues and I have found that veterans with PTSD often wake up early after having REM° sleep — perhaps because they've triggered a piece trauma in a dream." Other researchers have noticed this phenomenon as well, but think it's irrelevant to learning about PTSD."

We now know that both deep sleep and REM sleep play an important role in how memory changes over time. The brain during sleep regenerates memories by increasing the footprint of emotionally relevant information and fading out irrelevant information." In a series of meticulous studies, Stickgold and his colleagues showed that during sleep, the brain can even understand what information is irrelevant even though when we are awake, we have integrated that information into the memory system greater than 13.

Dreams keep replaying, recombining, and reintegrating old memory fragments for months, even years. They are constantly updating the implicit realities that determine what our minds pay attention to. And perhaps the most concerning thing about EMDR is that during REM sleep we trigger more distant associations than when we have non-REM sleep (such as shallow sleep, deep sleep) or when we are awake. For example, when subjects were awakened from non-REM sleep and took a word combination test, they would give common answers such as: hot/cold, hard/soft, etc. When awakened from REM sleep, they had answers that showed more novel associations such as thief/sailº. They also solved simple anagram puzzles more easily after REM sleep. This activation of distant associations may explain the fact that we have rather bizarre dreams 16.

Stickgold, Hobson, and colleagues found that dreams help create new relationships between ambiguous memories. Seeing new connections is a key feature of creativity; As we have seen, it is also necessary for healing. The inability to recombine experiences is also one of the hallmarks of PTSD. While little Noam in chapter 4 can imagine a spring cushion to save future victims of terrorism, traumatized people are trapped in frozen associations: Anyone wearing a shawl tries to kill me; Anyone who finds me attractive wants to rape me.

Finally, Stickgold suggests a clear link between EMDR and memory processing in dreams: "If EMDR stimulation can alter brain state in the same way that we see during REM sleep, we now have good evidence that EMDR will be able to take advantage of sleep-dependent processes, processes that may have been inhibited or inefficient in people with PTSD, to enable efficient memory processing and trauma relief"18. The basic EMDR guidelines for patients are, "Keep that image in your mind and keep watching my fingers move back and forth" can reconstruct quite well what happens in a dreaming brain.

LINKS AND INTEGRATIONS

Unlike conventional exposure treatment, EMDR spends very little time revisiting the initial trauma. Trauma itself is the starting point, but the focus is on stimulation and opening up the process of association. As our Prozac/EMDR study showed, people who are given medication can overshadow terrible images and feelings, but those images and sensations remain in the person's mind and body, are not integrated as an event that happened in the past and still cause patients significant anxiety. In contrast, people treated with EMDR no longer experience distinct markers of trauma: It has become a story of a terrible event that happened a long time ago. As one of my patients once said, "It's over."

We don't yet know exactly how effective EMDR is, nor do we know the exact effectiveness of Prozac. Prozac has an effect on serotonin, but it's unclear whether its levels go up or down, in which brain cells, and why it makes people feel less afraid. We also didn't know exactly why talking to a trusted friend was so relieving, and I was surprised how few seemed to want to explore that question.

Clinicians have only one obligation: to do whatever they can to help their patients get better. For this reason, clinical practice has always been a testing ground. Some experiments failed, some succeeded, and others, like EMDR, dialectical behavior therapy, and family therapy, went on to change treatments. Validating all of these treatments takes decades and is hampered by the fact that supporting research often follows methods that have been proven effective.