Slide 1

Valery Krupnik

EMDRIA 2016

INTEGRATING THE INTEGRATIVE: INTEGRATING EMDR INTO A NOVEL

THERAPY FOR DEPRESSION (TDD)

Slide 4

Cognitive behavioral therapy (comparable to anti-depressants, moderate to large ES)

ACT (close to CBT in ES) Interpersonal therapy (close to CBT in ES) Psychodynamic therapy (close to CBT in ES) Mindfulness-based therapies (close to CBT in ES) Cognitive behavioral analysis system of therapy Behavioral activation therapy (superior to CBT for severe depression) Web-based CBT (small ES) Aerobic exercise Massage therapy (depression as a symptom co-morbid with medical

problems, mild to large ES).

Jorm, A., Allen, N., Morgan, A., & Purcell, R.

(2009). A guide to what works for depression.

Melbourne, Victoria, Australia: beyondblue.

A list of effective therapies for depression.

Slide 5 And Yet…

20-40% of cases are treatment-resistant

Recurrence is the norm

First among mental and second among all illnesses in disability time.

Fava, M. (2003). Diagnosis and definition of

treatment-resistant depression. Biological Psychiatry,

53, 649-659.

Rush, A. J., Trivedi, M. H., Wisniewski, S. R., Stewart, J. W., Nierenberg, A. A., Thase, M. E., . . . Luther, J. F. (2006). Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression. The New England Journal of Medicine, 354, 1231–1242.

Slide 6

1. Are cognitive change procedures more efficacious in reducing symptoms than other procedures?

2. Do cognitive change procedures generate more cognitive change than other procedures?

3. Does cognitive change lead to symptom change? 4. Is cognitive change a specific predictor of symptom change only in the

context of cognitive change interventions?

Longmore & Worrell, 2007 – all conditions must be met

Lorenzo-Luaces et al., 2015 – only the 3rd is enough

Lorenzo Lorenzo-Luaces, et al., Cognitive-Behavioral Therapy: Nature and Relation to Non-Cognitive Behavioral Therapy, Behavior Therapy (2016), http://dx.doi.org/10.1016/j.beth.2016.02.012

Slide 7 Challenges (for the therapist)

• In its depth, depression is pre-verbal and pre-cognitive (thyroid depletion, interferon, high cortisol levels can trigger a depressive episode; prevalence of negative symptoms), which makes it hard for therapy to take traction.

• “Clinical depression is a strange state, and I have

claimed that if you can describe your severe depression, you haven‘t truly experienced one.”

Lewis Wolpert

Slide 9 Therapy Integration

• Technical eclecticism

• Common factors integration

• Principle-based assimilative integration

• Theoretical integration

Norcross, 2005

Norcross, J. C. (2005). A primer on psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 3-23). New York: Oxford University Press.

Slide 10 Level 1 – Goal

Level 2 – Objective/Theory

of psychopathology (T)

Level 3 – Mechanism (M)

Level 4 – Intervention (I)

Figure 1

Nested hierarchy of psychotherapy interventions.

T – theory of psychopathology, M – mechanism of change, I – intervention.

Downward arrows indicate the hierarchy of causation; upward arrows indicate feedback validation.

Dark triangles indicate the inverse relationships of universality vs specificity and flexibility vs treatment fidelity relative to the place

on the hierarchy.

CHANGE or MAINTENANCE UNIVERSALITY

SPECIFICITY

FIDELITY

FLEXIBILITY

T2 T1

M1

11

M2

11

M3

11

I1 I2 I3 I4 I5

Nested Hierarchy Principle of Therapy Integration

Slide 11 Theories of Depression

• The loss cluster– Anger/aggression turned in (Freud)

– Loss of a ‘good’ object (Object Relations)

– Disruption of attachment (Bowlby)

• The stress cluster– Learned helplessness (Seligman)

– Cognitive distortion (Beck)

– Monoamine dysregulation/depletion

– Cell death

– Dysregulation of relevant neural circuits

• Meta-theory (all-encompassing systemic level)

– Depressive response to insurmountable adversity (evolutionary theory)

For evolutionary theories depression see: Andrews, P. W., & Thompson, J. A. (2009).

The bright side of being blue: Depression as an

adaptation for analyzing complex problems.

Psychological Review, 116, 620–654; Gilbert, P. (2006). Evolution and depression: Issues and im-plications. Psychological Medicine, 36, 287–297; Nettle, D. (2004). Evolutionary origins of depression: A re-view and reformulation. Journal of Affective Disorders, 81, 91–102; Watt, D. F., & Panksepp, J. (2009). Depression: An evolu-tionarily conserved mechanism to terminate separation distress? A review of aminergic, peptidergic, and neural network perspectives. Neuropsychoanalysis, 11, 7–109.

Slide 12

Loss (Bowlby) Learned helplessness (Seligman) Social defeat (Gilbert, Koolhaas) Entrapment (Gilbert)

Failure to meet one’s needs (frustrated drives, DMN)

Slide 13 Depression is not a state but a process: Depressive response

Untreated depressive episodes remit on average within 12 months.

Kaufman, I. C., & Rosenblum, L. A.

(1967). The reaction to separation in

infant monkeys: Anaclitic depression

and conservation-Withdrawal.

Psychosomatic Medicine, 29, 648-675.

Slide 16 Exploratory Phase: Insight into Failure

Psychodynamic in nature

Building an alliance

Heavy use of empathy

Engagement of affect

The goal is to identify the ultimate failure

Slide 17 Acceptance Phase

Exposure to defeat. Gentle shattering of denial. Hopectomy

Therapeutic alliance and trust are paramount

The main technique – mindfulness, i.e. non-judgmental awareness

The goal is to ‘let go’

Timing is important. May backfire if the patient is not ready

Slide 18 Behavioral Activation Phase

Jumpstarting the system of motivation

The approach is behavioral

Engaging the main appetitive systems: food, sex, social involvement, as well as pleasurable stimulation and exploratory behavior

Timing is important. This is were the ‘downhill’ trend turns into an ‘uphill’ one. May backfire if the patient is not ready

Slide 14

Cognitive appraisal Cognitive re-appraisal

Primary emotional response Secondary emotional response

I can’t believeit’s happening

I’m worthless. I have no future.Nothing makes sense.I can’t do it.I don’t care anymore.I’m better off dead.

Protest

AnxietyAnger

SadnessAngst

Withdrawal

Co

mp

lete fre

eze

IOL

Slide 22 EMDR has been used for depression

Case studies Bae, Kim, & Park, 2008;

Broad & Wheeler, 2006; Grey, 2011; Uribe, Ramírez, & Mena, 2010

Controlled studies Hofmann et al., 2014

(adjunct)

Gauhar, M., & Wajid, Y. (2016) (stand alone)

Randomized trial Hase et al., 2015 (adjunct)

In all studies the standard EMDR protocol was used.

Why bother then?

Slide 23 Sources of Psychopathology from Different Theoretical

Perspectives (from F. Shapiro’s Presentation, 2014)

• Psychodynamic

– Intra-psychic conflict

• CBT

– Dysfunctional cognitions

• AIP

– Unprocessed memories

• Is something missing?

– Unmet needs

Maslow, A. H. (1943). A theory of human

motiva-tion. Psychological Review, 50, 370–

396. http://dx.doi .org/10.1037/h0054346

Slide 24 Sources of Psychopathology

• Congenital/Biological

• Trauma-induced

– Unprocessed memories

• Drama (not trauma)-induced

– Unmet needs

Slide 25

• F. Shapiro

– trauma is defined as any event that has had a lasting negative effect upon self and psyche.

• Webster dictionary– a : an injury (as a wound) to living tissue caused by an extrinsic agent

– b : a disordered psychic or behavioral state resulting from severemental or emotional stress or physical injury

• Oxford dictionary– Emotional shock following a stressful event or a physical injury, which

may be associated with physical shock and sometimes leads to long-term neurosis.

What is Trauma?

Slide 26

– Rejection? (shame)

– A lie? (mistrust)

– A loss? (depressive response)

– An assault? (avoidance/aggression)

What is trauma not?

Slide 27 Shortcomings of Over-inclusive Definition of Trauma

• Scientific: makes it difficult to operationalize trauma for research

• Philosophical: conflates pathology with normative adverse life experience

“Half the people you know are below average”

Steven Wright

• Esthetic: reduces all negative life experience to a Starbucks menu:

T T T

Slide 29

Ego strength

Severity of stress

Pathogenic

Stress

Traumatic

Stress

Drama Trauma

Trauma = a dislocated ego; Drama = an injured ego

Slide 30 To consider an experience traumatic the necessary and sufficient conditions have to be met.

– Necessary: compromised personal, occupational, or social functioning that is directly related to the experience

– Sufficient: breakdown of ego-functions (e.g. PTSD symptoms) directly related to the experience

The necessary condition is common for pathogenic and traumatic stress, whereas the sufficient one is specific to trauma.

Depressive response is a defense against traumatization.

Slide 31

Comparison of the theoretical models of EMDR and TDD

EMDR (AIP) TDD

Source of pathology Dysfunctionally stored

memories

Unmet needs

Goal of therapy Adaptive reprocessing of

dysfunctional memories

Completion of the depressive

response

The putative mechanism of

change

Transformation of

dysfunctional memories and

their integration into larger

adaptive networks

Disengagement from protest

through acceptance with

subsequent activation of the

reward circuitry

Slide 32 Nested hierarchy of TDD-EMDR.

Slide 33 EMDR interventions in TDD-EMDR aim at evoking the Experience of Acceptance

• Target - focus on the experience of failure (eliciting/exposing to protest)thoughts, images, feelings, visceral sensations (rate the feeling 0-10)

• BLS-processing (non-directive and mindful)waiting for the protest to deflate (sustaining awareness of the emotion)

• Acceptance-directed interventiontiming is paramount

• Assessment of the completeness of acceptance (0-10)serves to anchor the experience to accepting attitude (cognate to insight)

• Exposure to and solidifying of (‘installment’) of acceptanceslow BLS, deep breathing – bringing autonomic arousal in check (rate the feeling 0-10)

• Back to the target or support the emerged forward momentum (future-oriented cognition, positive self-statements, etc.) by further BLS-processing

• Reassessment of acceptanceReady to let go? Ready to move on?

Krupnik, V. (2015). Integrating EMDR into

an evolutionary‐based therapy for depression: a case study. Clinical case reports, 3(5), 301-307.

Krupnik, V. (2015). Integrating EMDR into a novel evolutionary-based therapy for depression: A case study of postpartum depression. Journal of EMDR Practice and Research, 9(3), 137-149.

Slide 34 What’s missing?

(compared to the standard protocol)

• Drama

• Trauma

• No emphasis on memory

• No positive-negative cognitions

• No future template….

• it often emerges spontaneously

Slide 35 But what exactly do you say?• …

• C: I feel ashamed. I don’t even have to do that much.• T: How intense is the feeing on a scale from 0 to 10?• C: Eight.• T: Go with it. -BLS• T: What are you thinking now?• C: I don’t like myself. I’m not right.• T: Is there anything you can do about it?• C: I can’t do anything about it.• T: Go with it. -BLS• T: What are you getting?• C: I don’t need people to like me. I just need to be able to do what I need to do.• …• C: I remember doing dishes while everybody was out there.• BLS• C: I started not caring about anything.• BLS• T: What are you getting now?• C: I was thinking about what I wanted to do when I come back.• BLS• C: I was thinking about making it home.• BLS• T: What are you getting now?• C: I feel ashamed.• T: What can you do about it now?• C: I talked to other guys. They all thought like that.• T: Go with it. -BLS• T: What are you thinking now?• C: I wonder if the guys I was with felt the way I did.• T: Go with it. -BLS• T: What are you thinking now?• C: I know I wasn’t the only one but I feel like I was.• T: Go with it. -BLS• C: It’s OK to feel like that.• T: Go with it. -BLS• C: I wasn’t the only one thinking this way.

Slide 36 T: What are you getting now?C: I remember sleeping in the next room to my wife.T: Go with it. –BLST: What are you thinking now?C: There was a lot of time to think, lying there.BLST: What are you getting now?C: Why wasn’t I good enough for her?T: Why weren’t you?BLST: What are you thinking now?C: Sometimes things don’t work out.T: Go with it. –BLST: What are you getting now?C: I wasn’t really happy with my wife. I just got used to that life.T: Go with it. –BLST: What are you getting now?C: My daughter. She makes me happy.T: Go with it. –BLST: What are you getting now?C: I get my daughter in a week. Feel super-happy about it.

Slide 37 Vignette

A 30 years old married man with one stepchild. Cpl with USMC. Presented with increasing depressive symptoms in a context of marital stress. Upon returning from deployment (no combat experience), he was upset by wife’s friendship with another man, which the Pt perceived as “emotional cheating.” That precipitated a drop in self-esteem that had always been low. He admitted that he was not very happy with his marriage, finding his wife aloof. This was his 1st mental health encounter.

His Sx included persistent sad or irritable mood, increased stress-related anxiety, insomnia at 5 hours of TST, loss of interest and motivation, anhedonia, fluctuating appetite, fatigue, poor concentration, feeling worthless and guilty, recurrent passive death wishes. Diagnosed with MDD, recurrent, mild.

Pt’s history revealed a troubled childhood, growing up as a small boy always picked on by bigger boys. He felt helpless and isolated; did not know how to fight back and felt ashamed. Pt was fascinated with Schwarzenegger and Stallone characters. Never felt “completely happy,” always “waiting for things go bad.” Looking for protection and sense of belonging Pt joined a street gang, functioning as an instigator and learning to fight. Left the gang after a couple of years. Still feels ashamed of that time. His hair started thinning in his 20s and by 30 he had a visibly receded hairline.

Despite the troubled childhood, Pt did not identify any index trauma and reported no re-experiencing.

No medications.

EMDR intervention went from session 2 – 4.

Slide 38 ProcessingT: Focus on that thought of being a small helpless boy and stay with it and the feeling. –BLST: What’s going through your mind?C: A desire to fit in.T: Go with it. –BLST: What are you getting now?C: I feel sad.T: Go with it. –BLST: What are you getting now?C: Anger. What am I missing other than my size? I feel rejected.T: Go with it. –BLS – PromptC: I wish I could change.T: Go with it. –BLS – PromptC: If I didn’t care, things would be better.T: Go with it. –BLS – PromptC: I wanted to rebel.T: Go with it. –BLS – PromptC: I needed to be fearless.T: Yes, I can see that, but what can you do about it now?C: I should not have let it get to me.T: Is there anything you can do about it now?C: Too late.T: Go with it. – BLS (slower and shorter) – Take a deep breath.T: What are you thinking now?C: I know good things about myself.T: Go with it…

Acceptance level at the session’s end was 5-6 on a 0/10 scale.

Slide 39 Change after four sessions

pre post pre post pre post

35 15 -5 3 17 17

BDI-II PANAS BAI

No documented mental health problems two years after

Slide 40 12 sessions

0

20

40

60

80

100

120

140

160

Pre-treatment Mid-treatment Post-treatment

Pe

rce

nt

of

the

pre

-tre

atm

en

t va

lue

BDI-II

BAI

AAQ

Self-report Measures

BDI-II pre 33+8

BDI-II post 12+8*

BAI pre 18+9

BAI post 11+10

AAQ pre 170+25

AAQ post 214+39*

Slide 41 What’s in the moving eye?

• Engaging and exposing to relevant affective circuitry (protest circuitry)

Slide 42 Systems theory view of therapeutic progression in depression

Depressiverumination

Acceptingdisposition

Appetitivedrive

Protest Acceptance Restarted motivation