Starting out in trauma work: EMDR, TF-CBT, and therapist fears (with Chris Long)

[00:00:05] Bronwyn: Hey, mental workers. You're listening to the Mental Work podcast, the podcast about working in mental health for early career mental health workers. As always, I'm your host, Bronwyn Milkins, and today we are talking about approaches to working with trauma, specifically EMDR, therapy and trauma-focused CBT.

You might be feeling unsure of how to approach trauma work, and that's incredibly common for early career mental health workers. In this episode, we're going to break down two evidence-based trauma approaches to help you understand what they actually look like in practise and how to figure out which might be the right fit for you and your clients.

Here to help us out this topic is our guest today, Chris Long. Hi Chris.

[00:00:40] Chris: Hello.

[00:00:41] Bronwyn: It's so lovely to have you here. Thanks for coming on. Could you please start us off by telling listeners who you are?

[00:00:47] Chris: Yeah, sure. So yeah, my name's Chris. I'm a registered psychologist in Sydney. I live in Surrey Hills, so like if anyone knows where that is, right in the centre of the city, basically. I've been a registered psych for about 4-, 3-, 4 years now, I think, yeah. Did my provisional, uh, started that about 2019, I think.

 I'm 37 years old, so I was a professional musician before I was a psychologist, and I found a lot of my musician buddies have become psychs and therapists and stuff, actually, which is kind of a bit of a kindred, weird, kindred spirit thing going on, I think.

 Really into, I do- do a lot of trauma work, so yeah, EMDR, um, trauma trauma-focused CBT, but also, uh, over the last couple of years really getting into schema therapy as well. So I think that influences my approach even if that's not specifically what I'm doing.

[00:01:43] Bronwyn: Awesome. And you're definitely not gonna get away with saying that you moved from being a professional musician to psychology. So what prompted that change?

[00:01:52] Chris: Uh, I went to therapy myself for some personal stuff and then, just really kind of enjoyed it. I was already quite interested in it. Had a few friends where, you know, maybe some of them had been, and we would talk about psychological stuff. Um, and then was just getting a bit over, you know, doing gigs and, um, spending all weekend working and, um, sort of having like the opposite time table to a lot of my friends, um, wanted a bit more security. So yeah, just wanted to try something new and I gave psychology a go and loved it.

[00:02:31] Bronwyn: So why do you think like your mates have also gone to psychology? Like, what is it about musicianship that translates into psychology?

[00:02:39] Chris: Yeah, a few of us have had this discussion, we've tried to figure it out. Um, dunno if we've solved it, but maybe there's kind like a curiosity that, you know, if, if we're gonna be psychological about it, maybe that like openness to experience kind of thing is a bit higher. Creativity, maybe curiosity about that.

[00:03:02] Bronwyn: Interesting trend. Could be a thesis for a listener out there.

[00:03:06] Chris: Yeah. Could be. There's probably some-, someone's probably already done-

[00:03:10] Bronwyn: I'm sure somebody's done a PhD or something on it already, but it's interesting nonetheless, and happy to have you join the psych field. So how did you come to be interested in working with clients who have experienced trauma?

[00:03:21] Chris: The place I work at, it's, uh, it's, it's part of the gig. So just kind of, again, just sort of gave it a go 'cause that was part of, part of the job. Um, but I do find it quite, yeah, fascinating. So we, um, at my work we see, uh, people through a whole range of different referral sources. So one of them is, uh, EAP, but then we do private clients. We do like the insurance scheme stuff, so CTP, so often that's car crashes. So CTP stands for like compulsory third party, like the, the green slip for your car. So we see people who've been in serious car accidents, um, or through workers' comp. There's quite often PTSD through there.

So I didn't necessarily choose to get into it initially, but uh, have found it really interesting and, I think learning about trauma really informs the rest of your psychological practise most of the time as well, 'cause you learn about avoidance and gradual exposure and you know, anxiety. Like all these things that, yeah, they can be the little T traumas or the big T, like, yeah.

[00:04:34] Bronwyn: Yeah, so it's not necessarily a niche that you sought out, but you're happily in that niche.

[00:04:41] Chris: Yep, yep. I'm not ne-, I wouldn't even necessarily say it's my niche either. Like, I love couples therapy and like, um, I do a bit of organisational stuff, like I supervise people. I, yeah, I do a few different things, but yeah, it's, it's one of the things I've been fairly trained up in and had a fair bit of experience in.

[00:05:00] Bronwyn: Awesome. So the first thing I wanted to unpack was, I guess, the concerns that early career psychs might have around working with clients that have experienced trauma. Is it all right if we unpack a few concerns that listeners may have just to hear your responses to them?

[00:05:17] Chris: Yep.

[00:05:18] Bronwyn: Okay, so I've got three of them. The first one is, I reckon there are some listeners who are like, I'm scared of making things worse for a client who has trauma by talking about the trauma, what would you say to that listener?

[00:05:34] Chris: Mm. It's a good point, and I think it'd be remiss to say it's not possible, you know, if you go in really heavy handed, um, or in a non-trauma informed way, uh, it's possible. I think though, I, I would also say on the flip side, you'd have to be fairly cavalier or something like that to not pick up on the signs that someone's getting distressed and, and, you know, pull back and just kind of check in with them and say like, you know, is it okay if you tell me about what happened or do you wanna do that next session?

Um, so if you're working with someone who's been traumatised you generally do need to hear at least a bit about the event or the events, um, their beliefs about what happened, all that kind of thing. But you don't necessarily need to hear all the gruesome details either. In fact most, um, people who teach trauma informed therapies recommend being kind of careful around that and not necessarily going all the way in. Um, so like protecting yourself as much as the client, um, and watching out for things like vicarious trauma, which is kind of like secondary trauma for those who aren't familiar with that term.

But I had a, um, one of my EMDR supervisors once, uh, said that when she, uh, starts off her sessions, so when she's starting off trauma processing sessions through EMDR, she'll say to her client, you know, did anyone die this week? Was there any, uh, did your house burn down or anything like that? And she's like, nope, okay, great. Let's get into it. So she's kind like, she doesn't necessarily wanna like go way off track or get hung up on things. And she also would say, if someone was gonna go right into detail and she didn't need to hear it, she just kind of like stopped them and be like, hey, you don't, you don't need to tell me all the details, like I know enough, I think, to get into this with you.

[00:07:43] Bronwyn: And because them sharing the details as well, they may unintentionally dysregulate themselves too.

[00:07:50] Chris: Yeah. Yeah, I think just like I, I know I've had, I've had that experience though where I have like, uh, maybe asked someone questions too fast. Like the first time I saw someone with PTSD, I think I didn't realise how significant it was for this person, and it was a really horrific case of sort of what had happened to this a person, so kind of like trial by fire for me. Um, not that it's about me, but, um, it was quite intense and I did just ask them quite casually also, you know, what, what happened? And that really did set them off.

So, uh, I should have learning curve for me was like, I should have checked the referral a little more closely and probably chatted to a supervisor before I first talked to this client, um, but that didn't happen.

[00:08:43] Bronwyn: Thank you for sharing that learning. Um, I'm sure that that's common for a lot of folks who are starting out working with clients who have experienced trauma, is that, yeah, we don't realise that these, I guess, quite simple questions can unlock a lot for some clients.

[00:08:59] Chris: Yep.

[00:08:59] Bronwyn: This is related to the next question, which is what would you say to a listener who is concerned about being emotionally overwhelmed by a client's trauma?

[00:09:08] Chris: Um, again, that's a good question. Uh, but I would say that's probably coming from a place of anxiety for that like the therapist or, you know, whoever it is working with the trauma. You're never really gonna know until you meet them and you try it and see what happens. The cases that you might think on paper are gonna be the most intense and severe and most upsetting for the person of yourself to deal with, it's not necessarily that straightforward, like it's not that linear. Sometimes those people are quite resilient and they've got so much like positive, um, so many positive beliefs and ways of like processing the trauma or resilience, like whatever you wanna call it, that it's actually pretty good working with them, like it's quite comfortable. And someone who you might think, oh, like this, this doesn't seem like it's that severe an event or injury, and they're so distressed... so it's not necessarily that straightforward.

[00:10:10] Bronwyn: I completely agree. And I wonder whether you've had times where you've been surprised how you were emotionally affected. Like maybe there were times when you're like, I should be more emotionally affected by this, but you're not.

[00:10:24] Chris: Yeah. Yeah, for sure. Yeah, I don't exactly know why that is, right? Like...

[00:10:30] Bronwyn: Yeah, I've like, I thought about that as well because as you were talking, I was reflecting back on a few cases and I was like, there's definitely been times where it's like, say a 10 out of 10 trauma. I'm like, I should probably. Feel more than I currently feel, but I don't, and then a one out of 10 trauma, and I'm like, oh, I almost feel like I'm crying. Um, and I think it might be related to like my own life as well. Like if there are things that the one out of 10 trauma like reminds me of and connects with, with current life, like, could that be maybe relevant to you as well?

[00:11:04] Chris: For sure, yeah. The countertransference stuff, yep, definitely comes up when you're working with trauma.

[00:11:10] Bronwyn: Yeah, absolutely. Um, so I mean it relates back to what you were saying that we can't really predict and we might be getting over anxious in ourselves trying to like lessen the emotional load when we don't actually know what it will be.

[00:11:22] Chris: Yep.

[00:11:23] Bronwyn: So final concern that we want to address is what would you say to a listener who is overwhelmed by the number of trauma approaches available and doesn't know which one to pick?

[00:11:33] Chris: Great question again. Who, who getting these good questions from?

[00:11:36] Bronwyn: ChatGPT.

[00:11:38] Chris: Oh, really? I was like, these insightful listeners of yours!

[00:11:43] Bronwyn: Um, I get, I get ChatGPT to help me out. I do edit the questions, so sometimes they're a bit of me and AI, but I, I, it would feel bad to take full credit for them.

[00:11:53] Chris: Fair enough. Um, what was the question again? Sorry, uh, too many trauma approaches, yeah.

[00:11:59] Bronwyn: there's, there's a lot, there's a lot of trauma approaches. How do you know, um, which one to pick? How do you not feel overwhelmed by the number?

[00:12:05] Chris: My practical simple tip would be start with Trauma Focused CBT because, uh, as we know with CBT, with so many things, it's like the foundational. Uh, sort of therapy or, or, you know, things like ACT and, uh, all kinds of things, schema therapy, like these are, these are built on the principles of CBT.

So I would always recommend starting with that. You know, you'll learn about how to educate the client about trauma. You'll learn stabilisation strategies. How to acclimatise them to therapy. You'll learn, uh, the gradual exposure kind of techniques, which pretty much- you pretty much need that stuff for any of the trauma therapies. It doesn't matter which one you're going use, you need it for EMDR. You don't just kind of go straight in with EMDR into the biggest, worst event, um, or very, very rarely anyway would you do that. Um, and same with Schema, like you wouldn't get someone to do imagery rescripting with something that, you know, was a 10 out of 10 straight away.

Um, so yeah, I, I, my practical simple advice would be start with Trauma Focused CBT, but start listening to podcasts like this one and all kinds of other ones, read books, uh, read articles about other approaches, and you'll probably find yourself gravitating naturally towards one or the other and then try that out too.

[00:13:41] Bronwyn: I really love your, um, sensible approach here. I think that's really sensible advice. As well, I would add that sometimes if you go off like CBT founded approaches, you might not have as many supervisors available to supervise you in it. I'm thinking of like somatic experiencing, which I know is like quite popular in the US and it's like a body-based approach that you know, has a good evidence base, but there's not much training here in Australia and you just might not have many supervisors who are trained in that to be able to supervise. So I feel like for an early career psych, it's like you're safer with Trauma Focused CBT and EMDR.

[00:14:20] Chris: Yeah, I agree. Yep. Because you know, you do just wanna stick with what's practical.

[00:14:26] Bronwyn: And it's like these kind of body-based approaches, it's like, because we're all trained in the CBT based approaches during like masters and five plus one, it's like, it's just a whole different area of learning. I guess you could just feel quite overwhelmed.

[00:14:40] Chris: Totally. Yeah. Yeah.

[00:14:41] Bronwyn: Yeah.

[00:14:42] Chris: How many trauma? I don't even know how many trauma therapies there are, but

[00:14:46] Bronwyn: There's a-

[00:14:47] Chris: -a lot, right?

[00:14:47] Bronwyn: There's a lot, I literally heard of a new one like a week ago and I was like, I don't wanna know!

[00:14:52] Chris: Yeah, yeah. Stop it!

[00:14:54] Bronwyn: Yeah, stop. Okay, so I wanted to chat about trauma-focused CBT and EMDR therapy. We're gonna do like a really brief overview, so I just wanna give like a disclaimer to listeners if you're thinking this is like, everything to do with trauma-focused CBT and EMDR, no, it is not, we are gonna do an overview. Um, so can you describe trauma-focused CBT in a nutshell? And then we'll do EMDR?

[00:15:23] Chris: Sure. Um, I should probably preface this though, with like, I'm not at all an expert in these things, this is just, this would be my little spiel. Um.

[00:15:30] Bronwyn: Yep. Should be all good.

[00:15:31] Chris: And someone else probably does it better. Um, but trauma focused CBT, I would say is, well, it's, it's CBT, but adapted to be trauma informed and to specifically, uh, treat and manage trauma, whether that's PTSD or adjustment disorder or little t traumas or something that's just happened, like the kind of acute trauma response.

 And, one of the reasons it's such a nice place to start is because it is really structured and there's lots of skills you can learn. You can, if you're starting out, almost get away with like learning stage by stage as you're doing it. Like I would-, you'd wanna have a decent idea of where you're going with it, but you could also just sort of learn, be like one or two steps ahead of your, where your client's up to, and um, just kind of walk through the steps. So, yeah, how would you describe it? Is that-?

[00:16:32] Bronwyn: No, that's pretty much how I'd describe it as well. It's a structured approach, I know it mainly focuses on stabilisation exposure. I know it's mostly, um, being used with adolescents in particular, um, like kids in adolescence, sense, like it's a focused approach, but also for adults it's works very well. And I guess like the assumption is that trauma creates, um, negative alterations in how we think about ourselves, other people in the world around us, and cognitive behavioural therapy is really good at examining, um, those trauma generated cognitions.

[00:17:08] Chris: So yeah, like a, well, I guess an example would be like, you know, if a car, someone had a car accident or was in a car accident and then they didn't feel safe driving, um, you might go through the steps of trauma focused CBT and at some point get to the point of like, you know, you're not necessarily gonna argue that, or try and convince them that driving is 100% safe, 'cause it's not. But you, but they might have a belief that it's, or feel that it's like terrifying now and not be leaving their like house or ever getting in a car, walking everywhere, even if it takes them hours, and so that could be quite debilitating. And so you might want to help them get to a point where they're taking like reasonable risks.

[00:17:56] Bronwyn: Mm.

[00:17:57] Chris: You know, we all know it's dangerous when we get in a car, but we do it 'cause we're like, it's convenient, you know, I wanna get to the shops and get home in half an hour or whatever, right? Yeah.

[00:18:11] Bronwyn: So that's like the exposure part. And I guess like another component is the behavioural experiments. So it's like going along your car accident route. Um, a person who's had a car accident, they may find that their belief is like, if I don't look left and right 10 times, then I'm going to be in a car accident. And you can design an experiment where you test that belief and it's with behavioural experiments, you're not actually trying to put your client at risk, we're not saying like flout all the road rules and never-

[00:18:42] Chris: Close your eyes and walk across the-

[00:18:44] Bronwyn: Yeah, no. Um, but we're going to be like, can we look like once left and right and then go?

[00:18:52] Chris: Yeah, yeah, Something reasonable.

[00:18:54] Bronwyn: Yeah, absolutely. Yeah, and like what's your experience of delivering this therapy? Like how do you feel doing it? Do you feel like it's a good one?

[00:19:02] Chris: I think, yeah, it's, it's, it's great. Like I said, I think it's really foundational. Um, and even if you're doing other therapies, you're kind of doing trauma focused CBT or you're thinking about these principles, especially the gradual exposure principles and challenging avoidance and unhelpful thoughts and beliefs and stuff.

Um, so if I go back to the, uh, example of working with people who've been in like car accidents, you might start with some, like, you'd, you'd develop like the gradual exposure hierarchy, right? So you'd help, you'd sit there with them and try and figure out, okay, well let's come up with a list of things that you are fearing related to cars and roads and driving and all that kind of thing. And at the top would be something like, you know, going for a long road trip, right? Driving for like six hours off the coast or something. But you don't start there, you start near the bottom and it might be like, go out the front of the house and just hear the road sound.

[00:20:01] Bronwyn: Mmm.

[00:20:02] Chris: And just sit with that. Right? It's so objectively safe and there's, there's, there's really no like rational, sort of reason not to do that other than the anxiety that it might bring up, which makes sense. And, and by this point you would've gone through the psychoeducation to, you know, you make them feel like this is understandable, it's normal, like your nervous system is reacting to this for a reason. Um, so they don't feel silly about it or anything, hopefully. It then really just becomes about anxiety, like and reducing, that anxiety down just as you would if someone had a phobia.

[00:20:41] Bronwyn: Totally, and I find that clients are really receptive to this understanding, like the way we're explaining it, I find that they can get on board with it pretty easily. Is that what you've found as well?

[00:20:52] Chris: Yeah, yeah. I think everyone has some kind of relatable experience of being scared of something. You commonly just end up talking about, like public speaking or something, right? Or, yeah.

[00:21:03] Bronwyn: Yeah.

[00:21:03] Chris: You know that like you got all clammy, right? Your heart was racing, like you were afraid of it, you were worried about what might happen and did anything bad happen?

[00:21:13] Bronwyn: It's like most of the time when we do public speaking, it's like, we're not in danger of somebody like attacking us most of the time, I guess it depends on the setting. But like we'd all be able to understand that maybe Jimmy and grade five, like threw a pencil at you when you were public speaking, and then your brain is conditioned to react in the same way as if Jimmy's in the audience now.

[00:21:35] Chris: Yeah, yeah, exactly.

[00:21:36] Bronwyn: Yeah. It's, I find it, yeah, I find it pretty easy to explain trauma in that way. It's like a conditioned response that your body is doing. Like you don't have much control, but we can help you regain control through exposure.

[00:21:48] Chris: Yep, if you're willing... kind of thing, yeah.

[00:21:51] Bronwyn: Yes. Such a, such a good point. Okay, so I feel like we've given a good overview of trauma-focused CBT and let's have a go at EMDR therapy.

[00:22:02] Chris: So in a nutshell, describing EMDR, well, I guess it stands for eye movement desensitisation and reprocessing therapy, which is a mouthful, which is why everyone calls it EMDR.

[00:22:16] Bronwyn: Yeah.

[00:22:17] Chris: And I think a lot of people think that it's really about the eye movement and I mean that's part of it, but it's really not the core of EMDR. The main theory behind EMDR is the Adaptive Information Processing model or AIP model, um, which, you know, you learn about a few of these trauma therapies and half of they're all really the same. So it's, it's based on the idea that a... when something traumatic happens, most of the time we have our acute response to that. But then over time, our adaptive beliefs or you know, if we're using the CBT model, our, like helpful thoughts, our good experiences and memories and stuff slowly help us make sense of that event and integrate it into our worldview or our view of ourselves or whatever. And then that trauma response just kind of naturally over time dissipates and we get back to our baseline or something like that.

And what we're trying to do in EMDR or what the AIP model, uh, pos is that, uh, that hasn't happened yet. So we're trying to link or unstick these traumatic experiences, sort of open 'em up, act-, activate those memory networks through prompts and then, we're trying to link that adaptive information to the traumatic memories and, and beliefs and stuff and events to sort of see them in a new way, uh, re-rocess those memories and then 'cause of what we know about memory and the science of memory, once you take a memory out and you sort of modify it, then when you like pack it away again, it's now changed or there's new information stored in there with it.

 And the eye movements part is really just about, uh, I, I explain it to clients like it's a little bit of a neurobiological kind of hack that we take advantage of. So there's, there's a kind of another theory there that it stimulates the, uh, visual cortex or the occipital part of the brain, it gets a lot of that visual imagery, um, happening, um, but that it also uses up a lot of your working memory. So it's kind of like you have one foot in the room and what you're doing right now and that a lot of your, um, working memory is taken up by that, and one foot in the trauma, and that sort of lessens that severity of that experience of the trauma or it stops people from like dissociating as much, that kind of thing.

[00:25:02] Bronwyn: Hmm. You explained that so well.

[00:25:05] Chris: Well, that's good to hear. I guess that's kind of the gist of how I try and explain it to, to clients. There's, there's quite a fair bit, there's a fair bit to cover.

[00:25:14] Bronwyn: There is, there is. I loved your neurobiological hack, um, I haven't heard that before, and I'm like, that's, that's genius. That's really good.

[00:25:22] Chris: Oh, that's good, yeah.

[00:25:22] Bronwyn: Yeah, I like that. And I like that you are describing it because like, I don't often feel, um, fear talking on the podcast, but like I actually notice that I feel scared talking about EMDR because I'm like, oh, the EMDR folks are gonna like crucify me if I say something wrong about it.

[00:25:39] Chris: Yeah, there's some pretty hardcore EMDR folks out there. Don't worry about them.

[00:25:43] Bronwyn: Yeah. Okay, let's not stress, but I think, I think you did a good job. The other metaphor I like for EMDR is like if you've got a wound, and then it's kind of like when the trauma gets stuck, it's like somebody's stuck a stick in the wound and we just need to get that stick out so that it can actually heal over. like EMDR is based on, like the brain has a natural ability to heal from trauma and something is making it stuck. And, so it's a way of getting unstuck.

[00:26:08] Chris: That's a good one. I haven't heard that one before. I'll stick it in my back pocket.

[00:26:13] Bronwyn: Was there anything else you wanted to say, like about EMDR, about the overview?

[00:26:17] Chris: I think just that, yeah, going back to like the, some of the trauma focused CBT principles, like those all come into it. So, you don't necessarily just, yeah, you don't, not necessarily, you just don't like dive straight into the biggest most feared memories, uh, you would often start with something really small, in fact sometimes it's good in EMDR to start with a positive experience.

So if someone has, we'll keep using this car crash example, um, if, if, um, someone had had positive experiences as a kid, um, with driving, like maybe they loved dodgem cars or something, I don't know, random, um, and so you might be like, Hey, tell me about a time where you were riding dodgem cars as a kid and like all your friends were there, family, you were having a great time. You remember laughing and wanting to have another go.

And so instead of processing a trauma you're actually strengthening that adaptive information and really taking that out of the box and expanding on it. And then, 'cause of what we know about how trauma memory networks work, all of that's gonna be kind of sitting adjacent to the traumas. And even if you're not explicitly talking about the trauma, like it's gonna start to get into similar territory, I guess.

[00:27:43] Bronwyn: Yeah. It's really interesting hearing you say that and it's like, I've never made this connection before, but it's like with the trauma focused CBT, it wants you to gather adaptive information through the exposure and the experimentation. So it's like go out to your letterbox, um, and just listen to the traffic and trauma-focused CBT wants you to be able to integrate that information you gain from your reality. Whereas EMDR is like, that's not quite enough, and the mechanism is the bilateral stimulation. It's like, no, we can get this adaptive information by making it more accessible and enriching it, like with the positive ones and then getting it in your brain that way.

[00:28:23] Chris: Yeah, yeah. Yeah, and so one of the important things I learned about EMDR, um, when I got more into it, uh, was that it only really works if people have adaptive information. And if they don't... So if you are working with say, someone who has, uh, you know, Complex PTSD from, you know, neglect and really difficult childhood experiences, um, maybe a very unsupportive or absent family, you know, really complex kind of case, then there's not necessarily gonna be the same or the, the typical like adaptive information that would often help people recover from traumas.

So, you know, we know that when people develop PTSD, it's not just about the event, it's about the whole, the whole life before that event, and people with a lot of adaptive information often don't need therapy because they just recover. They just, they believe the world's inherently good or safe or whatever, and then they just kind of deal with things and don't necessarily need help.

But we know that, uh, EMDR doesn't necessarily work unless there's that adaptive information. 'cause there's nothing to link the trauma to, to, to unstick it and think about it differently. Um, so sometimes in those cases you actually have to help them make adaptive information. Um, so a good way to test that, and again, this isn't just with EMDR, but a good way to test that is to see if they can like take a compliment.

[00:30:07] Bronwyn: Oh, hmm.

[00:30:09] Chris: So yeah, so one of my EMDR supervisors used to do this. She'd just say, you know, tell me something good about yourself. And if they couldn't say it, well then she'd, you know, whatever it was, she, she'd find something and she'd, she'd give them a compliment and say, you're, you're really good at this, or, you know, love that, you know, hairstyle you've got, or whatever, probably try and make it more personal than

[00:30:33] Bronwyn: Yeah.

[00:30:34] Chris: And, and if they couldn't take that in, if you could tell they would couldn't accept that or that made them anxious or kind of squeamish, then she, she, what was the phrase? Um, there was positive affect phobia, so like a, yeah, scared of feeling good or feeling joy or feeling happiness, 'cause that's a scary emotion, it leaves you vulnerable. So if you can't do that, it's pretty unlikely that you're gonna find EMDR, kind of standard protocol, very helpful, unless you work on that first.

[00:31:11] Bronwyn: Mm, so maybe there's something else to note. I realise that we've left out the, the fact that EMDR is also a structured approach, so it's not just the reprocessing phase. It's like, uh, it's, it's eight phases that you got. And one of those phases, um, like particularly for folks with complex trauma is like stabilisation and installation of like positive resources, because yeah, folks with complex trauma, any affect can be difficult and dysregulating for them. Um, so as you say, we need to bring up this adaptive stuff or instal it if they don't have access to it. So I quite like that EMDR is a structured approach as well. That's actually one of the reasons why I trained in it, because I heard it was very structured.

[00:31:53] Chris: Yeah. Do you do much of it?

[00:31:55] Bronwyn: I do. Yeah, yeah.

[00:31:57] Chris: How have you found it?

[00:31:58] Bronwyn: How have I found it? I, initially, I will say I found it very difficult. Um, I found that it was a very difficult therapy to learn, I think mainly because, and I wonder if this is your experience as well, when I learned EMDR, there was literally a glossary of terms, um, and I was like, I've never heard these terms before, like adaptive information processing model, um, installation of resources, um, what, bilateral stimulation. Like I'd never heard these words before. And it's like I'm talking about them pretty fluently now, but I remember when I started out I was like, I have no idea what you were talking about.

[00:32:34] Chris: Yeah, and they start using like the acronyms, like immediately, like BI...

[00:32:39] Bronwyn: Yeah!

[00:32:40] Chris: EMs, and you're like-

[00:32:41] Bronwyn: ...the positive automatic thoughts and, um, the negative cognitions and, and like NCs and they'll abbreviate it straight away, and I'm like, stop, stop!

[00:32:50] Chris: Yeah.

[00:32:51] Bronwyn: Um, so when I first started out, I literally had the scripts in front of me and our trainer was pretty cool with that. He was like, yeah, just have the scripts in front, clients don't mind, and I found that that was the case. Um, yeah, how about you?

[00:33:04] Chris: Yeah, very similar. Like it's very, it's quite a jargony therapy, which is a bit annoying, and tells take a while to get your head around. I think the best way to get around that is to just listen to lots of podcasts, there's actually a podcast called the EMDR podcast. I don't know if you've listened to it.

[00:33:22] Bronwyn: Yes, yep.

[00:33:24] Chris: That's a really good place to start. Uh, he talks about all of these concepts. Um, he's got some great metaphors for EMDR. Um, but yeah, it's a, it's a, it's a steep learning curve, I think because it is quite different to talk therapy. Yeah, it does have like maybe like similar kind of structured stages that something like trauma focused CBT would have, but once you get into the actual eye movement and processing part, it's pretty different to talk therapy, you don't do much talking.

[00:34:02] Bronwyn: No, and in fact, like talking is discouraged. It's like stop trying to hurry the client along, they can do it themselves most of the time, unless we use the interweaves, another jargony term, um, which is, yeah, helping their brain move along with some words that we say. But most of the time we don't do much.

[00:34:22] Chris: Right, I've found that to be the case, anecdotally, maybe about 50% of the time. And then, I would say a lot of the time, I think the interweaves and stuff are really important, and it is kind of coming back to that idea that if people would've recovered from PTSD, you know, they probably just would've done it if they had the adaptive information. So I, yeah, I personally, I've found that, you know, giving prompts and steering it a little bit more actively is quite helpful. But I know there are, yeah, those like hardcore EMDR purists out there who are like, nope, don't do that. That's just your own nonsense getting in the way, like...

[00:35:05] Bronwyn: Yeah, no, absolutely. Yeah, it's, yeah, there are purists. I've also found that interweaves work good. I just feel like I haven't gotten good at them, I feel like that's a skill in itself. And that's what I mean by I feel like it's quite a difficult therapy to master, um, because sometimes I'll be like, I'll say something and I'll be like, consider that you were a child, think about that, now follow my fingers, and they're like, I don't care that I was a child, I was an idiot, and I'll be like, oh, backfire.

[00:35:32] Chris: Yeah, yeah!

[00:35:33] Bronwyn: Yeah.

[00:35:34] Chris: Counter-weave.

[00:35:35] Bronwyn: yeah, exactly. Um, so, but I feel like it's got an easier, as I've gone along, I don't want any listeners to think that it's an un-, insurmountable therapy. It has gotten easier the more you familiarise yourself, you listen to podcasts, you talk about it. Have you found that too?

[00:35:51] Chris: Yep, yep. I find that with pretty much all therapies I learn. Like same with schema, it was the same with CBT. Like just go and find heaps of different sources of information about it. Hear lots of different people talk about it, watch whatever videos you can find for people doing it, and that's the best way I reckon.

[00:36:16] Bronwyn: Is there anything else you wanted to say about EMDR?

[00:36:19] Chris: Oh, I feel like I could talk about it forever. Um, I do have one good thing.

[00:36:23] Bronwyn: Okay.

[00:36:24] Chris: Another helpful thing I think about EMDR is a metaphor I got from, uh, that podcast, the EMDR podcast. So he talks about the boat and the whale metaphor. I don't know if you have heard him mention that. Oh, it's good, it, it really summarises EMDR really well. So I'm probably gonna butcher it a bit, but, um, the, the metaphor is that you're kind of like when, when you're doing trauma processing, you're often going after these, uh, traumatic memories that are kind of like whales, and your boat is kind of like your adaptive information.

And so he says that EMDR was, kind of, the adaptive information processing model that's underpins EMDR was developed really around the idea that, uh, for, for people who have kind of boats the size of cruise ships, I think is the way he describes it. So you go out there, you get a whale on the hook and it's like, you're fine. You can, that whale can thrash around and you'll be able to deal with it 'cause your boat is huge, you can handle that. But if you go out and you hook a whale and you're in a canoe, what are you gonna do? What are you gonna do now that you've woken up that whale?

And so. It, it's not necessarily just good for EMDR, again, it's kind of like good for the idea of working with trauma. This is why you wanna tread carefully and, uh, go slow and really assess the person well before you start doing anything like pro-, processing. And if they do have, you know, adaptive information the size of a canoe, that's fine, but you've gotta build up that boat. And so, you might try just going after a tiny little fish first, the smallest fish you can find.

And that's actually where I pretty much always start EMDR is to, so yeah, again, if it was a car crash, then I might, um, go with, I don't know, maybe the, they've got a memory of like when they were a kid and they heard a horn honk and it scared them something small. Like that, or even small, like the smallest you can find basically. Maybe the first time they were in a car and they felt bump and they were a bit like, what's that? You know, whatever it is, like the smallest you can find. And then just see how that goes, 'cause it's kind of like taking that canoe for like a little test drive and then you come back and you figure out, oh, there's a hole there, so we'll plug that hole up, and suddenly your canoe iss a bit stronger. And so, yeah, I just like this metaphor, 'cause then it's like your goal is to really build up the adaptive information and only go after fish that you can actually process.

[00:39:11] Bronwyn: I really love this metaphor, 'cause in my head I'm immediately like, I'll build them up to be a battleship and then they can on any whale!

[00:39:19] Chris: Yeah, yeah.

[00:39:21] Bronwyn: But maybe that's not the point of the metaphor, but I really liked it.

[00:39:23] Chris: No, it that's, that's a good one, right. I'm sure there'd be clients who'd be like, yeah, I'm gonna get a battleship.

[00:39:28] Bronwyn: Yeah!

[00:39:28] Chris: Like, cool.

[00:39:30] Bronwyn: Yeah. I'm gonna have 12 cannons... um, whatever mate.

[00:39:34] Chris: Yeah, yeah. Whatever works for you.

[00:39:37] Bronwyn: Yeah. Um, I really liked that and that's awesome. I wanted to ask you about trauma-informed approaches. Is that okay?

[00:39:45] Chris: Yeah.

[00:39:46] Bronwyn: Um, what do you think works best for working with clients who have experienced trauma? Just from your experience and what you know of the literature, um, what do you find works well? I guess I'm asking for some do's and some don'ts.

[00:39:59] Chris: One of the important things to think about early on, which I reckon we don't really get taught enough about, is seeking informed consent. And, you know, uh, just because you get a referral and it says on there that someone has PTSD doesn't mean you just dive in, you start doing trauma work. Um, you need to go slow and explain to that person, well actually probably start by like checking their understanding of like, do they know what PTSD is? Has anyone gone through this with them? And if you, if they were to come to therapy to work on that, do they know what that would look like? And once they then know and they're informed, is that something they actually want, want to do? Or would they rather not unpack this and keep it locked in that box? Which, if that's their choice, I mean, who are you to say they shouldn't, right?

Like, so I think that those informed consent, kind of like principles are really important to safely enter and, you know, we know that one of the things that goes out the window quite often when people are traumatised is that sense of control. So if you're just kinda launching into stuff and they don't quite know what they're getting into, that's really not helpful.

[00:41:20] Bronwyn: That's really important and I agree that it's something that is essential, but could be overlooked, but with the trauma-informed principle of empowerment, choice and control is really important.

[00:41:31] Chris: Yep, yep. So I think that's one of the main things. And not to underestimate the importance, the importance of that early stabilisation and education, in particular, phase. There's a risk that kind of stabilisation can go on for too long, quite often, and the literature does have a lot of evidence around not necessarily waiting until clients stabilise to do trauma work, because that might not necessarily happen. It's kind of like the chicken or the egg. Um, but you do what you can and you make sure they're making the choice, not you to get into the therapy and then go from there.

And then I think, um, I'd probably say just having a good understanding of how anxiety and avoidance turn up when it comes to trauma as well. And you know, you will get people who don't wanna talk about things or who don't wanna try these challenging things, and so you might need to get to a point with therapy as well, where you hold people accountable to that and sort of set some, not even boundaries, but just, you know, uh, be realistic with them. That like, if they don't want to go there, it's fine, they don't have to. But then don't be afraid to then ask, well, what do you wanna do? Like, what, why are you coming to therapy if you don't want to dive into these things?

And it might seem like a really nasty, harsh question or something like that, but I think it's something that most experienced psychs are quite comfortable doing because they've had the experience of going- treading really lightly around these topics or feeling like they're just not, you know, you might feel like you're not really getting someone with a client, but they don't want to deal with something quite difficult, so you let them not deal with it, but they keep coming to therapy 'cause they like the support, and before you know it, you're like 20 or 30 sessions in and you haven't really gotten anywhere, they just like coming there. And that might be fine for a while, but eventually they actually might get quite frustrated with you and be like, "Hey you've, you've, you know, I've spent all this money and I don't feel any better, and, I've been using all my time to come here and, you know, what is, what are we doing"? Sometimes they flip it back on you, so don't be afraid to have those kind of conversations.

[00:43:50] Bronwyn: You've named something so important. I consider this like a core dilemma in doing trauma therapy because, the client can be avoiding talking about the trauma or doing the trauma work, and we as a therapists can collude in that avoidance by not bringing it up. So we can be like, oh, but they don't really want to, but it's also that avoidance is a core maintaining and perpetuating factor of the trauma. So we need to be aware of when we are colluding under the guise of saying we are giving them like empowerment and choice.

It's a huge dilemma though, and I reckon one that's good to sort out in supervision too, because it's like, is this my feelings, like the countertransference, or is it like an actual thing that's happening? Um, but I've found it pretty good to bring up with clients by being like, Hey, I've noticed for the past three sessions we've been talking about X and we did have the goal of doing trauma processing for these three sessions, I wonder what happened, and what is happening between us. Um, so approaching it with curiosity and openness and non-judgment can be really helpful there.

[00:44:52] Chris: I agree. I think-

[00:44:54] Bronwyn: Oh, you go.

[00:44:55] Chris: No, you go, you go, you go.

[00:44:56] Bronwyn: I was gonna say otherwise, we do get to that situation of like 20 sessions down the track and the client's like "it's your fault".

[00:45:03] Chris: Yeah, and it can happen, like, you know, justifiably, clients can get annoyed 'cause they're like, what? Nothing's changed or I feel worse, you know?

[00:45:12] Bronwyn: Yeah.

[00:45:12] Chris: And I think the other way I've seen that play out is, I remember, uh, not a specific client, but like this kind of thing happens. So again, like we go, go the car crash example, right? It's very reliable. I remember trying to get someone to do their like gradual exposure hierarchy for weeks and weeks and week, months, right? And, and they would just be avoiding it, they'd, you know, maybe like just dip their toes in and they'd be like, nah, you know, they'd tell me they were gonna do it each session and then they'd come the next time and they still hadn't really done anything.

And then I remember sometimes logging in with some of these clients and then they'd be like sitting in the car on video and they'd be like sweating and they'd be like, I've decided we're gonna do it today, right. And they're like, and you're like, what? What do you mean you were just gonna like, you know, walk into the garage and walk back out? That was what, that was our next thing on the list, right? And then they're like sitting in the driver's seat with their hands on the wheel and they're like, "doing it today, I'm sick of this" kind of thing. And they've swung, they're kind of like overcompensating and they're just flooding, you know, they're just overwhelmed and it's probably gonna set them back, if anything, not help, um, their, their PTSD or anxiety.

So I think that can come about if you don't have these conversations about like, where are we at? Is this working for you? Uh, I feel like we're not really progressing. Uh, if you're not having those conversations, you can get stuck like that.

[00:46:45] Bronwyn: Mm, 100%. Chris, it's been so lovely speaking with you today. What do you hope that listeners will take away from our conversation?

[00:46:54] Chris: Oh, I dunno, maybe just hopefully a couple of tips or even one helpful idea. That'd be, that'd be nice.

[00:47:02] Bronwyn: Yeah, awesome. Yeah, I think there was a lot of great takeaways from what you said. I know that, um, I learned a lot from you today and I think there are a few things that stood out to me as worthwhile, so I hope listeners find that too.

[00:47:14] Chris: Yeah, well, I'm gonna take the stick in the wound idea from you.

[00:47:17] Bronwyn: Feel like I butchered that a little bit, let me just try-, I feel like it was like also rubbing dirt in the wound kind of thing, and we just need to get the dirt out, like, I reckon I made up the stick.

[00:47:27] Chris: It works, it works, it's good. It's stopping it from healing. Right, it's like It's a great metaphor.

[00:47:33] Bronwyn: I mean, and like we do this all the time with clients as well. Sometimes I do forget the metaphors I'm creating and then I make them up on the spot and I'm like, does that work? And then the client would be like, yeah, and I'm like, cool.

[00:47:43] Chris: Yeah, yeah, love a metaphor.

[00:47:46] Bronwyn: Yeah. If listeners wanna learn more about you or get in touch, where can they find you?

[00:47:50] Chris: Um, I probably just Google me, like I'll come up. Um, but I am actually about to get my board approved, supervisor approval. It's sort of just pending. I, I don't have a criminal record or anything, so it should come through soon. Um, so you might be able to find me that way as well.

[00:48:13] Bronwyn: Awesome. Well, thank you so much, Chris. Again, it's been lovely to speak and learn from you.

Listeners, if you found this episode helpful, make sure to follow Mental Work, share this episode with a mate who might benefit from it, and that's a wrap. Thanks for listening, I'm Bronwyn Milkins. Have a good one, and catch you next time, bye!