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Eye of the Beholder

Eye of the Beholder Medical personnel travel to New Orleans for workshops on a therapy that uses eye movements to help alleviate Post-traumatic Stress Disorder.



Anne Heard talks about a city in chaos -- about a world that she describes as "in many different stages of recovery." She talks about 15 people who live in a home barely big enough for four -- and about upheaval, and unemployment, and potholes. A licensed clinical social worker in New Orleans, Heard says all of her clients come in with "some post-Katrina suffering." In a meeting, on a street corner, standing in a grocery line: Katrina always becomes the topic of conversation. Everyone has a story -- one they tell over and over again.

Now it's hurricane season again, and while dealing with the threat of another disaster, everyone also is dealing with the anniversary and aftermath of the last. "Many of us did not lose something or someone we loved, but we lost a way of life that we did love," Heard says. Many who faced Katrina, taking care of business almost stoically, "have begun to fall apart," a possible sign of Post-traumatic Stress Disorder (PTSD), she says

"PTSD is a normal reaction to an abnormal amount of stress," says Dr. Gerald Murphy of New Orleans "Most of us live through trauma and our brains integrate the traumatic experiences with our positive experiences, and that allows us to cope." But PTSD may have a delayed onset -- even years or decades -- triggered by another stressful event. He says that natural disasters like Katrina can lead to PTSD that won't go away without help.

Trauma means injury, and Murphy says that just as the body can be injured, so can the mind. The development of PTSD symptoms as well as their severity has more to do with intensity and duration of the stressful event than emotional weakness; it's not about the thickness of your skin, but the force behind the blow. Clinical social worker Tamara Pellant says PTSD should not be confused with normal grief and adjustment, but is a normal reaction to an abnormal amount of stress.

Natural disasters like Katrina often lead to psychological disorders, Pellant says. "What is important to note for a diagnosis of PTSD is that there must be a real or perceived threat to one's life, real or potential bodily harm and real or perceived threat to the physical integrity of self," she says. "So it is possible to suffer PTSD when there is no actual physical harm, such as a near-collision with an 18-wheeler."

Many therapists like Pellant and Murphy use a therapeutic approach called Eye Movement Desensitization and Reprocessing (EMDR). The therapy was developed by American psychologist Dr. Francine Shapiro after she observed during a walk in a park that moving her eyes seemed to reduce the stress of disturbing memories. In 1989, she began to teach therapists how to guide patients in moving their eyes while they recalled troubling memories.

Shapiro describes EMDR as a form of therapy distinct from most traditional ones, but emphasizes that it still integrates all the major psychiatric orientations. Although eye movements are the most commonly used external stimulus, therapists have added auditory tones, tapping and other types of tactile stimulation in the therapy. In 2002, the California Psychological Association awarded Shapiro its Distinguished Scientific Achievement in Psychology award for her work. Later that year, she received the International Sigmund Freud Award for Psychotherapy presented by the City of Vienna in conjunction with the World Council for Psychotherapy.

Robert Robinson, a registered nurse and clinical social worker, regularly uses EMDR in his practice. "It's an effective and robust approach to trauma resolution," he says. "It has proven particularly powerful for PTSD." But Robinson notes that there also are traumas with "a little t" as opposed to "capital T" traumas like childhood sexual abuse, natural disasters or military combat. But even when a person experiences smaller traumas, those can add up and result in unconscious actions and self-defeating patterns. Robinson says that therapists customize EMDR to the client and instruct them just to notice whatever thought, feeling, image, memory or sensation comes to mind. Depending on what a patient reports, the clinician will facilitate the next focus of attention. This approach is a way to identify what is driving the actions and help break the patterns, Robinson says.

Many therapists who employ EMDR use it in conjunction with some form of traditional Cognitive Behavior Therapy (CBT) -- a kind of talking approach that works on a more intellectual level. Pellant says CBT explores negative thought patterns and personal beliefs and helps patients reframe them into more positive ones. But with PTSD, a person not only forms negative beliefs about himself, others and the world around him -- he also memorizes and relives intense feelings of fear, horror and helplessness.

Traumatic memories are recorded differently in the brain than other experiences and are "stored dysfunctionally in fragmented pieces of sensory impressions and emotional feelings," says Roger Solomon, an international EMDR trainer and facilitator. Solomon, who recently traveled to New Orleans to lead a Post Critical Incident seminar for NASA, says traumatic memories "can surface not only as images of the event but with the sounds, smells and bodily states associated with the event."

These memorized associations result in unpleasant and sometimes frightening sensations, Pellant says. They are very real, intensely distressing and easily triggered, she says, often leaving victims nauseated with a lump in their throat. Some victims feel heaviness in their chest. EMDR helps a person reprocess negative beliefs as well as physical sensations. CBT alone does not address these sensory responses like EMDR, Pellant says.

Social worker Michele McIntire describes the therapy as "a marvelous synthesis of cognition and biochemical processes, which allows the individual to be in control and part of their own self-healing." That is "the superior fundamental nature of EMDR," she adds. Dr. Paul Emmett agrees and says he uses EMDR to help patients access disjointed traumatic events and bring them back together to create "a cohesive picture."

Emmett, who used EMDR in his practice for 10 years prior to Hurricane Katrina, found the protocol while "searching for trauma therapy that treated a wide variety of patients in a wide variety of circumstances." He describes EMDR as "predictably efficient" and says he usually sees results after the first session. "EMDR takes advantage of the brain's adaptive nature -- and its natural ability to heal itself," Emmett says.

Dr. Jean Hawks, regional EMDR coordinator for Mississippi and in training to be a consultant for EMDR's international association EMDRIA, uses the eye movement therapy in conjunction with CBT to integrate thoughts, feelings, pictures and sensations "to create a coherent image." She prefers to use eye movement therapy over tappers and headphones -- unless she finds that someone is unable to hold a mental picture without closing their eyes.

The American Psychological Association recently gave EMDR the same level of approval as CBT. The Department of Veterans Affairs and Department of Defense in Washington, D.C., endorsed EMDR with its highest level of recommendation and approved it for treatment of PTSD. Insurance companies like CIGNA, Aetna, and Magellan also have approved EMDR therapy as part of their health packages.

New Orleans' Dr. Gerald Murphy is a team member of Eye Movement Desensitization and Reprocessing Humanitarian Assistance Program (EMDR HAP), which has a mission to promote recovery from traumatic stress. Over the past 10 years, EMDR HAP has provided personal counseling and community-based training in EMDR and has taught the therapy to thousands of licensed mental-health professionals throughout the world. Part of its mission is to "change the common denominator of suffering to one of hope and healing."

Following Katrina, EMDR HAP sent certified clinicians from all over the country to provide psychoeducation to more than 600 people. EMDR clinics gave both first responders -- police, fire, rescue workers, and EMTs -- and other victims of Katrina a chance to recognize their symptoms and determine if they had PTSD. The education normalized emotions and let everyone know that there was treatment. Each participant was offered a chance to speak to someone about what they were experiencing, and one out of four requested individual counseling. Between October 2005 and March 2006, more than 150 clinicians were trained in Level I EMDR, the first of two levels of training planned.

EMDR HAP Executive Director Bob Gelbach says that EMDR doesn't necessarily work "better and faster" than CBT. Traditional CBT also involves "recognizing unhelpful or destructive patterns of thinking and reacting, then modifying or replacing these with more realistic or helpful ones," he says, adding that "both CBT and EMDR re-expose clients to the traumatic memory." CBT, however, generally involves "homework" in which patients are asked to retrieve troubling memories as an assignment between sessions. EMDR doesn't require homework, but the treatment continues to work between sessions. "It's also recognized that EMDR uses re-exposure in smaller doses, and that this is less distressing for both client and clinician," Gelbach says.

Psychotherapist Jeffrey Thompson, who uses EMDR to help patients who are suffering PTSD symptoms related to Katrina, points to numerous studies that suggest the therapy is as effective as CBT but works more quickly in most cases. Although there is no required homework in EMDR, Thompson says it is sometimes suggested that patients keep a journal. As part of the EMDR protocol, he practices a visualization technique called "safe place," which Michele McIntire describes as "an emotional location that allows the mind to relax and offers the client physical comfort and emotional solace".

Clinical social worker Wendy Justus is a proponent of longer-term, more analytically informed therapy for many issues other than PTSD, but "traumatic stress can and should be addressed promptly and effectively to limit long-term damage -- cognitive, emotional and physical -- that we know results when trauma is left untreated," she says.

"Ideally, when one uses EMDR or any other therapeutic intervention, one has the luxury of time to create a working therapeutic alliance between practitioner and client. With national disasters like Katrina, you do not have that luxury. EMDR's protocol can be taught relatively quickly to helping professionals, and can thus be offered to significantly greater numbers of affected people in a shorter period of time."

Dr. Harvey Rifkin says he finds EMDR very useful "for a person who is in reasonably good mental health -- with a fairly simple, fairly focal, specific trauma from a prior event" and that the technique almost automatically relieves the stress. But Rifkin prefers to use EMDR in conjunction with a type of CBT and believes that for "anyone with ongoing stress from an ongoing situation, EMDR can help but it doesn't obliterate the reality." Rifkin begins sessions with basic principals of CBT and if that doesn't work fast enough, he adds EMDR. He stresses that "EMDR can be fairly remarkable, but that it is not a panacea for everyone suffering from PTSD."

During the past 12 years, therapists and researchers worldwide have taken an interest in EMDR. There are more controlled studies supporting EMDR as an effective treatment for trauma than any other therapy, and it has been expanded and refined to include applications for grief, phobias, anxiety and panic, aspects of depression, childhood abuse, performance anxiety and, more recently, addictions. Gelbach and the EMDR HAP team also have counseled children worldwide in order to heal traumas, which they believe can prevent those youngsters from becoming embittered adults prone to violence. That effect, the clinicians believe, can continue for generations.

EMDR HAP led Level II training in New Orleans last month. Forty-five mental-health clinicians assembled at Kingsley House on Aug. 18, and a team of five professional EMDR educators volunteered their time. Murphy was part of the HAP team; the group was led by Dr. Priscilla Marquis, a psychologist from San Francisco who trained clinicians in previous EMDR Level I workshops in New Orleans and Lake Charles. She has extensive experience in bringing EMDR to other disaster areas and has published research on the efficacy of the therapy. Local clinicians in New Orleans, including Steven Ball of Kingsley House, Thomas Stagg of Family Services of Greater New Orleans and Sarah Keith of Jewish Family Services in Metairie, coordinated the three-day training session for the benefit of their local colleagues.

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