How do I conceptualize the use of EMDR therapy with children with symptoms of reactive attachment disorder? This is a question that I struggled with when first learning EMDR therapy. This blog is just an overview, but I wanted to document a few strategies for case conceptualization.
The psychosocial intake is very important in order to add the appropriate valence to targets. I would suggest that interviewing the parent and the child both together and separately are important. Why is the child in your office? What do the parents want to accomplish and what does the child want to accomplish? Many children are very present oriented and in order to feel successful in therapy and in turn engage in the process of EMDR therapy, I focus on selecting targets initially that the child wants to address. "I don't want to get in trouble so much." Set up the treatment plan focused on this goal of treatment from the child's perspective and explain to parents why this is critical to efficacious treatment. It is important to remember that in the new training, we discuss that if the client is too overwhelmed by the process of defining the targeting sequence plan, the therapist may need to move to Preparation Phase to develop more advanced resources early in therapy before returned to History Taking. Dancing with the phases of EMDR therapy in psychotherapy makes great sense clinically. Moving to Preparation to teach self-soothing and calming and emotional regulation skills and advanced resourcing may be necessary before being able to identify and organize targets for trauma reprocessing. This is essential with many children because of the severity of trauma, less than secure attachments, as well as, the developmental overlay of the child's age and functioning.
When the child chooses targets as we do during the "Mapping" process, the child is much more likely to be engaged in the process of psychotherapy. Many therapists encounter what is labeled "resistance." I am uncomfortable with the word "resistance" and instead believe that is my job as the therapist to get the child to engage in the therapeutic process. If the child chooses the target and experiences the therapist as the child's ally in the treatment process, the child is much more likely to actively participate.
With children the presenting problems (symptoms) identified by the child may result in targeting sequences focused on a presenting problem defined by something other than a dominant core negative cognition (NC). Since children may be more focused on emotions and body sensations, a negative cognition or "what bad thought do you have about you" may be too confusing. In case conceptualization with children, this makes sense for children and parents to start with the symptom and focus on a presenting problem while a targeting sequence plan is developed. Children with symptoms of RAD, especially those adopted internationally may have no cognitive or verbal history, at least in English. Many of the children I work with were adopted from non-English speaking countries so even if they do remember, they remember in another language that they may have forgotten which makes it even more confusing! Again, this is part of learning about the unique issues of this population. At some point in treatment, it is helpful to have the child create a narrative of their own history and even make a Life Book can be helpful to resolve the past history that is often unknown. Using Joan Lovett's narrative is helpful to teach kids. I have kids write a Life Book with a story that tells what we know about their parents, their former home (s), their childhood before adoption and then what we know about the adoption process and what has happened since adoption. Adoptive parents can help with some of the information, but then this becomes the parents' story, not the child's. It surprises me what many children will report if I ask them to write their own story. Once the story is written, we can identify targets from the book that the child might think would have been uncomfortable for a child. This is very simplistic overview of the process, but I wanted to give the reader some thoughts about using EMDR with children.
Often when children are in unstable home and community environments (e.g. foster care, residential treatment and/or groups homes) and parallel interventions may be necessary in addition to reprocessing of appropriate targets. Examples of these interventions can be: developing and enhancing resources, teaching replacement behaviors, and/or new skills, etc. This process of establishing a base from which to process the trauma is important because many children with symptoms of attachment trauma and/or RAD do not have the emotional scaffolding with which to tolerate additional distress that may arise from trauma processing. Parallel interventions are often necessary with children with attachment trauma and the therapist may need to spend a great deal of time in Preparation Phase with children AND parents because parents often have their own unresolved attachment traumas, sometimes fertility trauma, and often trauma from trying to love and parent a child with attachment trauma.
Targeting chronologically may not be an appropriate course of treatment because the child/adolescent is not prepared to reprocess any past traumas. This is often true with children with trauma and especially with children with symptoms of RAD. So, I'm suggesting that establishing a targeting sequence may not be the first choice for children with RAD or for any client with a chronic trauma history. If the client does not remember or is too overwhelmed by the target selection process, I actually am more likely to install mastery experiences and a positive future template with any child. Installing mastery is asking the child, "Tell me about something you are really good at or something you've done that's made you really proud." Installing this mastery experience with short, slow sets of bilateral stimulation helps to build scaffolding for self-esteem, positive feelings about self, and establishes a positive association with the therapy process. In addition, installing a positive future template often helps the child have hope and believe that he or she has something to work towards in the future. Remember, with trauma and depression, a foreshortened sense of future and a negative lens of life may prevent the child from engaging in treatment. If by installing a positive future template, the client has hope for the future, the child may be more likely to engage in treatment. Installing mastery and a positive future template can also help when the therapist has a limited episode of care with the child such as occurs in residential treatment, group homes, shelters, schools, and other programs where the therapist may not have a great deal of time to treat the child. If the episode of care engages the child and creates a positive association with psychotherapy, the therapists has provided the foundation for the next therapist who works with the child.
These are some simple ideas for case conceptualization with EMDR therapy with children. EMDRIA has a Children's SIG, there are advanced trainings on using EMDR therapy with children listed in the EMDRIA website, and there are many books guiding therapists on how to use EMDR therapy with children.
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