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Small Wonders: Healing Childhood Trauma with EMDR

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Childhood can be an exciting time, full of joyous exploration, new skills, friends, and imaginative play. It can also be very frightening, especially when children have experiences that threaten their feelings of safety and well-being. Even common traumatic childhood events can deeply affect children's normal healthy development, their self-esteem, and their families. Many behavioral problems stemming from common traumatic events could require years of psychotherapy or medication. That is, they did — until the ...

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Small Wonders: Healing Childhood Trauma With EMDR

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Overview

Childhood can be an exciting time, full of joyous exploration, new skills, friends, and imaginative play. It can also be very frightening, especially when children have experiences that threaten their feelings of safety and well-being. Even common traumatic childhood events can deeply affect children's normal healthy development, their self-esteem, and their families. Many behavioral problems stemming from common traumatic events could require years of psychotherapy or medication. That is, they did — until the advent of EMDR. Developed by psychologist Francine Shapiro in the late 1980s, EMDR had already helped thousands of adult clients when Joan Lovett experienced its healing power firsthand.

Eye movement desensitization and reprocessing (EMDR) is a comprehensive therapeutic approach that helps patients release disturbing thoughts and emotions that originate in traumatic experiences. Experiences can be traumatic in the commonly accepted sense — abuse, disasters, violence — but children may also perceive and respond to more ordinary events as very threatening. A playground accident, the loss of a loved one, school problems, or choking on a piece of popcorn can be a part of growing up. They can also be critical incidents that cause a child to view him- or herself as helpless or powerless, to become fearful, and to develop debilitating behavioral problems.

In Small Wonders: Healing Childhood Trauma with EMDR, Joan Lovett, M.D., shares engaging clinical stories — mysteries involving children who present her with puzzling and disturbing behaviors. She imaginatively focuses her knowledge of pediatrics, play therapy, and EMDR to alleviate the real-lifeordeals of real-life children.

Featuring a foreword by Francine Shapiro, Small Wonders is the most comprehensive and insightful book to explore the potential of EMDR for child therapy. This enlightening book is intended for parents who are concerned with having their children feel confident, for adults who want insights into the way the events of their childhood shaped their self-image, and for professionals who want to know more about EMDR and how it can be adapted to meet the special needs of traumatized children.

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Product Details

  • ISBN-13: 9780684844466
  • Publisher: Free Press
  • Publication date: 3/28/1999
  • Edition description: New Edition
  • Edition number: 1
  • Pages: 256
  • Product dimensions: 6.47 (w) x 9.56 (h) x 0.91 (d)

Meet the Author

Joan Lovett, M.D., is a behavioral pediatrician in private practice in the San Francisco Bay area. A graduate of Wellesley College and the University of California San Francisco School of Medicine, Dr. Lovett trained in pediatrics at Montreal Children's Hospital/McGill University and Stanford University School of Medicine. She is an EMDR Institute Facilitator and has served as a Chair of the EMDR Medical Committee.

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Read an Excerpt

Chapter 2

HOW I BEGAN USING EMDR WITH CHILDREN

After completing EMDR training, I felt confident that I could treat adults for symptoms of posttraumatic stress, but how could I modify the method to meet the needs of young children? Perhaps a 10-year-old would cooperate with the standard adult protocols, but I didn't expect a 4-year-old child to be able to "hold in mind the picture representing the worst part of the accident, think the negative thought about yourself that still seems true about you today, and notice the feelings in your body while you move your eyes back and forth." Before using EMDR with children, I asked myself how treating children is different from treating adults, and how I could modify the method to be developmentally appropriate for children.

I am naturally conservative about trying new therapies with children, and I was extremely cautious about introducing EMDR into my work. I thought about how EMDR might affect a young child, and carefully considered similarities between EMDR and other methods I have used to calm infants and children. Repetitive alternating side-to-side movements are a natural part of soothing an upset baby. Crying babies respond well to rhythmic stimulation such as rocking, being bounced up and down on a parent's shoulder, swinging, or being cradled over the parent's forearm and being rocked from side to side. Distressed toddlers can frequently be comforted by engaging in games like "patty-cake," which involves some alternate hand tapping.

Children under the age of about 5 often cannot repeatedly move their eyes horizontally past the midline to follow a moving object. With young children, or anyone who finds the eyemovements uncomfortable, the alternating-stimulation aspect of EMDR is often done by gently and repetitively tapping first one hand and then the other, or by using auditory tones to draw attention alternately to the left and then to the right side.

It seemed to me that it would be safe to begin by thinking of EMDR as an extension of natural soothing methods that parents use every day. As with adults, I stop tapping when I notice a change in facial expression, a change in breathing patterns, or a change in the child's position. These shifts tell me that processing of the traumatic memory is progressing. I then ask, "What's coming up for you now?" or "What's happening now?" or simply, "How do you feel?"

USING EMDR TO ENHANCE POSITIVE FEELINGS

The calming effect I noticed after using EMDR techniques to soothe encouraged me to incorporate EMDR into play therapy whenever I saw an opportunity. Initially, I only used eye movement and alternate-tapping techniques for soothing or enhancing feelings of wellbeing and as natural extension of play. I found that the children liked imagining a safe place or a favorite place or a time when they had fun. Then they were willing to play tapping games to strengthen their feelings of safety and well-being.

Sometimes I asked a child to remember an experience of success and to concentrate on the associated physical sensation. Then we used rapid alternating stimulation, like eye movement or alternate hand tapping, to augment the feelings of accomplishment. EMDR, unlike most other psychotherapeutic methods, dissolves physical tension and reinforces physical sensations of relaxation and wellbeing. Every child has had some experiences of success, such as toilet training and learning to do various things: tie shoes, read, ride a bike, make a friend, or play a sport. I asked the child where he or she felt the physical sensation of success in the body. Almost every child was able to identify a body location associated with a positive feeling. Meredith, a young soccer player, felt power in her legs as she remembered kicking a goal; Mario felt pride in his chest as he recalled learning to read; and Regina felt beauty flowing from her hands as she imagined playing a favorite piece on the piano.

In EMDR terminology, using alternating stimulation to reinforce or instill positive thoughts and feelings is called "installation." We used EMDR to strengthen or "install" the self-affirmations and natural feelings of confidence and pride associated with competence, and the result was stronger self-esteem, EMDR seemed to enhance learning, and most important, I did not see any ill effects from adding eye movement or alternate tapping to play.

ALAN: USING EMDR TO TREAT CRITICAL-INCIDENT TRAUMA

EMDR is most likely to work quickly and completely in a healthy, well-adjusted child who experiences a single, time-limited, traumatic event. There have been more controlled studies confirming the effectiveness of EMDR in treating traumatized adults than for any other treatment method. The first research supporting the efficacy of EMDR with children who have suffered critical-incident trauma was presented in 1996. The study included 32 elementary school children who still had posttraumatic stress disorder 3 1/2 years after Hurricane Andrew, despite receiving postdisaster counseling that had been effective for the majority of children in Kauai. Following three EMDR sessions, most children reported significant reductions of trauma-related symptoms, and these gains remained at 6 months follow-up (Chemtob, 1996).

A healthy child who develops posttraumatic stress disorder following a critical-incident trauma may develop intrusive thoughts about the incident, nightmares, fears, and disturbed behavior. For example, 6-year-old Alan was startled awake one night by the sound of burglars breaking into the house, he saw two men stealing the television, and was left unharmed.

Two years later, Alan began to develop posttraumatic symptoms relating to safety. He suffered from excessive fears about strange men, intrusive memories about the break-in, nightmares, and had difficulty falling asleep. He became anxious whenever he heard the front door open. Alan startled and became anxious whenever he heard banging noises, even the sound of ice cubes dropping into the refrigerator tray. He developed ritualistic behaviors involving checking the front door repeatedly before he went to bed. By the time he came to me, the family had moved to another city, and their front door had been secured with a dead-bolt system. Even though Alan was safe, he suffered from these symptoms for years.

We used EMDR to desensitize and reprocess his memory of the break-in, so that he was able to fully believe, "It's over. Now, I'm safe in my house." Then we used EMDR to target and desensitize his fears about abrupt noises, like the sound of ice cubes dropping into a container. This work soon restored his sense of well-being and confidence, with complete resolution of the posttraumatic symptoms.

DANITRA AND RYAN: INTEGRATING EMDR WITH PLAY THERAPY

EMDR is also useful for addressing symptoms. When working with an adult, targeting a symptom (such as my inability to tolerate cracking noises) often spontaneously opens up earlier memories of a trauma that are in some way related to the current symptom. Using EMDR to target a memory of a template experience, or similar, earlier experience, usually reduces the anxiety associated with that memory, and also reduces the anxiety that fuels current posttraumatic symptoms.

I wondered whether targeting children's posttraumatic symptoms with EMDR would be as effective as targeting template experiences. I decided to begin by focusing on posttraumatic material that young children presented to me during our therapy sessions, rather than stimulating memories of the traumatic event itself. Children usually bring as much traumatic material to their play as they can tolerate.

For example, I thought about Danitra, a 4-year-old who was terrified of closed doors and had prolonged temper tantrums whenever her mother went out on the porch to bring in the mail. Marcia, her young mother, was in despair. "I don't know what to do," she told me. What could possibly be behind Danitra's mysterious behavior?

At first, Marcia could think of no reason for it. But careful questioning revealed a singular event. When Danitra was 18 months old, she had lifted her arms to her father -- who turned away from her, left the house, and slammed the door, leaving the family forever. No wonder this child was terrified of closing doors!

I wondered whether EMDR could help Danitra feel more comfortable when doors were closed, but I didn't expect a 4-year-old to be able to follow the EMDR protocol for treating critical-incident trauma in a way that would be suitable for an adult or adolescent. It also didn't seem appropriate to tell her to remember the day her father abandoned her, as she did not mention that event.

Children play, and children usually get over upsetting events by playing. Their imagination usually works the magic of healing. This child played repetitively and grimly, however, which is typical of posttraumatic play. It does not lead to resolution of the trauma, but repeats endlessly. Danitra wasn't just afraid of closing doors, she was terrified. Any closing door precipitated a full-scale meltdown, as if she were being abandoned -- as she was at the age of 18 months.

One day when Danitra entered my play room, she swung the door back and forth for a while, then settled herself under a table. I reasoned that she had "closing doors" on her mind, so I knew I had an opportunity. It occurred to me to adapt the children's song "Open, Shut Them" so that it would apply to doors instead of hands. Then I moved a pillow back and forth in front of her, singing, "Open, shut them, open, shut them, you are safe inside." I sang it several times, continued moving the pillow, and watched her relax.

When she returned the next week, I could hardly wait to ask her mother if she had noticed any changes over the past week. "No," Marcia said slowly, thinking over events of the past week. "No changes." I asked specifically, "Did you notice any changes in the way she responded to the door closing?" "Now that you mention it," she replied, "she did go into the bathroom this morning and shut the door. That's a first. And now that I think about it, she hasn't had to come with me or make a fuss when I go out to the front porch to get the mail." The child's behavior had changed without addressing the template experience.

Marcia was a very observant person, but she didn't remember this significant improvement in her daughter's behavior until I asked a specific question about her response to closed doors. Why? I have seen many children, as well as adults "not notice" improvements after EMDR until they are pointed out to them. It seems that once EMDR has stimulated the self-healing process and behavior has "righted itself," the change feels so natural that we just take it for granted that we feel fine in that aspect of our lives. Like having an annoying cold clear up, we may not focus on how good it feels to breathe easily for more than a few breaths.

Inspired by success with closing doors, I integrated more EMDR reprocessing techniques into play therapy, again as a natural extension of play. For example, I was working with Ryan, a child who had moved from foster home to foster home, and whose play consisted of driving toy trucks around and around the playroom. When he finally paused to rest, I picked up the truck and moved it back and forth, saying, "That's right, you can rest and feel safe now, the moving is over for now." I stopped moving the truck back and forth when I saw Ryan sigh and then relax, indicating a shift in his attitude about moving. I guessed that Ryan relaxed when he realized that moving was not only associated with danger; moving had finally brought him to safety. The theme of Ryan's play changed after that, and his foster mother said he seemed more relaxed at home. Was the change a result of EMDR? I had no way to be sure, but so far, it wasn't doing any apparent harm.

JAKE: USING EMDR TO TREAT NIGHTMARES

Next I was called on to treat Jake, a 5-year-old in foster care. He had been having terrible nightmares for 2 weeks, and everyone in the family was tired and irritable from being awake at night. "Do something!" they pleaded. Jake's regular therapist had referred the family to me because, as a pediatrician, I could prescribe a sedative. I don't like prescribing medication for children if there is another alternative. The foster mother had already tried soothing baths and warm milk at bedtime, quiet, comfortable bedtime stories, and lots of reassurance. Again, I wondered whether EMDR might help reduce this child's anxiety.

I asked what had been happening in Jake's life around the time when the nightmares began. I learned that the day before the first nightmare, a social worker had come to the home, where Jake had lived since infancy. There were four other children in the home, but the social worker directed his attention to this child. A distant relative of the boy had expressed an interest in adopting him. Although the social worker had spoken only with the foster mother about the possibility of adoption, Jake must have picked up on his foster mother's anxiety. He certainly noticed that the social worker was only interested in him, not his "brothers and sister." The foster mother was very attached to this boy, who she had raised "like her own." Although she was not prepared to adopt, she would have been heartbroken if the child had been removed from her care. She couldn't tell Jake what was troubling her, because she didn't want to alarm him unnecessarily about a change that might never occur.

I saw Jake alone, and he looked me straight in the eyes as he anxiously told me, "I have nightmares every night. The nightmares are always the same. A tiger jumps out of the moon, runs in through the kitchen window, and chases me around the house. Then I wake up screaming and crying and calling for my mom." In every dream, he explained, the tiger was only chasing him, never his brothers and sister, even though they were there too. He looked at me expectantly.

The dream seemed to represent the experience of having the social worker (the tiger in the dream) jump out of the moon (an unlikely event indeed, just as unlikely to this child as having an unknown social worker with an unspoken mission enter his life) and chase only the boy and not his siblings (the "why me?" associated with the social worker taking an interest in him and not his siblings). The strange visit aroused the foster mother's extreme anxiety, which she transmitted to the child. The anxiety was so enormous that Jake was unable to process it, and awoke from the nightmares in a panic.

I glanced to the shelf holding sand-tray toys and noticed a miniature tiger. I asked Jake if he would be willing to try something to see if we could make the nightmare less scary. "Sure," he said. I asked him to think about his dream as if it were a movie and to watch the toy tiger as I waved it back and forth. He steadily moved his eyes with the tiger, back and forth. I watched his face for a shift in expression, and then, when he swallowed and blinked, I stopped moving the tiger. "What happened?" I asked. He responded calmly, "The tiger jumped out of the moon the way it always does, and it chased me around the house and not my brothers and sister, but then the tiger licked my hand and went to sleep on the floor." Then he picked out some toy trucks and began building roads in the sand.

The dream had begun the same, but instead of Jake being devoured or waking in terror, the ending of the dream had changed to something less frightening. The tiger (like the social worker) tried to make friends and, though tamer, it stayed as a dormant risk to safety. Jake's EMDR experience seemed to allow him to have a more appropriate level of worry about his encounter with the social worker, even though he didn't have any additional information to help him make sense of the event.

His foster mother happily reported back to me that the sleep disturbance had stopped. No more nightmares. Eventually, the "threat" of adoption by a distant relative passed. I've never seen Jake again, but I've often wondered what made it possible for his excessive fear to dissipate, and how EMDR allowed him to have an amount of fear that was appropriate to the situation. It was intriguing to me that the tiger stayed on the floor near the boy and didn't go away in his EMDR-stimulated dream. EMDR seemed to allow him to validate that there was indeed some threat, though dormant, to his current well-being. This experience with moderation of anxiety in a young child encouraged me to trust that although EMDR changed a child's nightmare, it did not alter his very accurate perception of some kind of potential threat to his security.

USING EMDR TO TREAT ANXIETY-CHARGED PLAY

I continued to have success using EMDR to treat children, adolescents, and adults for critical-incident trauma, and I began to use the method to ameliorate the anxiety-charged play of children who were in long-term therapy to treat the effects of chronic abuse or neglect. I ask for the children's permission before doing EMDR, and I always tell them that they are in control, that they can tell me to stop at any time, and I will. I frequently offered EMDR to several children with histories of chronic abuse who had been in therapy with me for over a year. I knew their issues well, I had experience in judging their responses, and we had the kind of trusting relationship that is an essential foundation for doing trauma therapy. Initially, they accepted EMDR very well, when I used it to enhance positive feelings or to reinforce positive cognitions as they came up in play.

I began to present EMDR while 5-year-old Jana was doing highly charged, posttraumatic play (for example, having dolls reenact a scene of physical violence). I picked up the fighting dolls, moved them back and forth to guide the child's eye movements and asked her to remember the fighting and notice the feelings in her body. After a few minutes, Jana relaxed and said she felt better. With some children, this kind of intervention clearly reduced anxiety. Sometimes children told me to stop doing EMDR, however. I complied, of course, and postulated that the EMDR had opened up memories of the actual violence, and that they were flooded with anxiety (although there were few physical indicators of anxiety, as there seldom are in children during EMDR). Taylor had finally exclaimed, "I would rather die than do EMDR again!" and fell off his chair in mock collapse. He immediately got up and played, looking pleased that he had dramatized his point. I never attempted EMDR with him again. Since then, I use EMDR cautiously during play with children with chronic, complex PTSD who are in a tenuous living situation. I offer eye movement or alternate tapping for relaxation, for enhancement of self-esteem, for reinforcing positive cognitions that arise out of play, and for reprocessing upsetting material related to specific critical incidents.

WHEN EMDR WITH CHILDREN DOESN'T WORK

Although I have had great success using EMDR with children, there are some situations for which it seems neither suitable nor effective. EMDR may not reduce a child's anxiety when there is an underlying organic pathology, when there is unresolved trauma in the family and an unstable environment, or when the parents are what I call "too good," or when "health" appears to threaten the child or family.

ORGANIC PATHOLOGY

In my experience EMDR does not work for treating organically based disorders such as psychosis, bipolar disorder or manic-depressive illness, and learning disabilities. It does not change underlying conditions like attention-deficit hyperactivity disorder (ADHD), unless the child is actually suffering from PTSD that was misdiagnosed as ADHD. Both PTSD and ADHD can present with symptoms of anxiety, difficulty concentrating, impulsivity, low self-esteem, poor school performance, and difficulty in personal relationships.

EMDR can sometimes reduce the anxiety resulting from organic conditions, however, and can modify the beliefs the child has adopted as a result of the secondary trauma associated with having a handicapping condition. For example, a child with ADHD and learning disabilities may believe, "I'm stupid. I can't learn." EMDR might help to shift this child's self-assessment so that he believes, "I can learn in my own way" or "I can learn one step at a time." EMDR can have limited benefit for children with developmental disabilities that affect their cognitive processing. EMDR can treat their critical-incident trauma or anxiety-based symptoms, but the results may not generalize to other situations.

UNRESOLVED TRAUMA IN THE FAMILY AND AN UNSTABLE ENVIRONMENT

For adults, childhood trauma is in the past. Abusive, abandoning, or disturbed parents no longer have substantial power over adult children. Adults have choices about where they will live and whom they choose for friends and associates; children are truly dependent on their parents for their well-being.

In doing EMDR with adults whose high level of distress does not diminish while processing a traumatic memory, clinicians are trained to use a "cognitive interweave" to access information that would allow them to feel safe from their abuser, to alleviate self-blame, and to affirm that the adult has choices. Dr. Shapiro (1995), the originator of the EMDR method, coined the phrase "cognitive interweave" to refer to techniques that might help the adult client gain perspective on a situation that is no longer dangerous. For example, to facilitate processing of a memory of childhood abuse that continues to cause intense anxiety despite numerous sets of eye movements, she trains clinicians to pose questions such as "Whose responsibility was it?" or "Do you have choices now?" or "Are you safe now?" An adult might respond with a sigh of relief, "It was my father's responsibility. He was the adult. He should not have humiliated me and used abusive language with any child. I am safe now. I have choices about how I live my life and how I will treat my children."

For the child, however, the question, "Whose responsibility is it?" imposes an insoluble dilemma. If the child acknowledges that his parents are responsible for their mean actions, the child is a subordinate, doomed to a powerless position. If the child perceives himself as responsible for the parents' punishments, he views himself as bad or unlovable.

The question "What choices do you have?" is merely rhetorical. Children do not have choices about where they live, where they go to school, or who their parents are. Children may indeed be powerless over the safety of their environment. EMDR cannot change the reality of their situation, nor can it make them perceive harmful treatment as benign. The best the clinician can do may be to use EMDR to install "educational interweaves," or developmentally appropriate information, to teach children. For example, an abused child might need to know that children can never make an adult harm them (therefore children are not to blame for abuse), that all children deserve safety, and that they can go to a trusted adult when they need protection. EMDR can be used to reinforce the learning of these principles and to rehearse strategies for coping with difficult situations.

It is not only abusive parents who make it impossible for a child to feel safe. Often, attentive, caring parents carry feelings that make it difficult for a child to get over a traumatic event. For example, Sheena was injured at preschool, and her posttraumatic nightmares and fear of returning to school were initially resolved with EMDR. But her anxiety mounted again as her parents became increasingly upset about the inadequate supervision that permitted the accident to occur. The parents were reluctant to have Sheena return to school because they no longer trusted the school staff to protect their child. By the time her parents decided to sue the school for negligence, Sheena was understandably fearful about returning to school. She began clinging to her mother and her nightmares resumed. For Sheena, and other children in this position, EMDR does not clear out anxiety that belongs to other family members. If a parent continues to be anxious, that anxiety is continuously registered by the child.

The problem here is not that EMDR failed, but that the environment, both at school and at home, is not yet safe. In this situation the safety of the school environment must be secured first, the parents' own limiting beliefs -- such as "I can only keep my child safe if I am the sole caregiver, or I cannot protect my child" -- must be reprocessed, and all legal action must be settled before the child's anxiety level can return to normal. EMDR with the child alone will not usually be sufficient to restore his or her sense of well-being, unless resolution of the child's symptoms alone completely reassure the parents that all is well again.

"TOO GOOD" PARENTS

Another example of well-meaning parents "getting in the way" of their children's trauma resolution can be seen in what I call "too good" parents. These are parents who are determined to be sensitive to their perception of their child's needs, when in fact they are taking care of the needs they themselves had as children. For example, as a child, Jeff repeatedly felt invalidated by his father, who ignored his fears. When Jeff became a parent, he decided that he would always take his child's fears seriously.

Unfortunately, as a result, he proudly responded to his 5-year-old son Dylan's fears by validating Dylan's intense, frightened response to new or mildly scary situations with overly protective responses: "Oh, it is scary to go play at a friend's house without me. I'll stay with you or you don't have to go....I can see you're afraid to speak at circle time. I'll ask the teacher not to call on you....I know the dark is scary. You can have the light on, and I'll stay with you all night." In the name of being parents who are respectful of their child's feelings, "too good" parents like Jeff are actually depriving their child of the opportunity to develop his own courage.

Similarly, parents who suffered abuse or severe, restrictive criticism as children often "bend over backwards" not to coerce their children in any way. They may equate any discipline or limit setting with punishment. Although this philosophy is well-intentioned, it may result in parents who refuse to set important limits for their children or teach them about appropriate behaviors.

Parents must teach a child valuable life skills by advocating cooperation or encouraging a child to take on an age-appropriate task to promote independence. For example, Jeff could encourage Dylan to attend kindergarten, to practice taking a turn speaking at circle time, or to try some strategies for keeping himself company, in bed alone, after story time. Appropriate parenting is essential for sustaining the new confidence EMDR may promote.

WHEN "HEALTH" THREATENS THE CHILD OR THE FAMILY

Appreciating young children's profound dependency on their parents helps us to understand some of the variables that determine whether EMDR can work for a particular child. As we have seen, a hungry baby not only wants to be fed, he needs to be fed, for his very survival depends on it. If he isn't fed, he isn't merely disappointed, he is desperate. Children are exquisitely attuned to their parents' cues. They learn the nuances of their caregivers' emotions because being able to please, enchant, predict, and persuade the bonded caregiver means life itself for a vulnerable infant.

Trauma returns children to their most vulnerable state, and activates their most primitive survival instincts. Children's loyalty to their parents is of utmost importance in the hierarchy of the psyche's priorities for protection. EMDR only clears excessive anxiety when the ecology of the system permits. Sometimes a child's psyche appears to prefer disabling symptoms to "health," if health means that the child or the child's parents would be in jeopardy. Lack of motivation or disinterest in getting rid of fears and anxiety may appear to prevent trauma resolution, when in fact a child may be attempting to protect her family.

For example, EMDR initially did not seem to work for 13-year-old Jamie. Jamie's mother wanted her daughter treated successfully for increasingly severe phobias before she left on an assignment to Africa, where she would report on the effects of the devastating Ebola virus. Jamie believed that if she got well, her mother would go to Africa, contract Ebola virus, and die. Although her mother tried to persuade her daughter to move her eyes and think about her phobias, the girl repeatedly asserted that EMDR wouldn't help her, and, despite her mother's observations to the contrary, denied that there were any changes following EMDR. When her mother returned from Africa, the child's phobias cleared quickly with one EMDR session. Motivation to feel healthy and free of excess anxiety and interest in using the EMDR method are both important factors in the success of this approach to relieving stress.

USING EMDR TO TREAT "CASCADES OF TRAUMA"

Sometimes a series of traumatic events occur within a relatively short period of time or traumas are followed by a deluge of secondary traumatic losses. Some children live in a traumatic environment (for example, with an alcoholic or psychotic parent) in which upsetting events occur frequently and at unpredictable times. I call these overwhelming traumas "cascades of trauma" because they remind me of the cumulative force of a waterfall gathering power as it pours over rocky cliffs. Children and families who experience cascades of trauma never have a chance to recover fully from one crisis before they have to deal with the next. When EMDR is used in the treatment of cascades of trauma, it typically takes longer to achieve a significant reduction of anxiety, and treatment effects are less predictable and may be less complete than when treating a critical incident.

The hallmark of cascades of trauma is that the child or the family feels fearful and powerless for a prolonged period of time. Three-year-old Darius experienced the deaths of his grandfather and two uncles over a 3-month period, repeated school failures, and placement in a class for severely emotionally disturbed children, as well as his parents' ensuing alienation. Nine-year-old Eliza lived with her alcoholic father and never knew when she would be the subject of verbal abuse, so she fearfully anticipated her father's outbursts. Eleven-year-old Gordon had already been abandoned by his mother, expelled from school for fighting, and exposed to his father's drug-dealing friends when he was molested by a man at his uncle's house. Neither EMDR, therapy, nor medication can completely make up for lost years of childhood development. Nevertheless, EMDR helped each of these children achieve significant relief from fear and reduced many of their distressed and distressing behaviors.

SMALL WONDERS

Many of the cases you will read about in this book required only brief intervention for trauma resolution. In every case, in addition to play therapy, I used eye movement desensitization and reprocessing as a therapeutic tool. I have selected cases that present the drama of daily living and illustrate the effects on children of common upsetting events, from breaking a bone in a playground accident to having repeated bouts with head lice.

Most of these children are basically h

Chapter 3

WHO'S AFRAID OF A TOILET?

CRITICAL-INCIDENT TRAUMA

Three-year-old Tanya screamed relentlessly as her parents tried to persuade her to enter the kitchen of their newly remodeled home. Eyes wide, lips trembling, digging her fingernails into her mother's neck, she looked as if she were entering a torture chamber.

That wasn't all that was worrisome about Tanya these days. She was fearful about many things and seemed to be developing new fears daily. She insisted on riding with the car windows closed. She anxiously asked "Fire?" whenever she heard sizzling noises of food cooking. She backed away -- far away -- from anything hot, like a bowl of soup. Even clouds high in the sky upset her. "Smoke?" she worried. The toilet had become another cause for alarm. Confidently toilet trained by age two, Tanya now ran screaming from the bathroom whenever the toilet flushed. If she was in another room when she heard the toilet flush, she covered her ears.

Tanya's parents knew that she had been upset by seeing fire destroy their kitchen 3 months earlier. They were grateful that no one was hurt, but they were concerned because Tanya's new fears were popping up so fast. Before the fire Tanya had been a playful, bright, outgoing, feisty 3-year-old, and they assumed she would be her cheerful self again within a few weeks of the fire.

At first, they thought that Tanya's reactions to the fire were normal. Tanya was quieter and more irritable than usual, but her parents were stressed too. There were insurance people to talk with, the search for a temporary apartment, concern about time missed from work, and endless discussions about how to remodel the house. Tanya and her 8-year-old sister spent a lot of time together that summer. Her sister cut flames out of paper and both girls ran through them over and over. For her older sister, this was mastery play. She had triumphantly escaped the flames. Tanya, on the other hand, screamed in terror at this game. By the end of summer, Tanya became so anxious that she constantly worried that a fire would break out.

Tanya's parents did their best to soothe and reassure their daughter about her fears. As they approached the day for moving back into their newly remodeled home, they took her to the front porch of the house and talked to her about how pretty their house looked, all fixed up. They tried to coax her to look at her bedroom, where a new toy was waiting. Tanya started screaming as soon as she saw the house. She calmed a little on the front porch, but closed her eyes as her mother carried her inside and no amount of encouragement persuaded Tanya to open her eyes. She held tight to her mother's arms and her lips trembled.

Tanya's parents decided to ask for professional help. They had tried everything they knew to reassure their child, and they were concerned that forcing her to stay in the house she dreaded so much might make things worse. They called their pediatrician who referred the family to me.

CRITICAL-INCIDENT TRAUMA AND CHILDREN

A critical incident is a single event that is perceived as threatening to one's life or sense of safety. It can leave a child feeling helpless, powerless, and fearful. Sometimes, a parent can help a young child get over a critical incident by reassuring her that she is safe now (if that is true), by listening to and acknowledging the scary feelings, by being comforting, and by explaining what happened and pointing out that they know the incident is over now and that everyone is safe. Sometimes, the event is so threatening that parents, too, are very upset, and children read their parents' unspoken, profound fears. After all, children are highly sensitive to emotional cues, and the well-being of very young children truly rests on their ability to detect nonverbal, emotional signals of safety or danger. Sometimes the child experiences such fright in a critical-incident trauma that even the calmest, most competent, and appropriately reassuring parent cannot prevent posttraumatic stress.

When a child is traumatized there may be an identifiable moment when he appears "like a deer in the headlights," that is, too stunned to move, perceiving that death is nearly certain, and he doesn't have time to escape. Perhaps at that time there is a change instantaneously activated in the brain's biochemistry, so that the brain begins to process information differently. When this "emergency mode" is activated, the brain sorts all incoming information related to the traumatic event into one of two categories: safe and unsafe. The child or adult in a similar situation has no time to consider, "The sound of food cooking isn't dangerous unless it's accompanied by smoke and flames. Even that could be safe if someone is cooking over a camp fire." The emergency mode helps the threatened individual bypass time-consuming thinking that might waste lifesaving moments for escape.

Furthermore, this special biochemical configuration is designed to protect the individual from future harm by stimulating the anxiety response any time anything happens that remotely resembles the trauma. After a child has experienced a critical incident, like a fire, anything that looks, smells, sounds, or feels like the trauma will signal an alert and will stimulate the anxiety response.

So it is not surprising that everything that looked like smoke, sounded like steam hissing or food cooking, felt hot, or in any way reminded her of the traumatic incident caused anxiety for Tanya. Initially, it was not apparent why she had become afraid of toilets, but I suspected that something about a toilet was connected to the traumatic event.

The practitioner has to approach recent critical incidents differently from more distant critical incidents (those occurring more than 3 months previously). Recent critical incidents have to be processed frame by frame -- that is, EMDR must target every component of the trauma. In adults, memories of long-past critical incidents seem to consolidate, so that if the practitioner uses EMDR to target the worst part of the trauma, the benefit of EMDR generalizes to decrease anxiety related to the entire trauma. For young children, however, traumas seem to be stored in fragments, regardless of when the trauma occurred. For best results, the practitioner must use EMDR to target every aspect of the traumatic memory. Storytelling is an effective way to do this, and one I felt would work with Tanya.

STORYTELLING

When I first started treating young children using the EMDR method, I used eye movement to enhance feelings of safety and mastery or to diminish feelings of helplessness and anxiety that came up during play therapy. EMDR in conjunction with play therapy seemed to help children feel better more quickly than play therapy alone.

I was challenged to develop another way to apply EMDR when I met Hue (pronounced "Way"), a 20-month-old Vietnamese boy who spoke no English, but understood the expression, "good boy." Hue had been sitting comfortably in a child-safety seat in the back of his family car when all of a sudden his calm life changed to terror with a big jolt and bang as another car smashed into the side of the family car and sent it spinning out of control. The accident had left easygoing Hue irritable, angry, and disturbed by nightmares several times each night.

Because I was unable to communicate verbally with Hue, it occurred to me that Hue's parents could tell him the story of the accident, in Vietnamese, while I used EMDR tapping techniques to desensitize the memory of the frightening experience. I asked Hue's parents to tell me what they imagined his experience of the accident to have been, using language that Hue would understand if they were speaking Vietnamese. The story was brief and simple: "Riding in the car. Everybody happy. Big boom! Everybody scared and crying! Go to hospital. Everybody fine. Everybody go home. Go to sleep." I asked them to tell Hue the story of the accident while I tapped his knees alternately.

I wanted to make some connection with Hue before I tried to use alternating movements to desensitize frightening memories of the accident. Usually, I start my preparation for treatment with children by playing with them or having them imagine a favorite place or a safe place. Young children often identify a parent's lap as a safe place. Some children enjoy a favorite song as fun and relaxing. The idea is simply to practice EMDR tapping while enhancing a good feeling and teaching the child how to participate by tapping or being tapped. I decided that my verbal affirmation "Good boy" would have to be Hue's safe-place equivalent as well as his good thought about himself (in EMDR lingo, his positive cognition.)

First, I taught Hue to tap my hands repetitively. (Although there has been no research to date to determine the relative effectiveness of tapping the child's hands or knees or having the child tap the clinician's hands, it seems that these methods are equally effective.) Then I tapped his hands. I said, "Good boy," and watched him smile.

I prompted Hue's parents to tell him their story about the day of the car accident. Hue sat on his mother's lap while his father related the story in Vietnamese. I sat in front of Hue and expended my hands for him to tap alternately. As soon as the story became upsetting, Hue stopped tapping my hands. I gave him a toy car to hold, and I tapped his knees alternately while his father continued relating the story in a dramatic way. In less than a minute, when the storytelling and rapid-alternating stimulation were over, Hue sat peacefully on his mother's lap. I tapped Hue's knees alternately as I repeated "Good boy," and Hue smiled. Our session was over.

Follow-up calls to his parents and pediatrician revealed that after only one session, Hue's symptoms cleared completely. His cheerful disposition had returned and he was sleeping soundly through the night. Hue didn't need to come back. When I called his pediatrician several years later, I found that Hue had continued to grow and develop well, without any notable behavioral problems.

My rewarding experience with Hue prompted me to try a similar approach with other young children in which parents create and tell a story about the traumatic event. This approach has many advantages. Storytelling, in conjunction with EMDR techniques, is well suited to satisfying the developmental needs of young children. Children love stories, especially if the story is about them. Young children usually have difficulty verbalizing their fears or retelling the details of a trauma that has happened to them; because the parent tells the story, the child isn't required to speak, but may if she likes. The therapist has the opportunity to observe and evaluate the child's response to the story.

Children live in a family: Whenever a child has been traumatized, the parents have also been affected. Furthermore, the parents often feel inadequate or ashamed because they have not been able to protect their child from suffering. The storytelling approach gives the parents an opportunity to help their child feel better and can be an effective way of resolving some of their own issues about parenting and about the traumatic event.

Let us return to Tanya. I thought that Tanya sounded like an ideal candidate for my storytelling approach. The traumatic event that affected her was a discrete critical incident with a beginning, a middle, and an end. Her symptoms were traceable to the trauma itself and not in any way a result of her parents' attitudes or handling of the situation. Her parents were willing to be partners with me in her treatment, they were able to write a story about the event for their child, and their treatment goals for their daughter were realistic and appropriate.

PREPARING FOR THE STORY: THE FIRST VISIT

Tanya's parents came alone to their first visit, as I had requested. Tyrone and Roberta were both tall and gave an impression of strength and stability. They presented their concerns clearly. They wanted to handle things as well as possible so their young daughter could get over her fears and move back into their house comfortably. They enumerated Tanya's symptoms: She was fearful and covered her ears whenever she heard popping sounds, traffic noises, fire-engine sirens, cooking sounds, and hissing steam. She was afraid of being burned whenever she felt heat, and appeared terrified when the toilet flushed. She was almost constantly worried that a fire would break out again.

Aside from witnessing the fire, Tanya had had a calm life. She had no history of hospitalization, injuries, or significant illness. She was the 7-pound product of a normal pregnancy, labor, and delivery. She was breast-fed for 2 years and her developmental milestones were appropriate.

Tanya's mother started recounting the story of the night the house burned. "I was at work, as usual. I got home from work at 8 P.M., and when I turned onto our street I could see the fire engines and the smoke but at first I didn't even realize that it was our house that was on fire. As soon as I realized it was our house, I saw my husband coming down the driveway to meet me. Right away, my husband told me that our girls were safe at our neighbor's house, so I didn't have time to wonder whether anyone was hurt. We went over to the neighbor's house to get the children. Tanya was real glad to see us. She had just been quiet, sitting there watching TV. Tyrone will have to tell you what actually happened before I came home."

Tanya's father continued, "That night I fed the children dinner first, the way I usually do. I gave them some soup and sandwiches they wanted. They ate, then they went in the family room, behind the kitchen, to watch TV. I decided to fry up some chicken so Roberta and I could have it when she came home from work. I heated the grease. It started bubbling and smoking and before I knew it the grease caught on fire and the flames leaped up and started to race across the ceiling to the other side of the room. I grabbed the phone with one hand and called 911 while I turned off the stove and threw the lid over the flaming pot. By that time the room was filling with smoke and flames. I grabbed a dishtowel to cover my nose and looked up to see my older daughter run by the kitchen door to the front door to go outside.

"Then I saw Tanya. She stood in the kitchen doorway, frozen. Then she screamed, a long scream, still standing frozen. I rushed over and scooped her up and took her outside where I handed her over to our neighbor, who had come running over to see what was going on. I ran to get the garden hose and pulled it into the kitchen to start putting out the fire. By then the fire had destroyed the kitchen and was moving into the family room.

"I was pretty calm and level headed," Tyrone told me, "I guess because I was in Vietnam and had to deal with a lot worse stuff than this. I knew that the children were both safe. I only got a little burned on my arms. I went outside when the fire fighters started getting things under control. Just as I went down the driveway, I saw my wife and told her the girls were okay. We were both relieved that nobody was hurt.

"We went to get the girls. I knew they were upset, but Tanya seemed like she was in shock for a while. We were all a little disoriented, I guess. We went to a motel to spend the night. Then we had to start dealing with the insurance company in the morning. It's been pretty hectic since then."

I asked Tyrone and Roberta what beliefs Tanya might have about herself as a result of the fire. In EMDR terms these posttraumatic beliefs are called negative cognitions. Traumatic memories are also stored as beliefs about the helplessness, powerlessness, or worthlessness of the victim. Although the victim may have been helpless to stop the traumatic event, this belief is followed by a profound loss of self-confidence that does not serve the individual well after the critical incident has passed. Negative cognitions do not seem to change without intervention, and the untreated trauma survivor can continue to view herself as devalued and can continue to feel unsafe.

Roberta said, "I think Tanya feels, 'I'm not safe. It's going to happen to me again. I'm overwhelmed. I can't deal with it.'" I find that parents and young children are usually so close psychologically that the parents' perceptions about their child's beliefs are generally accurate. I asked what positive cognitions, or true and useful beliefs, they wanted their daughter to have about herself in relation to the fire. They talked for a few minutes and then Tyrone read me the list of beliefs they wanted Tanya to have: "I'm safe now. It's over. I can take care of myself by expressing myself and screaming or running when I need help."

I told Tyrone and Roberta that we could work together to help Tanya get over the fire and to regain her confidence. I explained EMDR and asked permission to use this new method to resolve the trauma. They agreed that it was worth a try. I asked whether they would write a story about the fire for Tanya. They nodded. I instructed them to begin the story with everyone being safe, to include any details leading up to the fire, to describe the fire as they imagined it appeared to Tanya, and to end the story with the fire over and everyone safe again. I suggested that they write the story about "a little girl," without mentioning Tanya's name. Some children can deal with the memory of something scary happening to someone else, but might be too upset to hear a story about their own trauma. Other children immediately claim the story as their own, and then the parents can personalize the story as much as they like. We would adjust the story later to meet Tanya's preference.

I asked Tanya's parents to tell her that she would be coming to see a doctor who helps families get over being upset and helps make things easier for children. Children may need reassurance that I am the kind of doctor who plays with them, not the kind who gives shots. I explained that the main goal of the first visit would be for Tanya to feel safe and to know that my office is a place where problems get better. Children love to hear their parents say good things about them, and I prepared Tanya's parents to expect me to ask questions such as, "What do you like best about Tanya? What are her favorite ways to play? Tell me about her imaginative power -- what does she like to pretend?" We set up an appointment for me to meet Tanya.

TANYA'S FIRST VISIT

Later that week Tanya's parents returned with their petite 3-year-old daughter. She held both of their hands as she entered my office, then let go when she spotted the doll house. I sat on the floor beside her to meet her at eye level, and said, "This room is a special place where problems have a way of getting worked out. We have only two rules in my playroom: One, the sand stays in the sand tray and two, you may play whatever you like but no thing and no one ever gets hurt for real." She nodded solemnly. I told her that she could choose to join her parents and me while we talked, or she could play. Tanya looked at me with big brown eyes and then turned to my playhouse with its castle-like air. Her choice was made. She sat on the floor and immediately started playing, putting dolls in the kitchen and intoning, "The day it burned up."

Then Tyrone handed me the story he had written for his daughter. I quickly read the story to myself while Tanya's parents hung up their coats and settled themselves on the sofa. The one-page story would do just fine. I tucked it in Tanya's chart. While Tanya played, I asked her parents to tell me about her special qualities. "Tanya loves to sing and dance," Roberta told me, clearly pleased, "and she's very creative. She loves to play imaginative games." I said that I am always interested to know how children meet developmental challenges, that is, to do really hard things like learn to use the toilet. Tanya glanced up. Of course, I already knew that she had learned to use the toilet fairly easily and with her parents' patient encouragement. Tanya listened as she played, and her parents praised the way she had mastered that skill.

Every child I have ever met in my office enjoys hearing the positive things her parents say about her. Even a child who appears to be deep in play is registering those words of appreciation. If the parent mentions that her child's favorite color is pink, the child might snap to attention and assert "No, purple!" Some children will check in by asking "Who? Are you talking about me?" Conversations in my office rarely escape young children, especially if they are the topic of interest. It's also important to remember that young children absorb and remember the emotional tone of everything they hear, even if the vocabulary is beyond their understanding.

When I ask questions about how a child met a particular developmental challenge, I hope to tap into the knowledge that if she has accomplished other hard things, she can master this difficult task, too. Toilet training is one of my favorite early-developmental milestones, because I figure that if a tiny child can use a toilet, she has a lot of courage. Imagine going up to a toilet that comes up to your chest, being lifted, naked, onto a cold seat, balancing so you won't fall into the water, emptying your contents into this bowl, then being wiped and lifted off just before the toilet flushing results in a big roar, and your contents are swirled away. Recalling these acts of bravery can be used to bolster the courage of a young child.

Tanya's parents surprised and intrigued me by telling me that Tanya has "magic" and that she knows it. I noted their choice of words with recognition: It is this feeling of power, of magic, that I work to elicit and enhance for every child I see. Tanya's mother explained, "Tanya can feel whether her magic is high or low. When Tanya feels her magic is low, I give her an extra special hug or kiss. When her magic is low, Tanya also tells her godmother, who rubs Tanya's hands and wrists to increase her magic or help her feel stronger." I decided to use their concept of magic, already familiar to Tanya, to strengthen her self-esteem.

I asked Tanya whether she would like to choose a doll to help her get her own magic so strong that the memory of the fire would not be scary any more. Adults usually watch my hand or a "wand" guide their eyes through EMDR movements. I find that most children and many adolescents like to choose a doll or sand-tray figure or wand to help them, rather than simply following the movement of my hand during EMDR. I then hold the chosen object in my hand, and they can follow that with their eyes as I move my hand back and forth. Young children who are unable to do EMDR with their eyes sometimes like to be tapped on their hands or knees by their chosen figure. The figure may bestow its powers of comfort, strength, or companionship on the child.

Tanya selected a "mother" doll and came to sit on her mother's lap. I asked whether the doll had a name and Tanya's mother prompted her daughter, "You can call her Magic Lady." I asked Tanya whether she would like Magic Lady to help her get her own magic strong. She nodded. I asked where in her own body Tanya could feel her magic. She pointed to her wrists. Probably the rubbing of Tanya's hands by her godmother worked to place the physical sensation of magic in her hands.

I asked Tanya if Magic Lady could dance from hand to hand to get her magic strong. She nodded. I asked Tanya if she would let Magic Lady know when her magic felt very strong. She nodded again. Whenever I work with a traumatized child, I give her many opportunities to be in control. After all, one of the hallmarks of trauma is a feeling of not having any control, and my job is to restore the child's appropriate feelings of control in the world. With her permission, I used Magic Lady to perform EMDR by tapping Tanya's hands, and in less than a minute, Tanya smiled and agreed that her own magic was getting stronger already. One of the benefits of EMDR is that it enhances positive states and strengthens a child's feelings of strength and well-being.

Then I handed the story back to Tanya's father. I explained that I would interrupt his reading to ask Tanya questions that would focus her on certain emotional experiences and physical sensations that would be either enhanced, like the feelings of being safe, loved, and secure, or direct her attention to erase the fears that were no longer justified. EMDR can only instill true beliefs and can only remove false beliefs.

I used Magic Lady to alternately tap Tanya's hands while Tanya's father began reading the story he had written. The storytelling session went like this (my interjections are written in italics, Tanya's responses are in parentheses, and sets of EMDR movements or tapping are represented by three dots:...).

TANYA'S FIRE STORY

Once upon a time there was this family composed of Father, Mother, and two sisters. Dad and Mom were very much in tune with their children. They loved both girls very much. The big Sister was clever and pretty. The little girl of the family was smart and pretty and also very sensitive.

Can the little girl feel her dad and mom loving her?...(Tanya nodded).

Can the little girl feel herself loving her mom and dad?...(Tanya nodded again and snuggled close to her mother.)

On one of the many evenings that the children and Dad are home together, there occurred an accident that would get the little girl's attention. This evening after Dad had fed the children and put on their pajamas to get them ready for bed, then it happened. Dad was heating grease to cook him some dinner when it (grease) went poof!

Can you hear the sounds the grease makes? Let Magic Lady know when it sounds better....(I want Tanya to remember the scary feeling associated with the sound of the grease sizzling, and I wait for an indication that she has processed the memory. I tap Tanya's hands alternately for about 10 seconds until she says "Better." When she says "better," I know that some of the scary feeling has dissipated.)

Before you knew it, the kitchen was full of flames and smoke.

Can you feel the heat? Let Magic Lady know when it feels better. (..."Better.")

Can you see the flames and smoke? (..."Better.")

The Big Sister ran past the flames and went out the door as her Dad had told her to do. The little girl was afraid to pass by the door because of the flames and the smoke. It turned out that the little girl was afraid and she also thought her father, who was fighting the flames, was on fire and would melt.

Can you see the father?...(Tanya looked at her father and nodded.)

Is Father safe now?...(Tanya examined her father. He nodded, and she nodded in response.)

She was also scared that she would melt too.

Is the little girl safe now?...Are you safe now?...(Tanya looked relieved as she nodded again.)

Where in your body do you feel that safe feeling? Point and show me....

(Tanya arched her back off her mother's lap and patted her buttocks.)

The little girl screamed.

Show me how she screamed....(Tanya opened her mouth and let out a scream of terror.)

What a smart girl to scream to get the help she needed....Think about how the girl got the help she needed by screaming. Can you feel how smart she is?...(Nods.)

Her father recognized what was happening so he stopped fighting the fire, picked up his little girl and carried her outside to safety. One of the neighbors held her while her dad returned to fight the fire. This action frightened the little girl again, and she cried. Then the firefighters came.

Can you hear the sounds of the fire truck?...Can you hear the sirens?...Can you see the lights flashing?...(She nods.)

The firefighters came and began to fight the fire. The little girl was taken to the neighbor's house so she could rest. After the fire was put out, Mom arrived, then Dad and Mother went to get their children. We didn't know it then but the little girl was very happy to see her dad not melted. The little girl and her family are all safe now. Their house has been remodeled and her family likes the new kitchen.

Can you see the new kitchen?...Can you imagine the sounds of yummy foods cooking?...(Tanya began to lick her lips.)

The storytelling was over for this session. I asked Tanya what helps to keep her safe. She spoke carefully, "Mommy, Daddy, Big Sister, friends, and...Magic Lady," and she leaned over to give Magic Lady a kiss. I asked Tanya where she felt the safe feeling, and she arched her back and patted her buttocks area again. It was time to stop our first session. Tanya's parents agreed that in the coming week they would notice Tanya's fearful behaviors and the situations that seemed to trigger them.

Tanya lifted her arms to her father. When he picked her up so that she was sitting on his arm, it became apparent that the safe feeling was literally seated in her buttocks area, the part of her that felt her father's arms carrying her away from the fire to safety.

"BETTER"

When they returned a week later, Tanya's parents reported that Tanya was much more relaxed and they had been able to move into their newly remodeled house. Tanya still responded to cooking noises by leaving the room or covering her ears and asking anxiously, "What is that?" She also became anxious and covered her ears whenever water faucets were turned on or the toilet was flushed. We agreed that the phobias about the sound of water running and the toilet flushing probably stemmed from the sound of water rushing through the fire hoses.

During the week since our last visit, there had been another upsetting incident. Smoke filled their newly remodeled kitchen while they were cooking, setting off the smoke detector and causing the parents to rush around anxiously, trying to open tight new windows. Understandably, this was upsetting to Tanya. Roberta told me that she had evoked the image of Magic Lady, and Tanya calmed down as her mother reminded her that Magic Lady was there to help her. For a few days, Tanya had talked about Magic Lady when she needed to calm herself. Tanya's parents were pleased that despite these difficulties, Tanya had begun to sleep throughout the night again without diapers.

Both of Tanya's parents noticed that Tanya had become bolder -- she had touched a hot coffee cup even after her mother warned her not to touch because it was "hot." She would appropriately warn her parents to "be careful" when she saw steam, however. They remarked that although Tanya was still anxious when she saw a fire engine, she was able to ask questions, such as, "What is it? What are they do ing? Where are they going?" She was able to ride in a car with the windows down, and traffic noises no longer bothered her.

Some of Tanya's fears had cleared in a single session, but some symptoms, such as worries about cooking sounds and steam, were probably rekindled by the incident that activated the smoke detector. The symptoms related to the sound of water going through the fire hoses had not yet been addressed. I decided to target the current symptoms this time, as well as targeting their precipitating traumatic origins. I asked Tyrone and Roberta to help me simulate the sounds of food sizzling, the smoke detector, fire-engine sirens, and water rushing through a hose to put out the fire. Tanya listen

Foreword

Some children eat too much and are overweight. Some get so anxious that they can't do their best in school. Some worry every time they try to fall asleep and as a result are chronically sleep deprived. These dysfunctional behaviors are common. They become part of the daily concerns of good parents, who try everything they know to help their child. Parents may be told, "It's just a stage; the child will grow out of it," but professional help may be needed to guide children along their normal developmental path.

Small Wonders is a book of short stories about children who have not outgrown their abnormal behaviors despite their parents' best efforts. Trauma precipitated these children's ongoing troubles. To the general public, the word "trauma" is associated with war, violent crime, earthquakes, hurricanes, fire, rape, and AIDS. However, more commonplace experiences, such as a grandparent dying, head lice, or being publicly criticized by a teacher, may cause persistent and profound symptomatology in a young child. If left untreated, these problems often get worse over time. The children do not grow out of them. But the children in Dr. Lovett's stories do get better when they are treated with EMDR.

What is EMDR? It is a comprehensive method of psychotherapy addressing problems that are based on earlier life experiences. There are more controlled studies supporting the use of EMDR with psychological trauma than for any other treatment method. The abbreviation stands for Eye Movement Desensitization and Reprocessing, which turned out to be a poor choice of name given the complexity and comprehensiveness of the method. The treatment approach emerged from my chance discovery in 1987 that eye movements had a distinct and beneficial effect on my thoughts and emotions. As I began working with this phenomenon, I discovered that in order for it to consistently reduce psychological disturbance and increase positive emotions, I had to develop a series of procedures around the eye movement. Eventually these procedures included aspects of all the major psychological orientations. Furthermore, experiences with blind patients and children who wouldn't or couldn't make eye contact taught us that the effects of the eye movements could be achieved as well with other types of repetitive stimulation, including tapping and auditory tones.

If I had to do it over again, I would probably name the method simply Reprocessing Therapy; however, the therapy now has such worldwide recognition that we keep using the letters EMDR for the same reason that AT&T retains its initials. Telegraphs aren't used anymore, but the name remains. It might be more useful, however, to think of the letters as standing for Emotional and Mental Development and Reorganization. That is, what is useful in an experience is learned, stored with appropriate emotions, and capable of guiding the person in the future, while that which is useless is discarded. Basically the client's psychological health can emerge on all levels -- emotional, cognitive, and physiological. In other words, although some experiences may be retained in the brain in a way that causes dysfunction, the primary message of EMDR is that the client is intrinsically healthy: once experiences are processed with EMDR, the client can quickly return to a state of equilibrium. Learning occurs as the client's negative memories become less salient and less valid, while positive experiences become more vivid and empowering.

As of 1990, when the first EMDR training was given to mental health professionals in the United States, the method began to evolve with input from a wide range of experienced clinicians. One of the most exciting areas of development and ongoing research over the years has been the use of EMDR with children. As this book so clearly and eloquently demonstrates, children are wonderfully resilient. Although symptoms may initially baffle both child and parent, a sensitive clinician trained in EMDR can generally unravel and clarify these mysteries of mind and body. Most importantly, children can often be returned to a state of psychological health that otherwise might have been persistently derailed or, if appropriate, they can frequently be carefully raised to a new plateau of wholeness and well-being that far surpasses their earlier status.

Dr. Lovett has written an extremely important book for both parents and therapists. Her considerable clinical expertise has led her to develop a new strategy for the use of EMDR, one that incorporates storytelling, along with play therapy and the more familiar EMDR protocols. Through careful explanations and detailed case histories, she illustrates how EMDR may be used for problems as wide-ranging as nightmares, trichotillomania (hair pulling), phobias, depression, sibling rivalry, grief, and a variety of complaints that can be traced to a child's lack of self-esteem and trust in the world. If left untreated, these problems can stunt the child's development regardless of how loving, nurturing, and concerned the parent may be. Just as it is clearly the parents' responsibility to provide their child with appropriate medical care, there is equally a necessity to find appropriate psychological care when symptoms do not remit despite loving parental attention. As Dr. Lovett so amply illustrates, co-participation among parent, child, and therapist is often vital to allow a return to health -- and potentially to peak achievement.

The comparison between medical and psychological care is particularly important for the developing child because EMDR has shown us that the brain takes experiences and processes them, much as the digestive system processes food. That is, if an experience is properly digested, it is integrated into the system and supports healthful growth. If a traumatic experience is not integrated because of the way it is stored in the brain, the child can suffer both psychologically and physically. In fact, physical symptoms with no obvious medical explanation may stem from earlier events that have been stored, with their accompanying disturbing sensations and emotions. Neither parent nor child can change the symptoms through an effort of will, but EMDR appears to tap into the physiological substrates of the information-processing system to rid the body and mind of the disturbance, leading to the resumption of healthful growth.

Dr. Lovett's detailed case examples and sensitive descriptions, combined with her expertise as a pediatrician and therapist, elucidate the striking complexity and beauty of the child's mind and guide both clinician and parent through a profound understanding of the child's experience. This book traverses the universe of childhood from one-and-a-half years of age through adolescence. It reveals how unhealed childhood experiences can haunt even the most intelligent and outwardly accomplished adult. Only through therapy that can release the client from the legacy of a negative past can he or she be provided with a healthful and happy present. Through all of these journeys Dr. Lovett is exquisitely careful to remind clients (of any age) that the "power" to heal is within themselves. This is why the children described in her book generally proclaim EMDR to be their "magic." For as importantly as anything else, this book shows its unbounded respect and concern for the children who suffered so valiantly and for the parents who had the courage to recognize the need for an intervention they could not personally supply. I believe that is why one of the children spontaneously calls Dr. Lovett by a name she has most certainly earned -- Dr. Love-it-all.

Francine Shapiro, Ph.D.

Senior Research Fellow Mental Research Institute Palo Alto, CA

July 5, 1998

Copyright © 1999 by Joan Lovett, M.D.

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Table of Contents

Acknowledgments
Foreword
Pt. I Understanding Trauma
1 "Why Am I Afraid of the Sound of Carrots Crunching?" 3
2 How I Began Using EMDR with Children 16
Pt. II Small Wonders: The Cases
3 Who's Afraid of a Toilet?: Critical-Incident Trauma 35
4 "I Get Real Nervous": A Car Accident 51
5 "I Have to Get Them Out!": Head Lice 62
6 "What If ... ? What If ... ?": Converging Stresses 77
7 "Wasitz?": Cascades of Trauma 88
8 "I'll Love You Forever": Unresolved Grieving 100
9 Never-Ending Love Is Round: Complex, Unresolved Grieving 110
10 "I Can't Swallow It": Not Simply a Critical Incident 123
11 "I Can't Move": Somatic Symptoms 133
12 Too Scared to Think: Test-Taking Anxiety 152
13 "We Did Something Wrong": Secret Coercion, Sexual Mistreatment 169
14 Monsters Come Out at Night: Sleep Disorders 192
Afterword 210
App. 1 Questions Frequently Asked About EMDR 211
App. 2 For Parents: What to Expect When Your Child Does EMDR 217
App. 3 Guidelines for Writing a Story for Your Child 221
App. 4 Guidelines for Clinicians: Using Storytelling and EMDR to Treat Young Children for Critical-Incident Trauma 224
App. 5 EMDR Resources 230
References 233
Bibliography 235
Index 237
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First Chapter

Chapter 3

WHO'S AFRAID OF A TOILET?
CRITICAL-INCIDENT TRAUMA

Three-year-old Tanya screamed relentlessly as her parents tried to persuade her to enter the kitchen of their newly remodeled home. Eyes wide, lips trembling, digging her fingernails into her mother's neck, she looked as if she were entering a torture chamber.

That wasn't all that was worrisome about Tanya these days. She was fearful about many things and seemed to be developing new fears daily. She insisted on riding with the car windows closed. She anxiously asked "Fire?" whenever she heard sizzling noises of food cooking. She backed away -- far away -- from anything hot, like a bowl of soup. Even clouds high in the sky upset her. "Smoke?" she worried. The toilet had become another cause for alarm. Confidently toilet trained by age two, Tanya now ran screaming from the bathroom whenever the toilet flushed. If she was in another room when she heard the toilet flush, she covered her ears.

Tanya's parents knew that she had been upset by seeing fire destroy their kitchen 3 months earlier. They were grateful that no one was hurt, but they were concerned because Tanya's new fears were popping up so fast. Before the fire Tanya had been a playful, bright, outgoing, feisty 3-year-old, and they assumed she would be her cheerful self again within a few weeks of the fire.

At first, they thought that Tanya's reactions to the fire were normal. Tanya was quieter and more irritable than usual, but her parents were stressed too. There were insurance people to talk with, the search for a temporary apartment, concern about time missed from work, and endless discussions about how to remodel the houg comforting, and by explaining what happened and pointing out that they know the incident is over now and that everyone is safe. Sometimes, the event is so threatening that parents, too, are very upset, and children read their parents' unspoken, profound fears. After all, children are highly sensitive to emotional cues, and the well-being of very young children truly rests on their ability to detect nonverbal, emotional signals of safety or danger. Sometimes the child experiences such fright in a critical-incident trauma that even the calmest, most competent, and appropriately reassuring parent cannot prevent posttraumatic stress.

When a child is traumatized there may be an identifiable moment when he appears "like a deer in the headlights," that is, too stunned to move, perceiving that death is nearly certain, and he doesn't have time to escape. Perhaps at that time there is a change instantaneously activated in the brain's biochemistry, so that the brain begins to process information differently. When this "emergency mode" is activated, the brain sorts all incoming information related to the traumatic event into one of two categories: safe and unsafe. The child or adult in a similar situation has no time to consider, "The sound of food cooking isn't dangerous unless it's accompanied by smoke and flames. Even that could be safe if someone is cooking over a camp fire." The emergency mode helps the threatened individual bypass time-consuming thinking that might waste lifesaving moments for escape.

Furthermore, this special biochemical configuration is designed to protect the individual from future harm by stimulating the anxiety response any time anything happens that remotely resembles the trau ma. After a child has experienced a critical incident, like a fire, anything that looks, smells, sounds, or feels like the trauma will signal an alert and will stimulate the anxiety response.

So it is not surprising that everything that looked like smoke, sounded like steam hissing or food cooking, felt hot, or in any way reminded her of the traumatic incident caused anxiety for Tanya. Initially, it was not apparent why she had become afraid of toilets, but I suspected that something about a toilet was connected to the traumatic event.

The practitioner has to approach recent critical incidents differently from more distant critical incidents (those occurring more than 3 months previously). Recent critical incidents have to be processed frame by frame -- that is, EMDR must target every component of the trauma. In adults, memories of long-past critical incidents seem to consolidate, so that if the practitioner uses EMDR to target the worst part of the trauma, the benefit of EMDR generalizes to decrease anxiety related to the entire trauma. For young children, however, traumas seem to be stored in fragments, regardless of when the trauma occurred. For best results, the practitioner must use EMDR to target every aspect of the traumatic memory. Storytelling is an effective way to do this, and one I felt would work with Tanya.

STORYTELLING

When I first started treating young children using the EMDR method, I used eye movement to enhance feelings of safety and mastery or to diminish feelings of helplessness and anxiety that came up during play therapy. EMDR in conjunction with play therapy seemed to help children feel better more quickly than play therapy alone.

I was challenged to develop another way to apply EMDR when I met Hue (pronounced "Way"), a 20-month-old Vietnamese boy who spoke no English, but understood the expression, "good boy." Hue had been sitting comfortably in a child-safety seat in the back of his family car when all of a sudden his calm life changed to terror with a big jolt and bang as another car smashed into the side of the family car and sent it spinning out of control. The accident had left easygoing Hue irritable, angry, and disturbed by nightmares several times each night.

Because I was unable to communicate verbally with Hue, it occurred to me that Hue's parents could tell him the story of the accident, in Vietnamese, while I used EMDR tapping techniques to desensitize the memory of the frightening experience. I asked Hue's parents to tell me what they imagined his experience of the accident to have been, using language that Hue would understand if they were speaking Vietnamese. The story was brief and simple: "Riding in the car. Everybody happy. Big boom! Everybody scared and crying! Go to hospital. Everybody fine. Everybody go home. Go to sleep." I asked them to tell Hue the story of the accident while I tapped his knees alternately.

I wanted to make some connection with Hue before I tried to use alternating movements to desensitize frightening memories of the accident. Usually, I start my preparation for treatment with children by playing with them or having them imagine a favorite place or a safe place. Young children often identify a parent's lap as a safe place. Some children enjoy a favorite song as fun and relaxing. The idea is simply to practice EMDR tapping while enhancing a good feeling and teaching the child how to participate by tapping or being tapped. I decided that my verbal affirmation "Good boy" would have to be Hue's safe-place equivalent as well as his good thought about himself (in EMDR lingo, his positive cognition.)

First, I taught Hue to tap my hands repetitively. (Although there has been no research to date to determine the relative effectiveness of tapping the child's hands or knees or having the child tap the clinician's hands, it seems that these methods are equally effective.) Then I tapped his hands. I said, "Good boy," and watched him smile.

I prompted Hue's parents to tell him their story about the day of the car accident. Hue sat on his mother's lap while his father related the story in Vietnamese. I sat in front of Hue and expended my hands for him to tap alternately. As soon as the story became upsetting, Hue stopped tapping my hands. I gave him a toy car to hold, and I tapped his knees alternately while his father continued relating the story in a dramatic way. In less than a minute, when the storytelling and rapid-alternating stimulation were over, Hue sat peacefully on his mother's lap. I tapped Hue's knees alternately as I repeated "Good boy," and Hue smiled. Our session was over.

Follow-up calls to his parents and pediatrician revealed that after only one session, Hue's symptoms cleared completely. His cheerful disposition had returned and he was sleeping soundly through the night. Hue didn't need to come back. When I called his pediatrician several years later, I found that Hue had continued to grow and develop well, without any notable behavioral problems.

My rewarding experience with Hue prompted me to try a similar approach with other young children in which parents create and tell a stor y about the traumatic event. This approach has many advantages. Storytelling, in conjunction with EMDR techniques, is well suited to satisfying the developmental needs of young children. Children love stories, especially if the story is about them. Young children usually have difficulty verbalizing their fears or retelling the details of a trauma that has happened to them; because the parent tells the story, the child isn't required to speak, but may if she likes. The therapist has the opportunity to observe and evaluate the child's response to the story.

Children live in a family: Whenever a child has been traumatized, the parents have also been affected. Furthermore, the parents often feel inadequate or ashamed because they have not been able to protect their child from suffering. The storytelling approach gives the parents an opportunity to help their child feel better and can be an effective way of resolving some of their own issues about parenting and about the traumatic event.

Let us return to Tanya. I thought that Tanya sounded like an ideal candidate for my storytelling approach. The traumatic event that affected her was a discrete critical incident with a beginning, a middle, and an end. Her symptoms were traceable to the trauma itself and not in any way a result of her parents' attitudes or handling of the situation. Her parents were willing to be partners with me in her treatment, they were able to write a story about the event for their child, and their treatment goals for their daughter were realistic and appropriate.

PREPARING FOR THE STORY: THE FIRST VISIT

Tanya's parents came alone to their first visit, as I had requested. Tyrone and Roberta were both tall and gave an impression of strength and stability. They presented their concerns clearly. They wanted to handle things as well as possible so their young daughter could get over her fears and move back into their house comfortably. They enumerated Tanya's symptoms: She was fearful and covered her ears whenever she heard popping sounds, traffic noises, fire-engine sirens, cooking sounds, and hissing steam. She was afraid of being burned whenever she felt heat, and appeared terrified when the toilet flushed. She was almost constantly worried that a fire would break out again.

Aside from witnessing the fire, Tanya had had a calm life. She had no history of hospitalization, injuries, or significant illness. She was the 7-pound product of a normal pregnancy, labor, and delivery. She was breast-fed for 2 years and her developmental milestones were appropriate.

Tanya's mother started recounting the story of the night the house burned. "I was at work, as usual. I got home from work at 8 P.M., and when I turned onto our street I could see the fire engines and the smoke but at first I didn't even realize that it was our house that was on fire. As soon as I realized it was our house, I saw my husband coming down the driveway to meet me. Right away, my husband told me that our girls were safe at our neighbor's house, so I didn't have time to wonder whether anyone was hurt. We went over to the neighbor's house to get the children. Tanya was real glad to see us. She had just been quiet, sitting there watching TV. Tyrone will have to tell you what actually happened before I came home."

Tanya's father continued, "That night I fed the children dinner first, the way I usually do. I gave them some soup and sandwiches they wa nted. They ate, then they went in the family room, behind the kitchen, to watch TV. I decided to fry up some chicken so Roberta and I could have it when she came home from work. I heated the grease. It started bubbling and smoking and before I knew it the grease caught on fire and the flames leaped up and started to race across the ceiling to the other side of the room. I grabbed the phone with one hand and called 911 while I turned off the stove and threw the lid over the flaming pot. By that time the room was filling with smoke and flames. I grabbed a dishtowel to cover my nose and looked up to see my older daughter run by the kitchen door to the front door to go outside.

"Then I saw Tanya. She stood in the kitchen doorway, frozen. Then she screamed, a long scream, still standing frozen. I rushed over and scooped her up and took her outside where I handed her over to our neighbor, who had come running over to see what was going on. I ran to get the garden hose and pulled it into the kitchen to start putting out the fire. By then the fire had destroyed the kitchen and was moving into the family room.

"I was pretty calm and level headed," Tyrone told me, "I guess because I was in Vietnam and had to deal with a lot worse stuff than this. I knew that the children were both safe. I only got a little burned on my arms. I went outside when the fire fighters started getting things under control. Just as I went down the driveway, I saw my wife and told her the girls were okay. We were both relieved that nobody was hurt.

"We went to get the girls. I knew they were upset, but Tanya seemed like she was in shock for a while. We were all a little disoriented, I guess. We went to a motel to spend the night . Then we had to start dealing with the insurance company in the morning. It's been pretty hectic since then."

I asked Tyrone and Roberta what beliefs Tanya might have about herself as a result of the fire. In EMDR terms these posttraumatic beliefs are called negative cognitions. Traumatic memories are also stored as beliefs about the helplessness, powerlessness, or worthlessness of the victim. Although the victim may have been helpless to stop the traumatic event, this belief is followed by a profound loss of self-confidence that does not serve the individual well after the critical incident has passed. Negative cognitions do not seem to change without intervention, and the untreated trauma survivor can continue to view herself as devalued and can continue to feel unsafe.

Roberta said, "I think Tanya feels, 'I'm not safe. It's going to happen to me again. I'm overwhelmed. I can't deal with it.'" I find that parents and young children are usually so close psychologically that the parents' perceptions about their child's beliefs are generally accurate. I asked what positive cognitions, or true and useful beliefs, they wanted their daughter to have about herself in relation to the fire. They talked for a few minutes and then Tyrone read me the list of beliefs they wanted Tanya to have: "I'm safe now. It's over. I can take care of myself by expressing myself and screaming or running when I need help."

I told Tyrone and Roberta that we could work together to help Tanya get over the fire and to regain her confidence. I explained EMDR and asked permission to use this new method to resolve the trauma. They agreed that it was worth a try. I asked whether they would write a story about the fire for Tanya. They nodded. I instructed them to begin the story with everyone being safe, to include any details leading up to the fire, to describe the fire as they imagined it appeared to Tanya, and to end the story with the fire over and everyone safe again. I suggested that they write the story about "a little girl," without mentioning Tanya's name. Some children can deal with the memory of something scary happening to someone else, but might be too upset to hear a story about their own trauma. Other children immediately claim the story as their own, and then the parents can personalize the story as much as they like. We would adjust the story later to meet Tanya's preference.

I asked Tanya's parents to tell her that she would be coming to see a doctor who helps families get over being upset and helps make things easier for children. Children may need reassurance that I am the kind of doctor who plays with them, not the kind who gives shots. I explained that the main goal of the first visit would be for Tanya to feel safe and to know that my office is a place where problems get better. Children love to hear their parents say good things about them, and I prepared Tanya's parents to expect me to ask questions such as, "What do you like best about Tanya? What are her favorite ways to play? Tell me about her imaginative power -- what does she like to pretend?" We set up an appointment for me to meet Tanya.

TANYA'S FIRST VISIT

Later that week Tanya's parents returned with their petite 3-year-old daughter. She held both of their hands as she entered my office, then let go when she spotted the doll house. I sat on the floor beside her to meet her at eye level, and said, "This room is a speci al place where problems have a way of getting worked out. We have only two rules in my playroom: One, the sand stays in the sand tray and two, you may play whatever you like but no thing and no one ever gets hurt for real." She nodded solemnly. I told her that she could choose to join her parents and me while we talked, or she could play. Tanya looked at me with big brown eyes and then turned to my playhouse with its castle-like air. Her choice was made. She sat on the floor and immediately started playing, putting dolls in the kitchen and intoning, "The day it burned up."

Then Tyrone handed me the story he had written for his daughter. I quickly read the story to myself while Tanya's parents hung up their coats and settled themselves on the sofa. The one-page story would do just fine. I tucked it in Tanya's chart. While Tanya played, I asked her parents to tell me about her special qualities. "Tanya loves to sing and dance," Roberta told me, clearly pleased, "and she's very creative. She loves to play imaginative games." I said that I am always interested to know how children meet developmental challenges, that is, to do really hard things like learn to use the toilet. Tanya glanced up. Of course, I already knew that she had learned to use the toilet fairly easily and with her parents' patient encouragement. Tanya listened as she played, and her parents praised the way she had mastered that skill.

Every child I have ever met in my office enjoys hearing the positive things her parents say about her. Even a child who appears to be deep in play is registering those words of appreciation. If the parent mentions that her child's favorite color is pink, the child might snap to attention and assert "N o, purple!" Some children will check in by asking "Who? Are you talking about me?" Conversations in my office rarely escape young children, especially if they are the topic of interest. It's also important to remember that young children absorb and remember the emotional tone of everything they hear, even if the vocabulary is beyond their understanding.

When I ask questions about how a child met a particular developmental challenge, I hope to tap into the knowledge that if she has accomplished other hard things, she can master this difficult task, too. Toilet training is one of my favorite early-developmental milestones, because I figure that if a tiny child can use a toilet, she has a lot of courage. Imagine going up to a toilet that comes up to your chest, being lifted, naked, onto a cold seat, balancing so you won't fall into the water, emptying your contents into this bowl, then being wiped and lifted off just before the toilet flushing results in a big roar, and your contents are swirled away. Recalling these acts of bravery can be used to bolster the courage of a young child.

Tanya's parents surprised and intrigued me by telling me that Tanya has "magic" and that she knows it. I noted their choice of words with recognition: It is this feeling of power, of magic, that I work to elicit and enhance for every child I see. Tanya's mother explained, "Tanya can feel whether her magic is high or low. When Tanya feels her magic is low, I give her an extra special hug or kiss. When her magic is low, Tanya also tells her godmother, who rubs Tanya's hands and wrists to increase her magic or help her feel stronger." I decided to use their concept of magic, already familiar to Tanya, to strengthen her s elf-esteem.

I asked Tanya whether she would like to choose a doll to help her get her own magic so strong that the memory of the fire would not be scary any more. Adults usually watch my hand or a "wand" guide their eyes through EMDR movements. I find that most children and many adolescents like to choose a doll or sand-tray figure or wand to help them, rather than simply following the movement of my hand during EMDR. I then hold the chosen object in my hand, and they can follow that with their eyes as I move my hand back and forth. Young children who are unable to do EMDR with their eyes sometimes like to be tapped on their hands or knees by their chosen figure. The figure may bestow its powers of comfort, strength, or companionship on the child.

Tanya selected a "mother" doll and came to sit on her mother's lap. I asked whether the doll had a name and Tanya's mother prompted her daughter, "You can call her Magic Lady." I asked Tanya whether she would like Magic Lady to help her get her own magic strong. She nodded. I asked where in her own body Tanya could feel her magic. She pointed to her wrists. Probably the rubbing of Tanya's hands by her godmother worked to place the physical sensation of magic in her hands.

I asked Tanya if Magic Lady could dance from hand to hand to get her magic strong. She nodded. I asked Tanya if she would let Magic Lady know when her magic felt very strong. She nodded again. Whenever I work with a traumatized child, I give her many opportunities to be in control. After all, one of the hallmarks of trauma is a feeling of not having any control, and my job is to restore the child's appropriate feelings of control in the world. With her permission, I used Magic Lady to perform EMDR by tapping Tanya's hands, and in less than a minute, Tanya smiled and agreed that her own magic was getting stronger already. One of the benefits of EMDR is that it enhances positive states and strengthens a child's feelings of strength and well-being.

Then I handed the story back to Tanya's father. I explained that I would interrupt his reading to ask Tanya questions that would focus her on certain emotional experiences and physical sensations that would be either enhanced, like the feelings of being safe, loved, and secure, or direct her attention to erase the fears that were no longer justified. EMDR can only instill true beliefs and can only remove false beliefs.

I used Magic Lady to alternately tap Tanya's hands while Tanya's father began reading the story he had written. The storytelling session went like this (my interjections are written in italics, Tanya's responses are in parentheses, and sets of EMDR movements or tapping are represented by three dots:...).

TANYA'S FIRE STORY

Once upon a time there was this family composed of Father, Mother, and two sisters. Dad and Mom were very much in tune with their children. They loved both girls very much. The big Sister was clever and pretty. The little girl of the family was smart and pretty and also very sensitive.

Can the little girl feel her dad and mom loving her?...(Tanya nodded).

Can the little girl feel herself loving her mom and dad?...(Tanya nodded again and snuggled close to her mother.)

On one of the many evenings that the children and Dad are home together, there occurred an accident that would get the little girl's attention. This evening after Dad had fed the children and put on their pajamas to get them ready for bed, then it happened. Dad was heating grease to cook him some dinner when it (grease) went poof!

Can you hear the sounds the grease makes? Let Magic Lady know when it sounds better....(I want Tanya to remember the scary feeling associated with the sound of the grease sizzling, and I wait for an indication that she has processed the memory. I tap Tanya's hands alternately for about 10 seconds until she says "Better." When she says "better," I know that some of the scary feeling has dissipated.)

Before you knew it, the kitchen was full of flames and smoke.

Can you feel the heat? Let Magic Lady know when it feels better. (..."Better.")

Can you see the flames and smoke? (..."Better.")

The Big Sister ran past the flames and went out the door as her Dad had told her to do. The little girl was afraid to pass by the door because of the flames and the smoke. It turned out that the little girl was afraid and she also thought her father, who was fighting the flames, was on fire and would melt.

Can you see the father?...(Tanya looked at her father and nodded.)

Is Father safe now?...(Tanya examined her father. He nodded, and she nodded in response.)

She was also scared that she would melt too.

Is the little girl safe now?...Are you safe now?...(Tanya looked relieved as she nodded again.)

Where in your body do you feel that safe feeling? Point and show me....

(Tanya arched her back off her mother's lap and patted her buttocks.)

The little girl screamed.

Show me how she screamed....(Tanya opened her mouth and let out a scream of terror.)

What a smart girl to scream to get the help she needed....Th ink about how the girl got the help she needed by screaming. Can you feel how smart she is?...(Nods.)

Her father recognized what was happening so he stopped fighting the fire, picked up his little girl and carried her outside to safety. One of the neighbors held her while her dad returned to fight the fire. This action frightened the little girl again, and she cried. Then the firefighters came.

Can you hear the sounds of the fire truck?...Can you hear the sirens?...Can you see the lights flashing?...(She nods.)

The firefighters came and began to fight the fire. The little girl was taken to the neighbor's house so she could rest. After the fire was put out, Mom arrived, then Dad and Mother went to get their children. We didn't know it then but the little girl was very happy to see her dad not melted. The little girl and her family are all safe now. Their house has been remodeled and her family likes the new kitchen.

Can you see the new kitchen?...Can you imagine the sounds of yummy foods cooking?...(Tanya began to lick her lips.)


The storytelling was over for this session. I asked Tanya what helps to keep her safe. She spoke carefully, "Mommy, Daddy, Big Sister, friends, and...Magic Lady," and she leaned over to give Magic Lady a kiss. I asked Tanya where she felt the safe feeling, and she arched her back and patted her buttocks area again. It was time to stop our first session. Tanya's parents agreed that in the coming week they would notice Tanya's fearful behaviors and the situations that seemed to trigger them.

Tanya lifted her arms to her father. When he picked her up so that she was sitting on his arm, it became apparent that the safe feeling was literally seat ed in her buttocks area, the part of her that felt her father's arms carrying her away from the fire to safety.

"BETTER"

When they returned a week later, Tanya's parents reported that Tanya was much more relaxed and they had been able to move into their newly remodeled house. Tanya still responded to cooking noises by leaving the room or covering her ears and asking anxiously, "What is that?" She also became anxious and covered her ears whenever water faucets were turned on or the toilet was flushed. We agreed that the phobias about the sound of water running and the toilet flushing probably stemmed from the sound of water rushing through the fire hoses.

During the week since our last visit, there had been another upsetting incident. Smoke filled their newly remodeled kitchen while they were cooking, setting off the smoke detector and causing the parents to rush around anxiously, trying to open tight new windows. Understandably, this was upsetting to Tanya. Roberta told me that she had evoked the image of Magic Lady, and Tanya calmed down as her mother reminded her that Magic Lady was there to help her. For a few days, Tanya had talked about Magic Lady when she needed to calm herself. Tanya's parents were pleased that despite these difficulties, Tanya had begun to sleep throughout the night again without diapers.

Both of Tanya's parents noticed that Tanya had become bolder -- she had touched a hot coffee cup even after her mother warned her not to touch because it was "hot." She would appropriately warn her parents to "be careful" when she saw steam, however. They remarked that although Tanya was still anxious when she saw a fire engine, she was able to ask questions, such as, "What i s it? What are they doing? Where are they going?" She was able to ride in a car with the windows down, and traffic noises no longer bothered her.

Some of Tanya's fears had cleared in a single session, but some symptoms, such as worries about cooking sounds and steam, were probably rekindled by the incident that activated the smoke detector. The symptoms related to the sound of water going through the fire hoses had not yet been addressed. I decided to target the current symptoms this time, as well as targeting their precipitating traumatic origins. I asked Tyrone and Roberta to help me simulate the sounds of food sizzling, the smoke detector, fire-engine sirens, and water rushing through a hose to put out the fire. Tanya listened intently while Magic Lady danced back and forth between her palms until Tanya signaled "better." Then I asked Tanya to imagine she could see her new kitchen. She nodded. I asked if she could hear the sounds of yummy food cooking. She nodded again and licked her lips.

The following week Tanya returned for her third session. Her parents reported significant changes. They were surprised that she had calmly watched a TV show about forest fires. Tanya had become so comfortable in the kitchen that her parents had to make sure that she did not get too close while they were cooking. They thought that she was fearless, just as she had been before the fire. Tanya thought otherwise. I asked her whether she wanted Magic Lady to help her with anything. She looked up from her play in the sand tray and said, "Flashing lights and toilets."

I took my small flashlight from the cupboard and picked up the toy fire engine. Tanya sat on her father's lap while I held the light and the fire engine in one hand and waved them in front of Tanya's eyes. With my other hand, I guided Magic Lady back and forth between Tanya's hands. Tanya's teeth began to chatter. I remembered that Tanya had been outside in the cool night air when she watched the flashing lights of the fire engines. Within a minute, Tanya's face relaxed and she said, "Better."

Finally, it was time to work on reducing Tanya's anxiety about toilet flushing. I asked Tanya if she would come to the bathroom with me so she could practice flushing the toilet. Tanya took my hand and together we approached the toilet, while her parents waited in the playroom. Tanya agreed to flush the toilet. She pushed the lever, then covered her ears as the noisy toilet flushed. Meanwhile, I stood behind Tanya and used EMDR tapping, first on one shoulder and then the other. I asked Tanya whether she wanted to practice again or whether she wanted to ask her parents to watch. Tanya knew she was ready. She went back to the office, returned to the bathroom with both of her parents, and marched confidently up to the toilet. She flushed, watched, and proudly strutted out of the room. When we returned to the office I asked Tanya, "Is there anything else we need to do?" She picked up Magic Lady and kissed her good-bye.

Tanya and her mother returned a week later. Tanya had had a good week with no evident fears and no mention of Magic Lady, and she was definitely feeling confident. Every once in a while she reported, "I'm okay, I'm not afraid." Proudly, she told me she had invented a chant: "I am Tanya, it is true, I can do what I want to do!"

Copyright © 1999 by Joan Lovett, M.D.

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Foreword

Foreword

Some children eat too much and are overweight. Some get so anxious that they can't do their best in school. Some worry every time they try to fall asleep and as a result are chronically sleep deprived. These dysfunctional behaviors are common. They become part of the daily concerns of good parents, who try everything they know to help their child. Parents may be told, "It's just a stage; the child will grow out of it," but professional help may be needed to guide children along their normal developmental path.

Small Wonders is a book of short stories about children who have not outgrown their abnormal behaviors despite their parents' best efforts. Trauma precipitated these children's ongoing troubles. To the general public, the word "trauma" is associated with war, violent crime, earthquakes, hurricanes, fire, rape, and AIDS. However, more commonplace experiences, such as a grandparent dying, head lice, or being publicly criticized by a teacher, may cause persistent and profound symptomatology in a young child. If left untreated, these problems often get worse over time. The children do not grow out of them. But the children in Dr. Lovett's stories do get better when they are treated with EMDR.

What is EMDR? It is a comprehensive method of psychotherapy addressing problems that are based on earlier life experiences. There are more controlled studies supporting the use of EMDR with psychological trauma than for any other treatment method. The abbreviation stands for Eye Movement Desensitization and Reprocessing, which turned out to be a poor choice of name given the complexity and comprehensiveness of the method. The treatment approachemerged fress salient and less valid, while positive experiences become more vivid and empowering.

As of 1990, when the first EMDR training was given to mental health professionals in the United States, the method began to evolve with input from a wide range of experienced clinicians. One of the most exciting areas of development and ongoing research over the years has been the use of EMDR with children. As this book so clearly and eloquently demonstrates, children are wonderfully resilient. Although symptoms may initially baffle both child and parent, a sensitive clinician trained in EMDR can generally unravel and clarify these mysteries of mind and body. Most importantly, children can often be returned to a state of psychological health that otherwise might have been persistently derailed or, if appropriate, they can frequently be carefully raised to a new plateau of wholeness and well-being that far surpasses their earlier status.

Dr. Lovett has written an extremely important book for both parents and therapists. Her considerable clinical expertise has led her to develop a new strategy for the use of EMDR, one that incorporates storytelling, along with play therapy and the more familiar EMDR protocols. Through careful explanations and detailed case histories, she illustrates how EMDR may be used for problems as wide-ranging as nightmares, trichotillomania (hair pulling), phobias, depression, sibling rivalry, grief, and a variety of complaints that can be traced to a child's lack of self-esteem and trust in the world. If left untreated, these problems can stunt the child's development regardless of how loving, nurturing, and concerned the parent may be. Just as it is clearly the parents' responsibility to provide their child with appropriate medical care, there is equally a necessity to find appropriate psychological care when symptoms do not remit despite loving parental attention. As Dr. Lovett so amply illustrates, co-participation among parent, child, and therapist is often vital to allow a return to health -- and potentially to peak achievement.

The comparison between medical and psychological care is particularly important for the developing child because EMDR has shown us that the brain takes experiences and processes them, much as the digestive system processes food. That is, if an experience is properly digested, it is integrated into the system and supports healthful growth. If a traumatic experience is not integrated because of the way it is stored in the brain, the child can suffer both psychologically and physically. In fact, physical symptoms with no obvious medical explanation may stem from earlier events that have been stored, with their accompanying disturbing sensations and emotions. Neither parent nor child can change the symptoms through an effort of will, but EMDR appears to tap into the physiological substrates of the information-processing system to rid the body and mind of the disturbance, leading to the resumption of healthful growth.

Dr. Lovett's detailed case examples and sensitive descriptions, combined with her expertise as a pediatrician and therapist, elucidate the striking complexity and beauty of the child's mind and guide both clinician and parent through a profound understanding of the child's experience. This book traverses the universe of childhood from one-and-a-half years of age through adolescence. It reveals how unhealed childhood experiences can haunt even the most intelligent and outwardly accomplished adult. Only through therapy that can release the client from the legacy of a negative past can he or she be provided with a healthful and happy present. Through all of these journeys Dr. Lovett is exquisitely careful to remind clients (of any age) that the "power" to heal is within themselves. This is why the children described in her book generally proclaim EMDR to be their "magic." For as importantly as anything else, this book shows its unbounded respect and concern for the children who suffered so valiantly and for the parents who had the courage to recognize the need for an intervention they could not personally supply. I believe that is why one of the children spontaneously calls Dr. Lovett by a name she has most certainly earned -- Dr. Love-it-all.

Francine Shapiro, Ph.D.
Senior Research Fellow
Mental Research Institute
Palo Alto, CA
July 5, 1998

Copyright © 1999 by Joan Lovett, M.D.

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