Sharing my mistakes
Lessons learned using EMDR tools for addiction recovery
By Annabel McGoldrick, PhD
My first therapy job, after beginning basic EMDR training in 2007, was in an addiction treatment centre in Australia called South Pacific Private, which used a trauma-based approach to support clients in their recovery. I found EMDR a great extension to my tool kit and a really good fit for my private work.
I began experimenting at an early stage with some of the well-known protocols including DeTUR, the urge reduction protocol (Popky, 2005); Jim Knipe’s tools for treating addictive disorders with Adaption Information Processing (AIP) Methods (2015); Laurel Parnell’s Attachment Focussed EMDR (2013) and later her Rewiring the Addicted Brain (2018), and Robert Miller’s Feeling State Addiction Protocol (FSAP).
I have found something useful in all of them, but I tend to use the FSAP most frequently to reduce the euphoria and buzz that goes with addiction. I have made quite a few mistakes as well as breakthroughs, which I’ll share in this article.
What do we mean by addiction?
According to Brewer (2019), addiction is the “continued use despite adverse consequences”. This is the simple definition given in his useful psycho-education video about everyday addictions, which I often send to clients. However, I prefer the definition I offered family members in my role as family therapist at the hospital: “actions or behaviours that are beyond the control of the conscious mind that have life threatening consequences” (South Pacific Private, 2009). To me, this is what makes addiction an ideal target for EMDR, both in the trauma that often causes it and the unconscious drivers that maintain it. It’s estimated that globally 35 million people suffer from drug use disorders (Grisel, 2019) so, as EMDR therapists, I think it’s really important to understand how to help clients recover.
Attending a talk by Robert Miller in November 2018, I realised that I’d been wrongly implementing his FSAP. It was apparent that he had made a number of changes to the protocol since I’d first learned it. So, let me outline some key learning points that helped me to understand how to use this protocol more effectively and how to link with other EMDR tools to bring relief to clients struggling to overcome the debilitating symptoms of addiction.
In summary the FSAP (see Figure 1) requires that we make the Feeling State (FS) our first target. According to Miller, “addictions are created when a desired feeling and behaviour become fixated together”. This “fixation” of feeling, which Miller now calls an Assured Survival Feeling (ASF), is “linked with specific objects or behaviours to form a state dependent memory” (Miller, 2017, p. 10). Note that there may be many ASFs. The Positive Feeling State (PFS) measures the strength of the association between the ASF and the substance or behaviour on a scale of 0-10. The FSAP uses the AIP model to integrate isolated neural networks of emotions and physical sensations that were created during a positive event using a behaviour or substance. Some readers may notice similarities with Jim Knipe’s Level of Positive Affect (LOPA) – a potentially controversial matter that is outside the remit of this article. The focus here is on what I’ve learned in applying Robert Miller’s FSAP. This includes both my interpretation of certain nuances in the protocol and learning from the mistakes I have made in my experience of working with it. I have called this my 12 Keys to working with addiction.
Key 1: Target selection
Targets are selected following Phases 1 and 2 of the Standard Protocol (SP) but the latter must include explaining to clients how fixated memories cause behavioural and substance addictions and that such addictions can also serve to avoid painful memories and feelings. In Phase 3 (Assessment) the therapist helps the client to identify the FS. The FS is what the client feels at the most intense moment of their drug ‘high’ or addictive behaviour. I sometimes invite the client to run a movie in their head, from the planning through to the consumption (or behaviour), then ask them to press pause and to focus on the most intense moment.
Some people may find it easier to think about the FS as an Addiction Memory (originally defined by Boening, 2001 in Knipe, 2015, p. 102) and contributed to by Hase and colleagues (2008), who described it as “a nonconscious, implicit memory with craving for a substance as its conscious manifestation”. Hase’s contribution is very important in that it points out that much of what drives addictive behaviours is nonconscious. Most addictive states of mind have an aspect that is automatic and therefore not under direct conscious control (Knipe, 2015, p. 102). The Feeling State, then, comprises the most intense positive feeling and the embedded ASF, including the associated cognitions, emotions and physical sensations.
Key 2: Assured Survival Feeling
The ASF is the positive feeling that is embedded in the FS. It drives the compulsive behaviour and is usually unconscious; it is a feeling that’s underneath the FS. It is crucial to understand the difference between the FS and the ASF. My mistake in the past was merely to identify the most positive feeling, but this may simply be the result of meeting the ASF’s needs, cravings or urges.
Let’s imagine, for example, a client who may be feeling unsafe or that they don’t belong. They may not be in touch with these feelings and therefore unable to articulate them clearly. Let’s say they discover that, by eating chocolate, those feelings temporarily disappear and are replaced by a feeling of calm and relaxation, which they then report as the most intense feeling. It is all too easy – as I have found in the past – to misidentify the feeling of calm and relaxation as the FS and potentially pointing to a ‘false’ target. In this example, the target should instead be the feeling of safety or of belonging, which the client temporarily enjoys via eating chocolate (i.e. the feelings of calmness and relaxation are additional but not drivers of the addiction). In this example, then, the ASF is the feeling of safety or belonging that is experienced at the peak of the addiction behaviour.
It is the ASF, the positive feeling the client is seeking, that I find particularly useful in Miller’s protocol. With this understanding it is easier to see why addictions persist even though trauma memories may have been fully processed.
Miller recognises four categories of ASF: Safety, Relational, Winning and Sensation – alive (see Figure 2). I find these useful in helping clients to tease out the ASF. Miller explains that only people with some developmental deficit in their early life will have the urge to artificially create such feelings. This is consistent with many theories of addiction as an attachment-based disorder. “The wondrous power of a drug is to offer the addict protection from pain while at the same time enabling her to engage the world with excitement and meaning” (Mate, 2018, p. 39). In other words, people with a secure attachment do not tend to develop addictions. For a victim of bullying who consequently feels like an outsider, the craving for cigarettes is not about the nicotine but about membership of the group that smokes behind the bike sheds.
Key 3: Link between behaviour and ASF
We’re not just asking the client to measure how positive the feeling is, but how strong the link is between behaviour and ASF e.g. ‘When you imagine yourself smoking with your buddies, how intensely do you feel that you belong?’ (Miller 2017, p.68). Or I might ask ‘When you imagine yourself smoking with your friends, how much is that linked with that sense that you belong?’ An easy mistake to make is to focus on the strength of the positive feeling rather than the strength of the link between the addiction behaviour and the ASF.
Key 4: No free association
In Phase 4, we desensitise the memory by inviting the client to imagine replaying this most intense moment whist focussing on the positive feeling (ASF) and the body sensation. We then add bilateral stimulation (BLS), eye-movements, audio or tactile, and between saccades ask for feedback on the PFS; i.e. the strength of the link between behaviour and ASF. We can ask: ‘is the link increasing or decreasing?’ until the PFS drops to 0 or 1.
Note that, unlike in standard EMDR, we are seeking only to desensitise the PFS; we don’t want the client to free associate. That comes later when we’re targeting the trauma underlying the dissociation. Again, this was a mistake I’d made in my early use of the FSAP which led to long and messy forays into irrelevant channels.
Key 5: The FS can be both a pleasure-seeking and a trauma-avoidance strategy
In his manual, Miller makes it clear that the FS is about seeking pleasure not avoiding pain or trauma. Personally, I don’t think it is that simple. The way I see it is that there is usually both avoidance of pain and seeking of pleasure. “It originates in a human being’s desperate attempt to solve a problem: the problem of emotional pain, of overwhelming stress, of lost connection, of loss of control, of a deep discomfort with the self. In short, it is a forlorn attempt to solve the problem of human pain” (Mate, 2018 p. xix).
Miller advocates that if the person is avoiding a feeling, the therapist should first work identify and process memory generating the guilt. For example, he writes, in the case of a gambler avoiding feelings of guilt, “the therapist should use the standard protocol to clear the memory generating the guilt. But in working with a gambler seeking a feeling of winning the therapist should use the FSAP” (Miller, 2017, p. 4).
I see the FS more like a lid, a form of dissociation that sits on top of the trauma, removing the pain and the memories. If we correctly identify and process the FS target, it can shift very fast and the client’s natural bodily responses to excessive food or alcohol will return, e.g. nausea. As mentioned earlier, only clients with a developmental deficit get this positive ‘hit/high’ from unhealthy behaviours. So it is the ASF they are compulsively seeking; e.g. a sex addiction is never about the sex but the feeling of adoration or safety. I tell my clients that I want them to have the positive feelings of safety, aliveness, belonging or winning as a matter of course and not by harming themselves through addiction.
In my experience using the FSAP I hadn’t fully understood the relationship between been the FS and the trauma and why we needed to process both. As Knipe says, “addictions often function as defences and incorporate both the avoidance affect (i.e. positive feelings of escape or relief from troubling feelings) and the positive affect of defensive idealisation (i.e. unrealistic overvaluation of an image, concept, action, or part of self)” (Knipe, 2015, p. 101).
A report issued by the National Center for Post-Traumatic Stress Disorder and The Department of Veterans Affairs showed a strong correlation between trauma and addiction in adults: An estimated 25-75 percent of people who survive abuse and/or a violent trauma develop issues related to substance abuse (Parnell, 2018, np)
Key 6: Process past traumas to complete the process
Miller proposes a few extra steps that are helpful before going directly to the trauma. He recommends that we:
- Process the hyper-need for the desired positive feeling (ASF) e.g. belonging, safety, connection. Ask the client to: ‘feel the need for the feeling X (state the feeling) as intensely as you can. On a scale of 0-10 how intense is it? Where do you feel it in your body?’ Do BLS until the number is 0 or 1 (Miller 2017, p. 57). I believe this step to be very similar to Popky’s measure of Level of Urge for the substance or behaviour used in the DeTUR protocol that focuses on desensitising the triggers.
- Miller then recommends identifying the negative cognition (NC) that underlies the feeling. (‘What negative belief do you have about yourself that makes you feel you can’t belong? Can’t connect? Aren’t important? Etc?’).
- Ask: ‘What emotion & body location goes with that NC?’
- Go back to earliest touchstone memory. I find Laurel Parnell’s Bridging technique to be the most simple and effective wording for this. First ask your client for an emotion and body location as they think of that NC then say: “Trace it back in time. Let whatever comes up come up without censoring it” (Parnell, 2017, p. 177). Parnell recommends not to ask for a memory “to keep the clients out of their heads, and their thinking, instead make this a right-brain experience” (p. 175). I haven’t had a client yet who has been unable to recall an early life incident. If you draw a blank, try again or add BLS before attempting a second or third bridge.
- Process the touchstone memory with the Standard or Modified protocol (Parnell 2013, p. 183) to SUDS of 0 or 1; install PC until there is a VoC of 7 and a clear body scan, thus completing Phases 4-7 of the SP.
- Create a Future Template of achieving the desired positive feeling (ASF) e.g. feeling of belonging or connectedness by doing something other than the addiction behaviour (this will generate an alternative image to work with). I believe this is very similar to Popky’s Positive Treatment Goal during the preparation phase of DeTUR. Here he recommends inviting the client to think of an imaginary day in the future where they are free from the need to smoke, drink, use pornography etc.
- Have the client imagine feeling that desired positive feeling (ASF) e.g. feeling of belonging or safety as part of themselves. E.g. ‘Where do you feel that ASF in your body?’ Add BLS. This is very similar to Popky’s Positive State which, again, forms part of the preparation phase of DeTUR.
- Check the PFS, the link between the addictive behaviour and the ASF e.g. feeling of belonging or connection. If it is greater than zero, add BLS until it is reduced to zero.
- Many people find being caught in an addictive cycle shaming and disempowering. This can generate NCs such as: ‘I am out of control’ or ‘I’m a failure’ which will also need to be reprocessed. “Determine the negative belief that was created as a result of the addictive behaviour and have the client choose a positive belief” (Miller, 2017, p. 69). Process using the SP and install PCs like ‘I am in control’ or ‘I can succeed’ to a VoC of 7.
- Identify the image or memories related to expectations or anxiety about relapsing. “Process the identified image or memories with the Standard EMDR protocol” (Miller, 2017, p. 69).
Key 7: Several FSs
It is common for there to be several feeling states each related to one of the four ASF categories (see Figure 2). Often these are generated by different stages of the addictive process, from fantasizing and planning the drinking or eating binge; buying the alcohol or chocolate; pouring the booze or unwrapping the chocolate; through the first sip or bite of chocolate. Each of these steps could have its own FS that all need to be processed separately. Addiction is held in place by a complex of set of threads that all have to be unpicked. Jim Knipe has a helpful picture in his book of two interlocking hands with the “clenched fingers symbolizing the many separate factors (dysfunctional channels of information) that maintain the tight hold of an addictive disorder” (Knipe, 2015, p. 114). These include: ways to dissociate, avoidance of disturbing memories, a way to feel good, addicted family and friends, the length of time the person has been addicted, unexpected triggers.
Key 8: If at first you don’t succeed, try, try again
The FS target selection can be tricky and working with any addiction is complex. Using trial and error in a spirit of curiosity, experimentation and exploration is very important. Loosening the grip of the separate interlocking factors of addiction takes time, diligence, patience, commitment and acceptance from both client and therapist.
Key 9: 12-step programmes
Robert Miller believes that 12-Step programmes are unnecessary partly because the FSAP does not require abstinence and many clients can enjoy non problematic use of alcohol, sugar, gambling etc. after clearing the FSs. The goal of the FSAP he says is “not to quit but to no longer want to do the addictive behaviour” (Miller, 2017, p. 12).
However, others like myself, Knipe, Popky and Parnell believe it’s not a ‘one size fits all’ and that 12 Step programmes can be helpful. Some people benefit from the support network they offer and I have found that they can make a huge difference to a client’s capacity to achieve abstinence or non-problem use. The primary objection many have is that 12-Step programmes are religious; members talk about God, although this is intended as a God of your understanding.
In addition to the original Alcoholics Anonymous, fellowships for other addictions using the same 12-step structure and philosophy have been established. They exist for addiction to food, pornography, sex, love, debt, work and so on. Co-dependents Anonymous helps those in relationships with addicts and Adult Children of Alcoholics Anonymous helps those parented by addicts or dysfunctional parents.
Key 10: Psychoeducation about addiction
It’s often helpful for clients with addiction issues to understand where they are on the Spectrum of Addiction, which is about frequency of use and consequences experienced:
- Abstinence means they don’t use e.g. alcohol at all;
- Non-problem use means they use alcohol like a beverage so may not even finish one glass.
- Problem use means there are consequences to drinking, the client may open a bottle then not be able to stop until they’ve drunk the whole bottle, thus having a mild hangover the next day.
- Abuse means they may drink between one and four bottles of wine when they take a sip, thus experiencing a very severe hangover and even miss the next day off work perhaps once a month.
- Dependency means they must have a drink every day or experience seizures and withdrawal.
Stages of recovery are also classified:
- Pre-contemplation is a state of total denial: ‘what do you mean? I don’t have a drinking problem, leave me alone’;
- Contemplation: ‘I might have a problem’;
- Preparation for recovery and abstinence, removing alcohol from the house, attending a 12-Step Programme, Therapy for trauma and Feeling States;
- Action to get clean;
- Maintenance of healthy living. (Stages of Change Model, accessed 2019)
I found Pia Mellody’s Codependency Model also known as developmental immaturity (Figure 3) useful in understanding the ego states of addicted clients. The Wounded Child (WC) is the part of self who responds to the childhood trauma by: having low self-esteem; no boundaries; distorts reality by filtering feelings and events to protect their vulnerability; over-dependency on others; behaving immaturely, chaotically and impulsively.
The WC is directly contrasted with the Adapted Adult Child (AAC). The AAC responds to the childhood trauma by having high self-esteem, feeling better than others and putting up walls rather than boundaries so that nothing gets in and nothing gets out. The AAC distorts reality by filtering feelings and events as a way of protecting vulnerability; being anti-dependent on others and manifesting super maturity, often by being extremely controlling.
The Functional Adult (FA) is right in between the polarised ego states of the WC and AAC. This healthy version of self has healed their childhood trauma so feels equal to others; has healthy boundaries to protect and contain the self. The FA can accept reality and accept life on life’s terms; is interdependent and is appropriately mature or carefree and flexible according to the circumstances.
The Codependency Model bears some similarity to Richard Schwartz’s Internal Family System (IFS) model with the Manager, Fire-fighter, Exiles and healthy Self in the middle. I find both models can be useful in helping clients to understand and separate their emotional parts and defences as well as giving them a map of health and wellbeing.
Mandy Seligari in her book Proactive Parenting (2019) offers a useful list of the Core Characteristics of addiction and codependency. If you’re new to the field of addiction recovery I recommend you read her book or watch her TedX Talk (Seligari, 2017). The book is an excellent tool for clients to understand themselves and other family members, particularly children.
Key 11: EMDR Resources
In the preparation phase, with all my clients, I always install Laurel Parnell’s external nurturing, protective and wise figures (Parnell, 2013). I find this to be vital when working with any complex trauma of which addiction is an outcome.
It’s also really important to reinforce the clients’ personal store of positive feelings as ways of surviving without that addictive behaviour. I ask the client to find or create an image of a day in the future when they are free from their addictive behaviours. What would be good about that? Perhaps clients wanting to overcome an alcohol addiction can see themselves at a party drinking only soft drinks, feeling clear-headed and confident. Or someone with morbid obesity can imagine themselves six stone lighter, with their family or playing football with a child and feeling strong, confident and free. Once they’ve got a good sense of that goal, strengthen it with BLS. As mentioned earlier this is part of Popky’s DeTUR method (2005).
I like to help clients identify certain positive feelings they want to feel more often, such as confidence, courage, hope, strength, groundedness, safety. One way of doing this is with Arne Hoffman’s Absorption method where the client recalls memories of having such feelings. I like to embellish this by drawing a picture of a gingerbread person and asking the client to assign a colour and body location to the feeling then add BLS. Next, I ask the client to draw that colour and body location on the gingerbread person. Many clients photograph the picture to use at home themselves on a difficult day, looking at the photograph and giving themselves the butterfly hug.
Parnell, in Rewiring the Addictive Brain: An EMDR-Based Treatment Model for Overcoming Addictive Disorders, has a long list of resources that can be tapped in, including memories of times of gratitude and inspiration; a circle of love; ideal mother and father; dream recovery team; resources for parts (ego states) to have their own safe place, with carers and to store these images inside the body (Parnell, 2018, np).
Key 12: Consequences
Parnell recommends installing with BLS a negative future image as well as a positive goal image. I have tried this a few times when faltering with the FSAP. I ask the client, ‘so what would happen in five years’ time if you carried on eating like this, how big will you be, where will you be living, what job will you have? Imagine that…’, and add BLS. I have then done a two-handed interweave: one future in one hand (e.g. the goal image, the positive future) and the image of the negative future in the other. “The therapist commences eye movements or tapping, or the client can alternate opening and closing hands (just notice.)
If there is distress in one or both of the choices, it is cleared with the SP. Both hands are then rechecked” (Shapiro, 2005, p 161.).
One man saw himself 10 stone heavier, sat in a chair, depressed, having lost his wife, child and job. He cried when BLS was added. His goal image was five stone lighter, at a party socialising, happy, then playing football with his son. He smiled and felt happy when BLS was added. He put the negative image in his left hand, the positive image in his right, and after several rounds of BLS felt more motivated to achieve his goal and avoid his negative future. Jim Knipe suggests inviting the client to give a percentage on their Level of Motivation to quit (Knipe, 2015, p. 110). In this case the client felt 70 percent motivated. I’m planning to measure this again in future sessions.
Pam Virdi in her book, Trauma-Informed Approaches to Eating Disorders suggests inviting the client to write two letters, one to their friend the eating disorder and the other to their foe, or the enemy the eating disorder. Again this can be turned into a two hand interweave to add BLS, as described above.
An example of how I have used Miller’s FSAP
Another client, a professional woman in her early thirties who had problems with binge drinking alcohol since she was a teenager, wrote to me about her experience of FSAP. She said the moment the alcohol hit her stomach it gave her a sense of aliveness and invincibility: “it feels like fireworks going off”, she said. Prior to this session we had had around 30 sessions, working on her early life trauma.
“Having been a problem drinker since the age of about 15, I have had a few sessions with Annabel working on removing the ‘buzz’, which I am chasing after that first drink. Within a week myself, my friends and family have seen a HUGE difference in the way I drink. I am quite happy to have a couple of drinks now and can stop myself, whereas before I would have carried on until I was in a complete state, drinking anything and everything. I now have no urge to drink wine or Prosecco which were always my main drinks, I can honestly say I feel completely repulsed by the thought of them and the taste is rank!! I used to fantasize about my first drink of wine or Prosecco and if I ever walked past the booze aisle at the shop I would grab a bottle, but now I don’t even notice the booze!! Another huge difference is when I have to order a drink when I am out I have no idea what to order as I no longer have that craving. It is very weird… I HIGHLY recommend Annabel and this treatment to anyone who is addicted to anything. It just works and Annabel is by far the best counsellor I have been to!!”