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Appendix One
The Fritz and How It Compares to Other Trauma-Focused Therapies
By Joseph Walden
&nb
sp; Eye movement desensitization and reprocessing (EMDR) and Prolonged Exposure (PE) are the two main competitors of the Fritz. I’ll do my best to describe these alternatives and compare them to what I am recommending.
Eye Movement Desensitization and Reprocessing (EMDR)
EMDR was developed by American psychologist Francine Shapiro in the late 1980s for the treatment of post-traumatic stress disorder (PTSD).1 The therapist uses an external stimulus to reduce the affective distress associated with the traumatic experience. The most common is bilateral eye-movements, but hand-tapping or audio stimulation are also used. Clients will be trained how to engage in bilateral eye-movements and then will be asked to engage in this behavior while they are telling their story of trauma. Several research studies have found that EMDR is an effective treatment, and the American Psychiatric Association2 has designated EMDR as an effective treatment for PTSD. Treatment is broken down into eight phases. The first phase is a history-taking session, essentially an intake session to identify problem areas and past traumas. Phase two ensures that the client has adequate and healthy coping skills before old traumatic injuries are stirred up. Phases three through six are related to vivid imagery of the traumatic memory, identifying negative beliefs about the self, and processing uncovered emotions. Phase seven is closure and monitoring the events the client experiences throughout the coming week. Phase eight is processing current issues that elicit distress. For more information on this treatment, please refer to Shapiro’s book, Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic Principles, Protocols, and Procedures.3
While research studies have concluded that EMDR is effective in clinical trials, the mechanism of this success was until recently mostly unknown. Lilienfeld and Arkowitz (2012) state that completing EMDR is better than doing nothing, but not as effective as other trauma-focused therapies, in this case things like prolonged exposure. They went on to say that the results that proved effective likely were due to the exposure, rather than the “eye movement.”4
My personal conclusions regarding EMDR stem from my clients who have completed this protocol. While talking to a therapist, learning various coping skills, and feeling “somewhat” better are positive, the traumas tend to creep back into the mind.
There are a number of significant differences between EMDR and the Fritz. Obviously, there has been no discussion of “eye movement” in this entire book up until this point. There is a reason for that: eye movement isn’t a requirement for healing, just as keeping your eyes fixed on a single point isn’t a requirement for healing. Missing from EMDR are the releasing and reframing steps of the Fritz. These two steps help people achieve the very important feeling of closure. With closure, the trauma or grief is over. That chapter of life is closed.
There are some elements of EMDR that are present in the steps of the Fritz. For example, EMDR typically includes guided imagery back into the period that the trauma was experienced, as does the Fritz. However, the mere element of exposure is inadequate to fully treat trauma. And while the clients I’ve worked with who experienced EMDR before seeing me were exposed to their traumas, they repeatedly told me that they still felt as if they had an open wound. Obviously, this is not the goal of the Fritz, and while EMDR is better than no treatment, I don’t believe it to be nearly as effective to treat trauma.
Prolonged Exposure (PE)
Prolonged Exposure (PE) was originally developed by Dr. Edna Foa, who has been the director of the Center for the Treatment and Study of Anxiety since the late 1990s. Prolonged exposure is commonly used to help people confront various fears and phobias. Most people want to avoid things that remind them of trauma (Mr. Avoidance). Since avoidance is thought to maintain the fear, exposure, obviously, is the opposite.
Prolonged exposure is a manualized treatment that occurs over the course of a three-month period. Usually, there are nine to twelve sessions, lasting about ninety minutes each.5 There are two types of exposure, imaginal and in vivo. Imaginal exposure is exposure in one’s imagination. The client imagines the traumatic event and is thereby exposed to a somewhat less threatening version of the trauma, simply because imagination is not reality. The client and therapist discuss any emotions that arise. In vivo exposure is confronting the feared stimuli outside of therapy, in the real world. As an example, someone with PTSD from a motor vehicle accident might be required to go sit in their car, drive locally, and eventually make an extended trip. The goal here is to get the client to challenge him/herself in a graduated fashion to remove associated fears.
Prolonged Exposure (PE) is largely regarded at the “gold standard” of trauma treatments. It had been shown to be effective in treating combat veterans, sexual assault survivors, refugees, and adult survivors of childhood abuse in all kinds of ethnic and racial groups.6 While prolonged exposure is a good treatment, there is something that is often overlooked. Dropout rates for those attending prolonged exposure therapy vary greatly, but some studies suggest rates as high as 50 percent.7 Several studies have looked at trauma treatments for PTSD, and again, the dropout rate of 20 percent is concerning.8
Prolonged exposure can indeed treat PTSD, and research tends to support that. Some of the elements of PE are similar to the Fritz, primarily the exposure element. Clients going through the Fritz will have to expose themselves to their traumatic memories in the “remember” and “express” steps of the Fritz. However, in my humble opinion, merely exposing yourself to these trauma memories over and over again is unnecessary punishment. This unnecessary punishment, I think, accounts for the high dropout rate of PE. As compared to the Fritz, during which the “exposure” element only occurs once and then the process of release begins; no unnecessary prolonged and continued exposures are needed.
Final thoughts on EMDR and PE
While both EMDR and PE have some supporting research, they both have limitations. I believe that the Fritz addresses these limitations. As stated earlier, as you’ve gone through this book, I’ve never once mentioned your eye movement. It simply isn’t necessary, because eye movement has little to do with healing from trauma. While the exposure element of PE is required for healing (and included in the Fritz), more is needed for closure and acceptance to occur. Reframing the trauma and releasing the trauma help people finish the unfinished business in their life. Adding these steps is what separates this treatment from others, and it is what helps people gain closure and move on with their lives.
References: Appendix One
1.EMDR Institute, Inc. (2018). What is EMDR? Retrieved fromhttp://www.emdr.com/what-is-emdr/
2.EMDR International Association. (2018). Does EMDR really work? Retrieved from https://emdria.site-ym.com/?122
3.Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic Principles, Protocols, and Procedures. Second Edition. New York, NY: Guilford Press.
4.Lilienfeld, S., Arkowitz, H. (2012). EMDR: Taking a closer look. Can moving your eyes back and forth help to ease anxiety? Retrieved from https://www.scientificamerican.com/article/emdr-taking-a-closer-look/
5.Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences, Therapist Guide. New York, NY: Oxford University Press.
6.Eftekhari, A., Stines, L. R., & Zoellner, L. A. (2006). Do You Need To Talk About It? Prolonged Exposure for the Treatment of Chronic PTSD. The Behavior Analyst Today, 7(1), 70–83.
7.Cottraux J, Note I, Yao SN, de Mey Guillard C, Bonasse FCO, Djamoussian D, Mollard E, et al. (2008). Randomized controlled comparison of cognitive behavior therapy with Rogerian supportive therapy in chronic posttraumatic stress disorder: A 2-year follow-up. Psychotherapy and Psychosomatics, 77(2):101–110.
8.Imel, Z. E., Laska, K., Jakcupcak, M., & Simpson, T. L. (2013). Meta-analysis of Dropout in Treatments for Posttraumatic Stress Disorder. Journal of Consulting and Clinical Psychology, 81(3), 394–404. http://do
i.org/10.1037/a0031474
Appendix Two
Our Top Ten Coping Skills
By Joseph Walden
Completing the Fritz is helpful, but there still might be other things that you need help with. Here is a list of my top ten coping skills. By no mean is this list comprehensive, and it isn’t intended to be, but if I had to pick only ten, it would be these ten.
1. Alcoholics Anonymous, Narcotics Anonymous, and Other Twelve-Step Programs
The twelve steps of Alcoholics Anonymous (AA) are the foundation of countless stories of sobriety. These time-tested pearls of wisdom have stood unchanged since Bill Wilson and Dr. Bob Smith co-authored them in 1935.1 Many therapists don’t appreciate AA, NA, and other twelve-step programs, but they can be extremely helpful, whether alone or in conjunction with psychotherapy. The results are hard to discount: AA has helped millions of alcoholics start and maintain recovery. For those who are reading this book and who have struggled with your own addiction, please read the next few paragraphs. For those in a relationship with someone with an addiction, I will detail other groups that may be helpful.
There are so many benefits to AA, but I’ll keep the list relatively short. First, AA is everywhere. You can search Google for “AA meetings in _______ county” and find meetings in nearly every county throughout the United States, or even internationally. In larger cities, there are AA meetings literally every hour. In rural areas, AA meetings are frequently held at local churches. Ease of accessibility is perhaps the greatest benefit of AA. As a psychologist, I work diligently to make myself available to my clients, but I cannot be available every day of the week, let alone every hour (as AA meetings are in some places), like an AA meeting can.
Another benefit of AA is that is totally free: no insurance, no copays, nor any in-network or out-of-network benefits to worry about. For many people struggling with addiction, stable employment and insurance simply aren’t available. Without insurance and a stable income, access to counseling may not be a possibility. But thankfully, community resources such as AA exist that can help with recovery from alcohol or drugs.
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