Autism and eye movement desensitization and reprocessing therapy (EMDR) — are they a good match? Recent findings suggest that EMDR might be particularly helpful for autistic individuals in relieving PTSD symptoms and addressing multiple mental health concerns.
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Today we're building on the last episode about post traumatic stress disorder and autism. So if you haven't already, you may want to listen to that episode first, especially if you're not clear on what's required for a PTSD diagnosis. Or if you want to know more about PTSD and its relationship to autism. So today we're talking about Eye Movement Desensitization and Reprocessing, commonly abbreviated to EMDR. EMDR is a more recent type of psychotherapy that is now often used in the treatment of PTSD. We know from the last episode that autistic people have increased risk for encountering traumatic events and developing trauma related conditions, PTSD happens to be one such trauma related condition. There are several hypotheses as to why we have this increased risk. Many of these hypotheses have been supported by research, and some examples were discussed in the previous episode. If you haven't already listened, I feel like it's a good introduction to what we're talking about today.
Very few autistic people get through childhood without significant interpersonal maltreatment. This has been known to play a significant role in the social isolation that is also common for many of us at various points in our lives. Social isolation itself is associated with increased risk of PTSD and other trauma related conditions as well as repeated victimization. Berkowitz and his team state that autistic youth, quote, may be particularly susceptible to be adversely affected by childhood trauma, which can deliver additional insults to an already taxed neuro psychological system, end quote. So if you picture an autistic person in this state, someone who has this taxed, constantly overloaded nervous system, and psychological system or neuro psychological system, they may also become less capable of detecting violations against them perpetrated by those around them. I really want you to vividly try to picture this person. Not only are they trying to juggle all of these interpersonal and psychological challenges constantly coming their way and things going on in their own minds, but they're also dealing with significant sensory differences, such as hyper reactivity, or hypo reactivity, or some combination of both. Neurotypicals don't know what it feels like to live with these sensory differences, so they tend to have a very hard time understanding the autistic experience.
Because of all this stuff going on, an autistic person is likely in constant fight or flight and their bodies are just in total overdrive, like almost all the time. Not only do they now have a long history of maltreatment and abuse and physiological overstimulation, but they're less likely to set boundaries, less likely to ask for help, and more inclined to enter into new relationships or friendships with those who would abuse them and take advantage of them. Not because we autistic folks are less capable, or talented or astute, but because things like boundaries and asking for help and protecting ourselves from victimization require energy. And we don't have much leftover energy, when so much of it is spent just trying to self regulate, and find ways to calm our sympathetic nervous systems. Like all the literal time! This type of scenario is so common to autistic people that de Jongh - I hope I'm saying it right - D E space J O N G H - and his team state that traits that are commonly attributed to autism might in fact be stress responses to a long series of the above mentioned adverse and traumatic and overwhelming types of events. This phenomenon is called diagnostic overshadowing. To try to really portray what this means, this diagnostic overshadowing when it comes to autism and PTSD, let's imagine a hypothetical imaginary population of autistic people. Let's say these autistic people live on their own island with a nice, temperate climate that magically lacks victimization and magically lacks situations or stimuli that lead to extreme stress. This imaginary autistic population does not encounter teasing or bullying or any kind of interpersonal abuse or maltreatment. In addition, they have control of their surroundings in such a way that they can reduce their sensory related reactivity. Everyday stress is kept to a minimum and supports are in place to deal with challenges and help identify and express emotions and thoughts, feelings, opinions, and so on in a timely manner. This sounds truly amazing. Right?
Now, autism in this hypothetical autistic population would look very different from autism in the real life autistic population that we know today, because it wouldn't have trauma related symptoms, or certain autistic symptoms or traits would be quite dialed down. In other words, what we think of as autism is actually autism plus PTSD, or autism plus any kind of trauma related condition - now, at least according to the diagnostic overshadowing theory. I don't know if I'm explaining this well, so please write me if you have questions or if you have a better way of explaining this. My email address is in the show notes. Anyway, this gives me hope that some of the more challenging or distressing traits associated with autism, such as easily going into burnout mode, feeling emotionally numb, things like that, can be treated or at least ameliorated by preventing, managing and treating trauma. Just don't take my autism away. Yes, I'm looking at you researchers who are still trying to cure autism, the C word, please get your hands off. Thanks and stop perpetuating myths and cure bullsh*t. I don't want to hear it. Instead, let's focus on curing a toxic culture that favors neurotypical traits over neurodiverse ones. All right.
Anyway, let's get into treatment for ongoing trauma and PTSD. Ideally, we'd avoid or prevent trauma before it actually happens. But we currently don't live in the kind of world where that's fully possible. So for those autistic people who have PTSD or complex PTSD, or if they tend to kind of move in and out of PTSD, what's a good choice of treatment? EMDR, or Eye Movement Desensitization and Reprocessing, has emerged in recent years as a great treatment option for PTSD in all populations. More recently, it's been successfully applied to other conditions, including anxiety, depression, and substance use. EMDR was originally developed in 1989 by Francine Shapiro and does not rely on talk therapy or medications, although some therapists will combine all of these approaches. I think it's highly dependent on the presenting conditions that the person comes into the therapist's office with, and also the approach of the particular therapist. Everyone's going to be different; it's definitely no one size fits all.
Interestingly, no one really knows yet how EMDR works exactly. So far, all we have are hypotheses and research underway to test those. That said, the positive effects of EMDR treatment have been scientifically confirmed via well controlled studies. In fact, EMDR is now supported by the American Psychiatric Association or APA, as effective for treating symptoms of acute and chronic PTSD. Recent research and anecdotal evidence show that it appears to be particularly useful for autistic people. The APA notes that EMDR is also very useful for those who have trouble talking about traumatic events, for whatever reason, Maybe they have a hard time remembering all the details or maybe it's just so traumatic that the person is really actually afraid to go there. They might just need to remember just a sliver of the trauma to get to this sort of physiologically activated place that they need to get to for EMDR to work. Additionally, the Department of Veterans Affairs and Department of Defense recommend EMDR for treatment of PTSD in military and non military populations alike.
During an EMDR session, the therapist has the patient think of a traumatic event that activates a physiological response. That means body based response. So the person might be crying, they might be shaking, they might just be really visibly distressed by the memory. And then the patient does something like follow a light or the therapist's finger with their eyes, left and right, left and right, over and over again, until the emotional charge or emotional state subsides a bit. This back and forth movement is called bilateral stimulation or BLS. Other bilateral stimulation can be used as well, such as tapping one leg then the other, or the use of buzzers or other auditory stimuli delivered to one side of the body then the other. And again, back and forth, back and forth. The goal of EMDR is to reduce the negative influence of traumatic memories. And it seems to work pretty good for most people. Many love the fact that full disclosure of traumatic events is not needed for the technique to work. In other words, you don't have to tell the therapist details of the trauma, though you can if you want to.
EMDR makes space for the various comfort levels of patients. You can say as little or as much as you want. There are also parts of the EMDR session where the negative memories and beliefs are sort of reprocessed or replaced with different perspectives, positive spins on those scenarios. The theory behind this is that the EMDR process allows for reprocessing of traumatic memories, allowing a patient to assign new perspectives to old events and ironing out distress related to those initial traumatic memories. Usually, a person will have six to 12 EMDR sessions delivered one to two times per week. EMDR is informed by the adaptive information processing model, which posits that current trauma symptoms such as flashbacks and somatic re-experiencing are due to unprocessed traumatic memories that are in effect stuck in a kind of cognitive loop. They just keep spinning around and around. When these memories are resolved, trauma symptoms also begin to fall away. Debbie Spain and her team note that EMDR may need to be adapted to an autistic person's preferences, strengths and any executive functioning challenges they might have, such as by focusing more or less on visual imagery, having shorter or longer preparation phases, making sessions shorter or longer, and so on.
So I'm curious, have you tried EMDR? If so, how did it go? Is it something you're going to continue using whenever there's trauma to process? Or are you going to keep on doing other forms of therapy, such as traditional talk therapy? Or is there some other type of therapy that you found that you prefer? Please shoot me an email email@example.com The email is also in the show notes.
I have read in research and I know through personal experience and talking to others, that a common form of treatment called Cognitive Behavioral Therapy or CBT, which a lot of therapists practice these days, is either it seems to work for autistic people or it doesn't. It seems to be more divided for autistic people than non autistic people or neurotypicals. And I've heard different reasons for why that is. Some autistic people have said that it seems kind of forced or fake or not immediate enough. And there's been research that shows that CBT is only a little bit effective for autistic children who experience anxiety. I've found that when I've worked through CBT type treatments, it didn't quite get into things deeply enough. But I guess that could have a lot to do with the therapist. I don't know. I have just found that a lot of autistic people actually have had bad experiences with CBT or just didn't find it very effective or their symptoms that they were trying to address came right back after a relatively short period of time. In a research article, where they conducted a systematic review and meta analysis, Peter Langdon and his team found that with cognitive behavioral therapy and people who are autistic, there was only a small or medium effect size, meaning small or medium success rates or effects from CBT or small to medium successful outcomes or outcome rates. The reason why this is an important study is that as a systematic review and meta analysis, they looked at several studies. Instead of, you know, conducting one themselves, they looked at studies that were already done and compiled all the data from those. These types of studies tend to be quite powerful in the conclusions that they can draw, or the conclusions that can be drawn from them. So they found, in particular, when CBT was being used for problematic symptoms associated with autism, they found a small but non significant effect favoring CBT. In other words, there was nothing to write home about. The results were underwhelming, basically, especially when rated by the individuals or the patients themselves. Interestingly, the effect sizes were higher when reported by the therapists or clinicians, which shows kind of like a pro CBT bias by the clinicians. So I would be more inclined to believe and accept the results from the patients themselves.
Well, that's all I have for you today. Thank you so much for joining me.
Until next time, bye.