From Cathryn Harris, Ph.D.
Dear Celtic Art Therapy (CAT) Interested Clinicians
I have received requests for information about how I use CAT in my practice, particularly incorporating EMDR. I have also been asked to formulate a research protocol to standardize the use of the CAT in EMDR so we can start collecting data (with or without EMDR explicitly).
This overview is an attempt to answer preliminary questions and begin formulating this protocol. The “shoulds” below are simply my suggestions. Please forgive the informal presentation style, used for sake of speed (I book over 40 hours of appointments a week so I’m a “bit” busy clinically!)
This is a first draft of some of my observations which include ideas to get discussion started. I would love your feedback submitted through this website. Celtic Art Therapy.com is “membership by request”, so I encourage you all to submit a membership query to email@example.com to participate in this discussion.
To begin, I am presuming some familiarity with EMDR standard protocol and techniques, or at least familiarity with relaxation techniques training in general.
There are two things that need research validation:
- Efficacy of CAT in eliciting the relaxation response, and
- Efficacy of CAT as a technique for bilateral stimulation in EMDR.
I will focus on #2, but along the way I involve some measurement of #1.
(1) INTRODUCING CAT TO THE CLIENT: THE VIDEO
I’m in the last stretch of editing and posting a video of CAT creator, Erin Rado, doing a training for my interns at Turning Point Counseling here in Southern California. This is obviously not specifically about EMDR, but it would be the necessary first step in a Research Protocol, since it introduces the CAT technique and is an example of what Erin says to the participant in helping them choose a pattern as she gets them used to the technique (posture, holding the stick, etc).
What we could do for protocol:
- I would recommend that all clinicians watch the training video.
- I would recommend that for study purposes we have a standard “script” to introduce the technique to the client (this approach was also followed in the original research protocol for EMDR if you recall).
(2) USE IN PHASE 1 EMDR PREP/ GENERAL RELAXATION TRAINING
What I do:
I demonstrate use of the CAT stimulus as a relaxation technique in the office. That is, so far I have been using it mostly in Phase 1 Preparation for EMDR, in which we make sure that the client has affective management techniques available to modulate the stress of EMDR. Those of you already using CAT for mindfulness and relaxation are already probably collecting good experiences in its effectiveness in this manner. I use it in a variety of ways:
(A) I first introduce it and demonstrate it in the office
Pretty much the way Erin does in the video to see if the client will respond to the CAT with a relaxation response. If they don’t respond (rarely) or don’t like it, I don’t continue using it.
(B) I use it while guiding them through a visualization of “safe place”.
When there is some urgency in starting Phase 2 and 3 EMDR assessment and bilateral stimulations with a new client – and I want to make sure I can decompress the client if necessary. Using the CAT is a good way to show them they are capable of modulating their affect right away (efficacy in influencing their own arousal). This also helps me evaluate their ability to do so (readiness for EMDR). That is, the CAT is my “emergency” plan with a new client unfamiliar or unconvinced of the efficacy of EMDR; i.e. the nervous client who is afraid they might be “too stimulated” and not be able to shut it off. I could probably come up with my standard script for this type of introduction.
What we could do for protocol:
Similar to the original research protocol with EMDR, when we would use a short set of bilateral stimulation to deepen the “Safe Place” relaxation response before working on the trauma, we now could use the CAT to deepen the relaxation response. Just as in the original protocol, this also serves to introduce the client to the mechanics of the technique and to “demystify” it before using it with a trauma trigger, and also helps increase the client’s confidence in the technique (although I’m not sure if Dr. Francine Shapiro ever put it this way).
To evaluate the CAT’s effectiveness in this context, we could have the client rate their degree of relaxation 0-10 with a safe place visualization script without the CAT (10 being most relaxed – a reverse SUDS scale). Then we could introduce the CAT according to the introduction script, and then redo the safe place visualization with the same script but adding the CAT and have them then rerate their relaxation.
This also independently provides a measure of the efficacy of the CAT as a relaxation tool (#1 above).
(C) I use it after an incomplete closure.
As in 2B, even if I don’t use the CAT as the bilateral stimulation for EMDR, I often use it as a decompression technique when an incomplete closure leaves someone in a high state of arousal. I use it both by itself, and with safe place visualization.
Measurement: SUDS change before/after.
(D) I encourage the client to use it at home between sessions, for relaxation or grounding.
This is one of the easiest and most readily accessible ways to help a client manage their arousal between sessions. So although I also teach butterfly hugs, progressive relaxation, safe place and deep breathing techniques, this one is a “no brainer” in that when a client is highly aroused they don’t even have to remember how to trace the CAT! Because the CAT uses more than the touch modality as in butterfly hugs, I think it is more grounding in involving more of the senses (tactile, proprioceptive, synesthetic, and visual).
Measurement: SUDS change with other methods versus with CAT alone versus with CAT combined with other methods.
(E) I sometimes use it with binaural beat auditory stimulation as well.
Sometimes I have the client pair the CAT simultaneously with binaural beat technology (Relax Melodies app or iDozer app) which involves directly influencing brain waves as well as music therapy. This results in a completely absorbing sensory experience to help clients who are feeling flooded or overwhelmed.
(3) USE AS BILATERAL STIMULATION
What I do:
I have experimented with just a few clients using it as bilateral stimulation instead of eye movements or tapping (I don’t have any of the cool high-tech machines for sound or pulse). I use it the same way you would use any bilateral stimulation technique in EMDR:
- Assess target for picture, affect, negative cognitions, sensations, rate distress with 10 point SUDS, rate VOC etc.
- Have client focus on this target while doing stimulation set
- Elicit feedback from client. Repeat as necessary until SUDS is lowered to 0 or 1.
I generally have them do the pattern a little longer (about a minute?) than I would with tapping (about 30 seconds) or UNTIL I SEE EVIDENCE OF PHYSIOLOGICAL RESPONSE (as with standard protocol). Remember that research shows that visual stimulation requires about 28-30 passes minimum for best processing to occur – which about 28-30 seconds at a moderate pace.
(A) The clients do process with the CAT in similar manner to other EMDR stimulation techniques
(B) Just as with other techniques in EMDR, it depends on client’s preference and efficacy in processing which technique I choose. Sometimes they like the CAT for relaxation but prefer traditional methods for processing. At present, because I’m not keeping factors constant for study purposes, I might switch to or away from the CAT if the client is looping or the SUDS isn’t lowering.
(C) In at least one case, CAT seemed more helpful than traditional methods in eliciting the processing
You might have already read on my CAT Introduction Letter to the Amen Clinic the following observation in a recommendation I wrote:
I have a theory that for some clients, the Celtic Art Therapy helps to particularly stimulate the cerebellum bilaterally because of the nature of the task, but of course I can’t validate that or any other theory regarding its effect on brain activity directly without a SPECT or fMRI.
I have one client who had their SPECT done at the Newport clinic and showed a “cold” cerebellum amongst other things. (under activity of the cerebellum) I was having difficulty helping him achieve any state of calm through the usual stimulation methods of EMDR. However, he responded very well to the Celtic Art Therapy! This suggests an interesting possible correlation between SPECT results and the choice of the most efficacious treatment methods in EMDR.
What we should do for protocol:
(A) Use as EMDR stimulation: Obviously we normally use what works with the client as well as the client’s preference in clinical practice in choosing the stimulation approach. For research purposes however, if the client has responded well to the CAT for safe place and likes it (We might set a minimum improvement in relaxation rating?) then the protocol would be to stick with just the CAT for stimulation to gauge its effectiveness lowering the SUDS. We should establish a minimum of sets or sessions to complete before discontinuing the research protocol to switch to a different kind of stimulation if the client is not responding (client would not continue in study). We would keep numbers on how many responded to relaxation training phase, how many it didn’t work for as EMDR etc.
(B) I consulted with Curt Rouanzoin, Ph.D. who has been working with Francine Shapiro right from the beginning, and he suggested using the subject selection criteria that were used in the first protocol in validating EMDR:
- Use for simple, one event trauma (not multiple or complex trauma) and
- With clients who don’t dissociate (not to be taken as an endorsement by Curt for the CAT since he’s not familiar with it specifically yet.)
(C) We should do a minimum of 30 seconds with the pattern (because of research mentioned above).
(D) We should probably use a standardized record-keeping form for sessions and to summarize results (demographical stats, type of trigger, numbers of sets, length of time for set, number of sessions, SUDS ratings etc) Volunteers???
(E) If using as EMDR stimulation technique, I would recommend against the client using it at home between sessions as a general relaxation technique because;
- We can’t monitor or control how often they use it
- We can’t monitor their response to it
- It might elicit more processing of negative material in an non-therapeutic setting – that is, generally we won’t know what’s going on! (initial EMDR research did not have the clients doing their own stimulation at home in between)
(F) Choice of design:
I would recommend using only ONE CAT design for the study, to control other variables. I would specifically recommend Celtic Curls as the most open/relaxed design. However, I know this is not how we usually introduce or use the CAT in terms of matching designs to the preference of the client’s brain. Thoughts??
- I would love to have Erin Rado create a new CAT design that is closest to the back and forth motion of traditional EMDR eye stimulation, and maybe have it continue from one side of the circle to the other all around the circle. Perhaps we should have two designs to choose from and compare in ABAB fashion.
I’m looking forward to a mutual beneficial and stimulating exchange of ideas!
Hoping this is a good springboard for that dialogue.
Regards, Cathryn Harris, Ph.D.