The information presented in this case study was submitted by the identified provider and reviewed by the Unyte Clinical Team. Modifications to the text have been made solely for the purpose of enhancing comprehension and clarity for the reader’s benefit, and were carefully applied while ensuring the accuracy and integrity of the original submission. Unyte Health makes every effort to use updated terms and inclusive language, this case study retains the author’s original descriptions to be most sensitive to the client’s identity and preferences.
About the Provider
Name: Laurie Belanger
Disciplines/credentials: LCSW-R
Modalities: Safe and Sound Protocol (SSP), Eye Movement Desensitization and Reprocessing (EMDR), ego-state therapy, cognitive behavioral therapy (CBT), insight-oriented and existential psychotherapy, play therapy and expressive arts approaches, Trust-Based Relational Interventions (TBRI), attachment theory
Client Background
Name: Ben (pseudonym)
Age and Gender: 11-year-old boy
Program Delivered: Safe and Sound Protocol (SSP)Core (Hours 1-5); Connect (Hours 1-2); Balance (Hours 1-5)
Ben was an orphaned child from a war-torn developing country and spent the first years of his life in very chaotic and somewhat unknown circumstances. At two years old, he entered institutional care in his country of origin. Ben was then adopted at four years old by a devout Christian family in a rural area of the U.S.
When Ben was adopted, mental health care was not initially sought out, as his adoptive parents relied on their pediatrician and faith community for support. While some health and learning concerns were addressed through those routes, Ben’s struggles with trust in the family system, reactions to trauma triggers, sensory system differences and feelings of low self-worth all became more evident over time. Ben’s parents decided to seek professional assistance when it became apparent that both they and Ben were no longer safe together in the home.
Ben’s parents had been exposed to Trust-Based Relational Interventions (TBRI®) within their church. TBRI® is an attachment-based, trauma-informed intervention that is designed to meet the complex needs of vulnerable children. TBRI® uses Empowering Principles to address physical needs, Connecting Principles for attachment needs, and Correcting Principles to disarm fear-based behaviors. While the intervention is based on years of attachment, sensory processing and neuroscience research, the heartbeat of TBRI® is connection. Upon learning about this approach, Ben’s parents sought out a qualified EMDR therapist with knowledge of attachment theory and TBRI® principles.
Ben’s parents were seeking help for a complex set of behavioral and emotional problems. They had begun to understand that these behaviors were Ben’s trauma responses and had also gained some insight into attachment work that they thought could be helpful.
Treatment goals were focused on safety and stabilization as well as continued assessment for dissociation. Assisting Ben in feeling “safe enough” to remain in the home was the first priority before any trauma processing could be attempted. Significant yet simple and concrete psychoeducation was provided to both Ben and his parents about Polyvagal Theory and dissociation. This helped begin the facilitation of routine changes at home and shame reduction, and began creating a foundation for future treatment.
For dissociative experiences, provider Laurie Belanger worked with Ben and his family toward a basic understanding of the EMDR concept of “parts.” Ben quickly identified a system of “animal friends inside” that helped him more clearly understand and communicate feelings and reactions.
The Safe and Sound Protocol (SSP) was used to help explain Polyvagal Theory during Phase 1 of EMDR. This further assisted with psychoeducation for both Ben and his parents. It also added to Laurie’s assessment of Ben’s sensory needs and provided stabilizing support for his nervous system before attempting any processing of EMDR targets.
The SSP was delivered as an important, supportive part of Phases 1 and 2 of EMDR therapy.
After the first complete delivery of SSP Core and significant time spent developing a playful and connected therapeutic connection with Ben using art and ego state therapy, Laurie was able to identify some practical EMDR targets to continue improving stability in the home.
These EMDR targets included:
- A deep fear of dogs related to an experience identified at about age three.
- A fear of showering connected to mistreatment in the orphanage.
Focusing on these targets was immediately useful as there were several dogs in Ben’s neighborhood and his poor hygiene was making it difficult for him to connect well at school. Laurie felt that Ben was ready to begin processing these initial targets because his behaviors had already begun to change. His suicidal ideation and dangerous behaviors had significantly reduced, he had transitioned from homeschooling to public school, he managed to eat meals regularly and he had not been becoming as severely dysregulated in the home setting.
The first EMDR targets were processed in a single session, Phases 3 to 8, with good results.
Ben’s Subjective Units of Distress Scale (SUDs) score dropped from a six or seven to a zero. Body sensations connected to emotions about the targets were resolved. Most importantly, both Ben and his parents noted that he was able to shower independently and exhibited greater emotional ease outdoors in his neighborhood, supported by encouraging outdoor play.
Following the completion of the initial EMDR targets, Ben listened to SSP Balance remotely for 15 minutes a day. Ben’s parents shared that this routine appeared to be very helpful.
The SSP was a part of the scaffolding of treatment throughout. Later, more complex and challenging EMDR targets connected to memories of abandonment, abuse and disorganized attachment and, at one point, the attachment difficulties required more Phase 2 resourcing. The SSP Core was repeated during that time to assist in creating more stability for Ben as he tackled deeply painful targets gradually.
Ben’s therapeutic goals included:
- Improve his attachment style to the level that he might experience felt safety in his home and with his parents.
- Reduce or eliminate triggers within his environment that produce emotional dysregulation and overwhelm.
- Improve self-esteem, self-acceptance and self-understanding.
- Function safely within the community and develop positive relationships and enjoyable hobbies.
Implementation of the Safe and Sound Protocol (SSP)
The SSP was delivered in just about every possible way for Ben. Both SSP Connect and then SSP Core were first delivered in person within the therapy session, while also engaging in creative arts and sensory-focused play activities. He enjoyed making slime with Laurie as a regulating activity, experimenting with a weighted ball and blanket, coloring mandalas and painting. SSP Balance was delivered mostly remotely with Ben’s parents as co-regulators.
Later, SSP Core was re-delivered through a combination of in-person listening sessions, remote listening sessions using telehealth and remote sessions with his parents. When listening at home, Ben often liked to sit with his cat in his lap and use a weighted blanket.
Ben experienced some significant dissociative symptoms so ego state therapy was incorporated into treatment. There were significant attachment style concerns, so concepts from attachment theory were integrated as well. Psychoeducation for both Ben and his family was integrated into every phase of treatment. A long sensory questionnaire was completed earlier by Ben’s parents, giving Laurie something of a sensory profile to work with when encouraging sensory-based activities in session.
TBRI® was the main source for assisting Ben’s parents in making trauma-informed parenting changes. Consultations with a sensory-focused occupational therapist and a developmental pediatrician were also important parts of the web of support for Ben and his family.
His pediatrician prescribed a mild anti-anxiety medication for a short period of time, initially used for sleep but then reduced and finally eliminated later in treatment. High-quality nutrition, including the addition of probiotics, was also prescribed. The doctor encouraged Ben’s connection with animals, eventually resulting in some elaborate bird feeders at home and some volunteer work with a local rescue, both activities that were deeply emotionally regulating for Ben.
Response
This case study represents two and a half years of treatment. Throughout that time SSP Core was delivered twice and SSP Balance was used as needed.
“At the time of this case write-up, Ben is doing well,” Laurie shared.
His home situation is stable, he is participating in school and attempting to navigate making friends, and he continues to better understand and work on his identified triggers. There is no suicidal ideation or significant self-harm and his self-care is within normal limits.
“In present-day therapy, there is alternation between EMDR processing of targets, most of which are connected to feelings of abandonment at this point; ego State work, where he is making progress being kind and compassionate to ‘all parts of who we are;’ and family and friends work, sometimes one-on-one [and] sometimes together with parents, focused on healthy communication, self-advocacy, and boundaries,” Laurie said.
He is much better at accepting “no” from a parent, and has begun to accept and give some affection. Ben continues to have significant sensory differences, for which he engages in occupational therapy sessions.
One of the largest treatment gains has been access to a more deeply regulated version of Ben. When he is able to experience new material in a ventral vagal state, he is receptive to new concepts and adjusts well to new routines.
“We have been able to slowly build health and healing in this way. Without this access, I do not believe much of the rest of Ben’s goals for therapy would have been possible. Processing EMDR targets without this stability would have been unsafe, possibly retraumatizing, and resulted in increased dissociation. Thanks to this scaffolding process of building more surety of safety into the nervous system, targets were and continue to be processed successfully for this very complex trauma client,” Laurie said.
Discussion
Laurie shared that she was more than a little impressed by the improvement of Ben’s window of tolerance. She also realized that both she and his teacher had underestimated his cognitive abilities. With more time spent in a regulated state, he had more space to access areas of his brain that are important for learning new things. His ability to develop self-reflection, insights into his own responses, and capacity for adjusting to new ideas continues to impress Laurie, though it’s no longer as surprising.
Family members have been showing increased flexibility in their own thinking as evidence has mounted that therapy is effective. Ben’s father came to realize important things about his own attachment style and emotional regulation, and has found a separate SSP provider and EMDR therapist for himself. This has yielded continued positive results for the entire family system.
Laurie shared that making nervous system-level resourcing a deeply important part of the treatment plan was crucial for the rest of the treatment plan to be reasonable and safe. Without adequate Phase 2 resourcing — not just cognitive and imaginal resources, but also resources that impact the autonomic nervous system — complex trauma processing would have been risky.
“Too many clients similar to Ben are written off by providers and educators, or experience abreactions and worsening behaviors when attempting EMDR therapy,” Laurie said. Sometimes, youth never manage to live in a family setting safely and this could have been one of those cases. EMDR therapists working with complex youth would do well to “slow down in order to speed up,” by focussing heavily on whole-person resourcing.
There are many creative ways to provide SSP delivery across the phases of EMDR therapy. As seen in this case study, the SSP was foundational for Ben in Phases 1 and 2, and SSP Balance was often used in Phase 8.
“Since the early times with this case, I have begun using the SSP more often in Phase 1 right away as a part of assessment, engagement, and psychoeducation with many complex client family systems,” Laurie said. “The SSP is a valuable resourcing tool to add to an EMDR treatment plan.”
Learn more about how the SSP and EMDR can work together to enhance results and support safe delivery through Unyte Health’s Combined Delivery Guidelines.
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