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Standard
EMDR (Eye Movement Desensitization and Reprocessing)
technique consists of repeatedly pairing recollections
of the trauma with sets of eye movements, until
patients subjective levels of distress (SUDS)
are dissipated for each and every aspect of
the trauma. Once major elements of the event
are desensitized, minor elements which were
"overshadowed" or "crowded out"
by the major elements of the event may surface.
It is necessary to ensure that all associations
and details of the trauma are recounted and
desensitized by the therapists use of EMDR.
When intense recollections
occur, the patients eyes occasionally stop tracking
the stimulus (often a moving finger or light).
When this occurs, it indicates that the intensity
of the recollection has a more powerful focus
for the mind than the concrete requirement to
track the eye movement stimulus. The therapist
needs to help the patient resume tracking. In
addition, whatever issue interrupted the tracking
requires careful, detailed processing to allow
for desensitization to occur.
Therapists can use eye movement
(EM) to strategically pace the clients "telling
of their story." They can initiate the
EM after each element of the story, and/or when
patients demonstrate an up welling of distress.
This allows the therapist to give their patients
a chance to dissipate viscerally experienced
emotions before continuing. It also reduces
the possibility that the recall will result
in a secondary traumatization. Finally, it provides
the therapist time to reflect on the clients
story and stabilize any countertransferential
responses they may have.
In some cases though, no matter
how careful and seemingly thorough the EMDR
technique, the detraumatization process seems
incomplete. These cases are characterized by
an incongruence or "a missing piece"
in the clinical presentation.
The first type of cases are
those in which patients complaints appear to
be "excessive" with regard to the
traumatic stimulus. Moreover, the symptoms do
not ameliorate with psychotherapy, either with
or without the use of EMDR. Also, the possibility
of malingering has been ruled out.
The second type involves cases
where SUDS levels dissipate "too quickly"
with regard to the quality and/or quantity of
the trauma described. Patients may claim "immediate
relief at the time of the session but will continue
to complain in following sessions of the continuing
existence of their original PTSD symptoms as
if no desensitization had occurred.
In both types, the discrepancies
can be understood if it is hypothesized that
the patient formed an extremely painful association
during or after the trauma, of which they are
not presently conscious. There may also be situations
in which they have not articulated to the therapist
perhaps because the patient feels to reveal
the association would lead to shame, embarrassment
or contempt. Some people may believe that it
is too unimportant or trivial to mention. In
either case, the therapist needs to find a way
to bring the hypothesized associations into
consciousness and/or help the client articulate
their realities or fantasies about the trauma.
An effective route in facilitating
this process is for the therapist to ask the
patient to imagine and then have them talk about
their "worst case scenario" of the
trauma. For instance, with traumatic events
involving narrowly missed death, consider who
or what would have been most affected
if the worst had occurred and the patient had
died. They might be asked to hypothesize about
the financial, emotional, social, political,
or economic future of their family, dependents,
co-workers, and friends. Who would pay for weddings,
funerals, relocation, debts, or college? Who
would know the car brakes, roof, line of credit,
or work backlog needed fixing? If injury might
have resulted then how would the patient have
managed their necessary or mandatory activity
with one leg, blind, brain injured, comatose,
or scarred? Who would have abandoned, rejected,
attached themselves or been intimate with them
as a result of the event?
When the prospect of the "worst
case scenario" is discussed, it frequently
triggers connections to suppressed associations
which reappear in the form of abreactions or
it gives patients permission to discuss associations
they hesitated to speak about for fear of being
diminished in the eyes of the therapist.
Case Example: Dissociated
Thoughts
On a dark winter evening, diners
were trapped inside a restaurant when a man
outside started shooting at police officers.
Bullets were thudding through the wooden walls
of the building forcing the diners to take refuge
under the tables. The lights were turned off
and there was noise from the sound of bullets,
sirens and screams. He feared that he would
be injured or killed and also feared for his
friends. He felt guilty since he had been the
one to suggest this particular restaurant. He
had no idea where his friends were and was unable
to hear them because of the noise. Even though
none of them were hurt, within two weeks he
had developed the symptoms of Acute Stress Disorder.
Using a standard EMDR desensitization
process, his subjective units of distress score
(SUDS) reduced somewhat and then reached a plateau
where they had been "stuck." Assuming
his worst case scenario was to be shot to death,
the next step was to speculate how this would
impact on the significant relationships that
he valued. He was asked if he had considered
his funeral during the event. Initially, he
appeared shocked and denied any such thoughts.
However, immediately following the next set
of eye movements, he recalled that while crouched
under the restaurant table, listening to bullets
thudding through the wooden walls, he had considered
the relative merits of facing the street so
he could die instantly with a bullet through
his skull or crouch with his back to the street
and risk a bullet entering his rear and fatally
injuring major organs as it traveled through
his body. In the first instance, with severe
head damage, he would have to have a closed
coffin which would distress his mother. In the
second instance, his face would be preserved.
He could have an open coffin, but he would die
more slowly and more painfully. As soon as these
thoughts resurfaced, they could be desensitized
and his SUDS dramatically reduced. On follow
up, one month and three months later, no symptoms
of Acute Stress Disorder were present and he
felt fully recovered.
Case Example: Incongruent
Recovery
This example is of a man forced
to open the safe of the store where he worked.
In the days immediately following the robbery,
he attended work regularly and denied any need
for treatment. Two weeks after the robbery,
his boss criticized him mildly for a poor decision
he had made. Later in the day, he reported feeling
consumed by an overwhelming sense of rage. Since
he normally handled occasional criticisms with
no problem, he was shocked by the virulence
of his feelings and called for an appointment.
He began treatment, highly anxious, hypervigilant
and suffering from insomnia and nightmares.
He could not stop obsessing about safety at
work and had begun to fear the robbers would
employ someone to track him down.
Following a classic desensitization
EMDR treatment model, he recounted in detail
the course of the robbery. He recalled how,
early in the morning while alone in the store,
he had been
threatened by two masked robbers
with a knife and gun who forced him to show
them the location and code for the safe and
then taped his wrists, arms and mouth. He was
made to face the wall, the phones were ripped
out and he was told he had better not turn around.
He was convinced he was going to be shot execution
style. After they departed, other employees
arrived and released him. The two men were arrested
by the police on the same day. He said that
he had experienced fear for his safety but felt
that he had handled the situation calmly and
cooperated with the robbers as company policy
dictated. He denied any history of abuse or
previous trauma which might contribute to his
presentation as suffering with Acute Stress
Disorder.
Within minutes, the EMDR desensitization
process resulted in a rapid reduction in his
SUDS levels to zero. In fact, as the speed of
his "recovery" was so incongruent
with the degree of distress he was reporting,
some degree of dissociative defense was assumed.
During intake, this patient had demonstrated
that he had a very close attachment to his young
daughter. On the premise that the dissociated
material would relate to an imagined "worst
case scenario" which would impact this
crucial relationship, he was asked, "Did
you think about your daughter attending your
funeral?" He collapsed into uncontrollable
sob which did not subside for several minutes.
His anxieties about never seeing his daughter
again, poured out of him. Only after the flood
of affect had subsided did he realize this imagined
scenario had been the focus of his thoughts
while facing the wall. He rated the thought
of permanently losing contact with this daughter
as absolutely unbearable and remembered deliberately
"shutting out the thoughts." Subsequent
dissociation had kept this painful association
out of his consciousness until the issue was
broached in treatment. Once the association
was evoked, the associated affect was released
and available for desensitization.
Conclusion
When dissociated material is
not brought into consciousness, it remains to
fuel reenactments of the emotional sequelae
to the trauma when elements in the environment
are reminiscent of some aspect of the trauma
or represent some aspect of the meaning of the
trauma. In cases which involve a "flight
into health" or where the desensitization
process becomes "stuck," it is suggested
that therapists think in terms of the concept
of the "worst case scenario." This
should be viewed as a way of projecting what
might have caused the severity of the traumatic
response, especially when the severity of the
actual trauma seems incongruent with the severity
of the PTSD or Acute Stress Disorder.
Since the treatment of severe
abreactions needs adequate processing time,
it is advised that therapists avoid asking exploratory
questions about "worst case scenarios"
near the end of sessions. If you are nearing
the end of a treatment session, it is recommended
that you wait until a subsequent session to
explore patients "worst case" fantasies
rather than risking an incomplete abreactic
process which may cause a secondary trauma to
the patient.
©1998 by
The American Academy of Experts in Traumatic
Stress, Inc. |
