| 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. |
