| 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. |
