Sylvia Mills, Ph.D.
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.
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.
Published by the American Academy of Experts in Traumatic Stress - 2020